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Abstract Background The Basic Emergency Care (BEC) course was created by the World Health Organization (WHO) in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM) to train frontline providers in low-resource settings. This study aims to evaluate long-term retention and maintenance of emergency care knowledge and confidence among University of Nairobi School of Medicine graduates after completing the BEC course. Methods This longitudinal, prospective, comparative study was conducted with recent graduates of the University of Nairobi School of Medicine from October 2021 to May 2023. Participants’ retention of emergency medicine knowledge was assessed comparing a pre/post course test and a multiple-choice examination 12 to 18 months after completing the BEC course. A survey assessed participants’ confidence in managing patients with emergencies 12–18 months after completing the BEC course using a 4-point Likert scale. These results were compared to a control group of recent University of Nairobi School of Medicine graduates who did not take the BEC course. Results The follow-up test scores were lower than the immediate post-course test scores, which suggests some knowledge loss over time. Compared to the control group, the BEC participants had higher test scores during the follow-up period although the difference was not significant. There was no difference between most of the immediate post-course and follow-up survey responses. On follow-up evaluation, BEC participants reported a significant decrease in confidence in understanding emergency drugs and managing an obstructed airway and a patient requiring immobilization. However, compared to the control group, BEC participants had significantly higher self-reported confidence in most areas assessed by the survey. Conclusion The WHO BEC course is effective for emergency care training for medical students at the University of Nairobi. However, the participants’ decrease in knowledge and confidence 12 to 18 months after the BEC course suggests the need for regular refresher courses.

Anthony Giuffrida,1 Christy Saia-Owenby,2 Chris Andriano,3,* Douglas Beall,4,* Ashley Bailey-Classen,5,* Patrick Buchanan,6,* Ryan Budwany,7,* Mehul J Desai,8,* Ashley Comer,9,* Andrew Dudas,10,* Vinicius Tieppo Francio,11,* Warren Grace,12,* Benjamin Gill,13,* Betsy Grunch,14,* Andrew Goldblum,13,* Rosa A Garcia,15,* David W Lee,16,* Chad Lavender,17,* Marco Lawandy,18,* Lyric Mandell,2,* Robin Mata,19,* Morteza Rabii,20,* Kiran Patel,21,* Raj G Patel,22,* Ankur A Patel,23,* Dawood Sayed,24,* Gurtej Singh,25,* Natalie Strand,26,* Jordan Tate,27,* Michael E Schatman,28 Timothy Deer29 1Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA; 2MOXY Company, Covington, LA, USA; 3Georgia Pain Care, Stockbridge, GA, USA; 4Oklahoma Spine Hospital, Oklahoma City, OK, USA; 5Trinity Pain Medicine Associates, Fort Worth, TX, USA; 6Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 7Center for Pain Relief, Charleston Area Medical Center, Charleston, WV, USA; 8International Spine, Pain, and Performance Center, Washington, DC, USA; 9The Spine and Nerve Centers of the Virginias, Charleston, WV, USA; 10Maya & Schnapp, Neurospine and Pain, Memphis, TN, USA; 11Anesthesiology and Pain Medicine, University of Kansas, Kansas City, KS, USA; 12Redefine Healthcare, Orthopedic Pain and Spine Center, Edison, NJ, USA; 13Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA; 14Longstreet Clinic, Gainesville, GA, USA; 15Larkin Hospital Health Systems, Miami, FL, USA; 16Interventional Pain and Spine, Fullerton Orthopedics, Yorba Linda, CA, USA; 17Department of Orthopaedics, Marshall University, Huntington, WV, USA; 18Physical Medicine and Rehabilitation, Montefiore Medical Center, New York, NY, USA; 19Department of Physical Medicine and Rehabilitation, University of Miami, Miami, FL, USA; 20Crimson Pain Management, Overland Park, KS, USA; 21Pain Medicine and Anesthesiology, Northwell Health, New York, NY, USA; 22Central Texas Interventional Pain Doctor, Capitol Pain Institute, Austin, TX, USA; 23Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA; 24Department of Pain Medicine and Neurology, University of Kansas Health System, Kansas City, KS, USA; 25Department of Pain Medicine, Rehabilitation, and Pain Medicine, the Center for Advance Orthopaedics, Cantonsville, MD, USA; 26Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA; 27Department of Pain Medicine and Physical Medicine and Rehabilitation, Southern Pain and Spine, Jasper, GA, USA; 28Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Grossman School of Medicine, New York, NY, USA; 29Department of Pain Management, Spine and Nerve Centers of the Virginias, Charleston, WV, USA*These authors contributed equally to this workCorrespondence: Lyric Mandell, MOXY Company, Covington, LA, USA, Email lyric@moxycompany.comPurpose: The American Society of Pain and Neuroscience (ASPN) identified a significant gap in resources and guidelines that aim to educate healthcare providers for best practices when engaging on social media. As part of the broader initiatives on Spine and Nerve practice, the executive board of ASPN has decided it would be beneficial to include comprehensive guidance for healthcare providers when engaging on social media.Methods: A panel of experts was chosen based on expertise, publications, diversity, and their social media presence. Along with expert guidance, the committee conducted an extensive analysis of peer-reviewed literature in communication and medical journals to determine best practices for healthcare practitioners on social media.Results: Social media messages significantly impact patients’ and colleagues’ perceptions and actions regarding medical issues. As such, providers and their teams must be aware of legal and ethical considerations in healthcare while maintaining a consistent, educational, and digestible persona online.Conclusion: The advancement of communication and medical technologies and systems necessitates continued education and resources to adapt to our rapidly changing media and medical landscape.Keywords: digital communication, social networking sites, healthcare providers, best practices, physician communication, social media, medical marketing, spine

