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Background The safety and immunogenicity profile of COVID-19 vaccines when administered concomitantly with seasonal influenza vaccines have not yet been reported. We therefore aimed to report the results of a substudy within a phase 3 UK trial, by evaluating the safety, immunogenicity, and efficacy of NVX-CoV2373 when co-administered with licensed seasonal influenza vaccines. Methods We did a planned exploratory substudy as part of the randomised, observer-blinded, placebo-controlled, phase 3 trial of the safety and efficacy of the COVID-19 vaccine (NVX-CoV2373) by co-administrating the influenza vaccine at four study hospitals in the UK. Approximately, the first 400 participants meeting the main study entry criteria—with no contraindications to influenza vaccination—were invited to join the substudy. Participants of the main study were randomly assigned (1:1) to receive two intramuscular injections of either NVX-CoV2373 (5 μg) or placebo (normal saline) 21 days apart; participants enrolled into the substudy were co-vaccinated with a single (0·5 mL) intramuscular, age-appropriate (quadrivalent influenza cell-based vaccine [Flucelvax Quadrivalent; Seqirus UK, Maidenhead] for those aged 18–64 years and adjuvanted trivalent influenza vaccine [Fluad; Seqirus UK, Maidenhead] for those ≥65 years), licensed, influenza vaccine on the opposite deltoid to that of the first study vaccine dose or placebo. The influenza vaccine was administered in an open-label manner and at the same time as the first study injection. Reactogenicity was evaluated via an electronic diary for 7 days after vaccination in addition to monitoring for unsolicited adverse events, medically attended adverse events, and serious adverse events. Immunogenicity was assessed with influenza haemagglutination inhibition and SARS-CoV-2 anti-spike protein IgG assays. Vaccine efficacy against PCR-confirmed, symptomatic COVID-19 was assessed in participants who were seronegative at baseline, received both doses of study vaccine or placebo, had no major protocol deviations affecting the primary endpoint, and had no confirmed cases of symptomatic COVID-19 from the first dose until 6 days after the second dose (per-protocol efficacy population). Immunogenicity was assessed in participants who received scheduled two doses of study vaccine, had a baseline sample and at least one post-vaccination sample, and had no major protocol violations before unmasking (per-protocol immunogenicity population). Reactogenicity was analysed in all participants who received at least one dose of NVX-CoV2373 or placebo and had data collected for reactogenicity events. Safety was analysed in all participants who received at least one dose of NVX-CoV2373 or placebo. Comparisons were made between participants of the substudy and the main study (who were not co-vaccinated for influenza). This study is registered with ClinicalTrials.gov, number NCT04583995. Findings Between Sept 28, 2020, and Nov 28, 2020, a total of 15 187 participants were randomised into the main phase 3 trial, of whom 15 139 received treatment (7569 received dose one of NVX-CoV2373 and 7570 received dose one of placebo). 431 participants were co-vaccinated with a seasonal influenza vaccine in the substudy (217 received NVX-CoV2373 plus the influenza vaccine and 214 received placebo plus the influenza vaccine). In general, the substudy participants were younger, more racially diverse, and had fewer comorbid conditions than those in the main study. Reactogenicity events were more common in the co-administration group than in the NVX-CoV2373 alone group: tenderness (113 [64·9%] of 174 vs 592 [53·3%] of 1111) or pain (69 [39·7%] vs 325 [29·3%]) at injection site, fatigue (48 [27·7%] vs 215 [19·4%]), and muscle pain (49 [28·3%] vs 237 [21·4%]). Incidences of unsolicited adverse events, treatment-related medically attended adverse events, and serious adverse events were low and balanced between the co-administration group and the NVX-CoV2373 alone group. No episodes of anaphylaxis or deaths were reported within the substudy. Co-administration resulted in no change to influenza vaccine immune response although a reduction in antibody responses to the NVX-CoV2373 vaccine was noted. NVX-CoV2373 vaccine efficacy in the substudy (ie, participants aged 18 to

OBJECTIVES The purpose of this study was to examine the prevalence and factors associated with objective and subjective cognitive dysfunction in older breast cancer survivors (BCS). MATERIALS AND METHODS This cross-sectional descriptive study leveraged previously collected data from older BCS (n = 335). Separate linear regression models were used to determine relationships between demographic factors (age, education), medical factors (comorbidities), disease factors (time since diagnosis, cancer stage), cancer-related symptoms (depressive symptoms, anxiety, fatigue, sleep disturbance) and cognitive dysfunction measures, including objective learning, delayed recall, attention, executive function-working memory, verbal fluency and subjective attentional function. RESULTS Cognitive dysfunction was prevalent with up to 18.6% of older BCS experiencing mild-moderate dysfunction (1.5 standard deviations below mean of non-cancer controls) in at least one cognitive domain. Poor to moderate subjective attentional function was reported by 26% of older BCS. More depressive symptoms were significantly related to poorer cognitive function including learning (p < .01), delayed recall (p < .05), verbal fluency (p < .001), and subjective attentional function (p < .001) but not attention and executive function-working memory. Age, education, anxiety, and fatigue were also negatively associated with cognitive function in some models (p < .05-0.001). CONCLUSION Cognitive dysfunction is common among older BCS and depressive symptoms, anxiety, and fatigue are related factors. Importantly, depressive symptoms were not only related to self-report, but also to cognitive performance. Healthcare providers should be aware of and assess for related factors and cognitive dysfunction itself in older BCS even years after diagnosis and treatment thorough geriatric assessment. Future longitudinal research is needed to discern these relationships.

Rationale: We aimed to predict the presence of vaccine-induced hypermetabolic lymph nodes (v-HLN) on 18F-FDG PET/CT after Coronavirus disease 2019 (COVID-19) vaccination and determine their association with lymphocyte counts. Methods: In this retrospective single-center study, we included consecutive patients who underwent [18F]-FDG PET/CT imaging after mRNA- or viral vector-based COVID-19 vaccination between early March and late April 2021. Demographic, clinical parameters and absolute lymphocyte count (ALC) were collected and their association with the presence of v-HLN in the draining territory was studied by logistic regression. Results: Two hundred and sixty patients were eligible, including 209 (80%) women and 145 (56%) with breast cancer. The median age was 50 years (range, 23-96). Two hundred thirty-three patients (90%) received the mRNA vaccine. Ninety (35%) patients had v-HLN with a median SUVmax of 3.7 [range, 2.0-26.3] and 74 (44%) displayed lymphopenia with a median ALC of 1.4 G/L [range, 0.3-18.3]. Age ≤ 50 years (odds ratio [OR] 2.2, 95%CI 1.0-4.5), the absence of lymphopenia (OR 2.2, 95%CI 1.1-4.3) and the delay from the last vaccine injection to the date of [18F]-FDG PET/CT, if < 30 days (OR 2.6, 95%CI 1.3-5.6), were independent factors for v-HLN in multivariate analysis. In breast cancer patients, the absence of lymphopenia was the only independent factor significantly associated with v-HLN (OR 2.9, 95%CI 1.2-7.4). Conclusion: Patients with normal values of ALC after COVID-19 vaccine were more likely to have v-HLN on [18F]-FDG PET/CT, which might both be associated to a stronger immune response to vaccination.

