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Insufficient physical activity (IPA) caused approximately 5% of mortalities in 2017 in Iran, almost double its global average. Despite the relatively considerable burden, a knowledge gap exists regarding the trend of IPA in recent years. We described the trend of IPA prevalence utilizing the data from six rounds of STEPwise approach to risk factor Surveillance (STEPS) in Iran. We estimated the physical activity status of Iranian adults from 2006 to 2016 after adjusting for years of schooling, urbanization percentage, and wealth index. We used the spatiotemporal model to interpolate and extrapolate the IPA prevalence for the years in-between the series and from 2001 to 2006, respectively. We used the data of 177,910 participants from six STEPS surveys and found that the national prevalence of IPA had steadily increased over the course of 16 years and had almost doubled in this time period (23.1% in 2001 to 55.4% in 2016). The increase was persistent across all age and gender strata and in every province. Moreover, IPA was more prevalent among women than their male peers regardless of their age category or province of residence. The prevalence of IPA in Khuzestan (highest prevalence) was almost double compared to that in Lorestan (lowest prevalence) in 2016. The IPA prevalence increased considerably and almost doubled in 16 years among Iranian adults, particularly women. Policies need to target IPA as a high priority contributing to the burden of Non-communicable diseases.

Objectives. To examine trends in opioid overdose deaths by race/ethnicity from 2018 to 2019 across 67 HEALing Communities Study (HCS) communities in Kentucky, New York, Massachusetts, and Ohio. Methods. We used state death certificate records to calculate opioid overdose death rates per 100 000 adult residents of the 67 HCS communities for 2018 and 2019. We used Poisson regression to calculate the ratio of 2019 to 2018 rates. We compared changes by race/ethnicity by calculating a ratio of rate ratios (RRR) for each racial/ethnic group compared with non-Hispanic White individuals. Results. Opioid overdose death rates were 38.3 and 39.5 per 100 000 for 2018 and 2019, respectively, without a significant change from 2018 to 2019 (rate ratio = 1.03; 95% confidence interval [CI] = 0.98, 1.08). We estimated a 40% increase in opioid overdose death rate for non-Hispanic Black individuals (RRR = 1.40; 95% CI = 1.22, 1.62) relative to non-Hispanic White individuals but no change among other race/ethnicities. Conclusions. Overall opioid overdose death rates have leveled off but have increased among non-Hispanic Black individuals. Public Health Implications. An antiracist public health approach is needed to address the crisis of opioid-related harms. (Am J Public Health. 2021;111(10):1851–1854. https://doi.org/10.2105/AJPH.2021.306431 )

Lower limb disability is common in chronic stroke patients, and aquatic therapy is one of the modalities used for the rehabilitation of these patients.To summarize the evidence of the effects of aquatic therapy on lower limb disability compared to land-based exercises in post-stroke patients.MEDLINE, PsycInfo, CENTRAL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to January 2019. The search included only randomized clinical trials. Two reviewers independently examined the full text and conducted study selection, data extraction, and quality assessment. Data synthesis was applied to summarize information from the included studies. The quantitative analysis incorporated fixed-effect models.Of the 150 studies identified in the initial search, 17 trials (629 participants) satisfied the eligibility criteria. Aquatic therapy improved balance based on the Berg Balance Scale (BBS) (standardized mean difference [SMD], 0.72; 95% confidence interval [CI], 0.50-0.94; IAquatic therapy had a more positive effect on walking speed, balance, and mobility than land-based exercises. Further research is needed to confirm the clinical utility of aquatic therapy for patients following stroke in the long term.

Objective: To investigate the effect of the Feldenkrais method versus core stability exercises on pain, disability, quality of life and interoceptive awareness in patients with chronic non-specific low back pain. Design: A single-blinded, randomised, controlled trial. Setting: Outpatient, sports medicine clinic of Mazandaran medical university. Participants: Sixty patients with chronic non-specific low back pain randomised equally into the Feldenkrais method versus core stability exercises groups. Intervention: Intervention group received Feldenkrais method consisting of training theoretical content and supervised exercise therapy two sessions per week for five weeks. Control group received educational programme and home-based core stability exercises for five weeks. Outcome measures: All patients were examined by World Health Organization’s Quality of life Questionnaire, McGill Pain Questionnaire, Oswestry Disability Questionnaire and Multidimensional Assessment of Interoceptive Awareness Questionnaire. All outcomes were measured at baseline and the end of the intervention Results: There were statistically significant differences between groups for quality of life ( P = 0.006, from 45.51 to 60.49), interoceptive awareness ( P > 0.001, from 2.74 to 4.06) and disability ( P = 0.021, from 27.17 to 14.5) in favour of the Feldenkrais method. McGill pain score significantly decreased in both the Feldenkrais (from 15.33 to 3.63) and control groups (from 13.17 to 4.17), but there were no between-groups differences ( P = 0.16). Conclusion: Feldenkrais method intervention gave increased benefits in improving quality of life, improving interoceptive awareness and reducing disability index.

OBJECTIVE The aim of the study was to determine outcome measures that women with vulvar lichen sclerosus (LS) rate as important in assessing disease severity with the ultimate goal of including these items in a disease severity rating tool. METHODS An online survey of women older than 18 years with a diagnosis of vulvar LS was performed. The survey was posted in Facebook LS support groups. Participants rated items on a scale from 1 to 5 (not important to include to essential to include) in a disease severity scale. Participants also rated how often they were affected by various symptoms on a scale from 1 to 5 (never to daily). Mean rating of importance and mean rating of frequency for each sign and symptom were calculated. T tests were used to compare patients with biopsy-proven disease with those with a clinical diagnosis of LS. RESULTS Nine hundred fifty-eight participants completed the survey (86% completion rate). Patients felt that the most important items to assess disease severity were irritation (4.39), fusion of the labia (4.38), soreness (4.37), itch (4.34), change in vulvar skin (4.34), and decrease in quality of life (4.33). The most frequently experienced items by those with LS were irritation (3.92), changes in appearance of vulvar skin (3.92), and discomfort (3.89). There were no differences between patients with biopsy-proven LS versus those diagnosed on clinical examination. CONCLUSIONS Future LS severity assessment tools will need to include a combination of patient-rated symptoms, clinical rated signs and anatomical changes, and quality of life measures.

