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Conspiracy beliefs have spread during the Covid-19 pandemic. It is important to understand them because of their potential to undermine trust in societal institutions and willingness to get vaccined. In the present research (N = 538), we assessed the links between conspiracy beliefs, trust in institutions (e.g., government, WHO), and attitudes towards the Covid-19 vaccination across the USA, Brazil and the UK. A moderated mediation analysis revealed the crucial role of political leaders in linking conspiracy beliefs with vaccination attitudes. Trust in the president was positively associated with conspiracy beliefs in Brazil because of its conspiracist president at the time (Bolsonaro), which in turn was negatively associated with vaccination attitudes. In contrast, trust in political leaders at the time in the UK (Johnson) and the USA (Biden) was negatively associated with conspiracy beliefs. In conclusion, our findings contribute to understanding the underlying mechanisms that link conspiracy beliefs with trust and vaccination attitudes., (© 2024 The Author(s). International Journal of Psychology published by John Wiley & Sons Ltd on behalf of International Union of Psychological Science.)

Introduction: Artificial Intelligence (AI) is revolutionizing medical imaging and radiation therapy. AI-powered applications are being deployed to aid Medical Radiation Technologists (MRTs) in clinical workflows, decision-making, dose optimisation, and a wide range of other tasks. Exploring the levels of AI education provided across the United States is crucial to prepare future graduates to deliver the digital future. This study aims to assess educators' levels of AI knowledge, the current state of AI educational provisions, the perceived challenges around AI education, and important factors for future advancements., Methods: An online survey was electronically administered to all radiologic technologists in the American Society of Radiologic Technologists (ASRT) database who indicated that they had an educator role in the United States. This was distributed through the membership of the ASRT, from February to April 2023. All quantitative data was analysed using frequency and descriptive statistics. The survey's open-ended questions were analysed using a conceptual content analysis approach., Results: Out of 5,066 educators in the ASRT database, 373 valid responses were received, resulting in a response rate of 7.4%. Despite 84.5% of educators expressing the importance of teaching AI, 23.7% currently included AI in academic curricula. Of the 76.3% that did not include AI in their curricula, lack of AI knowledge among educators was the top reason for not integrating AI in education (59.1%). Similarly, AI-enabled tools were utilised by only 11.1% of the programs to assist teaching. The levels of trust in AI varied among educators., Conclusion: The study found that although US educators of MRTs have a good baseline knowledge of general concepts regarding AI, they could improve on the teaching and use of AI in their curricula. AI training and guidance, adequate time to develop educational resources, and funding and support from higher education institutions were key priorities as highlighted by educators., (Copyright © 2024. Published by Elsevier Inc.)

Background: This research explores the capabilities of ChatGPT-4 in passing the American Board of Family Medicine (ABFM) Certification Examination. Addressing a gap in existing literature, where earlier artificial intelligence (AI) models showed limitations in medical board examinations, this study evaluates the enhanced features and potential of ChatGPT-4, especially in document analysis and information synthesis., Objective: The primary goal is to assess whether ChatGPT-4, when provided with extensive preparation resources and when using sophisticated data analysis, can achieve a score equal to or above the passing threshold for the Family Medicine Board Examinations., Methods: In this study, ChatGPT-4 was embedded in a specialized subenvironment, "AI Family Medicine Board Exam Taker," designed to closely mimic the conditions of the ABFM Certification Examination. This subenvironment enabled the AI to access and analyze a range of relevant study materials, including a primary medical textbook and supplementary web-based resources. The AI was presented with a series of ABFM-type examination questions, reflecting the breadth and complexity typical of the examination. Emphasis was placed on assessing the AI's ability to interpret and respond to these questions accurately, leveraging its advanced data processing and analysis capabilities within this controlled subenvironment., Results: In our study, ChatGPT-4's performance was quantitatively assessed on 300 practice ABFM examination questions. The AI achieved a correct response rate of 88.67% (95% CI 85.08%-92.25%) for the Custom Robot version and 87.33% (95% CI 83.57%-91.10%) for the Regular version. Statistical analysis, including the McNemar test (P=.45), indicated no significant difference in accuracy between the 2 versions. In addition, the chi-square test for error-type distribution (P=.32) revealed no significant variation in the pattern of errors across versions. These results highlight ChatGPT-4's capacity for high-level performance and consistency in responding to complex medical examination questions under controlled conditions., Conclusions: The study demonstrates that ChatGPT-4, particularly when equipped with specialized preparation and when operating in a tailored subenvironment, shows promising potential in handling the intricacies of medical board examinations. While its performance is comparable with the expected standards for passing the ABFM Certification Examination, further enhancements in AI technology and tailored training methods could push these capabilities to new heights. This exploration opens avenues for integrating AI tools such as ChatGPT-4 in medical education and assessment, emphasizing the importance of continuous advancement and specialized training in medical applications of AI., (© Anthony James Goodings, Sten Kajitani, Allison Chhor, Ahmad Albakri, Mila Pastrak, Megha Kodancha, Rowan Ives, Yoo Bin Lee, Kari Kajitani. Originally published in JMIR Medical Education (https://mededu.jmir.org).)

Artificial intelligence (AI) carries the potential for unprecedented disruption in radiology, with possible positive and negative consequences. The integration of AI in radiology holds the potential to revolutionize healthcare practices by advancing diagnosis, quantification, and management of multiple medical conditions. Nevertheless, the ever-growing availability of AI tools in radiology highlights an increasing need to critically evaluate claims for its utility and to differentiate safe product offerings from potentially harmful, or fundamentally unhelpful ones. This multi-society paper, presenting the views of Radiology Societies in the USA, Canada, Europe, Australia, and New Zealand, defines the potential practical problems and ethical issues surrounding the incorporation of AI into radiological practice. In addition to delineating the main points of concern that developers, regulators, and purchasers of AI tools should consider prior to their introduction into clinical practice, this statement also suggests methods to monitor their stability and safety in clinical use, and their suitability for possible autonomous function. This statement is intended to serve as a useful summary of the practical issues which should be considered by all parties involved in the development of radiology AI resources, and their implementation as clinical tools. KEY POINTS., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Artificial Intelligence (AI) carries the potential for unprecedented disruption in radiology, with possible positive and negative consequences. The integration of AI in radiology holds the potential to revolutionize healthcare practices by advancing diagnosis, quantification, and management of multiple medical conditions. Nevertheless, the ever‑growing availability of AI tools in radiology highlights an increasing need to critically evaluate claims for its utility and to differentiate safe product offerings from potentially harmful, or fundamentally unhelpful ones. This multi‑society paper, presenting the views of Radiology Societies in the USA, Canada, Europe, Australia, and New Zealand, defines the potential practical problems and ethical issues surrounding the incorporation of AI into radiological practice. In addition to delineating the main points of concern that developers, regulators, and purchasers of AI tools should consider prior to their introduction into clinical practice, this statement also suggests methods to monitor their stability and safety in clinical use, and their suitability for possible autonomous function. This statement is intended to serve as a useful summary of the practical issues which should be considered by all parties involved in the development of radiology AI resources, and their implementation as clinical tools., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: APB: member of the Insights into Imaging Scientific Editorial Board. He has not taken part in the review or selection process of this article. BA: No competing interests. JC: No competing interests. EK: Shareholder Gleamer, Paris and Contextflow, Vienna. NK: Consultant for ES3 (aerospace company), consultant for Synapsica Healthcare, partner (equity owner) at Radiology Partners (RP), sole or partial owner of several radiology practices managed by RP. RP has a minority interest in AIDOC. RP has an indirect minority interest in Rad AI. Associate Fellow Stanford AIMI Center. Hold several volunteer positions at RSNA, ACR, SIIM and RADequal. JM: Consultant, Microsoft (Nuance), Research funding, royalties, GE, Research funding, Siemens, Spouse employment, shareholder Annexon Biosciences, Spouse employment Bristol Meyers Squibb. LOR: No competing interests. DPDS: member of the Insights into Imaging Scientific Editorial Board. He has not taken part in the review or selection process of this article. AT: No competing interests. CW: Chair, Commission on Informatics and Member, Board of Chancellors, American College of Radiology. Advisor: Notable Systems, and RadPair. JS: No competing interests.