Category: Ankle; Arthroscopy Introduction/Purpose: A hypertrophic distal fascicle of the anterior tibiofibular ligament (ATiFLdf) is commonly encountered in patients with anterior ankle impingement. Repetitive snapping of the hypertrophic ATiFLdf has the potential to create osteochondral lesions (OCLs) at the lateral talar dome. However, the clinical manifestations of these OCLs in the setting of a hypertrophic ATiFLdf has not been described to date. The purpose of this retrospective review was to determine the prevalence of OCLs of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic ATiFLdf. In addition, we sought to evaluate the anatomy of the ATiFL to fully elucidate its role in creating chondral wear of the talus. Methods: Retrospective chart review identified 40 patients who underwent arthroscopy of the anterior ankle joint for the management of anterior ankle impingement. Pre-operative magnetic resonance imaging (MRI) scans were obtained and correlated with intra-operative arthroscopic findings. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, return to work data and return to sport data. Results: Thirty-two patients with a mean follow-up time of 29.3±10.4 months were included. The ATiFLdf was hypertrophic in 29 patients (90.6%), the mean thickness of which was 2.5±0.4 mm. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic ATiFLdf visualized during arthroscopy. The international cartilage repair society gradings of the lesions included: 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from pre-operative to post-operative (p< 0.001). No cases of syndesmotic instability were observed following resection of ATiFLdf. The mean post-operative Likert score was 4.1±0.4. There were 5 failures (15.6%) at a mean time of 9.0±4.7 months. Conclusion: This retrospective case series demonstrated that a hypertrophic ATiFLdf was closely associated with the development of an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, pre-operative MRI proved to demonstrate poor sensitivity for the detection of these OCLs. Suspicion should be raised for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf. Figure 1. (a) Hypertrophic ATiFLdf with associated OCL of the lateral talar dome; (b) Biter resecting hypertrophic ATiFLdf; (c) Resected hypertrophic ATiFLdf; (d) and (e) Hypertrophic ATiFLdf identified on coronal and axial MRI scans

