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IntroductionCOVID-19 has tested the resilience of health systems globally and exposed existing strengths and weaknesses. We sought to understand health systems COVID-19 adaptations and decision making in Liberia and Merseyside, UK.MethodsWe used a people-centred approach to carry out qualitative interviews with 24 health decision-makers at national and county level in Liberia and 42 actors at county and hospital level in the UK (Merseyside). We explored health systems’ decision-making processes and capacity to adapt and continue essential service delivery in response to COVID-19 in both contexts.ResultsStudy respondents in Liberia and Merseyside had similar experiences in responding to COVID-19, despite significant differences in health systems context, and there is an opportunity for multidirectional learning between the global south and north. The need for early preparedness; strong community engagement; clear communication within the health system and health service delivery adaptations for essential health services emerged strongly in both settings. We found the Foreign, Commonwealth and Development Office (FCDO) principles to have value as a framework for reviewing health systems changes, across settings, in response to a shock such as a pandemic. In addition to the eight original principles, we expanded to include two additional principles: (1) the need for functional structures and mechanisms for preparation and (2) adaptable governance and leadership structures to facilitate timely decision making and response coordination. We find the use of a people-centred approach also has value to prompt policy-makers to consider the acceptance of service adaptations by patients and health workers, and to continue the provision of ‘routine services’ for individuals during health systems shocks.ConclusionOur study highlights the importance of a people-centred approach, placing the person at the centre of the health system, and value in applying and adapting the FCDO principles across diverse settings.

The rapid increase in marine shipping activity in Inuit Nunangat (i.e. in settled land claim regions of Arctic Canada), propelled by climate change and international interest in Arctic maritime trade, has heightened concerns among Inuit communities about the risks that more ships could pose for sustainable and subsistence hunting, fishing, and gathering (berries, plants, eggs, etc.) (referred to as harvesting in this article) activities considered vital for cultural well-being and local livelihoods. As part of the Arctic Corridors and Northern Voices project, (www.arcticcorridors.ca) a series of workshops, focus groups, and interviews were conducted in and with 14 communities across Inuit Nunangat that involved 133 marine experts and 59 youth community researchers. In this paper, we present the concerns identified by Inuit and local marine users about the risks of increased shipping activity specifically with respect to harvesting activities and then identify governance needs that could support sustainability. Results of the study are organised by three major risk themes: (1) Marine ecosystem contamination and degradation; (2) Disruption to harvesters’ travel and safety; and (3) Interference and disturbance of wildlife. All of these risks negatively impact harvesting activities in Inuit Nunangat. Considering the region is expected to be ice-free in summer by the end of the twenty-first century and that subsistence harvesting is crucial to the well-being of Inuit and northern communities, it is vital that research on this topic be conducted and then considered within ongoing Arctic governance and co-governance efforts.

Ship traffic has nearly tripled in the Canadian Arctic over the past decade and additional growth is expected as climate change continues to increase navigability in the region. In response, the Canadian Government is developing Low Impact Shipping Corridors as an adaptation strategy that supports safety and sustainability under rapidly changing environmental conditions. The corridors are specified voluntary maritime routes where services and infrastructure investments are prioritized. While a large amount of data from different sources were used to establish the location of the corridors, important local and traditional knowledge from Arctic communities has yet to be considered in much detail. The Arctic Corridors and Northern Voices (ACNV) project was established in response to this fundamental gap in knowledge. The purpose of this paper is to outline perspectives and recommendations for the corridors from 13 Canadian Inuit communities across Inuit Nunangat (Inuit homeland) that were involved in the ACNV project through a series of participatory community mapping exercises. A summary of the recommendations for the corridors that emerged from communities is presented including spatial representations for: 1) preferred corridors, 2) areas to avoid, 3) restrictions by season, 4) modification of vessel operation and 5) areas where charting is needed. The findings of the study further reiterate the vital need for meaningful inclusion of northern voices and science alongside federal government agencies in the development of Arctic shipping policy and governance.

In the mid-2000s a survey was conducted to evaluate fish mercury in lakes across New York State. Approximately 10 years later a second survey examining adult sportfish from 103 lakes and reservoirs was conducted to evaluate the response of fish mercury to recent declines in US mercury emissions. Of those lakes, 43 were part of the earlier survey and were examined to determine if mercury concentrations in four popular sport species, Yellow Perch, Walleye, and Small- and Largemouth Bass, declined in response to decreasing emissions. Water samples were also collected at 35 of these lakes and analyzed for mercury, methylmercury and other analytes. The Adirondack and Catskill regions remain biological mercury hotspots with elevated concentrations in fish. The most widely sampled species, Yellow Perch, showed significant increases in mercury in the Northeast and West regions of New York State over the past decade. The increases in Yellow Perch mercury is not consistent with significant reductions in water concentrations of both total and methylmercury observed corresponding in lake water samples. This discrepancy suggests watershed and in-lake processes beyond mercury emissions, such as recovery from acid deposition, impacts from climate change, or changes in food web structure may be controlling fish mercury concentrations. These results demonstrate a need for a consistent, long-term program to monitor fish mercury to inform the status of mercury contamination in New York State.