Aim: To analyze the characteristics and trends in published research on perinatal depression between 1920 and 2020., Methods: A search strategy in Web of Science identified all published literature on perinatal depression between January 1, 1920, and December 31, 2020. Output from Web of Science was used to analyze bibliometric information, and VOSViewer was used to visualize the networks of linkages between identified publications., Results: There were 16,961 publications identified. Among these publications, there were 82,726 unique authors and 140 countries represented. The United States had the highest frequency of publications (44.6%). Most publications (69.8%) occurred between 2011 and 2020, with the first publication identified in 1928. There were 2197 unique journals identified, with over half publishing only one (n = 948, 43.2%) or two relevant publications (n = 314, 14.3%). Authors with the largest number of publications were Wisner (n = 115), Dennis (n = 95), and Murray (n = 92), while authors with the largest number of citations were Cox (n = 7225), Murray (n = 2755), and O'Hara (n = 2069)., Limitations: While the Web of Science is a representative database identifying the greatest number of relevant articles, it may be unrepresentative of all published literature., Conclusion: This is the first study mapping publications on perinatal depression between 1920 and 2020. The rate of publication on perinatal depression has been steadily increasing in recent years with a wide variety of authors, countries, and journals represented. As the field continues to grow, trends may shift as early career researchers emerge and the importance of mental health in low-income countries is prioritized., (© 2023 The Authors. Birth published by Wiley Periodicals LLC.)

The association between hypertension and mild cognitive impairment (MCI) is complex. Both are increasing in prevalence worldwide and will have disproportionate effects on lower income countries across Latin America. Despite this, there is insufficient evidence investigating this relationship in this region or those of Hispanic or Latino ancestry in higher income countries. In this context, the Study of Latinos-Investigation of Neurocognitive Aging represents a unique dataset. Although more research is required, Márquez and colleagues show that hypertension in this population in the United States is associated with decline in cognitive measures and greater odds of MCI over seven years follow-up.

The strength of evidence for specific ambulatory care prescribing cascades, in which a marker drug is used to treat an adverse event caused by an index drug, has not been well characterized. To perform a structured, systematic, and transparent review of the evidence supporting ambulatory care prescribing cascades. Ninety-four potential prescribing cascades identified through a previously published systematic review. Systematic search of the literature to further characterize prescribing cascades. (1) Grading of evidence based on observational studies investigating associations between index and marker drugs, including: Level I-strong evidence [i.e. multiple high-quality studies]; Level II-moderate evidence [i.e. single high-quality study]; Level III-fair evidence [no high-quality studies but one or more moderate-quality studies]; and Level IV-poor evidence [other]. (2) Listing of the adverse event associated with the index drug in the product's United States Food and Drug Administration (FDA) label. (3) Synthesis of the evidence supporting mechanisms linking index drugs and associated adverse events. Of 99 potential cascades, 94 were supported by one or more confirmatory observational studies and were therefore included in this review. The 94 cascades related to 30 types of adverse drug reactions affecting 10 different anatomic/physiologic systems and were investigated by a total of 88 confirmatory studies, including prescription sequential symmetry analysis (n = 51), cohort (n = 30), and case-control (n = 7) studies. Overall, the evidence from observational studies was strong for 18 (19.1%) prescribing cascades, moderate for 61 (64.9%), fair for 13 (13.8%), and poor for 2 (2.1%). Although the evidence supporting mechanisms that link index drugs and associated adverse events was variable, FDA labels included information about the adverse event associated with the index drug for most (n = 86) but not all of the 94 prescribing cascades. Although we identified 18 of 94 prescribing cascades supported by strong clinical evidence and most adverse events associated with index drugs are included in FDA label, the evidentiary basis for prescribing cascades varies, with many requiring further evidence of clinical relevance., (© 2023 The Authors. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.)

Improving diet quality while simultaneously maintaining planetary health is of critical interest globally. Despite the shared motivation, advancement remains slow, and the research community continues to operate in silos, focusing on certain pairings (diet-climate), or with a discipline-specific lens of a sustainable diet, rather than examining their totality. This review aimed to summarize the literature on adherence to a priori defined dietary patterns in consideration of diet quality, metabolic risk factors for noncommunicable diseases (NCDs), environmental impacts, and affordability. A methodology using PRISMA guidelines was followed, and searches were performed in 7 databases as of October 2022. The Appraisal tool for Cross-Sectional Studies (AXIS) and the National Institutes of Health (NIH) quality assessment tool for observational cohort studies were employed for quality appraisal. The evidence was narratively synthesized according to the characteristics of the diet quality metrics. The review includes 24 studies published between 2017-2023. Thirteen distinct diet quality scores were identified, with those measuring adherence to national dietary guidelines the most reported. Thirteen distinct environmental impact indicators were identified, with greenhouse gas emissions (n=23) reported most. All studies reported on body mass index, and 7 studies assessed the cost of adherence. Our results are consistent with previous findings that healthier diets can reduce environmental impacts; however, incongruities between population and planetary health can occur. Hence, the "sustainability" of dietary patterns is dependent on the choice of indicators selected. Further, healthy, lower impact diets can increase financial cost, but may also provide a protective role against the risk of obesity. Given the Global Syndemic, strategies to reduce obesity prevalence should emphasize the win-win opportunities for population and planetary health through dietary change. Research should identify diets that address multiple environmental concerns to curtail burdens potentially transferring, and harmonize this with sociocultural and equity dimensions. This review was registered at PROSPERO as CRD42021238055., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Research on substance use disorder (SUD) among Muslims in the United States (US) is limited. There are several unique factors, including denial and stigma, that make this population at risk of SUD. This study explored the prevalence, treatment utilization, and impact of SUD among Muslims in the US compared with a matched control group from general respondents., Methods: Data from 372 self-identified Muslims were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions III. A matched non-Muslim control group (N = 744) were selected based on demographics and other SUD-related clinical variables. The impact of SUD was assessed using the 12-Item Short Form Health Survey (SF-12)., Results: Among the 372 Muslims, 53 (10.85%) had lifetime alcohol/drug use disorder, while 75 (18.42%) had lifetime tobacco use disorder (TUD). With statistical significance, alcohol use disorder (AUD) was lower while TUD was higher in the Muslim group than in the control group. The rates of all other substances were not statistically different between the Muslim and control groups. The Muslim group have higher help-seeking and a lower mean score on the SF-12 emotional scale than the control group., Conclusion and Scientific Significance: Muslim Americans have higher prevalence of TUD, lower prevalence of AUD, and similar prevalence of other SUD compared to the public. Affected individuals have poor emotional functioning which may be exacerbated by the impact of stigma. This is the first study to estimate prevalence of variety of SUD in American Muslims from a national representative sample., (© 2023 The Authors. The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry (AAAP).)