Category: Arthroscopy; Other Introduction/Purpose: Posterior Tibial Tendon Insufficiency (PTTI) is a common pathology of the foot and ankle and the leading cause for adult-aquired flatfoot deformity. PTTI typically presents with loss of medial arch of the foot which may progress to hindfoot valgus, forefoot abduction, and development of midfoot osteoarthritis. Following failure of conservative management, tenosynovectomy is indicated in early stage PTTI. However, current tendoscopy techniques lead to significant soft tissue damage. Minimally invasive approaches to these arthroscopic procedures minimize damage to soft-tissue and allow for a much faster recovery. The purpose of this retrospective review is to evaluate the therapeutic and diagnostic potential of In-Office Posterior Tibial Needle Tendoscopy for PTTI. Methods: Chart review was conducted to identify patients who underwent In-Office Posterior Tibial Needle Tendoscopy with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analog scale (VAS) scores, return to sport (RTS), and failures. Results: Eleven patients were included at a mean follow-up of 17.4 ± 9.0 months and a mean age of 40.8 ± 14.64 years. Five patients (45.5%) were stage 1 PTTI, 5 patients were stage 2a PTTI and 1 patient was stage 2b PTTI. The mean AOFAS score improved from 45 ± 5.4 preoperatively to 70 ± 18.5 at final follow-up (p< 0.01). The mean VAS improved from 6 ± 0.7 preoperatively to 3.7 ± 1.6 at final follow-up (p< 0.01). The failure rate was 36.3%. All patients with stage 1 PTTI were asymptomatic at final follow-up. Four of the 6 patients (66.7%) with stage 2 PTTI warranted further surgical intervention. Conclusion: This retrospective study demonstrated there is therapeutic and diagnostic potential for In-Office Posterior Tibial Needle Tendoscopy. Patients with early stage PTTI had improved subjective clinical outcomes and rapid return to sport. For moderate to severe PTTI, in-office needle tendoscopy may be less beneficial. Further high quality studies are necessary to determine the optimal role of In-Office Posterior Tibial Needle Tendoscopy in the management of Posterior Tibial Tendon injury.

Category: Arthroscopy; Sports Introduction/Purpose: The purpose of this retrospective review is to evaluate the clinical and radiological outcomes following In-Office peroneal Needle Tendoscopy for peroneal tendon dysfunction. Methods: Chart review was conducted to identify patients who underwent In-Office Peroneal Needle Tendoscopy with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analog scale (VAS) scores, return to sport (RTS), and failures. Results: Ten cases were included. The mean follow-up was 30±6.3 months and the mean age was 45.27±22.15 years. There were 6 men and 4 women. IONT identified 5 tears that were not identified on pre-operative MRI. The mean AOFAS improvement was not statistically significant from 49.3 ± 8.3 preoperatively to 53.2±19.7 at final follow-up (p=0.45). There was no change in mean VAS at 5.4±2.2 preoperatively to 4.6±2.7 at final follow-up (p=.27). All patients returned to work at an average time of 3 days, however only 2 patients reported returning to their sport at the same level following in-office needle tendoscopy. The complication rate was 50% and the failure rate at final follow-up was 80%. The mean time to failure was 8 months. Conclusion: This retrospective study found that IONT is an effective modality in the management of peroneal tendon dysfunction. In particular, IONT identified peroneal tears that were not captured on pre-operative MRI and thus required treatment in an operating suite. The exact role of IONT for the management of peroneal tendon disorders remains unclear, thus further research is warranted.

Problem Considered: Burden of chronic kidney disease (CKD) is increasing globally. We present chart analysis of data obtained during community screening for kidney disease between 2011-2021 in various parts of Kenya with objectives to document and stratify risks for kidney disease in the community. Methods: This was a descriptive analysis charts. Age, sex, individuals’ data on smoking, diabetes, hypertension, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), random blood sugar (RBS), dipstick urinalysis, as well as family history of CKD, hypertension and diabetes were analysed. Continuous variables had mean, standard deviation (SD), median and interquartile range (IQR) while frequencies for categorical variables were calculated. Results: About 10,675 individuals were analysed. Median age was 41 years (25 – 53). Females were 6,092(57.1%). Known hypertensive, diabetic and smokers were 2,028(19.0%), 881(8.3%) and 523(4.9%) respectively. Family history of hypertension, diabetes and CKD was reported by 3,810(35.7%), 2,751(25.8%) and 978(9.2%) respectively. In 10,121(94.8%) RBS was tested. About 470(4.6%) had RBS < 4.0 mmol/L, 9,298(91.9%) 4.0-11.0 mmol/L while 368(3.6%) was > 11.0 mmol/L. Incidental hyperglycemia was in129 (1.2%). Median SBP and DBP was 128 mmHg (116-143) and 78 mmHg (70 – 87) respectively. Mean BMI was 25.96±5.27 kg/m2. Subgroups with diabetes and hypertension had higher mean age, SBP, DBP and RBS, family history of hypertension, diabetes and CKD. Conclusion: Burden of risks for CKD in the community high. Blood sugar and blood pressure controls were suboptimal. There was concordance in the findings of hypotensive, diabetic and family history of similar conditions.