A protocol for a scoping review to identify cross-sector collaboration and adaptation of processes and products to promote innovation which may apply to aged care

AIM To identify practices, beliefs, and potential gaps in knowledge about parteria tradicional in Latin America. BACKGROUND/INTRODUCTION Parteria tradicional (lay midwifery) refers to ancestral knowledge used by laypersons, mainly parteras tradicionales (lay midwives), to provide health care to women and children. This care, initiated prior to formalization of health care continues today. Descriptions of the intergenerational oral transmission of parteria tradicional knowledge and practice in Latin America exist without related synthesis. METHODS Qualitative synthesis of the literature, including publications in Spanish, English, and Portuguese indexed in public databases over the previous 22 years concerning parteria tradicional. Identification of categories, themes, and bias reporting via PRISMA processes, using the Thomas and Harden's approach and the Noblit and Hare's methodological recommendations. RESULTS Parteria tradicional themes included "ancestral knowledge," "destiny and a spiritual calling," "woma's heritage," and "a means for providing health care." DISCUSSION Parteras tradicionales are key providers of health care for rural and urban marginalized communities. Limited knowledge and understanding of this practice impacts interactions between parteras tradicionales, midwives, and nurses. An interchange of knowledge is fundamental for care congruent with culture and the humanization of women's reproductive health. CONCLUSIONS AND POLICY IMPLICATIONS Communities with unresolved health care needs benefit via collaboration between formal health practices and parteria tradicional. A compelling need for inquiry to preserve the art of parteria tradicional exists internationally. Parteras tradicionales must be considered when formulating health care policy, thereby enhancing their historic role among the most vulnerable populations in Latin America: protecting, caring, and addressing health care needs.

Resume Objectif de l’etude Evaluer les indications actuelles et potentielles de la photobiomodulation (PBM) et leur niveau de preuve dans la prevention ou le traitement des effets secondaires lies a la radiotherapie. Materiels et methodes Les bases de donnees Embase, Medline/PubMed, Cochrane, EBSCO, Scopus, et LILACS ont systematiquement ete passees en revue afin d’inclure et d’analyser les publications d’etudes cliniques ayant evaluees la photobiomodulation dans la prevention ou la prise en charge des effets secondaires liees a la radiotherapie. Les mots-cles utilises etaient « photobiomodulation » ; « low level laser therapy » ; « acute oral mucositis » ; « acute dysphagia » ; « acute radiation dermatitis » ; « lymphedema » ; « xerostomia » ; « hyposalivation » ; « trismus » ; « bone necrosis » ; « osteoradionecrosis » ; « radiation induced fibrosis ». Les etudes prospectives ont ete incluses, alors que les cohortes retrospectives et les articles non originaux ont ete exclus de l’analyse. Resultats La photobiomodulation dans le spectre du rouge ou de l’infrarouge a demontre son efficacite dans des essais controles randomises dans la prevention et la prise en charge de certaines complications liees a la radiotherapie, en particulier de la mucite aigue, de l’epitheliite et du lymphœdeme du membre superieur. Le niveau de preuve associe a la photobiomodulation etait heterogene, mais restait globalement modere. Les principales limites etaient la diversite et la manque de precision des protocoles de traitement qui a pu compromettre l’efficience et la reproductibilite des resultats de la photobiomodulation. Conclusion Les donnees publiees suggerent que la photobiomodulation pourrait donc etre envisagee comme un soin de support a part entiere pour les patients traites par irradiation, au moins dans le cadre d’essai clinique therapeutique. Toutefois, tant que des donnees solides n’auront pas ete publiees sur son innocuite a long terme, l’utilisation de la photobiomodulation doit etre envisagee avec prudence, particulierement lorsqu’elle est pratiquee proche des zones avec des tumeurs connues ou possibles. Le patient doit etre informe des avantages et des risques theoriques de la photobiomodulation afin d’obtenir son consentement eclaire avant le traitement.

Objective To evaluate outcomes before and after implementation of a risk-stratified heparin-based obstetric thromboprophylaxis protocol. Methods We performed a retrospective cohort study of all patients who delivered at our tertiary care center from 2013 to 2018. Deliveries were categorized as preprotocol (2013-2015; no standardized heparin-based thromboprophylaxis) and postprotocol (2016-2018). Patients receiving outpatient anticoagulation for active venous thromboembolism (VTE) or high VTE risk were excluded. Coprimary effectiveness and safety outcomes were postpartum VTEs and wound hematomas, respectively, newly diagnosed after delivery and up to 6 weeks postpartum. Secondary outcomes were other wound or bleeding complications, including unplanned surgical procedures (eg, hysterectomies, wound explorations) and blood transfusions. Outcomes were compared between groups, and adjusted odds ratios (aORs) and 95% CIs were calculated using the preprotocol group as reference. Results Of 24,229 deliveries, 11,799 (49%) occurred preprotocol. Although patients were more likely to receive heparin-based prophylaxis postprotocol (15.6% vs 1.2%, P Conclusion Risk-stratified heparin-based thromboprophylaxis in a general obstetric population was associated with increased wound and bleeding complications without a complementary decrease in postpartum VTE. Guidelines recommending this strategy should be reconsidered.

BACKGROUND: Patients with SARS-CoV-2 may present or eventually develop central nervous system and ophthalmic signs and symptoms. Varying reports have emerged regarding isolation of viral RNA from these tissue sites, as well as largely autopsy-based histopathologic descriptions of the brain and the eye in patients with CoVID-19. EVIDENCE ACQUISITION: A primary literature search was performed in literature databases such as PubMed, Google Scholar, and Cochrane Library. Keywords were used alone and in combination including the following: SARS CoV-2, CoVID-19, eye, brain, central nervous system, histopathology, autopsy, ocular pathology, aqueous, tears, vitreous, neuropathology, encephalitis. RESULTS: The reported ophthalmic pathologic and neuropathologic findings in patients with SARS-CoV-2 are varied and inconclusive regarding the role of direct viral infection versus secondary pathology. The authors own experience with autopsy neuropathology in CoVID-19 patients is also described. There is a particular paucity of data regarding the histopathology of the eye. However, it is likely that the ocular surface is a potential site for inoculation and the tears a source of spread of viral particles. CONCLUSIONS: Additional large post-mortem studies are needed to clarify the role of SARS-CoV in the ophthalmic and neuropathologic manifestations of CoVID-19.