Background: Internationally, colorectal cancer screening participation remains low despite the availability of home-based testing and numerous interventions to increase uptake. To be effective, interventions should be based on an understanding of what influences individuals' decisions about screening participation. This study investigates the association of defensive information processing (DIP) with fecal immunochemical test (FIT)-based colorectal cancer screening uptake., Methods: Regression modeling of data from a cross-sectional survey within a population-based FIT screening program was conducted. The survey included the seven subdomains of the McQueen DIP measure. The primary outcome variable was the uptake status (screening user or nonuser). Multivariable logistic regression was used to estimate the odds ratio (OR) for screening nonuse by DIP (sub)domain score, with adjustments made for sociodemographic and behavioral factors associated with uptake., Results: Higher scores (equating to greater defensiveness) on all DIP domains were significantly associated with lower uptake in the model adjusted for sociodemographic factors. In the model with additional adjustments for behavioral factors, the suppression subdomains of "deny immediacy to be tested" (OR, 0.53; 95% confidence interval [CI], 0.43-0.65; p < .001) and "self-exemption" (OR, 0.80; 95% CI, 0.68-0.96; p < .001) independently predicted nonuse of FIT-based screening., Conclusions: This is the first study outside the United States that has identified DIP as a barrier to colorectal cancer screening uptake, and it is the first focused specifically on FIT-based screening. The findings suggest that two suppression barriers, namely denying the immediacy to be tested and self-exempting oneself from screening, may be promising targets for future interventions to improve uptake., (© 2023 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Background: The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services., Methods: Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes., Results: The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance., Conclusion: The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture., Competing Interests: PD and LMK are currently employed by the Health Information and Quality Authority, which is the regulatory authority for health and social care in Ireland. However, this does not present any conflict of interest for this review., (Copyright: © 2023 Dunbar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction/aims: There are disparities in the availability of systemic anticancer therapies (SACTs) globally. We set out to investigate the cost and reimbursement of SACTs in the United Kingdom (UK) and the Republic of Ireland (ROI) in conjunction with efficacy and licensing authority decisions in the United States (US) and the European Union (EU)., Methods: We sought data pertaining to licensing in the EU, reimbursement in ROI/UK and cost/efficacy of SACTs licensed by the Food and Drug Administration (FDA) between January 2015 and May 2021. Independent samples t tests, chi-square test and Pearson's correlation were used for statistical analysis., Results: We identified that the majority of FDA-approved regimens are licensed by the European Medicines Agency (EMA) (n = 91, 67.9%). However, only a minority of these are currently reimbursed in the UK (n = 60, 45%) or the ROI (n = 28, 21%) as of the 1 st of May 2021. In addition, only a minority of regimens have demonstrated a statistically significant OS benefit (n = 54, 40%). There was no association between cost of regimens and either the presence (t = 0.846, p = 0.40) or duration of OS benefit (t =  - 0.84, p = 0.64)., Conclusions: Our study highlights that many licensed systemic anticancer treatments are not currently reimbursed in ROI/UK. The high cost of these medicines is independent of the presence of an OS benefit. Collaboration between regulatory agencies, governments and industry partners is needed to ensure health expenditure is directed towards the most effective treatments., (© 2022. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Background: Live dietary microbes have been hypothesized to contribute to human health but direct evidence is lacking., Objectives: This study aimed to determine whether the dietary consumption of live microbes is linked to improved health outcomes., Methods: Data from the NHANES 2001-2018 were used to assess microbial intake and their adjusted associations with selected physiological parameters (e.g., blood pressure, anthropometric measures, and biomarkers) among adults aged 19 y and older. Regression models were constructed to assess the microbial intake with each physiological parameter and adjusted for demographics and other covariates. Microbial intake was assessed as both a continuous variable and a 3-level categorical variable. Fermented foods were assessed in a separate model., Results: In continuous models, an additional 100-g intake of microbe-containing foods was associated with a lower systolic blood pressure (regression coefficient: -0.331; 95% CI: -0.447, -0.215 mm Hg), C-reactive protein (-0.013; 95% CI: -0.019, -0.008 mg/dL), plasma glucose -0.347; 95% CI: -0.570, -0.124 mg/dL), plasma insulin (-0.201; 95% CI: -0.304, -0.099 μU/mL), triglyceride (-1.389; 95% CI: -2.672, -0.106 mg/dL), waist circumference (-0.554; 95% CI: -0.679, -0.428 cm), and BMI -0.217; 95% CI: -0.273, -0.160 kg/m 2 ) levels and a higher level of high density lipoprotein cholesterols (0.432; 95% CI: 0.289, 0.574 mg/dL). Patterns were broadly similar when microbial intake was assessed categorically and when fermented foods were assessed separately., Conclusions: To our knowledge, this study is the first to quantify, in a nationally representative data set of American adults and using stable sets of covariates in the regression models, the adjusted associations of dietary intakes of live microbes with a variety of outcomes, such as anthropometric measures, biomarkers, and blood pressure levels. Our findings suggest that foods with higher microbial concentrations are associated with modest health improvements across a range of outcomes., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Children today are conceived and live in a sea of wireless radiation that did not exist when their parents were born. The launch of the digital age continues to transform the capacity to respond to emergencies and extend global communications. At the same time that this increasingly ubiquitous technology continues to alter the nature of commerce, medicine, transport and modern life overall, its varied and changing forms have not been evaluated for their biological or environmental impacts. Standards for evaluating radiation from numerous wireless devices were first set in 1996 to avoid heating tissue and remain unchanged since then in the U.S. and many other nations. A wide range of evidence indicates that there are numerous non-thermal effects from wireless radiation on reproduction, development, and chronic illness. Many widely used devices such as phones and tablets function as two-way microwave radios, sending and receiving various frequencies of information-carrying microwave radiation on multiple simultaneously operating antennas. Expert groups advising governments on this matter do not agree on the best approaches to be taken. The American Academy of Pediatrics recommends limited screen time for children under the age of two, but more than half of all toddlers regularly have contact with screens, often without parental engagement. Young children of parents who frequently use devices as a form of childcare can experience delays in speech acquisition and bonding, while older children report feelings of disappointment due to 'technoference'-parental distraction due to technology. Children who begin using devices early in life can become socially, psychologically and physically addicted to the technology and experience withdrawal upon cessation. We review relevant experimental, epidemiological and clinical evidence on biological and other impacts of currently used wireless technology, including advice to include key questions at pediatric wellness checkups from infancy to young adulthood. We conclude that consistent with advice in pediatric radiology, an approach that recommends that microwave radiation exposures be As Low As Reasonably Achievable (ALARA) seems sensible and prudent, and that an independently-funded training, research and monitoring program should be carried out on the long term physical and psychological impacts of rapidly changing technological milieu, including ways to mitigate impacts through modifications in hardware and software. Current knowledge of electrohypersensitivity indicates the importance of reducing wireless exposures especially in schools and health care settings., (Copyright © 2023. Published by Elsevier Inc.)

Objectives: To document how many pregnant women with COVID-19 reported in the literature had participated in randomised trials, what treatments they received outside such trials and compare the latter with evidence-based treatment recommendations., Study Design: A systematic review of observational studies., Methods: Two clinical trial registries were searched to identify COVID-19 trials open to pregnant women. Studies were then extracted from a regularly updated list of scientific case reports and case series of confirmed or suspected maternal COVID-19 in pregnancy to identify the number of women enrolled into a trial and the pharmaceutical treatments they received outside such trials., Results: 156 studies (case reports, case series and registries) reporting 43,185 pregnant women with COVID-19, after de-duplication. Of these 2,671 (6.2%) were potentially eligible for a randomised trial but only seven women (0.26%) were reported to have enrolled. For 2,839 women the papers included information on treatment received, 1515/2829 (54%) women had received ≥ 1 treatment and in total a COVID-19 pharmaceutical treatment was administered 1,296 times outside of a trial. In 566 (44%) cases the treatments administered to the pregnant women were not recommended by the National Institutes of Health (NIH) at the time of administration. Of 179 case reports of women with COVID 19 in pregnancy, 109/179 women received ≥ 1 COVID-19 pharmaceutical treatment and in total COVID-19 experimental pharmaceutical treatments were administered 274 times., Conclusion: During the early phase of the COVID-19 pandemic, pregnant women excluded from randomised trials did not avoid unproven or ineffective treatments., (Copyright © 2022. Published by Elsevier B.V.)

Background: Consuming live microbes in foods may benefit human health. Live microbe estimates have not previously been associated with individual foods in dietary databases., Objectives: We aimed to estimate intake of live microbes in US children (aged 2-18 y) and adults (≥19 y) (n = 74,466; 51.2% female)., Methods: Using cross-sectional data from the NHANES (2001-2018), experts assigned foods an estimated level of live microbes per gram [low (Lo), <104 CFU/g; medium (Med), 104-107 CFU/g; or high (Hi), >107 CFU/g]. Probiotic dietary supplements were also assessed. The mean intake of each live microbe category and the percentages of subjects who ate from each live microbe category were determined. Nutrients from foods with live microbes were also determined using the population ratio method. Because the Hi category comprised primarily fermented dairy foods, we also looked at aggregated data for Med or Hi (MedHi), which included an expanded range of live microbe-containing foods, including fruits and vegetables., Results: Our analysis showed that 52%, 20%, and 59% of children/adolescents, and 61%, 26%, and 67% of adults, consumed Med, Hi, or MedHi foods, respectively. Per capita intake of Med, Hi, and MedHi foods was 69, 16, and 85 g/d for children/adolescents, and 106, 21, and 127 g/d for adults, respectively. The proportion of subjects who consumed live microbes and overall per capita intake increased significantly over the 9 cycles/18-y study period (0.9-3.1 g/d per cycle in children across categories and 1.4 g/d per cycle in adults for the Med category)., Conclusions: This study indicated that children, adolescents, and adults in the United States steadily increased their consumption of foods with live microbes between the earliest (2001-2002) and latest (2017-2018) survey cycles. Additional research is needed to determine the relations between exposure to live microbes in foods and specific health outcomes or biomarkers., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

The Enhanced Interrogation programme was a medicalised interrogation programme that was designed by the United States in the wake of 9/11. It is now widely recognized that the Enhanced Interrogation programme engaged in some activities that were, at the least, tantamount to torture. The programme was designed by Psychologists and overseen by other professionals, including medical professionals. This article argues that the Enhanced Interrogation programme displayed many of the features of what Sociologists refer to as Edgework. It demonstrated voluntary risk-taking by health and other professionals; this risk-taking pressed up against catastrophic outcomes across multiple dimensions; risks were taken for the purposes of escaping a death-saturated macrosocial context; and the health professionals in the programme were highly skilled. The article argues that a new form of Edgework can be detected by studying the programme, which the article refers to as 'Institutional Edgework'., (© 2022 Foundation for Sociology of Health & Illness.)