Abstract Background Point-of-care ultrasound (POCUS) is recognized as a key imaging modality to bridge the diagnostic imaging gap in Low- and Middle-Income Countries (LMICs). POCUS use has been shown to impact patient management decisions including referral for specialist care. This study explored the impact of POCUS use on referral decisions among trained healthcare providers working in primary rural and peri-urban health facilities in Kenya. Methods A concurrent mixed methods approach was used, including a locally developed survey (N = 38) and semi-structured interviews of POCUS trained healthcare providers (N = 12). Data from the survey was descriptively analyzed and interviews were evaluated through the framework matrix method. Results Survey results of in-facility access to Xray, Ultrasonography, CT scan and MRI were 49%, 33%, 3% and 0% respectively. Only 54% of the facilities where trainees worked had the capacity to perform cesarean sections, and 38% could perform general surgery. Through a combined inductive and deductive evaluation of interview data, we found that the emerging themes could be organized through the framework of the six domains of healthcare quality as described by the Institute of Medicine: Providers reported that POCUS use allowed them to make referral decisions which were timely, safe, effective, efficient, equitable and patient-centered. Challenges included machine breakdown, poor image quality, practice isolation, lack of institutional support and insufficient feedback on the condition of patients after referral. Conclusion This study highlighted that in the setting of limited imaging and surgical capacity, POCUS use by trained providers in Kenyan primary health facilities has the potential to improve the patient referral process and to promote key dimensions of healthcare quality. Therefore, there is a need to expand POCUS training programs and to develop context specific POCUS referral algorithms.

Background: The purpose of this systematic review was to evaluate outcomes following intra-articular injection of hyaluronic acid (HA) for the treatment of hallux rigidus. Methods: During April 2024, a systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data collected and analyzed were number of patients, patient age, follow-up, subjective clinical outcomes, complications, and failures. Results: Five studies were included. In total, 218 patients (218 feet) underwent intra-articular injection of HA at a weighted mean follow-up time of 4.4 ± 1.4 months (range, 3-6). There was an improvement in postinjection visual analog scale (VAS) pain at rest scores, VAS pain during activity scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and Foot Health Status Questionnaire (FHSQ) scores. In total, 21 complications (10.0%) were observed, the most common of which was transient postinjection pain in 20 patients (9.6%). There were 7 patients (3.2%) who underwent secondary procedures (3.2%). One randomized control trial (RCT) demonstrated no difference in outcomes between an intra-articular injection of HA compared to an intra-articular injection of saline. One RCT demonstrated superior FHSQ scores following between an intra-articular injection of HA compared to an intra-articular injection of triamcinolone acetonide. Conclusion: This systematic review suggests that intra-articular injection of HA for the treatment of hallux rigidus may lead to improved clinical outcomes with a low complication rate at short-term follow-up. However, the low level and quality of evidence underscores the need for further high-quality studies to be conducted to identify the precise role of HA in the treatment of hallux rigidus.

Purpose: To assess outcomes following Achilles in-office needle tendoscopy (IONT) for the treatment of chronic Achilles tendinopathy (cAT) at a minimum 12-month follow-up. Methods: A retrospective case series was conducted to evaluate patients who underwent Achilles IONT for cAT between January 2019 and December 2022. Inclusion criteria were patients ≥18 years of age and clinical history, physical history, and magnetic resonance imaging findings consistent with cAT who did not respond to a minimum of 3 months of conservative management for which each patient underwent Achilles IONT and had a minimum 12-month follow-up. Clinical outcomes were evaluated using the Victorian Institute of Sport Assessment–Achilles and visual analog scale scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale. Results: Twelve patients (13 Achilles) with a mean age of 50.9 ± 14.6 years were included in the study. The mean follow-up time was 26.3 ± 6.3 months. The mean Victorian Institute of Sport Assessment–Achilles scores improved from a preoperative score of 35.6 ± 5.9 to a postoperative score of 83.6 ± 14.1 (P < .001). The mean visual analog scale score improved from a preoperative score of 6.6 ± 1.0 to a postoperative score of 1.3 ± 1.7 (P < .001). There were 10 patients (83.3%) who participated in sports activities before the IONT procedure. Within this group, 9 patients (90.0%) returned to play at a mean time of 5.9 ± 2.6 weeks. The mean time to return to work was 4.2 ± 1.2 days. Patients reported an overall positive IONT experience with a mean rating scale of 4.5 ± 0.9. Conclusions: This retrospective review demonstrated that Achilles IONT for the treatment of cAT results in significant improvements in subjective clinical outcomes and a low complication rate together with high patient satisfaction scores at short-term follow-up. Level of Evidence: Level IV, therapeutic case series.