The discovery of a high-energy cosmic neutrino flux has paved the way for the field of neutrino astronomy. For a large part of the flux, the sources remain unidentified. The KM3NeT detector, which is under construction in the Mediterranean sea, is designed to determine their origin. KM3NeT will instrument a cubic kilometre of seawater with photomultiplier tubes that detect Cherenkov radiation from neutrino interaction products with nanosecond precision. For single cascade event signatures, KM3NeT already showed that it can reach degree-level resolutions, greatly increasing the use of these neutrinos for astronomy. In this contribution, we further refine the cascade reconstruction by making a more detailed model of the neutrinos events and including additional information on the hit times. The arrival time of light can be used to improve the identification of double cascade signatures from tau neutrinos, and the angular resolution of both single and double cascade signatures. Sub-degree resolution is achieved in both cases., Comment: 10 pages, 5 figures, ICRC 2021 contribution

Objective Effective clinical governance can improve delivery of health outcomes. This exploratory study compared perceptions of clinical governance development held by registered health professionals employed by two different but interrelated health organisations in the broader New Zealand (NZ) health system. Most staff in public sector healthcare service delivery organisations (i.e. District Health Boards (DHBs)) are registered health professionals, whereas these clinical staff represent a small minority (5%) in social insurance organisations (i.e. the Accident Compensation Corporation (ACC)). Given these different contexts, comparison of results from three surveys of clinical governance perceptions identified key learnings for the development of clinical governance. Methods The Clinical Governance Development Index (CGDI) was administered to registered health professional staff in NZ DHBs and ACC, at different time points. The data were explored, compared and reported. Results Responses to survey items completed by NZ DHB staff and registered health professionals employed by ACC were compared. For each administration, there was a similar profile of positive responses across the seven CGDI items. The 2020 ACC survey results for one item were clearly different. This item asked about perceptions of full and active involvement in organisational processes and decision making (i.e. clinical engagement). Conclusions Perceptions of registered health professionals working in the NZ public sector delivering health services were compared with those held by staff employed by a NZ social insurer predominantly commissioning and influencing care. The results indicated similar levels of clinical governance development. Clinical governance development in the ACC context can benefit from clear communication, building strong supporting structures and greater management–clinical provider partnerships. Clinical governance development drives health outcomes and regular measurement of developmental progress can provide momentum. There is room across the NZ health system to raise awareness and leverage clinical governance to deliver improved health outcomes. What is known about the topic? Little is known about the perceptions held by registered health professionals employed by social insurance organisations. There are no published comparative studies exploring differences in perceptions between registered health professionals across two different organisational contexts, both with a goal of improving health outcomes. What does this paper add? Effective clinical governance drives coordinated, quality systems that promote optimal health outcomes. Social insurance organisations predominantly commission healthcare providers to deliver health outcomes. Although registered health professionals employed by social insurance organisations represent a small total number of staff, their perspective on clinical governance, as reported via survey, indicated there is most to be gained in the development of partnerships between management and clinical providers. This exploratory study fills a gap in the existing clinical governance development literature and evidence base. What are the implications for practitioners? Any health organisation can leverage clinical governance to deliver improved health outcomes. Effective clinical governance interventions are targeted to specific organisational context and culture. For ACC, a clear definition, enhanced management-clinical provider partnerships and strong supporting structures or organisational arrangements can be further developed. The survey results indicated that a focus on management–clinical provider partnerships is a clear priority for ACC clinical governance development. Partnerships based in empowered collaboration require greater clinical engagement, as well as increased capability for aligning with organisational priorities. Effective clinical governance development requires attention to context and culture. It can improve delivery of health outcomes.

A Woman with Cognitive Impairment, Headache, and Memory Loss A 64-year-old woman was admitted with a 6-week history of cognitive impairment, headache, and memory loss. She had hyperreflexia and imp...

Purpose Older breast cancer survivors (BCS) may be at greater risk for cognitive dysfunction and other comorbidities; both of which may be associated with physical and emotional well-being. This study will seek to understand these relationships by examining the association between objective and subjective cognitive dysfunction and physical functioning and quality of life (QoL) and moderated by comorbidities in older BCS. Methods A secondary data analysis was conducted on data from 335 BCS (stages I–IIIA) who were ≥ 60 years of age, received chemotherapy, and were 3–8 years post-diagnosis. BCS completed a one-time questionnaire and neuropsychological tests of learning, delayed recall, attention, working memory, and verbal fluency. Descriptive statistics and separate linear regression analyses testing the relationship of each cognitive assessment on physical functioning and QoL controlling for comorbidities were conducted. Results BCS were on average 69.79 (SD = 3.34) years old and 5.95 (SD = 1.48) years post-diagnosis. Most were stage II (67.7%) at diagnosis, White (93.4%), had at least some college education (51.6%), and reported on average 3 (SD = 1.81) comorbidities. All 6 physical functioning models were significant (p p Conclusions A greater number of comorbidities and poorer subjective attention were related to poorer outcomes and should be integrated into research seeking to determine predictors of physical functioning and QoL in breast cancer survivors.

At any time, a medical crisis could result in an individual too sick to make one's own health care decisions. Advance care planning (ACP) is an important step to ensure that each person receives the medical care desired. Despite its significant importance and proven benefits, the completion rate for advance directive is approximately one-third among the general population in the United States and lower among Chinese Americans. This study explored Chinese Americans' knowledge and attitudes about ACP following completion of a web-based culturally tailored health education program. Ninety-six individuals completed the study between October 1 and December 31, 2020. Prestudy-poststudy outcomes measured included the Advance Directive Knowledge Survey and Advance Directive Attitude Scale administered before and after completion of the education program. Each measure has 9 questions and 16 questions, respectively. Participants' Advance Directive Knowledge Survey scores (pre: mean, 6.04 [SD, 2.28]; post: mean, 8.75 [SD, 0.53]; P < .01) and Advance Directive Attitude Scale scores (pre: mean, 47.31 [SD, 5.69]; post: mean, 53.59 [SD, 4.37]; P < .01) increased significantly following program completion. Findings indicated feasibility for integration of web-based technology and culturally tailored approaches to promote ACP knowledge and attitudes among Chinese Americans.

Purpose Younger breast cancer survivors (BCS) often report cognitive impairment and poor quality of life (QoL), which could be interrelated. The purpose of this study was to examine the association of cognitive impairment and breast cancer status (BCS versus healthy control (HC)), with QoL, which included psychological (depressive symptoms, well-being, perceived stress, and personal growth) and physical well-being (physical functioning and fatigue). Methods Four hundred ninety-eight BCS (≤45 years at diagnosis) who were 3 to 8 years post-chemotherapy treatment and 394 HC completed subjective questionnaires and a one-time neuropsychological assessment, including tests of attention, memory, processing speed, and verbal fluency. For each test, cognitive impairment was defined as scoring 1.5 and 2.0 standard deviations below the mean of the HC group. Separate linear regression models for each outcome were ran controlling for known covariates. Results BCS reported significantly more memory problems than HC (p < 0.0001), with up to 23% having significant impairment. Cognitive performance did not differ significantly between BCS and HCs. BCS vs. HCs had greater depression and fatigue, yet more personal growth. Objective and subjective cognitive impairment were significantly related to greater depressive symptoms and perceived stress and lower well-being and physical functioning; whereas, objective impairment was related to less personal growth and subjective impairment was related to greater fatigue. Conclusions Younger BCS report significant cognitive impairment years after treatment which may relate to greater decrements in QoL. Implications to Cancer Survivors Assessment and interventions to address cognitive concerns may also influence QoL outcomes in younger BCS.