Background: Pregnant women's stress, mental and physical health, and health behaviours can have important implications for maternal and child health outcomes., Aim: To examine pregnant women's levels of stress, mental and physical health, and health behaviours during the COVID-19 pandemic., Methods: A cross-sectional survey was conducted online, with recruitment and data collection occurring between 16/6/20 and 17/7/20. Participants were pregnant women recruited via online pregnancy/parenting communities. Participants self-reported their levels of general stress, pregnancy-specific stress and COVID-19 related stress, mental and physical health, general health behaviours, and COVID-19 related health behaviours., Findings: 573 pregnant women participated in the survey. Participants were most commonly resident in the United States (42.6%, n=243), Ireland (41.2%, n=235) or the United Kingdom (10%, n=57). The majority (80.0%, n=457) were married and educated to degree level or above (79.3, n=453). Pregnant women reported high levels of pregnancy-specific and COVID-19-related stress, and low levels of mental and physical health, during the pandemic. Encouragingly, pregnant women in this study generally reported high levels of adherence to public health advice and pregnancy health behaviours. Stress and general mental health outcomes were best predicted by well-being factors (including stress and social support). Health impairing behaviours (e.g. poor diet) were predicted by both well-being and demographic factors., Discussion: Interventions targeting pregnancy- and pandemic-specific stress at the population level will be essential to support mental health and minimise adverse outcomes for women and children during the pandemic., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Endocrine therapy resistance in advanced breast cancer remains a significant clinical problem that may be overcome with the use of histone deacetylase inhibitors such as entinostat. The ENCORE301 phase II study reported improvement in progression-free survival (PFS) and overall survival (OS) with the addition of entinostat to the steroidal aromatase inhibitor (AI) exemestane in advanced hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer., Patients and Methods: E2112 is a multicenter, randomized, double-blind, placebo-controlled phase III study that enrolled men or women with advanced HR-positive, HER2-negative breast cancer whose disease progressed after nonsteroidal AI. Participants were randomly assigned to exemestane 25 mg by mouth once daily and entinostat (EE) or placebo (EP) 5 mg by mouth once weekly. Primary end points were PFS by central review and OS. Secondary end points included safety, objective response rate, and lysine acetylation change in peripheral blood mononuclear cells between baseline and cycle 1 day 15., Results: Six hundred eight patients were randomly assigned during March 2014-October 2018. Median age was 63 years (range 29-91), 60% had visceral disease, and 84% had progressed after nonsteroidal AI in metastatic setting. Previous treatments included chemotherapy (60%), fulvestrant (30%), and cyclin-dependent kinase inhibitor (35%). Most common grade 3 and 4 adverse events in the EE arm included neutropenia (20%), hypophosphatemia (14%), anemia (8%), leukopenia (6%), fatigue (4%), diarrhea (4%), and thrombocytopenia (3%). Median PFS was 3.3 months (EE) versus 3.1 months (EP; hazard ratio = 0.87; 95% CI, 0.67 to 1.13; P = .30). Median OS was 23.4 months (EE) versus 21.7 months (EP; hazard ratio = 0.99; 95% CI, 0.82 to 1.21; P = .94). Objective response rate was 5.8% (EE) and 5.6% (EP). Pharmacodynamic analysis confirmed target inhibition in entinostat-treated patients., Conclusion: The combination of exemestane and entinostat did not improve survival in AI-resistant advanced HR-positive, HER2-negative breast cancer., Competing Interests: Roisin M. ConnollyOther Relationship: Pfizer Kathy D. MillerConsulting or Advisory Role: Merck, Genentech/Roche, Athenex, AstraZeneca, Bristol Myers Squibb/CelgeneResearch Funding: Taiho Pharmaceutical, Novartis, Seattle Genetics, Pfizer, Astex Pharmaceuticals, British Biotech, CytomX Therapeutics, Alphamab Karen L. SmithStock and Other Ownership Interests: AbbVie, Abbott LaboratoriesHonoraria: ASiM CMEResearch Funding: Pfizer Ursa A. Brown-GlabermanConsulting or Advisory Role: Novartis, Biotheranostics, Eisai, Seattle Genetics, Taiho OncologyResearch Funding: Seattle Genetics Bryan A. FallerConsulting or Advisory Role: L.E.K. ConsultingTravel, Accommodations, Expenses: Genentech, Novartis, EB SQUIBB, Celgene, Boehringer Ingelheim, Eisai, AstraZeneca, Lilly, Amgen, Merck, TakedaOpen Payments Link: https://openpaymentsdata.cms.gov/physician/127090 Adedayo A. OnitiloConsulting or Advisory Role: Kite, a Gilead Company, Envision CommunicationsSpeakers' Bureau: GlaxoSmithKline, Puma Biotechnology, Kite/Gilead, AbbVie Mark E. BurkardConsulting or Advisory Role: Pointcare Genomics, Strata Oncology, NovartisResearch Funding: AbbVie, Strata Oncology, Puma Biotechnology, Loxo, Merck, Arcus, Apollomics, Elevation Oncology, GenentechPatents, Royalties, Other Intellectual Property: I have a patent for implantable or localized drug delivery device that can sample the tumor microenvironment and deliver drug. I have a patent for a method to detect recombination events with CRISPR-mediated editing. I have a patent for conducting expansion microscopy without specialized equipment George T. BuddHonoraria: DecipheraConsulting or Advisory Role: Deciphera, Epic SciencesSpeakers' Bureau: DecipheraResearch Funding: Genentech/Roche, TRACON Pharma, Daiichi Sankyo/Lilly, AmbrxOpen Payments Link: https://openpaymentsdata.cms.gov/physician/774695/summary Ellis G. LevineResearch Funding: Oncolytic BiotechPatents, Royalties, Other Intellectual Property: UpToDate Peter A. KaufmanStock and Other Ownership Interests: AmgenHonoraria: LillyConsulting or Advisory Role: Polyphor, Roche/Genentech, Lilly, Eisai, Macrogenics, Pfizer, Merck, AstraZenecaSpeakers' Bureau: LillyResearch Funding: Eisai, Polyphor, Roche/Genentech, Lilly, Novartis, Macrogenics, Pfizer, SanofiTravel, Accommodations, Expenses: Lilly, Polyphor, Macrogenics Alexandra ThomasStock and Other Ownership Interests: Johnson & Johnson, Gilead Sciences, Bristol Myers Squibb, PfizerConsulting or Advisory Role: BeyondSpring Pharmaceuticals, LillyResearch Funding: SanofiPatents, Royalties, Other Intellectual Property: UpToDate RoyaltiesTravel, Accommodations, Expenses: Genentech Jane B. TrepelResearch Funding: Syndax, EpicentRX, AstraZeneca Antonio C. WolffConsulting or Advisory Role: Ionis PharmaceuticalsPatents, Royalties, Other Intellectual Property: Antonio Wolff has been named as inventor on one or more issued patents or pending patent applications relating to methylation in breast cancer and has assigned his rights to JHU and participates in a royalty-sharing agreement with JHUOpen Payments Link: https://openpaymentsdata.cms.gov/physician/357301/summary Joseph A. SparanoStock and Other Ownership Interests: MetastatConsulting or Advisory Role: Genentech/Roche, Novartis, AstraZeneca, Celgene, Lilly, Celldex, Pfizer, Prescient Therapeutics, Juno Therapeutics, Merrimack, Adgero Biopharmaceuticals, Cardinal Health, GlaxoSmithKline, CStone Pharmaceuticals, Epic Sciences, Daiichi Sankyo, BMSiSpeakers' Bureau: Eisai, CertaraResearch Funding: Prescient Therapeutics, Deciphera, Genentech/Roche, Merck, Novartis, Merrimack, Radius Health, Olema PharmaceuticalsTravel, Accommodations, Expenses: Menarini Silicon Biosystems, Roche/Genentech, Adgero Biopharmaceuticals, Myriad Genetics, Pfizer, AstraZeneca, Rhenium MedicalNo other potential conflicts of interest were reported.