Study objective: To determine the pre-operative evaluation, surgical management and referral practices in patients with advanced stage endometriosis by Canadian gynaecologists. Design: A survey of obstetricians and gynaecologists. Setting: The survey was initiated and piloted at an academic centre by general gynaecologists and endometriosis specialists. Intervention: Electronically distributed to 733 individuals by the Society of Obstetricians and Gynaecologists of Canada. This included all members, irrespective of subspecialty and practice patterns. Measurement: Responses were collected using a web-based survey tool and analysed using Excel. Results: The response rate was 15.7% (115 respondents). Pre-operatively, 62.2% of respondents perform a transvaginal ultrasound on all of their patients, while magnetic resonance imaging is reserved for patients with physical exam findings suspicious for advanced endometriosis (26.7%) or in whom the surgeons suspect deep infiltrating endometriosis, bowel, bladder or uterosacral disease (54.4%). Most surgeons (81.4%) report encountering advanced disease that they did not suspect pre-operatively Conclusion: Our study identified significant variability in the management of advanced endometriosis in Canada. Understanding these patterns will help us formulate a more universal investigation and management plan, which may improve the identification of patients pre-operatively with advanced stage endometriosis that could benefit from treatment by an endometriosis specialist.

Introduction. The objective of the present study was to investigate whether certain intrinsic factors (foot hyperpronation, generalized joint laxity) and clinical tests (anterior drawer and talar tilt tests, single-leg balance test and star excursion balance test, ankle and first metatarsophalangeal range of motion) could predict the incidence of lateral ankle sprains among elite football and basketball players during a full year. Method. In a prospective cohort study, 106 elite basketball and football players were recruited. During the preseason period, players underwent baseline measurements. Team physicians in following year reported occurrence of new ankle sprains. Results. Ankle sprain was more frequent among basketball players ( P = .01). The history of recurrent ( P = .001) and acute ankle sprain ( P = .01) and each 5-year increase in age ( P = .039) were predictive factors for ankle sprain. No evidence for relationship between other risk factors and occurrence of ankle sprain were achieved. Conclusion. In our study, the history of recurrent and acute ankle sprain was the strongest predictor for ankle injuries. Considering the limitations of this study, it seems mandatory to conduct more prospective studies with a larger sample size and longer follow-up period. Levels of Evidence: Level II: Prognostic

Background Nowadays, breast cancer is the second cause of death after cardiovascular diseases. In general, about one out of eight women (about 12%) suffer from this disease during their life in the USA and European countries. If breast cancer is detected at an early stage, its survival rate will be very high. Several methods have been introduced to diagnose breast cancer with their clinical advantages and disadvantages. Main text In this review, various methods of breast imaging have been introduced. Furthermore, the sensitivity and specificity of each of these methods have been investigated. For each of the imaging methods, articles that were relevant to the past 10 years were selected through electronic search engines, and then the most relevant papers were selected. Finally, about 40 articles were studied and their results were categorized and presented in the form of a report as follows. Various breast cancer imaging techniques were extracted as follows: mammography, contrast-enhanced mammography, digital tomosynthesis, sonography, sonoelastography, magnetic resonance imaging, magnetic elastography, diffusion-weighted imaging, magnetic spectroscopy, nuclear medicine, optical imaging, and microwave imaging. Conclusion The choice of these methods depends on the patient’s state and stage, the age of the individual and the density of the breast tissue. Hybrid imaging techniques appear to be an acceptable way to improve detection of breast cancer. This review article can be useful in choosing the right method for imaging in people suspected of breast cancer.

Background: Due to widespread abuse of anabolic-androgenic steroids among professional athletes and amateur sportsmen and their health-related problems, determining the prevalence and the pattern of anabolicandrogenic steroid misuse at the national level seems to be vital for designing efficient preventive and educational measures. Methods: This systematic review and meta-analysis was conducted via comprehensive searches of the electronic databases including PubMed, MedLine, Scopus, Google Scholar and National Persian Databases including SID, Magiran, IranDoc (between 1980 and Dec 2019 in English and Persian languages) and also from citations in the selected papers. Overall, 39 articles met the criteria and were included in qualitative and quantitative synthesis. Results: The overall prevalence rate of anabolic-androgenic steroid misuse in the Iranian athletic population was 36.2% (95% confidence interval (CI), 29-43) with significant heterogeneity between studies (I2=99.0%, P

Purpose: Coronavirus disease 2019 (Covid-19), first reported in December 2019 in Wuhan, China, has become a pandemic. Chest imaging is used for the diagnosis of Covid-19 patients and can address problems concerning Reverse Transcription-Polymerase Chain Reaction (RT-PCR) shortcomings. Chest X-ray images can act as an appropriate alternative to Computed Tomography (CT) for diagnosing Covid-19. The purpose of this study is to use a Deep Learning method for diagnosing Covid-19 cases using chest X-ray images. Thus, we propose Covidense based on the pre-trained Densenet-201 model and is trained on a dataset comprising chest X-ray images of Covid-19, normal, bacterial pneumonia, and viral pneumonia cases. Materials and Methods: In this study, a total number of 1280 chest X-ray images of Covid-19, normal, bacterial and viral pneumonia cases were collected from open access repositories. Covidense, a convolutional neural network model, is based on the pre-trained DenseNet-201 architecture, and after pre-processing the images, it has been trained and tested on the images using the 5-fold cross-validation method. Results: The accuracy of different classifications including classification of two classes (Covid-19, normal), three classes 1 (Covid-19, normal and bacterial pneumonia), three classes 2 (Covid-19, normal and viral pneumonia), and four classes (Covid-19, normal, bacterial pneumonia and viral pneumonia) are 99.46%, 92.86%, 93.91 %, and 91.01% respectively. Conclusion: This model can differentiate pneumonia caused by Covid-19 from other types of pneumonia, including bacterial and viral. The proposed model offers high accuracy and can be of great help for effective screening. Thus, reducing the rate of infection spread. Also, it can act as a complementary tool for the detection and diagnosis of Covid-19. Copyright © 2021 Tehran University of Medical Sciences.