BackgroundThe prevalence of mental health issues among secondary school students is on the rise. Secondary school teachers, outside the home environment, are often in a prime position to identify adolescents facing mental health challenges. Limited knowledge regarding the experiences and perspectives of secondary school teachers when encountering this particular group of students, particularly in Asian countries.ObjectivesThis study aimed to describe the lived experiences of secondary school teachers exposed to students with mental health issues in the classroom in a Chinese context.MethodsA descriptive phenomenological approach within the tradition of Husserl was used. A purposive sampling method was used to collect the participants in Changsha, Hunan, China. Sixteen secondary school teachers participated in this study. Individual, face-to-face interviews were conducted, tape-recorded, and transcripted. Colaizzi’s seven-step descriptive phenomenological method was used to do the data analysis.ResultsOne Central theme: Living in fear at the unpredictability of mental health issues in the classroom and four sub-themes emerged: (1) Worried and anxious by the uncertainty of student mental health issues; (2) Scared and afraid by students’ unpredictable behaviors; (3) Afraid of students’ failure and its potential outcome; (4) Students having mental health issues are dangerous.Conclusions and implicationsThe teachers in this study found managing the unpredictability of mental health issues in the classroom deeply distressing and challenging. A comprehensive approach to address the cultural, social, and educational factors influencing secondary school teachers’ experiences is encouraged.

Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiographic outcomes in patients who received extracellular matrix cartilage allograft (EMCA) during surgical intervention for osteochondral lesions of the talus (OLT). Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies evaluating outcomes in patients who received EMCA during surgical intervention for osteochondral lesions of the talus. Data regarding lesion characteristics, surgical characteristics, subjective clinical outcomes, radiographic outcomes, complication rates, failure rates and secondary surgical procedure rates were extracted and analysed. In total, 5 clinical studies were included in this review. Results: In total, 162 patients received EMCA during surgical intervention for OLT at a weighted mean follow-up of 23.8 ± 4.2 months. The weighted mean lesion area was 77.9 ± 42.6 mm 2 . Overall, 111 (68.5%) of OLTs were located medially, 45 (27.8%) of OLTs were located laterally and 6 (3.7%) OLTs were located centrally. Four studies performed arthroscopic debridement and bone marrow stimulation with ECMA, 3 studies utilized concentrated bone marrow aspirate and 1 study performed autologous osteochondral transplantation. Improvements were noted in AOFAS, FAOS and VAS scores following surgical intervention. The weighted mean post-operative MOCART score was 76.3 ± 2.9. In total, 17 (10.5%) complications were reported across the 5 studies. Twelve failures (7.4%) were recorded, all of which required further surgical intervention. Conclusion: This systematic review demonstrated improvements in subjective clinical outcomes and radiological outcomes at short-term follow-up following surgical intervention for OLTs augmented with ECMA. A low failure rate and moderate complication rate was noted. However, there was marked heterogeneity between the included studies with regards to surgical technique utilized, lesion size and patient cohort size. Further research is warranted to determine the optimal role of ECMA in the management of OLT.

IntroductionMind Space is an experiential mental health exhibition in Hong Kong, aiming to raise public awareness and provide education regarding mental health. This prepost study aimed to 1) examine the relationships between visitors’ characteristics and their mental health stigma at baseline, and 2) provide a preliminary evaluation of the effectiveness of Mind Space in reducing stigma and promoting help-seeking attitudes toward mental health conditions.MethodsWe analyzed data from all consenting visitors who attended Mind Space between September 2019 and December 2021. Visitors’ attitudes toward mental health conditions and their willingness to seek professional psychological help were measured through online questionnaires before and after visits. Multiple linear regression was used to identify the demographic predictors of outcome variables at baseline. Changes in outcome variables after attending Mind Space were assessed using paired sample t-tests.ResultsA total of 382 visitors completed the baseline questionnaires, among which 146 also completed the post-test. At baseline, higher socioeconomic levels and personal contact with people with mental health conditions predicted more positive attitudes and understanding toward mental disorders. Tentatively, the results also showed that after attending Mind Space, a significant reduction in negative attitudes about mental illness (t=4.36, p=

Abstract Childhood obesity is one of the biggest public health challenges globally. It is associated with various adverse health consequences throughout life. Prevention and early intervention represent the most reasonable and cost‐effective approaches. Considerable progress has been achieved in the management of obesity in children and adolescents; yet, implementation in the real world remains a challenge. This article aimed to present an overview of the diagnosis and management of obesity in children and adolescents.