Aims: To investigate self-reported out-of-pocket expenses (OoPE) associated with insulin and diabetes supplies for people living with type 1 diabetes (T1D) worldwide., Methods: A web-based, cross-sectional survey was conducted from August to December 2020. The analysis included comparisons between responses from countries with no, partial, and full healthcare coverage., Results: 1,066 participants from 64 countries took part in the study. ~25% of respondents reported having underused insulin at least once within the last year due to perceived cost. A significant correlation was observed between OoPEs and reported household income for respondents with partial healthcare coverage. 63.2% of participants reported disruption of insulin supplies and 25.3% reported an increase of prices related to the COVID-19 pandemic., Conclusions: This study confirms previous reports of ~25% of people in the United States with T1D using less insulin and/or fewer supplies at least once in the last year due to cost, a trend associated with the extent of healthcare coverage. Similar trends were observed in some middle/low income countries. Moreover, patients reported an increase in insulin prices and disruption of supplies during the COVID-19 pandemic. This study highlights the importance of self-reported OoPEs and its association with underuse/rationing of insulin., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: EP is employed as Executive Director of T1International. KB received funding from the European Commission Horizon 2020 program, the DFG-funded Berlin Institute of Health (BIH) Digital Clinician Scientist program, the BIH Junior Clinician Scientist program, the BIH QUEST center, the German Diabetes Association (DDG) and Wellcome Trust; and fees for medical consulting and public speaking from Roche Diabetes Care, Dexcom, Medtronic Diabetes, Diabeloop, Sanofi Diabetes, BCG Digital Ventures and Novo Nordisk; all outside the submitted work. AT analyzed the data in quality of consultant for T1International. KG received fees for public speaking from Novo Nordisk and is an employee of Diabetes Ireland, an organization cooperating with companies producing insulin and supplies. All other authors declare no conflict of interest., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

For the first time, a simple and robust HPLC method has been developed for dissolution studies for cannabidiol (CBD) in hemp oil products. An isocratic elution of samples performed on SOLAS™ C18 150 mm x 4.6 mm, 5 μm column with a mobile phase consisting of 75:25 acetonitrile-water v/v, delivered at a flow rate 1.5 mL/minutes to variable wavelength detector using 214 nm. An in-house validated assay test was executed for calculating the purity of hemp oil products and also for considering the dissolution medium to be used. For dissolution studies, equivalent of 5 mg and/or 10 mg of the active was introduced into 500 mL of simulated gastric and intestinal fluids separately, and dissolution was performed at 50 rpm using paddles for 180 min. Dissolution profiles for hemp oil products purchased from the United States and Europe were compared. Additionally, dissolution testing was conducted to study the effect of percentage CBD release on increased agitation speed of 75 and 100 rpm and also, on extended dissolution runtime of 240 min., (Copyright © 2021. Published by Elsevier Inc.)

Competing Interests: The authors declare no competing interest.

The development and enhancement of occupational health services (OHS) at the national level is central to ensuring the sustainable health, well-being and work engagement of the working population. However, due to differences in national health, social security and occupational safety and health systems, the content, capacity, coverage and provisions of OHS vary considerably across national contexts. Obtaining a better understanding in terms of such similarities and variations internationally is essential as such comparative information can help inform evidenced-based decision-making on OHS at both policy and practice levels. This paper therefore reviews and analyses the key policies, standards and approaches in OH systems and services, using both academic and grey literature, across 12 industrialised countries (Australia, Canada, Finland, France, Germany, Ireland, Italy, Japan, The Netherlands, Poland, United Kingdom and the United States of America). It provides a detailed overview and categorization of OHS in these selected countries in terms of the legal and policy context, organisation and financing and coverage and staffing while specifically discussing variations aimed at psychosocial risk management and the promotion of mental health and well-being at work. It draws conclusions on key development needs of OHS internationally to ensure psychosocial risk management and mental health promotion are prioritised effectively in a preventive manner.

Down syndrome (DS) is the most common genetic cause of intellectual disability worldwide. The purpose of this analysis was to determine the internal consistency reliability of eight language versions of the Family Management Measure (FaMM) and compare family management of DS across cultures. A total of 2,740 parents of individuals with DS from 11 countries completed the FaMM. The analysis provided evidence of internal consistency reliability exceeding .70 for four of six FaMM scales for the entire sample. Across countries, there was a pattern of positive family management. Cross-cultural comparisons revealed parents from Brazil, Spain, and the United States had the most positive family management and respondents from Ireland, Italy, Japan, and Korea had the least positive. The rankings were mixed for the four remaining countries. These findings provide evidence of overall strong internal consistency reliability of the FaMM. More cross-cultural research is needed to understand how social determinants of health influence family management in families of individuals with DS.

We examine the manner in which the population prevalence of disordered gambling has usually been estimated, on the basis of surveys that suffer from a potential sample selection bias. General population surveys screen respondents using seemingly innocuous "trigger," "gateway" or "diagnostic stem" questions, applied before they ask the actual questions about gambling behavior and attitudes. Modeling the latent sample selection behavior generated by these trigger questions using up-to-date econometrics for sample selection bias correction leads to dramatically different inferences about population prevalence and comorbidities with other psychiatric disorders. The population prevalence of problem or pathological gambling in the United States is inferred to be 7.7%, rather than 1.3% when this behavioral response is ignored. Comorbidities are inferred to be much smaller than the received wisdom, particularly when considering the marginal association with other mental health problems rather than the total association. The issues identified here apply, in principle, to every psychiatric disorder covered by standard mental health surveys, and not just gambling disorder. We discuss ways in which these behavioral biases can be mitigated in future surveys.

Background: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery., Methods: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice., Results: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38)., Conclusions: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication., (© 2020 Wiley Periodicals LLC.)

Purpose: To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems., Data Sources: We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries., Study Selection: National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada., Data Extraction: Data were extracted from 19 documents using an a priori framework developed from the published literature., Results: We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement., Conclusion: Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: A videofluoroscopic swallowing study (VFSS) is a fluoroscopic examination conducted by radiographers and speech-language therapists (SLTs) to assess dysphagia. Given the potential of SLTs to feed patients during the procedure, they may be exposed to radiation. The research aimed to assess radiation protection practices utilised by SLTs to determine if radiographers have a role in providing ongoing practical education., Methods: An online questionnaire was distributed to SLTs from six countries (Australia, Canada, Ireland, New Zealand, United Kingdom and United States of America). Responses were analysed quantitatively using frequencies and chi-square analysis (p = 0.05) and supported by written comments., Results: A total of 224 responses were analysed. Thyroid shields (94%) were used more frequently than full aprons (72%). Differences (p < 0.0001) were seen between Australian and USA participants regarding the use and position of radiation monitors; 43% of Australian participants stating they always used a monitor, compared to 75% of USA participants. Nearly all Australian SLTs wore monitors under shielding (92%) and at waist level (69%), while USA participants reported wearing them outside shielding (97%) and at thyroid level (94%). Participants' radiation practice was influenced primarily by other SLTs (64%), followed by radiographers (57%). However, written comments revealed the significance of the radiographer in providing training as "radiographers are excellent at ensuring we [use] right equipment, stand in the right places and use exposure monitoring"., Conclusion: SLTs did not always adopt the ICRP principle of shielding and there were inconsistencies with regards to the use and placement of radiation monitors. Radiographers are well positioned to provide advice with regards to safe practice., Implications for Practice: Opportunities to enhance radiation protection practices are evident, as is the advising role of radiographers., Competing Interests: Conflict of interest statement None., (Copyright © 2020 The College of Radiographers. All rights reserved.)