BACKGROUND: Men between the ages of 20 and 34 years are at highest risk for testicular cancer yet many lack knowledge and confidence in performing self-examination. The Self-Efficacy to Perform Testicular Self-Examination Scale (SEPTSES) is a 7-item questionnaire to be completed by men, which is designed to measure their confidence in self-examining their testicles. The purpose of this methodological study was to determine the validity and reliability of this self-report measure. METHODS: Content validity of the scale and clarity of items were established with a panel of experts. The SEPTSES and three valid scales of related constructs were completed by two samples of men (homeless [n = 150] and non-homeless [n = 156]) aged 18–34 years. RESULTS: A single factor explained 51.5% of the variance of the scale and Cronbach’s alpha was satisfactory (a = 0.84). Construct validity was further supported by significant correlations with the other three scales; further support was established by a significant difference in mean scores between the two samples [t (303) = −5.44, p < 0.001]. CONCLUSION: The SEPTSES is a valid, unidimensional scale and it can be used in further research and in clinical practice as an assessment of this aspect of men’s health.

The limited contact dynamic compression plate and partial contact plate were designed to decrease contact with cortical bone in an attempt to decrease cortical ischemia, remodeling, and eventual porosis under the plate after use of standard dynamic compression plates. This study quantified cortical bone blood flow beneath the plate with these three different designs in a sheep tibia fracture model. In 18 skeletally immature sheep, the right tibia was fractured and then was internally fixed with an interfragmentary screw and a dynamic compression plate, limited contact dynamic compression plate, or partial contact plate. At 12 weeks, cortical bone perfusion was assessed with laser Doppler flowmetry in nine areas beneath the plate. The baseline (before fracture) cortical bone cell flux averaged 100 +/- 60 mV. After fracture, this decreased to 60 +/- 48 mV (p < 0.0003); immediately after plating, the perfusion averaged 29 +/- 25 mV (p < 0.01). Cortical bone perfusion then increased to 106 +/- 52, 165 +/- 71, and 163 +/- 71 mV at 2, 6, and 12 weeks after fracture (p < 0.001 for all when compared with values after plating). No significant differences in cortical perfusion were seen between the types of plate. Cortical porosity under the plate was assessed with digital density analysis of microradiographs of this region. No significant difference was seen between the types of plate in this analysis or in biomechanical and disulphine blue perfusion analysis. Thus, no significant advantage was seen for the new plate designs used in this model. This lack of advantage may be a result of the immature animals used in the study, the protocol for blood flow measurement, the invasive periosteal stripping employed to create the fracture, or all three. However, as advantages with the new plate designs have been seen in other studies, this area warrants further investigation.

A multitude of skin lesions that are seen following organ transplantation have been presented. Many of them, such as opportunistic infections, are related to the immunosuppressive agents used to prevent graft rejection and graft-versus-host disease. Corticosteroids and cyclosporine commonly produce other skin changes as well. A high index of suspicion for unusual infections and skin cancer should lead the dermatologist to initiate the proper diagnostic procedures in these patients.