BackgroundChronic heart failure (CHF) poses a significant burden on both patients and their family caregivers (FCs), as it is associated with psychological distress and impaired quality of life (QOL). Acceptance and Commitment Therapy (ACT) supports QOL by focusing on value living and facilitates acceptance of psychological difficulties by cultivating psychological flexibility. A protocol is presented that evaluates the effectiveness of a dyad ACT-based intervention delivered via smartphone on QOL and other related health outcomes compared with CHF education only.MethodsThis is a single-center, two-armed, single-blinded (rater), randomized controlled trial (RCT). One hundred and sixty dyads of CHF patients and their primary FCs will be recruited from the Cardiology Department of a hospital in China. The dyads will be stratified block randomized to either the intervention group experiencing the ACT-based intervention or the control group receiving CHF education only. Both groups will meet two hours per week for four consecutive weeks in videoconferencing sessions over smartphone. The primary outcomes are the QOL of patients and their FCs. Secondary outcomes include psychological flexibility, psychological symptoms, self-care behavior, and other related outcomes. All outcomes will be measured by blinded outcome assessors at baseline, immediately post-intervention, and at the three-month follow-up. Multilevel modeling will be conducted to assess the effects of the intervention.DiscussionThis study is the first to adopt an ACT-based intervention for CHF patient-caregiver dyads delivered in groups via smartphone. If effective and feasible, the intervention strategy and deliverable approach could be incorporated into clinical policies and guidelines to support families with CHF without geographic and time constraints.Trial registrationClinicalTrials.gov Identifier: NCT04917159. Registered on 08 June 2021.

Long-term exposure to ambient air pollution even at relatively low concentrations is associated with adverse health effects especially for children, the elderly and people with pre-existing chronic disease. Due to a variety of urban planning decisions, essential building premises attended by these vulnerable groups may be sited in locations exposed to higher levels of air pollution. Using high spatial resolution air pollution concentrations estimated by satellite-based Land Use Regression (LUR) models in Australia, we mapped and approximated the annual average concentrations of particulate matter (PM2.5) and nitrogen dioxide (NO2) at schools, child care centres, aged care facilities and hospitals across Sydney. We found that 137 (3.1 %) and 287 (6.4 %) of the total number of essential buildings assessed were exposed to annual average PM2.5 and NO2 concentrations, respectively, where: the air pollutant concentrations were greater than the median concentration of other locations in the surrounding Local Government Area (LGA), and; air pollutant levels were greater than the 90th percentile concentrations for Sydney, and; air pollution at the essential building location was at least 1 µg/m3 for PM2.5 or 2 ppb for NO2 greater than the 25th percentile concentration of other locations in the LGA. Based on these criteria, we found that many essential building premises in Sydney were in high air pollution locations and there were other meaningfully lower air pollution locations within the surrounding area. Air quality is becoming an increasingly important issue for local jurisdictions to consider as more essential amenities are required to serve denser populations in busier places exposed to more air pollution. Our study showed that high resolution maps can be used as a health-based planning tool to encourage the siting of buildings at locations better protective of health.

Category: Ankle Arthritis Introduction/Purpose: End-stage ankle osteoarthritis is a debilitating pathology and is most commonly preceded by trauma. Surgical intervention via ankle arthrodesis or ankle arthroplasty is the mainstay management option. Heterotopic ossification (HO) is a common finding following joint arthroplasty. However, no consensus regarding the impact of heterotopic ossification on clinical outcomes following total ankle arthroplasty has been reached to date. The purpose of this systematic review and meta- analysis was to evaluate the prevalence and clinical outcomes of heterotopic ossification following total ankle arthroplasty. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies reporting heterotopic ossification following TAA. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. Results: Twenty-seven studies with 2639 patients (2695 ankles) at a weighed mean follow-up time of 52.8 ± 26.9 months were included. The pooled prevalence rate was 45% (0.25; 0.66). The implant with the highest rate of HO was the INBONE I (100%) and BOX (100%) implants. The most common modified Brooker staging was grade 1 (120 patients, 33.9%). Random effects models of standardized mean differences found no difference in AOFAS, VAS and ROM between patients with HO and patients without HO. Random effects models of correlation coefficients found no correlation between AOFAS, VAS and ROM and the presence of HO. The surgical intervention rate for symptomatic HO was 10.5%. Conclusion: This systematic review and meta-analysis found that HO is a common finding following TAA that is not associated with inferior clinical outcomes. Surgical intervention was required only for moderate-severe, symptomatic HO following TAA. This study is limited by the significant heterogeneity and low level and quality of evidence of the included studies. Further higher quality studies are warranted to determine the precise prevalence and impact of HO on outcomes following TAA.