Background: Rapid changes to how maternity health care is delivered has occurred in many countries across the globe in response to the COVID-19 pandemic. Maternity care provisions have been challenged attempting to balance the needs and safety of pregnant women and their care providers. Women experiencing a pregnancy after loss (PAL) during these times face particularly difficult circumstances., Aim: In this paper we highlight the situation in three high income countries (Australia, Ireland and USA) and point to the need to remember the unique and challenging circumstances of these PAL families. We suggest new practices may be deviating from established evidence-based guidelines and outline the potential ramifications of these changes., Findings: Recommendations for health care providers are suggested to bridge the gap between the necessary safety requirements due to the pandemic, the role of the health care provider, and the needs of families experiencing a pregnancy after loss., Discussion: Changes to practices i.e. limiting the number of antenatal appointments and access to a support person may have detrimental effects on both mother, baby, and their family. However, new guidelines in maternity care practices developed to account for the pandemic have not necessarily considered women experiencing pregnancy after loss., Conclusion: Bereaved mothers and their families experiencing a pregnancy after loss should continue to be supported during the COVID-19 pandemic to limit unintended consequences., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Purpose: Romidepsin dosing recommendations for patients with malignancy and varying degrees of hepatic dysfunction was lacking at the time of regulatory approval for T-cell lymphoma. We conducted a multicenter phase I clinical trial (ETCTN-9008) via the NCI Organ Dysfunction Working Group to investigate safety, first cycle MTD, and pharmacokinetic profile of romidepsin in this setting., Patients and Methods: Patients with select advanced solid tumors or hematologic malignancies were stratified according to hepatic function. Romidepsin was administered intravenously on days 1, 8, and 15 of a 28-day cycle and escalation followed a 3 + 3 design in moderate and severe impairment cohorts. Blood samples for detailed pharmacokinetic analyses were collected after the first dose., Results: Thirty-one patients received one dose of romidepsin and were evaluable for pharmacokinetic analyses in normal ( n = 12), mild ( n = 8), moderate ( n = 5), and severe ( n = 6) cohorts. Adverse events across cohorts were similar, and dose-limiting toxicity occurred in two patients (mild and severe impairment cohorts). The MTD was not determined because the geometric mean AUC values of romidepsin in moderate (7 mg/m 2 ) and severe (5 mg/m 2 ) impairment cohort were 114% and 116% of the normal cohort (14 mg/m 2 )., Conclusions: Data from the ETCTN-9008 trial led to changes in the romidepsin labeling to reflect starting dose adjustment for patients with cancer and moderate and severe hepatic impairment, with no adjustment for mild hepatic impairment., (©2020 American Association for Cancer Research.)

Introduction: The American College of Cardiology Foundation (ACCF) with other professional societies developed appropriate use criteria (AUC) for diagnostic coronary angiography. This study aims to examine the appropriate use of elective coronary angiography for patients with suspected stable coronary artery disease in an Irish tertiary referral center., Methods: A retrospective chart review of all elective outpatient diagnostic coronary angiograms performed in Cork University Hospital in 2014 was carried out. Data on demographics, risk factors, clinical presentation, and prior non-invasive investigations were extracted. Each patient was evaluated according to the 2012 ACCF appropriate use criteria and classified as appropriate, uncertain, or inappropriate. Univariable and multivariable logistic regression analysis was performed to investigate the factors that predict patients undergoing appropriate diagnostic coronary angiography., Results: Of 417 elective outpatient diagnostic coronary angiograms, 259 (62%) were included in the analysis. Of these, 108 (42%) were classified as appropriate, 97 (37%) as uncertain, and 54 (21%) as inappropriate. In multivariable analysis, those with private health insurance were more likely to have an appropriate indication for coronary angiogram (OR 2.1, 95% CI 1.2-3.7) as were those with atrial fibrillation (OR 3.9, 95% CI 1.2-12.8). Ever smokers were less likely to have an appropriate indication for coronary angiogram than never smokers (OR 0.5, 95% CI 0.3-0.9)., Conclusion: This is the first Irish study to evaluate the appropriate use of elective coronary angiography. Rates were similar to those of studies in other jurisdictions; however, there remains significant potential for quality improvement.

Introduction: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. Very few studies have assessed how medical centers overseas perform against AUC. Evidence is now emerging that inappropriate referral rates in Europe are similar to those reported in the US., Objective: This study systematically reviewed published evidence to identify (1) whether the 2011 AUC are applicable to medical centers outside the US (2) the level of adherence to the AUC across multiple centers, (3) the main factors which cause deviation from AUC, (4) any changes in referral rates since the publication of AUC, and (5) any factors and/or intervention strategies which promote adherence to AUC., Methods and Results: Electronic databases were systematically searched for papers related to AUC and cardiac imaging. Following screening and application of eligibility criteria, data was extracted from ten reports involving 8561 TTE studies. Classification rates were 99.5 and 98% for US studies and studies outside the US respectively. Overall, 7119 TTE studies were classified as appropriate (83.1%) of which 3724 were US referrals (84.7%) and 3395 originated outside the US (81.5%). Six of the included studies independently observed significantly more appropriate referrals among inpatients compared to outpatients (p < 0.001). US centers observed no significant difference in appropriate referral rates between physician specialties while one UK study showed cardiac surgeons ordered inappropriate TTEs more frequently than other specialties (p < 0.05). This review found no obvious trend in appropriate referral rates between 2012 and 2015 indicating no temporal change in physician ordering patterns. Only one educational interventional study met the author's criteria which showed that while intervention was effective during its implantation (26% reduction in TTEs ordered per day), TTE referral rates regressed to pre-intervention levels overtime., Conclusions: In conclusion, the American guideline AUC are applicable to centers outside the US and their implementation across five international centers suggest almost 1 in 5 scans could be avoided.

Background: Prior studies suggest that fish may be protective for rheumatoid arthritis (RA) risk perhaps through the anti-inflammatory effect of omega-3 fatty acid, but this relationship has not been clearly established. Therefore, we investigated fish intake and RA risk by serologic status, age of onset, and smoking using a prospective cohort study with large sample size, repeated measures of dietary intake, and lengthy follow-up., Methods: We studied fish intake and RA risk among 166,013 women in two prospective cohorts, the Nurses' Health Study (NHS, 1984-2014) and NHSII (1991-2015). Fish intake was assessed using food frequency questionnaires at baseline and every 4 years. Incident RA during follow-up and serologic status were determined by medical record review. Pooled Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for RA (overall and by serologic status and age at diagnosis) for fish intake frequency. We tested for a smoking-fish interaction for RA risk., Results: During 3,863,909 person-years of follow-up, we identified 1080 incident RA cases. Increasing fish intake was not associated with all RA (≥4 servings/week: multivariable HR 0.93 [95%CI 0.67-1.28] vs. < 1 serving/month; p for trend = 0.42), seropositive RA (p for trend = 0.66), or seronegative RA (p for trend = 0.45), but had increased risk for RA diagnosed > 55 years old (p for trend = 0.037). Among women ≤55 years old, frequent fish intake (vs. infrequent) had HRs (95%CIs) of: 0.73 (0.52-1.02) for all RA, 0.85 (0.55-1.32) for seropositive RA, and 0.55 (0.32-0.94) for seronegative RA. Ever smokers with infrequent fish intake had highly elevated risk for RA onset ≤55 years (HR 2.59, 95%CI 1.65-4.06), while ever smokers with frequent fish intake had modestly elevated RA risk (HR 1.29, 95%CI 1.07-1.57; vs. never smokers/frequent fish intake; p for smoking-fish interaction = 0.039)., Conclusion: In this large prospective cohort study, we found no clear protective effect of fish or marine omega-3 fatty acid intake on RA risk, overall or by serologic status. We found that fish intake attenuated the strong association of smoking for RA diagnosed ≤55 years of age, but this requires further study.

Competition arising from the increasing availability of biosimilar medicines has resulted in healthcare savings and has provided greater patient access to high cost therapeutics in Europe. The biosimilar market in the USA is relatively new so the full impact of biosimilar availability remains to be seen. Educational initiatives relating to the use of biosimilar medicines are currently being undertaken by regulators, policy makers and industry. The debate on biosimilars has moved on from the appropriateness of the regulatory framework which governs their approval, to the practice of interchangeability. Interchangeability is an important issue for healthcare professionals but different definitions and regulatory frameworks exist in the USA and Europe. In the USA, an interchangeable biological product is a biosimilar which may be substituted by a pharmacist, subject to local State policies. The interchangeability of a biosimilar with its reference medicine will be evaluated by the United States Food and Drug Administration (FDA) in cases where approval as an 'interchangeable product' is sought. In contrast, the European Medicines Agency (EMA) does not assess or make recommendations on interchangeability, therefore, in Europe, interchangeability does not mean substitution but is generally physician-led or driven by national policy. This paper provides an overview of the regulation of biosimilar medicines. Challenges associated with the demonstration of interchangeability and practical considerations relating to switching are also discussed. Finally, we present policies that have been adopted to date in several European countries, the USA and Australia, which aim to promote the use of biosimilar medicines.