Introduction: Safety and efficacy of prophylactic HPV vaccines against HPV infection and associated cervical cancers and precursors is well documented in the literature; however, their efficacy against vulval and vaginal endpoints has not been previously assessed.Areas covered: Published results of trials involving licensed HPV vaccines were included. Main efficacy outcomes were histologically confirmed high-grade vulval and vaginal precancer distinguishing those associated with vaccine HPV types and any vulval and vaginal precancerous lesions. Exposure groups included women aged 15-26 or 24-45 years being initially negative for high-risk HPV (hrHPV), negative for the HPV vaccine types, and women unselected by HPV status.Expert opinion: Our results show that the HPV vaccines are equally highly efficacious against vulval/vaginal disease as previously noted for cervical disease. The vaccines demonstrated excellent protection against high-grade vulval and vaginal lesions caused by vaccine-related HPV types among young women who were not initially infected with hrHPV types or types included in the vaccines (vaccine efficacies more than 90%). No protection against high-grade vulval and vaginal lesions associated with HPV16/18 was observed for mid-adult women. Trials were not powered to address protection against invasive cancers.

Genital ulcer disease can be caused by a wide variety of sources. Most commonly, genital ulcer disease is grouped into infectious and noninfectious causes. HSV, syphilis, lymphogranuloma venereum, and chancroid represent some common infectious ulcers. Noninfectious causes on the other hand can be inflammatory, noninflammatory, or malignant (eg, squamous cell carcinoma). Depending on the etiology, genital ulcers may present with unique features that can help clinicians identify the etiology and start treatment in a timely manner. The clinical presentation and management of infectious and noninfectious genital ulcers will be discussed in this review.

Background Severe hypertriglyceridemia (sHTG) is a rare condition, complicated by episodes of acute pancreatitis (AP), which can cause pain and/or life-threatening multi-organ dysfunction. Currently, there are no disease-specific patient-reported outcome (PRO) measures evaluating symptoms or dietary impact for this condition. Objective The objective of this study was to explore patient-reported symptoms and impacts of sHTG and AP and develop new measures to capture the symptoms and dietary impacts of this condition using patient language. Methods In-depth, semi-structured concept elicitation interviews were conducted with 12 US-based participants to explore their experience and identify key symptoms and impact on dietary behavior, both during and between episodes of AP. Participants had a range of AP severity with a previous triglyceride reading > 1000 mg/dL, and at least one attack of AP within the last 12 months. Transcripts were coded using thematic analysis. Results Qualitative data analysis revealed the substantial burden of AP associated with sHTG. Participants reported experiencing symptoms, especially abdominal pain, both during and between attacks of AP, and discussed considerable diet changes to prevent or minimize future attacks. A conceptual model was refined, based on patient input, and reviewed by clinical experts to determine key concepts for inclusion within two PRO measures, one evaluating symptoms and another evaluating impact on dietary behavior. Items were drafted using patient-derived language. A 19-item symptoms measure [Hypertriglyceridemia and Acute Pancreatitis Symptom Scale (HAP-SS)] and a 6-item dietary impact measure (Hypertriglyceridemia and Acute Pancreatitis Dietary Behavior (HAP-DB) measure) were developed, both with a 24-h recall period. Conclusions The qualitative analysis confirmed the substantial burden of AP associated with sHTG. This research resulted in development of two disease-specific PRO measures for use during and between attacks of AP. These measures are being utilized in a clinical trial, which will confirm content, structure, and psychometric properties. Electronic supplementary material The online version of this article (10.1007/s41669-019-0155-y) contains supplementary material, which is available to authorized users.

Background One of the leading causes of disability in the world with enormous economic burden is stroke. Objective To quantify the effectiveness of different protocols of cycling with/without functional electrical stimulation on functional mobility after stroke. Methods Multiple databases were searched till 2018. Data extraction was performed using a pre-determined data collection form. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation. Results A total of 14 trials satisfied eligibility criteria and were included. Cycling had a positive effect on the 6-meter walking test performance (SMD, 0.41; 95% CI, 0.11 -0.71; I2 = 0% ) compared with no or placebo intervention (control). Compared with control, cycling had a positive effect on 10-meter walking speed (SMD, 0.30; 95% CI, 0.05 -0.55; I2 = 0% ), and on balance based on the Berg score (SMD, 0.32; 95% CI, 0.06 -0.57; I2 = 49% ). Cycling with functional electrical stimulation had a positive effect on balance (SMD, 1.48; 95% CI, 0.99 -1.97; I2 = 91% ) compared with cycling alone. Conclusions It appears that cycling has a positive effect on walking speed, walking ability and balance. Functional electrical stimulation combined with cycling has positive effects on balance beyond cycling alone.

Stroke is one of the leading causes of disability in western countries. A variety of rehabilitation programs for the treatment of patients after stroke have been proposed. We describe the outcomes of a 49-year-old female patient with a 5-year history of right upper extremity hemiparesis after stroke. Physical examination revealed a right wrist extensor strength grade of 1 according to the Medical Research Council Manual Muscle Testing scale, Stage 4 according to the Brunnstrom hand functional recovery, and Grade 1 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. Magnetic resonance imaging taken immediately after the stroke was indicative of an abnormal signal in the left paraventricular and lentiform nucleus. After receiving a single session of dry needling and electrical stimulation, the patient had significant improvement including a strength grade of 3 for the right wrist extensor muscles, Stage 6 according to the Brunnstrom hand functional recovery, and Grade 0 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. This case report found that dry needling combined with electrical stimulation may be effective in hand function recovery, wrist extensor muscles strength, and decreased wrist and finger spasticity. Keywords: Dry needling, Electrical stimulation, Rehabilitation, Stroke

Introduction The infant mortality rate (IMR) in the United States remains higher than most developed countries. To understand this public health issue and support state public health departments in displaying and analyzing data in ways that support learning, states participating in the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN) created statistical process control (SPC) charts for rare events. Methods State vital records data on live births and infant deaths was used to create U, T and G charts for Kansas and Alaska, two states participating in the IM CoIIN who sought methods to more effectively analyze IMR for subsets of their populations with infrequent number of deaths. The IMR and the number of days and number of births between infant deaths was charted for Kansas Non-Hispanic black population and six Alaska regions for the time periods 2013-2016 and 2011-2016, respectively. Established empirical patterns indicated points of special cause variation. Results The T and G charts for Kansas and G charts for Alaska depict points outside the upper control limit. These points indicate special cause variation and an increased number of days and/or births between deaths at these time periods. Discussion T and G charts offer value in examining rare events, and indicate special causes not detectable by U charts or other more traditional analytic methods. When small numbers make traditional analysis challenging, SPC has potential in the MCH field to better understand potential drivers of improvements in rare outcomes, inform decision making and take interventions to scale.