Category: Ankle Arthritis; Other Introduction/Purpose: The purpose of this systematic review and meta-analysis was to evaluate potential predictors of failure following total ankle arthroplasty (TAA) for the management of end stage ankle arthritis. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to evaluate potential predictors of failure following total ankle arthroplasty for the management of end stage ankle arthritis. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, odds ratios, hazard ratios, correlation coefficients, failure rates and complications were extracted and analysed. Results: In total, 15117 patients (15198 ankles) underwent TAA at a weighted mean follow-up of 64.0 ± 21.8 months. Pooled Odds ratio found that diabetes was a statistically significant predictor of failures following TAA (OR: 2.1; [1.9861, 2.2284], p = 0.003). Other variables such as age, gender, body mass index, implant type and arthritis aetiology were not associated with failure. Conclusion: This systematic review and meta-analysis found that the presence of diabetes mellitus was a statistically significant predictor of failure following TAA. However, there was marked heterogeneity between the included studies with regards to statistical data collection which significantly limits the robustness of the conclusions of this study. Thus, further higher quality research with more consistent data collection is warranted to identify potential predictors of failure post TAA.

Category: Ankle Arthritis; Other Introduction/Purpose: End stage ankle osteoarthritis is a significantly debilitating pathology that is most commonly preceded by trauma. The emergence of 3rd and 4th generation total ankle arthroplasty (TAA) implant designs have led to more favorable outcomes compared to its predecessors. TAA implants can be broadly divided into fixed bearing and mobile bearing implant designs, however, no consensus has been reached regarding the optimal TAA implant design for the management of end stage ankle arthritis. The purpose of this systematic review and meta-analysis was to compare outcomes between patients who received fixed bearing TAA implants and mobile bearing TAA implants. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies comparing outcomes between patients who underwent fixed bearing TAA implant and patients who underwent mobile bearing TAA implant for the management of end stage ankle arthritis. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. Results: Overall, 13 studies were included in this review. In total, 2793 patients underwent mobile bearing TAA implant and 2241 patients underwent fixed bearing TAA implant for the management of end stage ankle arthritis. No difference existed between the 2 cohorts with regards to post-operative subjective clinical outcome scores nor radiological outcomes. The mobile bearing TAA implant cohort was associated with higher complications (RR = 1.4710; [1.0375-2.0857]; p = 0.0373) and failures (RR = 1.3916; [1.2038 - 1.6086]; p = 0.0032) compared to the fixed bearing TAA implant cohort. Conclusion: This systematic review and meta-analysis found no difference in subjective clinical outcomes and radiological outcomes between patients who underwent mobile bearing TAA implant and fixed bearing TAA implant for the management of ankle arthritis. Interestingly, the mobile bearing TAA implant cohort was associated with higher complications and failures compared to the fixed bearing TAA implant cohort. Due to the marked under-reporting of data and significant heterogeneity between the included studies, further high quality research is warranted to determine the optimal TAA implant type for the management of end stage ankle arthritis.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review and meta-analysis is to compare outcomes between patients who underwent open chevron osteotomy (OCO) and minimally invasive Chevron osteotomy (MICA) for the management of hallux valgus deformity. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies comparing outcomes between patients who underwent open chevron osteotomy (OCO) and minimally invasive Chevron osteotomy (MICO) for the management of hallux valgus deformity. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. In total, 6 comparative studies were included in this review. Results: In total, 183 patients (208 feet) underwent OCO and 209 patients (244 feet) MICA for the management of hallux valgus deformity. Meta-analysis demonstrated no difference in post-operative MOFXQ scores (SMD: 0.0849, [-0.2584, 0.4282], p = 0.6277), hallux valgus angle (SMD: -0.1245, [-0.4204, 0.1715], p = 0.4099), intermetatarsal angle (SMD:-0.2565, [-0.5539, 0.0408], p = 0.909) and failures (RR: 1.0765, [0.0993, 11.6760], p = 0.9278) between the OCO cohort and the MICO cohort. There was a lower complication rate in the OCO cohort compared to the MICO cohort (RR: 0.2614, [0.1453, 0.4704], p < 0.0001). Conclusion: This systematic review found comparable improvements in subjective clinical outcomes, functional outcomes and radiographic outcomes following both OCO and MICO at short-term follow-up. However, a lower RR with respect to complications was found in the OCO cohort compared to the MICO cohort. Despite the significant heterogeneity across the included studies, the similar outcomes between the 2 cohorts reinforces that further research is warranted to determine the optimal role of OCO and MICO in the management of hallux valgus deformity.