Background and Objectives: The purpose of this study was to determine whether the addition of ketorolac tromethamine to local anesthesia for ankle block alters the quality or duration of analgesia after podiatric surgery. The second aim was to determine the chemical stability of ketorolac tromethamine when added to local anesthetic solutions. Methods: The study design was double-blinded, placebo-controlled, and randomized. Seventy-nine American Society of Anesthesiologists (ASA) class I or II patients scheduled for bunionectomy or hammer toe repair, or both were randomized to 1 of 4 groups. Group L received plain 1.73% lidocaine for their ankle block. Group K received 1.73% lidocaine with ketorolac (4 mg/mL) added to the local solution. Group Kiv received 1.73% plain lidocaine for ankle block and 20 mg of ketorolac intravenously. Group E received 1.73% lidocaine with .67% ethanol added. The final concentration of lidocaine for all groups was 1.73%. The block performed in each patient was a 5-point ankle block. Beginning at 1 hour after the completion of the block and every 30 minutes thereafter, visual analogue scale (VAS) and verbal pain scores were recorded. The time from performance of the block to the initial pain and time to the first oral pain medication intake were also recorded. The time and amount of postoperative oral analgesics in the first 9 hours after the block were recorded. Adverse events were also recorded for each group. Results: There were significantly lower overall VAS and verbal pain scores for group K compared with groups E and L and group Kiv compared with group E. Group K also had a significantly longer time to the first reported pain and first oral pain medications than groups E and L, but not with Group Kiv. The same group had significantly fewer average doses of pain medications postoperatively than Groups E and L. Group E had significantly shorter times to first report of pain and first pain medications and higher mean dose of postoperative oral analgesics than group K and Group Kiv. There were no untoward side effects reported from any group. Chemical analysis by gas chromatography (GC) and capillary electrophoresis (CE) showed no significant change in composition of the solutions when ketorolac was mixed with lidocaine and/or bupivacaine and stored at 37°C for 1 week. Conclusions: The addition of ketorolac to lidocaine for ankle block contributed to longer duration and better quality analgesia after foot surgery compared with plain 1.73% lidocaine or 1.73% lidocaine plus intravenous ketorolac. The ethanol vehicle is unlikely responsible for the analgesic effects of ketorolac. Ketorolac retains its chemical stability when placed in local solutions of lidocaine or bupivacaine. Reg Anesth Pain Med 2000;25:506-513.

Background : The addition of clonidine to lidocaine intravenous regional anesthesia (IVRA) has been previously reported to improve postoperative analgesia in patients undergoing upper extremity surgery. Our objective was to perform a dose ranging study in order to determine the optimal dose of clonidine used with lidocaine in IVRA. Design & Setting : We performed a double-blinded randomized placebo-controlled study with 60 patients scheduled for elective endoscopic carpal tunnel release under IVRA with 50 ml lidocaine 0.5%. University-affiliated outpatient surgery center. Data collected in operating rooms, recovery room, and by telephone after discharge from surgery center. Materials &; Methods : Sixty adult ASA I or II patients undergoing outpatient endoscopic carpal tunnel release under intravenous regional anesthesia.Patients were randomized into five study groups receiving different doses of clonidine in addition to 50 ml 0.5% lidocaine in their IVRA. Group A received 0 mcg/kg, group B 0.25 mcg/kg, group C 0.5 mcg/kg, group D 1.0 mcg/kg and group E 1.5 mcg/kg of clonidine.Intraoperative fentanyl, recovery room pain scores, time to first postsurgical analgesic, total number of acetaminophen/codeine tablets consumed postsurgery, incidence of sedation, hypotension and bradycardia. Results & Conclusions : There was no benefit from any dose of clonidine compared to placebo. There were no clonidine-related side effects seen within the dose range studied. In short duration minor hand surgery, the addition of clonidine to lidocaine-based intravenous regional anesthesia provides no measurable benefit.

Clinical experience with calcipotriene has shown its efficacy in the treatment of psoriasis, both alone1-5and in combination with other agents. This double-blind, placebo-controlled study was designed to provide clinical experience in the United States with once-daily treatment of plaque-type psoriasis with 0.005% calcipotriene ointment. Patients and Methods. Two hundred thirty-five otherwise healthy nonpregnant patients, aged 18 to 86 years (mean, 45.1 years), with stable plaque-type psoriasis covering 5% to 20% of skin surface and showing plaque elevation of at least 4 on a 9-point scale, were entered into a randomized, double-blind, clinical trial of 0.005% calcipotriene ointment applied once a day for 8 weeks. Scaling, erythema, plaque elevation, and physician's global assessment were scored on a 9-point scale. Patients were evaluated at baseline and at weeks 1, 2, 4, 6, and 8 of treatment (Figure 1). Results. Forty percent of patients treated with the active drug and 2.2%

REPORT OF A CASE A 53-year-old woman with Down's syndrome was referred from a nursing home for evaluation of a severe diffuse rash. She had lived in the same institution for nine years. She had a seven-year history of a nonspecific dermatitis and dry skin. Four months previously, she had been treated with lindane lotion on two occasions with minimal benefit. Subsequently, betamethasone diproprionate was applied to the hands and elbows regularly with some improvement until one month previously, when her dermatitis worsened. One week prior to evaluation, a lotion containing triamcinolone acetonide was applied for two days. On the third day her hands became red and swollen. Heavy crusts formed "overnight" on the swollen areas. She developed a diffuse erythroderma within a few days. Allergic contact dermatitis was suspected, and the steroid lotion therapy was discontinued. At the time of our evaluation, her treatment consisted of clear water compresses