ΔΕΝ ΔΙΑΤΙΘΕΤΑΙ ΠΕΡΙΛΗΨΗ, Cardiac side effect of 5-hydroxytryptamine-3 receptor antagonists has been a concern for clinicians. There is a substantial need for greater clarity about the safety of granisetron hydrochloride, an antiemetic agent of this class used in oncological and parvoviral gastroenteritis with acute vomiting in dogs. This study aimed to assess the electrocardiographic effects of a single dose of intravenous granisetron. We randomly assigned 16 adult crossbreed female healthy dogs into two groups of intervention and control and injected them intravenously with granisetron and normal saline, respectively, at a dose of 0.5 ml/kg over one minute. Standard electrocardiography (ECG) was recorded at the baseline, as well as 5, 15, 30, 60, 120, 360, and 720 minutes after the intervention. Heart rate and ECG parameters (PR intervals, QRS duration, ST-segment, T-wave amplitudes, QT, JT, QTc and JTc intervals) were evaluated in lead II.No significant difference was observed between the intervention and the control groups in any of the measured variables at any of the time-points. Mean values of measured parameters showed no significant difference compared with baseline values in the control group, while the granisetron group saw statistically significant but clinically asymptomatic changes in heart rate, PR, QRS, QT, JT, and QTc at different time-points, compared to the baseline values (P

Context.— The Surveillance, Epidemiology, and End Results (SEER) cancer registry program is currently evaluating the use of archival, diagnostic, formalin-fixed, paraffin-embedded (FFPE) tissue obtained through SEER cancer registries, functioning as honest brokers for deidentified tissue and associated data. To determine the feasibility of this potential program, laboratory policies for sharing tissue for research needed to be assessed. Objective.— To understand the willingness of pathology laboratories to share archival diagnostic tissue for cancer research and related policies. Design.— Seven SEER registries administered a 27-item questionnaire to pathology laboratories within their respective registry catchment areas. Only laboratories that processed diagnostic FFPE specimens and completed the questionnaire were included in the analysis. Results.— Of the 153 responding laboratories, 127 (83%) responded that they process FFPE specimens. Most (n = 88; 69%) were willing to share tissue specimens for research, which was not associated with the number of blocks processed per year by the laboratories. Most laboratories retained the specimens for at least 10 years. Institutional regulatory policies on sharing deidentified tissue varied considerably, ranging from requiring a full Institutional Review Board review to considering such use exempt from Institutional Review Board review, and 43% (55 of 127) of the laboratories did not know their terms for sharing tissue for research. Conclusions.— This project indicated a general willingness of pathology laboratories to participate in research by sharing FFPE tissue. Given the variability of research policies across laboratories, it is critical for each SEER registry to work with laboratories in their catchment area to understand such policies and state legislation regulating tissue retention and guardianship.

Nowadays, as technology grows, human life formation changes every second. These changes sometimes create harmful habits and affect our lifestyle, which unfortunately bring various diseases and disorders. ADHD (Attention Deficit Hyperactivity Disorder) & SPD (Sensory Processing Disorder) are common disorders in children. By giving children the right treatment at the younger ages, we can help them overcome their disabilities and not face any symptoms in their adulthood. The multi-sensory balance board is designed and developed to help medics diagnose the disorders in patients at early stages and monitor the treatment progress. The balance board uses multiple sensors to detect common human senses, visual, auditory, balance, and tactile sensing. Due to the safety issues for children during the COVID-19 pandemic, the balance board has been clinically tested for adults with stroke disorder. The research has concluded that it provides a fast low-cost with reliable results to diagnose the disorders in patients.

Objective The aim of the study was to investigate the knowledge of vulvar anatomy and vulvar self-examination (VSE) in a sample of Italian women attending a gynecology clinic. Methods For this original research from May to July 2019, 512 women attending the Lower Genital Tract Clinic at the Department of Surgical Sciences of the University of Torino were invited to participate in a 29-question survey about vulvar anatomy, VSE, and sociodemographic details. Data were analyzed using descriptive statistics. Results Of 512 patients, 500 completed the questionnaire (98% response rate). The mean age of respondents was 41 years (range = 17-77 years). Education level was evenly distributed between elementary, high school, and university graduates. Only 15% of interviewed women were able correctly sketching vulvar anatomy. Seventy-six percent of the women had not heard about VSE, and 61% of the women approach their genitalia with feelings of shame and embarrassment. Only 23% of the women would seek medical advice after identification of possible abnormalities during VSE. A majority (69%) of the women would like to have more information about VSE and vulvar health through educational videos and social media. Conclusions Education about VSE may lead to earlier diagnosis of vulvar cancers and other pathologies. Further efforts are needed to disperse information about normal external female genital anatomy and VSE to achieve self-confidence among women.

Background: Considering the well-established benefits of physical activity in the health domain, the economy, and environment, physical activity programs should be considered as an important agenda in public health policymaking. Objectives: The objective of this qualitative study was to identify “Why the prevalence of physical inactivity has increased during the past decade in Iran, despite having various national physical activity documents? "using a Delphi technique. Methods: The “Delphi technique” process in this study consisted of literature review, selecting the research question, selection and recruitment of panel members, pilot study and conduction of round one (using an open question), round 2 (using a 5-point Likert scale), and round three (final ranking). Results: Statements with the highest scores in round three were recognized as the most important causes of the decreased level of physical activity based on the experts’ responses in Iran. Conclusions: The absence of executive support, coordination mechanisms, and appropriate infrastructure for conducting physical activity were the top challenges in improving the physical activity level in Iran.