Highlights • Deep learning accelerates 4D-MRI recon for online adaptive MR-guided radiotherapy. • First reconstruction of high resolution whole thorax 4D-MRI for 16 phases in 28 s. • First use of dCNNs for midposition reconstruction from undersampled 4D-MRI in 28 s. • Excellent agreement between deep learning-based tumour midposition and reference., Background and Purpose 4D and midposition MRI could inform plan adaptation in lung and abdominal MR-guided radiotherapy. We present deep learning-based solutions to overcome long 4D-MRI reconstruction times while maintaining high image quality and short scan times. Methods Two 3D U-net deep convolutional neural networks were trained to accelerate the 4D joint MoCo-HDTV reconstruction. For the first network, gridded and joint MoCo-HDTV-reconstructed 4D-MRI were used as input and target data, respectively, whereas the second network was trained to directly calculate the midposition image. For both networks, input and target data had dimensions of 256 × 256 voxels (2D) and 16 respiratory phases. Deep learning-based MRI were verified against joint MoCo-HDTV-reconstructed MRI using the structural similarity index (SSIM) and the naturalness image quality evaluator (NIQE). Moreover, two experienced observers contoured the gross tumour volume and scored the images in a blinded study. Results For 12 subjects, previously unseen by the networks, high-quality 4D and midposition MRI (1.25 × 1.25 × 3.3 mm3) were each reconstructed from gridded images in only 28 seconds per subject. Excellent agreement was found between deep-learning-based and joint MoCo-HDTV-reconstructed MRI (average SSIM ≥ 0.96, NIQE scores 7.94 and 5.66). Deep-learning-based 4D-MRI were clinically acceptable for target and organ-at-risk delineation. Tumour positions agreed within 0.7 mm on midposition images. Conclusion Our results suggest that the joint MoCo-HDTV and midposition algorithms can each be approximated by a deep convolutional neural network. This rapid reconstruction of 4D and midposition MRI facilitates online treatment adaptation in thoracic or abdominal MR-guided radiotherapy.

Background A high prevalence of pulmonary embolism (PE) has been described during COVID‐19. Our aim was to identify predictive factors of PE in non‐ICU hospitalized COVID‐19 patients. Methods Data and outcomes were collected upon admission during a French multicenter retrospective study, including patients hospitalized for COVID‐19, with a CT pulmonary angiography (CTPA) performed in the emergency department for suspected PE. Predictive factors significantly associated with PE were identified through a multivariate regression model. Results A total of 88 patients (median [IQR] age of 68 years [60‐78]) were analyzed. Based on CTPA, 47 (53.4%) patients were diagnosed with PE, and 41 were not. D‐dimer ≥3000 ng/mL (OR 8.2 [95% CI] 1.3‐74.2, sensitivity (Se) 0.84, specificity (Sp) 0.78, P = .03), white blood count (WBC) ≥12.0 G/L (29.5 [2.3‐1221.2], Se 0.47, Sp 0.92, P = .02), and ferritin ≥480 µg/L (17.0 [1.7‐553.3], Se 0.96, Sp 0.44, P = .03) were independently associated with the PE diagnosis. The presence of the double criterion D‐dimer ≥3000 ng/mL and WBC ≥12.0 G/L was greatly associated with PE (OR 21.4 [4.0‐397.9], P = .004). Conclusion The white blood count, the D‐dimer and ferritin levels could be used as an indication for CTPA to confirm PE on admission in non‐ICU COVID‐19 patients.

Background Perceptions of autonomy in practice affect Neonatal Nurse Practitioner (NNP) job satisfaction, retention, and motivation to pursue NNP roles. However, Novice to Expert theory describes the processes for transitioning to nurse practitioner roles are not in relationship with NNP practice autonomy. Purpose Relationships between Advanced Practice Registered Nurse (APRN) practice authority, state restrictions, APRN volume, and health care access exist. However, do APRN perceptions of autonomy relate to motivation to pursue practice authority? This study provides an exploration of perceptions of NNP practice autonomy in this context. Methodology Semistructured interviews conducted with NNPs and neonatologists practicing in a restricted setting explored perceptions of practice expertise and autonomy, based on Patricia Benner's Novice to Expert theoretical framework. Laddered methodology organized survey questions, and the Framework Method was used for analysis of results. Results The majority of eligible NNPs (n = 12, 67%) and neonatologists (n = 8, 67%) agreed to study participation. Identified themes were grouped into larger concepts, including "NNP practice authority," "NNP expertise," and "NNP autonomy." For example, "NNP expertise" included the theme "determining NNP expertise" and associated factors included "procedural skills," "years and acuity of practice level," and "confidence in management plan and emergent situations." Conclusions Both neonatologists and NNPs perceived neonatologists as a practice authority with support for NNP autonomy. Factors indicating NNP expertise correlated with domains in Benner Novice to Expert theory. Implications These findings support previous work concerning the evolution of expertise and transition to practice. More inquiry to understand perspectives of APRNs in restricted practice settings is indicated.

Using a cluster randomized trial, we investigated the effects of mathematics professional development on student achievement in elementary schools. Pairs of schools were matched on prior mathematics; percentage of students receiving free or reduced-price lunch and percentage of limited English proficient students were randomly assigned to two groups. One received professional development on mathematics that focuses on diagnosing student thinking and the other received professional development on formative assessment. Student-level achievement data (pretest and posttest performance on a standardized test of mathematics) were nested within grades and schools and analyzed using mixed-effects multi-level linear modeling. The results indicate students in schools that were provided the mathematics professional development had greater mathematics achievement than students in schools in a control condition. The effect held across grade levels.

Background: Noninvasive diagnostic methods are urgently required in disease stratification and monitoring in nonalcoholic fatty liver disease (NAFLD). Multiparametric magnetic resonance imaging (MRI) is a promising technique to assess hepatic steatosis, inflammation, and fibrosis, potentially enabling noninvasive identification of individuals with active and advanced stages of NAFLD. Purpose: To examine the diagnostic performance of multiparametric MRI for the assessment of disease severity along the NAFLD disease spectrum with comparison to histological scores. Study Type: Prospective, cohort. Population: Thirty-seven patients with NAFLD. Field Strength/Sequence: Multiparametric MRI at 3.0 T consisted of magnetic resonance (MR) spectroscopy (MRS) with multi-echo stimulated-echo acquisition mode, magnitude-based and three-point Dixon using a two-dimensional multi-echo gradient echo, MR elastography (MRE) using a generalized multishot gradient-recalled echo sequence and intravoxel incoherent motion (IVIM) using a multislice diffusion weighted single-shot echo-planar sequence. Assessment: Histological steatosis grades were compared to proton density fat fraction measured by MRS (PDFF MRS), magnitude-based MRI (PDFF MRI-M), and three-point Dixon (PDFF Dixon), as well as FibroScan® controlled attenuation parameter (CAP). Fibrosis and disease activity were compared to IVIM and MRE. FibroScan® liver stiffness measurements were compared to fibrosis levels. Diagnostic performance of all imaging parameters was determined for distinction between simple steatosis and nonalcoholic steatohepatitis (NASH). Statistical Tests: Spearman's rank test, Kruskal–Wallis test, Dunn's post-hoc test with Holm-Bonferroni P-value adjustment, receiver operating characteristic curve analysis. A P-value

Background Melanoma incidence has been dramatically increasing worldwide. Psoralen, a known photocarcinogen, is naturally abundant in citrus products, leading to the hypothesis that high citrus consumption may increase melanoma risk. Objectives To investigate the association between total citrus consumption and melanoma risk, and the association between individual citrus products and melanoma risk, and to test for interactions between total citrus intake and established melanoma risk factors. Methods Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between citrus consumption and melanoma risk among 1592 cases and 197 372 controls from the UK Biobank cohort. Citrus consumption data were collected via five rounds of 24-h recall questionnaires. International Classification of Diseases codes were used to determine melanoma outcome. Results After adjusting for potential confounders, participants in the highest category of total citrus intake (> 2 servings per day) had a significantly increased risk of melanoma (OR 1·63, 95% CI 1·24-2·12) relative to those with no consumption. For individual citrus products, participants with the most orange and orange juice consumption (> 1 serving per day) had a significantly increased melanoma risk relative to those with no consumption (OR 1·79, 95% CI 1·07-2·78 and OR 1·54, 95% CI 1·10-2·10, respectively). Fair- or very fair-skinned participants with high citrus consumption had an even greater melanoma risk (OR 1·75, 95% CI 1·31-2·29). Conclusions High citrus consumption was associated with an increased risk of melanoma in a large, prospective, population-based cohort. Further validation of these findings could lead to improved melanoma prevention strategies.