Clear-cutting alters natural ecosystem processes by reducing landscape heterogeneity. It is the dominant harvesting technique across the boreal zone, yet understanding of how environmental heterogeneity and beta diversity are structured in forest ecosystems and post-clear cut is lacking. We use ground-dwelling arthropods as models to determine how natural succession (progression from deciduous to mixed to coniferous cover types) and clear-cutting change boreal forests, exploring the role of environmental heterogeneity in shaping beta diversity across multiple spatial scales (between-cover types and between-stands of the same cover type (1600 to 8500 m), between-plots (100 to 400 m) and within-plots (20 to 40 m)). We characterise environmental heterogeneity as variability in combined structural, vegetational and soil parameters, and beta diversity, as variability in assemblage composition. Clear-cutting homogenised forest environments across all spatial scales, reducing total environmental heterogeneity by 35%. Arthropod beta diversity reflected these changes at larger scales suggesting that environmental heterogeneity is useful in explaining beta diversity both between-cover types and between-stands of the same cover type. However, at smaller scales, within- and between-plots spider beta diversity reflected the lower environmental heterogeneity in regenerating stands, whereas staphylinid and carabids assemblages were not homogenised 12 years post-harvest. Differences in environmental heterogeneity and staphylinid beta diversity between cover types were also important at small scales. In regenerating stands, we detected a subtle yet notable effect of pre-felling cover type on environmental heterogeneity and arthropods, where pre-felling cover type accounted for a significant amount of variance in beta diversity, indicating that biological legacies (e.g. soil pH reflecting pre-harvest conditions) may have a role in driving beta diversity even 12 years post-harvest. This study highlights the importance of understanding site history when predicting impacts of change in forest ecosystems. Further, to understand drivers of beta diversity we must identify biological legacies shaping community structure., Competing Interests: We have read the journal's policy and the authors of this manuscript have the following competing interests: the data collection took place on the EMEND experimental site, which receives some funding and support from two companies with commercial interest: Daishowa-Marubeni International Ltd. and Canadian Forest Products Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objectives: To provide current national estimates of lesbian, gay, bisexual, and questioning (LGBQ) adolescents' (grades 9-12) substance use risks., Methods: The 2015 national Youth Risk Behavior Survey included questions for 19 substance use outcomes covering 15 substances. LGBQ adolescents' substance use was described and their risk relative to heterosexual adolescents was estimated after controlling for sociodemographic confounders., Results: In controlled analyses, we found that LGBQ adolescents were 1.12 (95% confidence interval [CI] = 1.06, 1.19) times as likely as heterosexual adolescents to report any lifetime and 1.27 (95% CI = 1.14, 1.41) times as likely to report past 30-day substance use. LGBQ adolescents were at significantly greater risk for all but 1 studied substance, including alcohol, cigarettes, cigars, cocaine, ecstasy, electronic vapor usage ("vaping"), hallucinogens, heroin, inhalants, marijuana, methamphetamine, prescription drugs (without physician direction), steroids, and synthetic marijuana., Conclusions: LGBQ adolescents are at substantially greater risk for substance use. Public Health Implications. Policymakers should invest in prevention and early intervention resources to address substance use risks among LGBQ adolescents.

Objectives: Previous studies have found a negative population-level correlation between medical marijuana availability in US states, and trends in medical and nonmedical prescription drug use. These studies have been interpreted as evidence that use of medical marijuana reduces medical and nonmedical prescription drug use. This study evaluates whether medical marijuana use is a risk or protective factor for medical and nonmedical prescription drug use., Methods: Simulations based upon logistic regression analyses of data from the 2015 National Survey on Drug Use and Health were used to compute associations between medical marijuana use, and medical and nonmedical prescription drug use. Adjusted risk ratios (RRs) were computed with controls added for age, sex, race, health status, family income, and living in a state with legalized medical marijuana., Results: Medical marijuana users were significantly more likely (RR 1.62, 95% confidence interval [CI] 1.50-1.74) to report medical use of prescription drugs in the past 12 months. Individuals who used medical marijuana were also significantly more likely to report nonmedical use in the past 12 months of any prescription drug (RR 2.12, 95% CI 1.67-2.62), with elevated risks for pain relievers (RR 1.95, 95% CI 1.41-2.62), stimulants (RR 1.86, 95% CI 1.09-3.02), and tranquilizers (RR 2.18, 95% CI 1.45-3.16)., Conclusions: Our findings disconfirm the hypothesis that a population-level negative correlation between medical marijuana use and prescription drug harms occurs because medical marijuana users are less likely to use prescription drugs, either medically or nonmedically. Medical marijuana users should be a target population in efforts to combat nonmedical prescription drug use.

Importance: Animal evidence suggests that endocrine disruptors affect germline cells and neurodevelopment. However, to date, the third-generation neurodevelopmental outcomes in humans have not been examined., Objective: To explore the potential consequences of exposure to diethylstilbestrol or DES across generations-specifically, third-generation neurodevelopment., Design, Setting, and Participants: This cohort study uses self-reported health information, such as exposure to diethylstilbestrol during pregnancy and attention-deficit/hyperactivity disorder (ADHD) diagnosis, from 47 540 participants enrolled in the ongoing Nurses' Health Study II. The 3 generations analyzed in this study were the participants (F1 generation), their mothers (F0 generation), and their live-born children (F2 generation)., Main Outcomes and Measures: Participant- and mother-reported exposure to diethylstilbestrol during pregnancy and physician-diagnosed child ADHD., Results: The total number of women included in this study was 47 540. Of the 47 540 F0 mothers, 861 (1.8%) used diethylstilbestrol and 46 679 (98.2%) did not while pregnant with the F1 participants. Use of diethylstylbestrol by F0 mothers was associated with an increased risk of ADHD among the F2 generation: 7.7% vs 5.2%, adjusted odds ratio (OR), 1.36 (95% CI, 1.10-1.67) and an OR of 1.63 (95% CI, 1.18-2.25) if diethylstilbestrol was taken during the first trimester of pregnancy. No effect modification was observed by the F2 children's sex., Conclusions and Relevance: This study provides evidence that diethylstilbestrol exposure is associated with multigenerational neurodevelopmental deficits. The doses and potency level of environmental endocrine disruptors to which humans are exposed are lower than those of diethylstilbestrol, but the prevalence of such exposure and the possibility of cumulative action are potentially high and thus warrant consideration.