ObjectivesCoordinated measurement strategies are needed to inform collaborative approaches to improve access to and quality of care for persons with sickle cell disease (SCD). The objective of our study was to develop a multilevel measurement strategy to assess improvements in access to and quality of care for persons with SCD in 4 US regions.MethodsFrom 2014 through 2017, regional grantees in the Sickle Cell Disease Treatment Demonstration Program collected administrative and patient-level electronic health record (EHR) data to assess quality improvement initiatives. Four grantees—covering 29 US states and territories and an SCD population of 56 720—used a collective impact model to organize their work. The grantees collected administrative data from state Medicaid and Medicaid managed care organizations (MCOs) at multiple points during 2014-2017 to assess improvements at the population level, and local patient-level data were abstracted from site-level EHRs at regular intervals to track improvements over time.ResultsAdministrative data were an important source of understanding population-level improvements but were delayed, whereas patient-level data were more sensitive to small-scale quality improvements.ConclusionsWe established a shared measurement approach in partnership with Medicaid and Medicaid MCO stakeholders that can be leveraged to effectively support quality improvement initiatives for persons with SCD in the United States.

Introduction: Ovarian sex cord-stromal tumors are a rare type of ovarian tumor which can be benign or malignant. Steroid cell tumors are a subtype of these tumors, representing Case Report: A 58 year old post-menopausal white female presented with deepening of voice, male pattern hair loss, increased muscle mass, weight gain, clitoromegaly, acne, increased axillary & facial hair growth. This had occurred over a period of 1.5 years. Initial investigatory labs revealed markedly elevated testosterone level of 630 ng/dL (n 2-45ng/dL). Normal FSH/LH, morning ACTH and cortisol, DHEAS, 17 OHP, androstenedione, prolactin and IGF1. Exogenous intake of testosterone was excluded. A transvaginal ultrasound showed thickened and cystic endometrial lining but no cysts or masses in the ovaries. An endometrial biopsy was normal. In the absence of a definitive source of elevated androgens, CT abdomen pelvis was done & showed remarkable for bilateral adrenal adenomas. Serum metanephrines were normal. An overnight dexamethasone suppression test was abnormal; morning cortisol level 3.1 (n 4.0-22.0). With a normal DHEAS these adenomas were considered to be the less likely etiology of her virilization. Given concern for an ovarian malignancy, a hysterectomy was recommended. Her total testosterone level right before surgery was 954 ng/dL. Post-operatively, not only did the total testosterone levels drastically fall to 18 ng/dL merely on POD 4, but the patient reported new scalp hair growth, decreased abdominal girth & skin smoothing. Her surgical pathology was with that of a steroid tumor of the ovary. Conclusion Steroid cell tumors of the ovary can be benign or malignant. A prompt diagnosis is critical. In the presence of elevated testosterone levels or virilizing symptoms, an ovarian etiology must be suspected. Given the malignant potential of these tumors, if there is clinical suspicion, an expedited total hysterectomy and bilateral salpingo-oophorectomy is recommended. The objective of surgical treatment is to relieve symptoms and for staging in the case of malignancy. Timely management of the tumor can reduce metastasis and significantly improve quality of life, as seen in our case. References 1.Kurman, R. J., Ellenson, L. H., & Ronnett, B. M. (2011). Blaustein’s pathology of the female genital tract (6th ed.). New York; London: Springer.

Objective: Attitudes and barriers towards HPV vaccination were explored in a population of male surgeons in Gynecology and Otolaryngology in Ontario, Canada. Materials/methods: An internet-based survey was distributed to male residents and physicians affiliated with the departments of Obstetrics and Gynecology, and Otolaryngology at six Ontario universities. The survey consisted of 16 questions (3 demographic, 3 workplace exposure, 6 regarding personal vaccination, and 3 regarding patient vaccination). Subgroup analyses examined differences between residents versus staff physicians and gynecologists versus otolaryngologists. Results: Most respondents (51/63, 81.0%) had not been vaccinated against HPV, yet would consider vaccination in the future (41/51, 80.4%). Significantly more residents would consider vaccination compared to staff physicians (p = .03). Personal protection from benign HPV disease was the most common motivating factor (25/59, 42.4%) among participants. A notable barrier to vaccination was “age over recommendations” (9/44, 20.4%). Most participants would recommend the HPV vaccine to both male patients (49/62, 79.0%) and male partners of female patients (47/62, 75.8%). Conclusions: This study demonstrates male gynecologists and otolaryngologists had largely favorable attitudes towards HPV vaccination though few had received vaccination. These findings may be used to increase HPV vaccine uptake among male health care professionals and their patients. Keywords: Human papillomavirus (HPV), Vaccination, Males, Physicians, Attitudes, Barriers

Objectives The present study was undertaken to determine the possible effects of the placement two different types of eyelid speculum on intraocular pressure (IOP) measurement in clinically normal cats. Methods Thirty healthy cats were divided randomly into two groups of 15, group B (Barraquer wire speculum) and group W (Williams eye speculum). All cats were sedated with intramuscular medetomidine (Dorbene vet; 100 μg/kg) then placed in right lateral recumbency, and IOP was recorded in the left eye using a Tono-Pen Vet tonometer without and with an eyelid speculum in place in both groups. Results The without-speculum IOPs for cats in group B and group W were 13.8 ± 3.0 mmHg and 13.2 ± 3.6 mmHg, respectively, and did not differ significantly. A significant increase in IOP (19.8 ± 3.7 mmHg) was observed in group W in with-speculum measurements in comparison to the without-speculum values ( P Conclusions and relevance The Barraquer wire speculum has no effect on IOP compared with the Williams eye speculum in normal cats, and may be an appropriate choice in cats for intraocular surgeries that cannot tolerate acute increases in IOP.

Rectal squamous cell carcinoma (SCC) is a rare tumor with unresolved etiology. Human immunodeficiency virus-infected individuals and solid organ transplant recipients experience >30-fold and approximately 3-fold elevated rates of rectal SCC, respectively, suggesting immunosuppression plays a role.1 Human immunodeficiency virus-infected homosexual men have >60-fold higher rates of rectal SCC, similar to anal SCC. These patterns, which differ from the more common rectal adenocarcinoma (AdCA), raise the possibility of shared etiology between rectal and anal SCC, with human papillomavirus type 16 (HPV16) being a likely candidate.2.