PURPOSE The purpose of this article is to provide an overview of common adverse effects and management strategies related to atypical antipsychotic use. CONCLUSIONS Atypical antipsychotics are commonly prescribed. While effective, atypical antipsychotics are associated with metabolic syndrome, extrapyramidal symptoms, and tardive dyskinesia, among others adverse effects. Management strategies can mitigate adverse effects and promote optimum quality of life. PRACTICE IMPLICATIONS To be able to identify and manage adverse effects associated with the use of atypical antipsychotics, it is important to build a supportive therapeutic environment at each interaction with patients and their caregivers.

Objectives Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. Design Observational field study. Setting and Participants Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). Methods Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). Results Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. Conclusions and Implications Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

Human papillomavirus (HPV) is a primary cause of cervical cancer. Multiple strains of HPV lead to cervical intraepithelial injuries that later progress to cervical cancer. The purpose of this study was to assess attitudes toward and acceptability of self-sampling among Mexican women who have HPV. Methods: The descriptive, cross-sectional design included a convenience sample of Mexican women with a previous diagnosis of cervical dysplasia. Results: Women ( n = 61) were young adults ( M = 27 years, SD = 6.92) reporting single marital status (55%) and sexually active (93%). Mean age at onset of sexual activity was 17 years; a majority of women (78.8%) had more than one sexual partner in their lifetime with 56.6% reporting between two and five partners. All (100%) of the women indicated that they would “choose self-sampling for HPV detection” and would recommend it to other women. Concerning “attitudes toward HPV,” the women responded that it is necessary to comply with HPV treatment and understand that preventative measures can avoid HPV transmission. Conclusion: Women reported high acceptability for self-sampling and positive attitudes toward HPV diagnostic procedures. Women indicated substantial interest in learning more about HPV, its transmission, preventive measures, routine testing, and recommended self-sampling for HPV detection.

OBJECTIVE This study assessed the feasibility of administering a multidimensional, self-report pain assessment protocol to children in an inpatient, acute pain context, and sought insight into the interrelationships between sensory, affective, and evaluative pain dimensions. METHODS A total of 132 children (5 to 16 y) experiencing acute pain were recruited from acute pain ward rounds or the short-stay surgical unit. A multidimensional self-report assessment protocol was administered, assessing pain intensity, pain-related affect, bother, perceived unfairness, and pain expectations (for tomorrow and in 1 wk). Duration of protocol administration was assessed and ease of administration was rated. Pain-related behaviors were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale. RESULTS The duration of protocol administration was

Publisher Copyright: © 2020 The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Molecular Biology and Evolution. Identification of partial sweeps, which include both hard and soft sweeps that have not currently reached fixation, provides crucial information about ongoing evolutionary responses. To this end, we introduce partialS/HIC, a deep learning method to discover selective sweeps from population genomic data. partialS/HIC uses a convolutional neural network for image processing, which is trained with a large suite of summary statistics derived from coalescent simulations incorporating population-specific history, to distinguish between completed versus partial sweeps, hard versus soft sweeps, and regions directly affected by selection versus those merely linked to nearby selective sweeps. We perform several simulation experiments under various demographic scenarios to demonstrate partialS/HIC's performance, which exhibits excellent resolution for detecting partial sweeps. We also apply our classifier to whole genomes from eight mosquito populations sampled across sub-Saharan Africa by the Anopheles gambiae 1000 Genomes Consortium, elucidating both continent-wide patterns as well as sweeps unique to specific geographic regions. These populations have experienced intense insecticide exposure over the past two decades, and we observe a strong overrepresentation of sweeps at insecticide resistance loci. Our analysis thus provides a list of candidate adaptive loci that may be relevant to mosquito control efforts. More broadly, our supervised machine learning approach introduces a method to distinguish between completed and partial sweeps, as well as between hard and soft sweeps, under a variety of demographic scenarios. As whole-genome data rapidly accumulate for a greater diversity of organisms, partialS/HIC addresses an increasing demand for useful selection scan tools that can track in-progress evolutionary dynamics. publishersversion published

Women have been the major victims of the Colombian armed conflict for more than 50 years. Nowadays, when the country faces an aftermath focused on reconciliation, understanding women’s experiences during the conflict is key to providing them tools for social justice and effective fulfilling of their needs. This qualitative synthesis of literature includes publications in Spanish and English of electronic databases over the past 20 years regarding rural women and the Colombian armed conflict. Studies were included for review if they were published between 2000 and 2019, were qualitative peer-reviewed articles, and addressed directly or indirectly the pregnancy process as well as the women’s sexual and reproductive health in rural Colombia. Seven of 169 articles initially identified were included for an inductive analysis of categories and themes. After the analysis process, three main themes emerged from the literature: (a) crumbling families, (b) being a woman: the challenges between being a peacemaker and a victim, and (c) protecting and caring of life. These three themes comprise 10 categories and 20 subcategories that provide support to the inductive qualitative synthesis. This review provides a comprehensive synthesis of the Colombian armed conflict focused on the victimization of women. It concludes with reflections about the Colombian women’s role in transitioning toward peace.

Objectives To evaluate (a) the prevalence of genitourinary symptoms, (b) which demographic and clinical factors predict genitourinary symptoms, and (c) the association between genitourinary symptoms and sexual functioning in breast cancer survivors. Sample & setting A secondary analysis of cross-sectional, patient-reported outcomes data from 1,085 breast cancer survivors was conducted. Methods & variables Prevalence and correlations with demographics, clinical factors, and sexual functioning were identified using descriptive analysis, multivariable logistic regression analysis, chi-square tests, t tests, and Pearson correlation coefficients. Results Symptoms included vaginal/vulvar irritation, pelvic discomfort, problems with urinary control, vaginal infection, and vaginal bleeding. Younger age, more comorbidities, and taking treatment for menopausal symptoms were significantly related to reporting genitourinary symptoms. Experiencing more symptoms was associated with lower sexual functioning. Implications for nursing The prevalence, correlates, and relationship of genitourinary symptoms with sexual functioning supports the assessment and treatment of these symptoms as part of routine care for breast cancer survivors.

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.

This study aimed to evaluate the antimicrobial activity of clove (Syzygium aromaticum), citronella (Cymbopogon winteranius) and melaleuca (Melaleuca alternifolia) essential oils (EOs) on CoPS. Of the 67 cerumen samples collected, 17 CoPS strains were isolated. Using the microdilution method in a 96-well plate, EOs were added at a maximum concentration of 10% and minimum of 0.04%. It is concluded that the EOs of clove and citronella demonstrate antimicrobial activity against strains of CoPS isolated from canine external otitis. At the concentrations used, melaleuca essential oil did not show any bacteriostatic or bactericidal effects.