Purpose: To determine the inter-rater reliability (IRR) of a procedure-specific checklist scored in a binary fashion for the evaluation of surgical skill and whether it meets a minimum level of agreement (≥0.8 between 2 raters) required for high-stakes assessment., Methods: In a prospective randomized and blinded fashion, and after detailed assessment training, 10 Arthroscopy Association of North America Master/Associate Master faculty arthroscopic surgeons (in 5 pairs) with an average of 21 years of surgical experience assessed the video-recorded 3-anchor arthroscopic Bankart repair performance of 44 postgraduate year 4 or 5 residents from 21 Accreditation Council for Graduate Medical Education orthopaedic residency training programs from across the United States., Results: No paired scores of resident surgeon performance evaluated by the 5 teams of faculty assessors dropped below the 0.8 IRR level (mean = 0.93; range 0.84-0.99; standard deviation = 0.035). A comparison between the 5 assessor groups with 1 factor analysis of variance showed that there was no significant difference between the groups (P = .205). Pearson's product-moment correlation coefficient revealed a strong and statistically significant negative correlation, that is, -0.856 (P < .000), indicating that as intra-operative error rate scores increased, the IRR decreased., Conclusions: Arthroscopy Association of North America shoulder faculty raters from across the United States showed high levels of IRR in the assessment of an arthroscopic 3-anchor Bankart repair procedure. All paired assessments were above the 0.8 level and the mean IRR of all resident assessments was 0.93, indicating that they could be used for high-stakes decisions., Clinical Relevance: With the move toward outcomes-based performance evaluation for graduate medical education, high-stakes assessments of surgical skill will require robust, reliable measurement tools that are able to withstand challenge. Surgical checklists employing metrics scored in a binary fashion meet the need and can show a high (>80%) IRR., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: We have previously developed a food allergy-specific developmental model, that explained emotions and coping styles, among children aged 6 to 15years in Ireland., Objective: The objective of this study was to investigate the usefulness of the developmental model in a large multicountry data set, including any mediators of coping style, and to use the findings to generate an item pool that will form the basis for 3 age-appropriate self-report questionnaires to measure coping and emotions., Methods: We conducted deductive thematic analysis on secondary data from interviews with 274 participants aged 6 to 23 years, and 119 parents from Australia, Ireland, Italy, the UK, and the USA. Analysis was undertaken across the entire data set., Results: The Food Allergy Coping and Emotions (FACE) model has 5 major themes: (1) experiences and emotions, (2) search for normality, (3) management and coping, (4) "external mediators," and (5) "internal mediators" (between emotions and coping). These themes were present across countries, but differed according to age., Conclusions: Early-life experiences provide the foundation for later cognitions and behaviors. The expanded FACE developmental model is useful in explaining emotions and coping styles across different age groups and countries. These data will also be used to generate an age-specific bank of items for the development of 3 (age-specific self-report, and parent proxy) questionnaires to assess emotions and coping in food allergy. Findings provide insight into how particular styles of coping develop and vary from patient to patient and may also guide clinician-patient communication and the development of individualized management strategies., (Copyright © 2018. Published by Elsevier Inc.)

Background: Food allergy health-related quality of life has been defined, but self-efficacy is poorly described., Objective: To examine the preliminary reliability, validity, and clinical performance of a novel food allergy self-efficacy index., Methods: An 8-item Food Allergy Self-Efficacy Questionnaire (FASEQ) was adapted for food allergy-related themes and coadministered with the Food Allergy Quality of Life Parental Burden (FAQL-PB) index to caregivers self-reporting a food allergic child (group A) and those with children followed up at a food allergy referral center clinic (group B). FASEQ split-half reliability, 2-week recall, factor analysis, and construct and discriminative validity were assessed. Multiple linear regression was used to explore predictive associations between the FAQL-PB and the FASEQ., Results: Among 2,308 caregivers, the mean FASEQ score was 2.69 (95% CI, 2.66-2.73) and was lower (better) among group A (mean FASEQ score, 2.52; 95% CI, 2.49-2.56) vs group B (mean FASEQ score, 3.75; 95% CI, 3.66-3.84; P < .001). The FASEQ Cronbach α was 0.87, and the 2-week intraclass correlation coefficient (ICC) was 0.75. Total and 6 of 8 individual FASEQ domain scores were significantly lower among caregivers with children having anaphylaxis or epinephrine use vs none and peanut or tree nut allergy vs milk or egg allergy, demonstrating good discriminative validity. Total FASEQ score was associated with FAQL-PB score (ICC, 0.13; 95% CI, 0.06-0.19; P < .001), with 6 of 8 FASEQ individual domains significantly associated (ICC range, -0.17 to 0.3; P < .01 for all). Factor analysis revealed 2 domains (medical care and social functioning) with construct validity., Conclusion: We present preliminary evidence the FASEQ is a valid tool to assess caregiver food allergy self-efficacy. Self-efficacy is a distinct but related concept that captures aspects of self-management that are an important companion to health-related quality of life., (Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: It is important to ensure that tools are valid and reliable in the context in which they are used. The development of age and country norms is part of this process., Objectives: The primary aim of the present study was to examine the performance of the Food Allergy Quality of Life Questionnaire - Parent Form (FAQLQ-PF) in a countrywide American sample of children with food allergy. The secondary aim was to compare age differences in impact across 9 European countries., Methods: In a cross-sectional quantitative design, questionnaires were completed by the parents of 1029 food-allergic children (0-12 years). Participants were recruited via support groups and allergists. Data were analyzed by using multivariate analysis of variance and tests for internal consistency and validity. The average score was calculated for each age group in 15 studies in Ireland, Switzerland, the Netherlands, Spain, Portugal, Germany, Italy, Denmark, Israel, and the United Kingdom., Results: The FAQLQ-PF has high convergent validity (child: r = 0.49, n = 695, P = .01; parent: r = 0.36, n = 696, P = .01) and discriminant validity, parent: t (719) = 4.67, P = .001 (anaphylaxis yes vs no); t (513), P = .009 (single vs multiple allergens). Internal consistency was excellent (r = 0.96). US health-related quality of life was worse than European health-related quality of life, as indicated by higher FAQLQ-PF scores in US samples. Burden increased with age in all populations., Conclusions: The FAQLQ-PF is appropriate for use in an American population. Findings will form the basis for further work in the development of an online manual with food allergy-normed age scores to allow for precise measurement, interpretation of scores, and comparison across countries and cultures, in clinical and research settings., (Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Aim: To develop and psychometrically test Readiness for Hospital Discharge Scale for older people and to reduce the scale to a more practical short form., Background: The Readiness for Hospital Discharge Scale is the only available and validated scale measuring patients' perceived readiness just prior to discharge., Design: Secondary analysis of hospital studies data from three countries., Method: Data were collected between 2008-2012. The study sample comprised 998 medical-surgical older patients. Factor analysis was undertaken to identify the factor structure of the Readiness for Hospital Discharge Scale. Group comparisons for construct validity and predictive validity for readmission were also conducted., Results: The Readiness for Hospital Discharge Scale original four factor solution does not appear to be consistent with the observed data of older people in the three countries. Confirmatory factor analysis revealed that a 17-item scale with three factors produced the best model fit. Nine items, three from each factor, loaded consistently on their respective factors in each country sample. Confirmatory factor analysis of this short form model indicated that the model adequately fit the data. Patients who lived alone, were older, or who indicated 'not ready' for discharge had lower Readiness for Hospital Discharge Scale for Older People scores, which were also associated with readmission risk., Conclusion: The revised three factor structure of the Readiness for Hospital Discharge Scale for Older People in long and short forms more adequately assesses core components of discharge readiness in the older adult population than the original adult form., (© 2015 John Wiley & Sons Ltd.)

Objective: To determine periextubation practices in extremely preterm infants (<28 weeks gestation)., Design: A survey consisting of 13 questions related to weaning from mechanical ventilation, assessment of extubation readiness and postextubation respiratory support was developed and sent to clinical directors of level III NICUs in Australia, Canada, Ireland, New Zealand and USA. A descriptive analysis of the results was performed., Results: 112/162 (69%) units responded; 36% reported having a guideline (31%) or written protocol (5%) for ventilator weaning. Extubation readiness was assessed based on ventilatory settings (98%), blood gases (92%) and the presence of clinical stability (86%). Only 54% ensured that infants received caffeine ≤24 h prior to extubation. 16% of units systematically extubated infants on the premise that they passed a Spontaneous Breathing Test with a duration ranging from 3 min (25%) to more than 10 min (35%). Nasal continuous positive airway pressure was the most common type of respiratory support used (84%) followed by nasal intermittent positive pressure ventilation (55%) and high-flow nasal cannula (33%). Reintubation was mainly based on clinical judgement of the responsible physician (88%). There was a lack of consensus on the time frame for definition of extubation failure (EF), the majority proposing a period between 24 and 72 h; 43% believed that EF is an independent risk factor for increased mortality and morbidity., Conclusions: Periextubation practices vary considerably; decisions are frequently physician dependent and not evidence based. The definition of EF is variable and well-defined criteria for reintubation are rarely used. High-quality trials are required to inform guidelines and standardise periextubation practices., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Dependence relations among disease and risk factors are a key ingredient in risk modeling and decision support models. Currently such information is either provided by experts (costly and time consuming) or extracted from data (if available). The published medical literature represents a promising source of such knowledge; however its manual processing is practically infeasible. While a number of solutions have been introduced to add structure to biomedical literature, none adequately recover dependence relations. The objective of our research is to build such an automatic dependence extraction solution, based on a sequence of natural language processing steps, which take as input a set of MEDLINE abstracts and provide as output a list of structured dependence statements. This paper presents a hybrid pipeline approach, a combination of rule-based and machine learning algorithms. We found that this approach outperforms a strictly rule-based approach.