Introduction Physical activity-enhancing websites have created a new accessible and cost-effective method to increase the level of physical activity. The purpose of this study was to assess the impact of an individualized internet-based physical activity program on improving physical activity level. Methods This study conducted May-Dec 2018 was a single blind parallel group randomized controlled trial. Participants were recruited by distributing advertisements on popular Persian websites. Participants meeting eligibility criteria were randomly assigned to individualized (N=91) or non-individualized internet-based physical activity (N=93) intervention groups. The designed website for the study included an interactive computer-tailored exercise program that generated progressing physical activity recommendations for individualized intervention group based on the progression process for 10 weeks and a fixed exercise program for non-individualized group. Results Drop outs in the individualized group were 15 and in the non-individualized group were 14. Following the ten-week exercise program, the individualized group's physical activity level according to GPAQ questionnaire assessments was significantly improved in the travel section (p-value Conclusions Based on the current study, an individualized internet-based physical activity intervention might be effective in improving the level of physical activity. Conducting future studies during the COVID-19 pandemic is mandated to assess the impact.

This study's objective was to assess the knowledge of prenatal screening for Trisomy 21 in pregnant women in one institution in Canada. A cross-sectional survey measuring demographics, knowledge of screening, and health literacy, was administered to pregnant women. Of the 135 women who completed the survey, 74% had adequate knowledge of Trisomy 21 and associated screening procedures. Twenty-eight point one percent of women did not receive any counseling. Overall, 29.5% of women did not know that the screening test was optional and 10.2% of women underwent screening prior to having been counseled. Multigravidity (p < 0.05) and prior counseling (p < 0.001) were positively correlated with knowledge while first language other than English (p < 0.001) was negatively correlated with knowledge. Given these findings, an effort needs to be made on the part of health care providers to increase counseling rates to 100%, stressing the optional nature of the test to attain true informed consent.

Human–robot interaction is an important issue in robotic researches which is the key in many rehabilitation and robot-assisted therapy applications. Impedance control can properly handle soft interaction of robots with the environment. Optimal target impedance selection can increase the performance of the overall system and guarantee the stability. The target impedance cannot be selected without proper knowledge about the stiffness and inertia parameters of the human. In this paper, a systematic analysis is done to introduce a method to estimate the human stiffness and consequently adjust the robot target stiffness. Then, particle swarm optimization is used to find the damping and inertia parameters of the robot to minimize the peak of the interaction force. Also, no assumption is made for the passivity of the human dynamic. The passivity analysis of the human–robot system is investigated. The novelty of this paper is in introducing a practical approach to select the robot target impedance. Finall...

Introduction Despite strong evidence supporting the benefit of 17-alpha hydroxyprogesterone caproate (17P) in preventing recurrent preterm birth, this treatment still does not reach most eligible patients. This study sought to identify approaches to measuring the appropriate use of 17P, with the goal of helping health systems better monitor and improve the implementation of this intervention. Methods Semi-structured telephone interviews were used to gather data on measures for 17P use being developed and implemented by state team members participating in the Infant Mortality Collaborative Improvement and Innovation Network (IM CoIIN)-a national quality improvement initiative. Strengths and limitations of these measurement approaches were described. Results Six approaches to measuring 17P use to prevent preterm birth were identified: practice-level data, population-based surveys, three measures employing insurance claims with or without linked birth certificate data, and revised birth certificates. Each measure had particular strengths and limitations. Practice-level measures were useful in rapid-cycle improvement, but were not generalizable across sites. In contrast, population-based measures (i.e., surveys, claims) were useful for broad comparisons, but were limited in their timeliness, and in how accurately they identified candidates who were truly eligible for 17P. Additionally, such measures required complex data linkage and analytic capabilities. Discussion A variety of imperfect measures for the appropriate use of 17P are available. No "best" measure was identified-the optimal measurement option must fit the specific needs of a health agency. Better data infrastructure and harnessing information from integrated electronic health records could improve the quality of 17P use measurement for improvement efforts.

Introduction Vulvodynia is a chronic pain disorder that negatively impacts the quality of life of affected women. Aim The goal of this study was to identify unmet needs among localized provoked vulvodynia patients. Methods A qualitative needs assessment was performed in a subspecialized vulvar clinic in a single academic institution in Canada. Semistructured interviews were conducted, recorded, and analyzed using the constant comparative method of grounded theory to identify common themes. Main Outcome Measures Interviews were conducted until theme saturation was achieved. Results A diverse sample of 8 patients completed all components of the study. The most prominent unmet needs raised by patients in their interviews were categorized into 3 main themes: (1) challenges related to obtaining a diagnosis of vulvodynia and finding practitioners who are knowledgeable about vulvodynia; (2) challenges related to the current impact of the disease physically, emotionally, and in social relationships with patients' intimate partners; and (3) barriers to adherence with recommended therapy. Solutions recommended by patients include better education of physicians regarding vulvodynia and the development of multidisciplinary programs that provide access to physiotherapy, sex therapy, mindfulness and psychology services on-site, information classes for new patients, and the creation of peer support networks for patients and their partners. Conclusion A patient-focused needs assessment suggests optimal vulvodynia care requires better education of physicians and a multimodal approach to therapy, ideally with multiple services offered in 1 location.

Objective To reduce opioids consumed after discharge from hospital after elective cesarean delivery by 50%. Methods This was a 2-week parallel group non-blinded randomized controlled trial at Mount Sinai Hospital. Eligible women undergoing elective cesarean delivery were assigned by random number generation to receive the hospital's standard post-cesarean opioid prescription of 20 1-mg hydromorphone tablets or a prescription for 10 1-mg hydromorphone tablets if opioids were required in hospital or no hydromorphone if no opioids were required in hospital. Patients completed a study questionnaire at 2 weeks postpartum detailing outcome measures. The primary outcome was the amount of opioid consumed after discharge. Results A total of 40 women were randomly assigned to a study group and 37 were included in the data analysis; 17 patients were in the control group and 20 in the experimental group. The median number of tablets consumed did not differ between groups (P = 0.407). The median number of excess tablets prescribed was 20 (range 2–18) in the control group and 0 (range 0–10) in the experimental group (P Conclusions The current standard discharge practice of giving 20 1-mg hydromorphone tablets to all patients post-discharge after cesarean delivery contributes to a substantial excess of opioids in the community. These opioids can be diverted for unintended or accidental usage, and exacerbate larger societal issues of opioid misuse and addiction. Decreasing the number of opioids prescribed with tailored discharge prescriptions based on in-hospital opioid use provides nearly all patients with adequate pain control.