Refereed/Peer-reviewed In recent years, considerable efforts have been made by cultural heritage institutions across the globe to digitise cultural heritage sites, artifacts, historical maps, etc. for digital preservation and online representation. On the other hand, ample research projects and studies have been published that demonstrate the great capabilities of web-geographic information systems (web-GIS) for the dissemination and online representation of cultural heritage data. However, cultural heritage data and the associated metadata produced by many cultural heritage institutions are hetero-geneous. To make this heterogeneous data more interoperable and structured, an ever-growing number of cultural heritage institutions are adopting linked data principles. Although the cultural heritage domain has already started implementing linked open data concepts to the cultural heritage data, there are not many research articles that present an easy-to-implement, free, and open-source-based web-GIS architecture that integrates 3D digital cultural heritage models with cloud computing and linked open data. Furthermore, the integration of web-GIS technologies with 3D web-based visualisation and linked open data may offer new dimensions of interaction and exploration of digital cultural heritage. To demonstrate the high potential of integration of these technol-ogies, this study presents a novel cloud architecture that attempts to enhance digital cultural heritage exploration by integrating 3D digital cultural heritage models with linked open data from DBpedia and GeoNames platforms using web-GIS technologies. More specifically, a digital interactive map, 3D digital cultural heritage models, and linked open data from DBpedia and GeoNames platforms were integrated into a cloud-based web-GIS architecture. Thus, the users of the architecture can easily interact with the digital map, visualise 3D digital cultural heritage models, and ex-plore linked open data from GeoNames and DBpedia platforms, which offer additional information and context related to the selected cultural heritage site as well as external web resources. The architecture was validated by applying it to specific case studies of Australian cultural heritage and seeking expert feedback on the system, its benefits, and scope for improvement in the near future.

The amount of digital cultural heritage data produced by cultural heritage institutions is growing rapidly. Digital cultural heritage repositories have therefore become an efficient and effective way to disseminate and exploit digital cultural heritage data. However, many digital cultural heritage repositories worldwide share technical challenges such as data integration and interoperability among national and regional digital cultural heritage repositories. The result is dispersed and poorly-linked cultured heritage data, backed by non-standardized search interfaces, which thwart users’ attempts to contextualize information from distributed repositories. A recently introduced geospatial semantic web is being adopted by a great many new and existing digital cultural heritage repositories to overcome these challenges. However, no one has yet conducted a conceptual survey of the geospatial semantic web concepts for a cultural heritage audience. A conceptual survey of these concepts pertinent to the cultural heritage field is, therefore, needed. Such a survey equips cultural heritage professionals and practitioners with an overview of all the necessary tools, and free and open source semantic web and geospatial semantic web platforms that can be used to implement geospatial semantic web-based cultural heritage repositories. Hence, this article surveys the state-of-the-art geospatial semantic web concepts, which are pertinent to the cultural heritage field. It then proposes a framework to turn geospatial cultural heritage data into machine-readable and processable resource description framework (RDF) data to use in the geospatial semantic web, with a case study to demonstrate its applicability. Furthermore, it outlines key free and open source semantic web and geospatial semantic platforms for cultural heritage institutions. In addition, it examines leading cultural heritage projects employing the geospatial semantic web. Finally, the article discusses attributes of the geospatial semantic web that require more attention, that can result in generating new ideas and research questions for both the geospatial semantic web and cultural heritage fields. Refereed/Peer-reviewed

There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification.We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis.Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients.Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification.PROSPERO no. CRD42018107083.Le processus d’audit des centres de traumatologie gagne en popularité, mais ses effets concrets ne sont pas bien connus. La présente revue systématique a cherché à résumer les données probantes disponibles sur l’efficacité de l’audit des centres de traumatologie.Nous avons effectué des recherches systématiques dans les bases de données CINAHL, Embase, HealthSTAR, MEDLINE et ProQuest, de même qu’une recherche dans la littérature grise sur les sites Web d’organisations majeures du domaine des traumas, de leur création à juin 2019, sans restriction de langue. La population à l’étude était l’ensemble des patients blessés traités en centre de traumatologie. L’intervention était l’audit du centre de traumatologie. Les groupes de comparaison correspondaient aux centres de traumatologie n’ayant pas subi d’audit, ou le même centre, avant son premier audit ou un audit subséquent. Le principal résultat à l’étude était la mortalité en milieu hospitalier; les résultats secondaires étaient les événements indésirables, l’utilisation des ressources et les processus de soins. Nous avons calculé des estimations sommaires par méta-analyse à effets aléatoires sur données groupées.Sur les 5125 citations retenues, 29 publications sur des études menées aux États-Unis répondaient à nos critères d’inclusion. La mortalité était le résultat le plus souvent à l’étude (n = 20), puis suivaient les processus de soins (n = 12), l’utilisation des ressources (n = 12) et les événements indésirables (n = 7). Le risque de biais était important ou critique dans 22 études. Nous avons observé une association imprécise entre l’audit et une baisse de la mortalité (risque relatif 0,74; intervalle de confiance à 95 % 0,52 à 1,06) chez les patients ayant subi un trauma grave.Notre revue a conclu qu’il y avait des associations mitigées et manquant d’uniformité entre l’audit et les processus de soins ou les issues pour les patients. La validité des données à l’étude était limitée par un manque de contrôles fiables, ainsi que par l’absence de données provenant d’autres pays que les États-Unis, ce qui empêche l’extrapolation à d’autres systèmes de santé. Des études quasi expérimentales devront être menées pour évaluer les effets de l’audit des centres de traumatologie.Registre PROSPERO, numéro CRD42018107083.

To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury. We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay. Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups. Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation. Systematic reviews and meta-analyses, Level II.

Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf). Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major, deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.

Background: Substantial health inequities exist for Indigenous Peoples in Canada. The remote and distributed population of Canada presents unique challenges for access to and use of surgery. To date, the surgical outcome data for Indigenous Peoples in Canada have not been synthesized. Methods: We searched 4 databases to identify studies comparing surgical outcomes and utilization rates of adults of First Nations, Inuit or Metis identity with non-Indigenous people in Canada. Independent reviewers completed all stages in duplicate. Our primary outcome was mortality; secondary outcomes included utilization rates of surgical procedures, complications and hospital length of stay. We performed meta-analysis of the primary outcome using random effects models. We assessed risk of bias using the ROBINS-I tool. Results: Twenty-eight studies were reviewed involving 1 976 258 participants (10.2% Indigenous). No studies specifically addressed Inuit or Metis populations. Four studies, including 7 cohorts, contributed adjusted mortality data for 7135 participants (5.2% Indigenous); Indigenous Peoples had a 30% higher rate of death after surgery than non-Indigenous patients (pooled hazard ratio 1.30, 95% CI 1.09–1.54; I2 = 81%). Complications were also higher for Indigenous Peoples, including infectious complications (adjusted OR 1.63, 95% CI 1.13–2.34) and pneumonia (OR 2.24, 95% CI 1.58–3.19). Rates of various surgical procedures were lower, including rates of renal transplant, joint replacement, cardiac surgery and cesarean delivery. Interpretation: The currently available data on postoperative outcomes and surgery utilization rates for Indigenous Peoples in Canada are limited and of poor quality. Available data suggest that Indigenous Peoples have higher rates of death and adverse events after surgery, while also encountering barriers accessing surgical procedures. These findings suggest a need for substantial re-evaluation of surgical care for Indigenous Peoples in Canada to ensure equitable access and to improve outcomes. Protocol registration: PROSPERO-CRD42018098757