Introduction: Thyroglobulin (Tg) is used as a surveillance marker in those with a history of differentiated thyroid cancer. Thyroglobulin antibodies (TgAb) interfere with Tg measurement. Here we present a case with transiently elevated TgAb and Tg levels in a patient receiving intravenous immunoglobulin (IVIG). Case: A 36-year-old female with a history of SLE transitioned her medical care to our facility. She had previously undergone total thyroidectomy following discovery and fine needle aspiration of a 1.7 cm thyroid nodule. Pathology at that time demonstrated a follicular adenoma and micro papillary thyroid carcinoma for which she underwent radioactive thyroid ablation according to practice prior to the 2015 American Thyroid Association guidelines. She remained in remission for 7 years. During this time, surveillance Tg and TgAb were negative using an immunometric (IMA) assay. Her exam during the visit revealed a palpable left cervical lymph node. Tg and TgAb were drawn and returned detectable via radioimmunoassay (RIA). Repeat levels were similar. Although unlikely, this raised concern for cancer recurrence. Neck ultrasound obtained showed a benign-appearing lymph node and no suspicious lesion in the surgical bed. Detailed history revealed that the patient had recently begun monthly IVIG infusions for her SLE. The most recent infusion being 4 days prior to TgAb and Tg levels. Given the reassuring neck ultrasound and the fact that patient’s TgAb and Tg had been undetectable previously, the elevated Tg was thought to be secondary to transmission of TgAb via IVIG. The patient was subsequently followed clinically with serial TgAb and Tg. IVIG therapy was discontinued, repeat Tg levels were undetectable and remained so 4 months later confirming the diagnosis (Table 1). Table 1:Tg=ng/ml TgAb=IU/ml08/10/18 Tg=

Introduction: Thyroid storm is a rare, life threatening condition with a reported mortality rate of up to 30 percent. Immediate treatment is critical and should begin with a beta-blocker, iodine, thionamides, and glucocorticoids. Thionamides are avoided in hepatic dysfunction. We report a case of treatment of thyrotoxicosis using methimazole in a patient with ischemic hepatitis. Clinical case: A 54 year old woman with history of untreated Graves’ disease was admitted to the ICU in atrial fibrillation with rapid ventricular response and multi-organ failure. Just prior to admission, she had undergone CT imaging with IV contrast. Laboratory testing revealed an undetectable TSH (0.3-4 uIU/mL), free T4 4.0 ng/dL (0.8-1.4 ng/dL) with a TSI level of 514 (

A urethral caruncle is a benign lesion of the distal urethra. Urethral prolapse occurs when the urethral mucosa is everted circumferentially all the way around the urethral meatus. In contrast, with a urethral caruncle, there is only partial eversion of the distal urethra. Often the terms urethral prolapse and urethral caruncle are incorrectly used interchangeably. Caruncles occur most commonly in low estrogen states and are treated with topical estrogen if they are causing symptoms.

Mammary-like gland adenoma (hidradenoma papilliferum) is a rare benign tumor arising from mammary-like anogenital glands. The etiology is unknown, but these tumors are the most common vulvar adnexal lesion. The lesions are often asymptomatic slow-growing nodules that do not require treatment but should be excised or biopsied if there are concerning features for malignancy.

A total of 10 healthy anesthetized long-eared hedgehogs ( Hemiechinus auritus ) were used to determine normal electrocardiographic reference values for this species. Each animal was anesthetized with intramuscular ketamine and diazepam. Standard 6-lead electrocardiography (leads I, II, III, aVR, aVL, and aVF) were obtained in hedgehogs positioned in right lateral recumbency. All recorded rhythms were regular sinus rhythm and the mean heart rate was 264 ± 53 beats per minute. Mean electrical axis was between −19° and +6° in the entire study population (mean ± standard deviation; −6 ± 10°). The P wave was always positive on lead I, II, and aVF. There was no correlation between electrocardiographic values, sex, and weight of the animals. Mean heart rate in this species was slightly higher than in African hedgehogs ( Atelerix albiventris ) and less than in the Amur hedgehogs ( Erinaceus amurensis ). QT interval was slightly higher than in both the Amur and African hedgehogs. Mean electrical axis in long-eared hedgehogs showed a left axis shift compared with the African hedgehogs.

Childhood maltreatment has been linked to preterm birth (37 weeks gestation) in some studies, but these findings have been inconsistent, and it remains unclear whether type, timing or severity of maltreatment are associated with risk of preterm birth. The aim of this observational study was to explore type of maltreatment (child and adolescent physical and sexual abuse and harsh parenting) as risk factors for preterm birth.We examined these associations in a cross-sectional analysis of the Nurses' Health Study II cohort of female nurses. Women completed a questionnaire about experiences of sexual abuse, physical abuse or harsh parenting, along with pregnancy outcomes. Logistic regression models adjusted for relevant covariates including age, race, alcohol and cigarette use during pregnancy, age at menarche, marital status, adult income, body mass index (kg/m(2)) at age 18, physical abuse in pregnancy, and childhood socioeconomic position.Among 51 434 first births, 4110 were preterm (8% of births). Forced sexual activity in childhood or adolescence was associated with a 22% increased odds of preterm birth (OR=1.22, 95% CI 1.10 to 1.35). Maltreatment involving sexual touch, physical abuse or harsh parenting was not associated with preterm birth in this sample.Women who experience forced sexual activity in childhood or adolescence may have an increased likelihood of delivering preterm in adulthood.

The dynamic behavior of nonuniform-thickness laminated composite beams, such as helicopter blades, wind turbine blades, and robot arms, is of high importance in the design and fabrication of such elements. Changing the thickness of laminated structures is a significant challenge during fabrication because different tapering configurations may significantly alter the stiffness of the structures and thus the dynamic response of the structures. In this study, the effect of adding nanoparticles to resin on the stiffness and dynamic behavior of nonuniform-thickness laminated composite beam elements was investigated. A set of experiments were conducted to examine the natural frequencies and damping coefficients of nonuniform-thickness laminated composite beams with different tapering configurations. Adding nanoparticles up to 3% increased the natural frequencies for all tapering configurations. Beyond 3% and up to 7% of nanoparticles, the natural frequency of the beam decreased. The addition of 10% of nanoparticles to resin sharply reduced the natural frequency of the beam but significantly improved the damping coefficient for all the investigated taper models.