The goal of this study was to examine the medication wasting and disposal practices of oral and maxillofacial surgeons (OMSs) who deliver outpatient anesthesia using controlled substances, and to determine what factors, if any, influence those practices.The investigators composed an anonymous online survey that was emailed to OMSs currently practicing in the United States. Participants were questioned about their length of practice experience, drug disposal training, specific methods employed for medication disposal, and the use of a witness during the disposal process. Descriptive and bivariate statistics were computed. The P value was set at 0.05.A total of 5,551 surveys were sent, yielding 719 responses (13%) and 656 completed surveys. The most common disposal methods reported were pouring the unused medications into an absorbent (n = 207, 32.4%), pouring into the sink (n = 196, 30.7%), placing into the sharps container (n = 141, 22.1%), and pouring into the trash (n = 32, 5%). Most respondents (n = 543, 84.7%) utilize a witness during the drug inactivation process. There was a statistically significant negative relationship between years of practice experience and receiving formal training in guidelines for the disposal of controlled substances during residency (P .001). Those OMSs who received formal training regarding drug inactivation were more likely to standardize medication disposal methods (P .001) and to utilize witnesses during the process (P = .013). OMSs who employed a standard method for drug disposal were more likely to involve witness confirmation during the process (P .001).Medication disposal practices vary widely among OMSs who deliver outpatient anesthesia using controlled substances. Formal training in this area is associated with a greater likelihood of maintaining a standardized disposal method that utilizes a witness during drug disposal but is not associated with rendering the medications nonretrievable during the process. Further educational opportunities among OMSs and residents may help to improve compliance with drug disposal regulations.

BACKGROUND Screening provides earlier colorectal cancer (CRC) detection and improves outcomes. It remains poorly understood if these benefits are realized with screening guidelines in remote northern populations of Canada where CRC rates are nearly twice the national average and access to colonoscopy is limited. AIM To evaluate the participation and impact of CRC screening guidelines in a remote northern population. METHODS This retrospective cohort study included residents of the Northwest Territories, a northern region of Canada, age 50-74 who underwent CRC screening by a fecal immunohistochemical test (FIT) between January 1, 2014 to March 30, 2019. To assess impact, individuals with a screen-detected CRC were compared to clinically-detected CRC cases for stage and location of CRC between 2014-2016. To assess participation, we conducted subgroup analyses of FIT positive individuals exploring the relationships between signs and symptoms of CRC at the time of screening, wait-times for colonoscopy, and screening outcomes. Two sample Welch t-test was used for normally distributed continuous variables, Mann-Whitney-Wilcoxon Tests for data without normal distribution, and Chi-square goodness of fit test for categorical variables. A P value of < 0.05 was considered to be statistically significant. RESULTS 6817 fecal tests were completed, meaning an annual average screening rate of 25.04%, 843 (12.37%) were positive, 629 individuals underwent a follow-up colonoscopy, of which, 24.48% had advanced neoplasia (AN), 5.41% had CRC. There were no significant differences in stage, pathology, or location between screen-detected cancers and clinically-detected cancers. In assessing participation and screening outcomes, we observed 49.51% of individuals referred for colonoscopy after FIT were ineligible for CRC screening, most often due to signs and symptoms of CRC. Individuals were more likely to have AN if they had signs and symptoms of cancer at the time of screening, waited over 180 d for colonoscopy, or were indigenous [respectively, estimated RR 1.18 95%CI of RR (0.89-1.59)]; RR 1.523 (CI: 1.035, 2.240); RR 1.722 (CI: 1.165, 2.547)]. CONCLUSION Screening did not facilitate early cancer detection but facilitated higher than anticipated AN detection. Signs and symptoms of CRC at screening, and long colonoscopy wait-times appear contributory.

A 44-year-old woman presented with 2 painful and self-limited episodes of binocular horizontal diplopia within 1 year that at the beginning were thought to be secondary to microvascular insult. Her medical history was significant for Cushing syndrome status post transsphenoidal resection with bilateral adrenalectomy 4 years prior, hypertension, and diabetes mellitus. Neuro-ophthalmic evaluation was significant for left abduction deficit and incomitant esotropia consistent with left abducens nerve palsy. Of note, the patient had experienced a similar episode but on the contralateral side a few months prior. Although initially MRI of the brain demonstrated stable residual postoperative finding in the sella, upon review, an heterogenous T-1 hypointense marrow in the clivus was noted. Hypermetabolism of the clivus was also noted on computed tomography positron emission tomography of the skull base. A clival biopsy demonstrated a corticotroph adenoma with elevated proliferation index and scattered mitoses. A corticotroph pituitary adenoma after adrenalectomy, also known as Nelson syndrome, was diagnosed. Radiation therapy was offered to the patient, and resolution of symptoms was gradually observed.

Purpose Online adaptive radiotherapy would greatly benefit from the development of reliable auto-segmentation algorithms for organs-at-risk and radiation targets. Current practice of manual segmentation is subjective and time-consuming. While deep learning-based algorithms offer ample opportunities to solve this problem, they typically require large datasets. However, medical imaging data is generally sparse, in particular annotated MR images for radiotherapy. In this study, we developed a method to exploit the wealth of publicly available, annotated CT images to generate synthetic MR images, which could then be used to train a convolutional neural network (CNN) to segment the parotid glands on MR images of head and neck cancer patients. Methods Imaging data comprised 202 annotated CT and 27 annotated MR images. The unpaired CT and MR images were fed into a 2D CycleGAN network to generate synthetic MR images from the CT images. Annotations of axial slices of the synthetic images were generated by propagating the CT contours. These were then used to train a 2D CNN. We assessed the segmentation accuracy using the real MR images as test dataset. The accuracy was quantified with the 3D Dice similarity coefficient (DSC), Hausdorff distance (HD) and mean surface distance (MSD) between manual and auto-generated contours. We benchmarked the approach by a comparison to the inter-observer variation determined for the real MR images, as well as to the accuracy when training the 2D CNN to segment the CT images. Results The determined accuracy (DSC: 0.77±0.07, HD: 18.04±12.59 mm, MSD: 2.51 ± 1.47mm) was close to the inter-observer variation (DSC: 0.84±0.06, HD: 10.85±5.74 mm, MSD: 1.50±0.77 mm), as well as to the accuracy when training the 2D CNN to segment the CT images (DSC: 0.81±0.07, HD: 13.00±7.61 mm, MSD: 1.87±0.84 mm). Conclusion The introduced cross-modality learning technique can be of great value for segmentation problems with sparse training data. We anticipate using this method with any non-annotated MRI dataset to generate annotated synthetic MR images of the same type via image style transfer from annotated CT images. Furthermore, as this technique allows for fast adaptation of annotated datasets from one imaging modality to another, it could prove useful for translating between large varieties of MRI contrasts due to differences in imaging protocols within and between institutions.