This study was conducted to determine the effects of intravenous detomidine on schirmer tear test (STT) results in clinically normal horses . Eighteen adult horses were randomly divided into two groups of nine horses each. The treatment group was sedated with intravenous detomidine alone (20 μg/kg) and the control group received only intravenous saline (0.2 ml/100 kg). STT was performed just before intravenous administration of detomidine or saline in treatment and control groups respectively. STTs were repeated 5, 20, 60 and 120 mins later. Horses enrolled in this study consisted of nine males and nine females. Breeds were Arabian and Hanoverian, ranging from 3 to 6 years in age. In the treatment group, the pretreatment and subsequent post-treatment mean ± SD values were 17.0 ± 6.9 (0 min), 11.8 ± 2.9 (5 min), 12.1 ± 2.0 (20 min), 12.1 ± 3.1 (60 min), and 15.0 ± 2.8 (120 min) mm wetting/minute. In this group of horses, a significant reduction was observed in STT values at 5, 20 and 60 min after treatment with detomidine hydrochloride in comparison to the pretreatment values (ANOVA with post hoc testing; P 5 =0.004, P 20 =0.007, P 60 = 0.006). There was no significant difference between baseline values and post-treatment values in the control saline group (P ≥ 0.08). We conclude that intravenous detomidine causes a significant reduction in STT values in clinically normal horses. In horses, practitioners should measure STT values prior to intravenous administration of detomidine in order to accurately assess the results.

Background The Schirmer tear test (STT) is widely used in both human and veterinary ophthalmology. Two types of STTs have been developed: STT I and SST II. The STT I measures the basal and reflex tear production and is the most widely used STT. However, several factors influence the STT results such as the person performing the test and the location of the strip placement within the conjunctival sac. The aim of this study was to measure the basal and reflex tear production (STT I) in clinically normal horses with open versus closed eyes. Results Forty clinically healthy horses without any ocular diseases were included. On day 1, the STT I was first performed on all the horses with the eyes open followed by an STT I with closed eyes performed 30 min later. On day 2, all horses had their eyes closed during the first STT and the eyes open during the second test performed 30 min later. The mean value of the STTs performed on open eye was significantly less than the STT performed on closed eye on both days of examination. Conclusion This study showed a small but statistically significant difference between STT values obtained with open versus closed eyes in clinically normal horses.

Key Points Question Do differences by maternal race and ethnicity exist in the use of methadone or buprenorphine medications for the treatment of opioid use disorder during pregnancy? Findings In this cohort study of 5247 women with opioid use disorder who delivered a live infant, black non-Hispanic and Hispanic women with opioid use disorder were significantly less likely to use any medication for treatment and were less likely to consistently use medication for treatment during pregnancy compared with white non-Hispanic women with opioid use disorder. Meaning This study found racial and ethnic disparities in the use of medications for the treatment of opioid use disorder during pregnancy among a large population-level sample of women with opioid use disorder in Massachusetts; further investigation is warranted to explore the factors associated with inequitable access to and receipt of medication., Importance Racial and ethnic disparities persist across key health and substance use treatment outcomes for mothers and infants. The use of medications, such as methadone or buprenorphine, for the treatment of opioid use disorder (OUD) has been associated with improvements in the outcomes of mothers and infants; however, only half of all pregnant women with OUD receive these medications. The extent to which maternal race or ethnicity is associated with the use of medication to treat OUD, the duration of the use of medication to treat OUD, and the type of medication used to treat OUD during pregnancy are unknown. Objective To examine the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of OUD in the year before delivery among pregnant women with OUD. Design, Setting, and Participants This retrospective cohort study used a linked population-level statewide data set of pregnant women with OUD who delivered a live infant in Massachusetts between October 1, 2011, and December 31, 2015. Of 274 234 total deliveries identified, 5247 deliveries among women with indicators of having OUD were included in the analysis. Maternal race and ethnicity were defined as white non-Hispanic, black non-Hispanic, or Hispanic based on self-reported data on birth certificates. Main Outcomes and Measures Main outcomes were the receipt of any medication for OUD, the consistency of the use of medication (at least 6 continuous months of use before delivery, inconsistent use, or no use) for the treatment of OUD, and the type of medication (methadone or buprenorphine) used to treat OUD. Multivariable models were adjusted for maternal sociodemographic characteristics, comorbidities, and any significant interactions between the covariates and race and ethnicity. Results The sample included 5247 pregnant women with OUD who delivered a live infant in Massachusetts during the study period. The mean (SD) maternal age at delivery was 28.7 (5.0) years; 4551 women (86.7%) were white non-Hispanic, 462 women (8.8%) were Hispanic, and 234 women (4.5%) were black non-Hispanic. A total of 3181 white non-Hispanic women (69.9%) received any type of medication for the treatment of OUD in the year before delivery compared with 228 Hispanic women (49.4%) and 108 black non-Hispanic women (46.2%). Compared with white non-Hispanic women, black non-Hispanic and Hispanic women had a substantially lower likelihood (adjusted odds ratio [aOR], 0.37; 95% CI, 0.28-0.49 and aOR, 0.42; 95% CI, 0.35-0.52, respectively) of receiving any medication for the treatment of OUD. Stratification by maternal age identified greater disparities among younger women. Black non-Hispanic and Hispanic women also had a lower likelihood (aOR, 0.24; 95% CI, 0.17-0.35 and aOR, 0.34; 95% CI, 0.27-0.44, respectively) of consistent use of medication for the treatment of OUD compared with white non-Hispanic women. With respect to the type of medication used to treat OUD, black non-Hispanic and Hispanic women had a lower likelihood (aOR, 0.60; 95% CI, 0.40-0.90 and aOR, 0.77; 95% CI, 0.58-1.01, respectively) than white non-Hispanic women of receiving buprenorphine treatment compared with methadone treatment. Conclusions and Relevance This study found racial and ethnic disparities in the use of medications to treat OUD during pregnancy, with black non-Hispanic and Hispanic women significantly less likely to use medications consistently or at all compared with white non-Hispanic women. Further investigation of patient, clinician, treatment program, and system-level factors associated with these findings is warranted., This cohort study assesses the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of opioid use disorder in the year before delivery among pregnant women with opioid use disorder in Massachusetts.