Recent stroke studies have shown that the ipsi-lesional thalamus longitudinally and significantly decreases after stroke in the acute and subacute stages. However, additional considerations in the chronic stages of stroke require exploration including time since stroke, gender, intracortical volume, aging, and lesion volume to better characterize thalamic differences after cortical infarct. This cross-sectional retrospective study quantified the ipsilesional and contralesional thalamus volume from 69 chronic stroke subjects’ anatomical MRI data (age 35–92) and related the thalamus volume to time since stroke, gender, intracortical volume, age, and lesion volume. The ipsi-lesional thalamus volume was significantly smaller than the contra-lesional thalamus volume (t(68) = 13.89, p

BackgroundPeriodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.MethodsWe included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.ResultsThere were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to −9.08 (95% CI −13.29 to −4.87) and −9.60 (95% CI −15.77 to −3.43) percentage point reductions in mortality and complications, respectively.ConclusionAccreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

To determine FDG-PET biomarkers associated with long-term benefit (LTB) and survival in advanced non-small cell lung cancer (NSCLC) patients receiving first-line immunotherapy. In this multicenter study, we retrospectively analyzed advanced NSCLC patients with a PD-L1 tumor proportion score (TPS) ≥ 50%, who underwent FDG-PET/CT before first-line pembrolizumab, received from August 2017 to September 2019. Parameters extracted were SUVmax, SUVmean, TMTV (total metabolic tumor volume) and TLG (total lesion glycolysis). LTB was defined as objective (complete or partial) response or stable disease as best overall response, maintained for ≥ 12 months. A multivariate prediction model was developed using logistic regression for LTB and Cox models for progression-free survival (PFS) and overall survival (OS). On the 63 eligible patients, with a median follow-up of 13.4 (range, 1.5–29.1) months, 17 (27%) had LTB. Median PFS and OS were 7.7 months (95%CI 5.0–10.5) and 12.1 months (95%CI 8.6–15.6). In multivariate analyses, high TMTV (> 84cm3) and high tumor SUVmean (> 10.1) remained independent factors for predicting LTB (OR 0.2; p = 0.03 and OR 3.7; p = 0.04) and PFS (HR 2.2; p = 0.02 and HR 0.5; p = 0.045). High TMTV was significantly associated with poor OS (HR 3.1; p = 0.03). No association was observed between tumor SUVmax or TLG and clinical outcomes. In patients with advanced NSCLC and PD-L1 TPS ≥ 50%, baseline low TMTV and high tumor SUVmean correlate with survival and LTB from upfront pembrolizumab. Beyond the initial staging, FDG-PET/CT scan could provide relevant biomarkers associated with clinical outcomes that should be taken into account when considering first-line treatment options.

BACKGROUND: Approximately 60% of the more than 3.8 million breast cancer survivors (BCS) living in the United States are 60+ years old. BCS experience many symptoms including cognitive dysfunction; however, little is known regarding how age affects these symptoms. OBJECTIVE: This integrative review was conducted to synthesize the literature on cognitive dysfunction in older BCS. The purpose was to: (1) describe the prevalence of objective and subjective cognitive dysfunction and (2) examine factors associated with cognitive dysfunction in older BCS. METHODS: Whittemore and Knafl’s integrative review methodology was used to examine cognitive dysfunction in BCS 60+ years old. RESULTS: Twelve quantitative studies were included. Up to 41% of older BCS experienced cognitive dysfunction on neuropsychological exam and up to 64% reported cognitive dysfunction on subjective measures pre-treatment. Approximately half of older BCS experienced cognitive decline from pre-to post-treatment regardless of cognitive measure. The domains most impacted were memory, executive functioning, and processing speed. Objective and subjective cognitive dysfunction was associated with age, comorbidities, chemotherapy receipt, sleep, neuropsychological symptom cluster, frailty, and quality of life. CONCLUSIONS: Cognitive dysfunction among older BCS was common both prior to and following treatment. Cognitive dysfunction was associated with multiple factors that are compounded in the aging population and could be detrimental to quality of life and independent living. IMPLICATIONS TO PRACTICE: Early assessment and intervention by healthcare providers, including nurses, for cognitive dysfunction in older BCS is essential. Future research should focus on evidence-based interventions for cognitive dysfunction incorporating the unique needs of older BCS.

HPV vaccination prevents most HPV-related cancers yet vaccination rates remain low. In this cross-sectional study, we examined the association between maternal HPV experiences and HPV vaccination uptake among children and whether this association may be explained by perceived benefits of vaccination. We used logistic regression models to estimate the effect of (1) maternal history of abnormal Pap smear, (2), family/friend history of cervical cancer, and (3) maternal history of cervical cancer on HPV vaccination uptake among children. Separate mediation analyses were conducted to determine if perceived benefits mediated the relationship between each maternal HPV experience and HPV vaccination uptake. History of abnormal Pap smear (OR = 1.50, 95% CI = 1.15, 1.97), family history of cervical cancer (OR = 1.72, CI = 1.26, 2.35), and personal history of cervical cancer (OR = 3.00, CI = 1.82, 4.95) predicted HPV vaccination of children. Perceived benefits mediated the relationship between history of abnormal Pap smear (indirect effect =.146, SE =.069, 95% CI =.014, .289), family history of cervical cancer (indirect effect =.228, SE =.079, CI =.080, .387), and personal history of cervical cancer (indirect effect =.298, SE =.116, CI =.082, .533) on HPV vaccination. Our results suggest that personal experiences with HPV-related disease may influence maternal HPV vaccine decision-making.

Purpose: The purposes of this study were to determine whether the presence of upper extremity chemotherapy-induced peripheral neuropathy (CIPN) symptoms (burning, pins/needles, numbness, pain, and skin crawls) among breast cancer survivors (BCS) varied according to age (≤45 years or 55–70 years) and to examine age group differences in upper extremity CIPN symptom distress. Methods: The study was a secondary analysis of younger (n = 505) and older (n = 622) BCS. Inclusion criteria were age of ≤45 years or 55–70 years; patient at 3–8 years postdiagnosis; patient received the chemotherapy regimen of paclitaxel, doxorubicin, and cyclophosphamide; and patient did not have recurrence. The Symptom Survivor Checklist was used to assess presence and distress of upper extremity CIPN symptoms. Analyses explored whether age group predicted CIPN symptom presence and distress while controlling for sociodemographic and medical variables. Results: Older BCS reported fewer pins/needles, numbness, and pain symptoms (odds ratios: 0.623–0.751). Heart disease (odds ratios: 1.59–1.70) and progesterone-negative breast cancer (odds ratio: 0.663) were significantly associated with one or more CIPN symptoms. Symptom distress ratings did not differ by age groups; both age groups indicated distress from CIPN symptoms, with 25% or more reporting distress as “moderately” or “quite a bit.” Conclusions: Younger BCS reported more upper extremity CIPN symptoms. BCS in both groups continued to report bothersome CIPN symptoms years after treatment. Study findings will assist clinicians in identifying BCS at higher risk for upper extremity CIPN as well as inform development of appropriate tailored interventions to mitigate these symptoms and facilitate restoration to age-related baseline function, thereby improving quality of life for BCS.

Otitis media is very common in Aboriginal children in Western Australia and chronic ear disease causes major problems in speech and language development and education. Up until recently, most progr...