Category: Ankle; Sports Introduction/Purpose: Chronic ankle instability occurs in 15-20% of patients with ankle sprains who do not recover following conservative management and typically requires surgical intervention. There is recent interest in Anterior Talofibular Ligament (ATFL) Repair techniques that may improve outcomes and expedite recovery. Evidence for the use of suture-tape as an internal in ATFL Repair is limited in the literature. The purpose of this study was to retrospectively assess outcomes and return to sport following ATFL Repair with and without suture-tape (ST) augmentation at greater than 1-year follow-up. Methods: Chart review was conducted to identify patients who underwent Anterior Talofibular Ligament (ATFL) Repair with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, Foot and Ankle Outcome Score (FAOS), visual analog scale (VAS) scores, return to sport (RTS), complications, and failures. Linear regression was performed to identify potential predictors of outcomes. Results: Eighteen cases of ATFL repair augmented with suture-tape (ST) and 20 cases of ATFL repair alone were included. The mean follow-up in the ST cohort was 20.8 ± 7.9 months and the mean follow-up time in the ATFL repair alone cohort was 25.3 ± 13.2 months. Improvements in FAOS and VAS scores were observed in both cohorts at final follow-up (p < 0.01). No statistically significant difference in FAOS and VAS scores at final follow up was found between the 2 cohorts. The mean time to RTS was 8.6 ± 3.3 weeks in the ST cohort and 13.3 ± 2.7 weeks in the ATFL repair alone cohort (p < 0.01). No statistically significant difference in complication rates nor failure rates was observed between the 2 cohorts. Conclusion: This retrospective study found that ATFL Repair with and without suture-tape augmentation produced comparable subjective clinical outcomes, complication rates and failure rates at short-term follow-up. A superior mean time to RTS was found in the ST cohort. The early results of this surgical technique are promising, but further studies with larger patient cohorts and longer follow-up times are needed to determine the optimal role of suture-tape augmentation of ATFL repair.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate outcomes following intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies evaluating outcomes in patients who underwent intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus. Data regarding injection characteristics, subjective clinical outcomes, failure rates and complications were extracted and analysed. Results: In total, 5 studies were included in this review. In total, 209 patients underwent intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus at a weighted mean follow-up of 4.4 ± 1.4 months. The weighted mean VAS improved from a pre-injection score of 6.4 ± 0.3 to a post-injection score of 2.8 ± 0.4. A 10.1% complication rate was noted, the most common of which was transient 1st MTPJ swelling. One infection (0.5%) was reported. A symptomatic recurrence rate of 18.6% was observed at a weighted mean time of 7.3 ± 4.2 months Conclusion: This systematic review demonstrated that intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus led to a reduction in pain and a moderate complication rate at short-term follow-up. In addition, intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus produced a symptomatic recurrence rate of 18.6% at approximately 7.3 months, suggesting that HA provides short-term relief. The lack of quality comparative studies limits the generation of robust conclusions, reinforcing the need for further research to identify the optimal role of HA in the management of hallux rigidus.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to examine the clinical and radiological outcomes of various surgical treatments for symptomatic accessory naviculars. Methods: During February 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical treatment for symptomatic accessory navicular. Data regarding surgical characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analyzed. 26 studies were included for review. Results: In total, 520 patients (614 feet) underwent surgical treatment for the management of symptomatic accessory navicular. The weighted mean age was 28.18 ± 8.18 and the weighted mean follow-up time was 46.23 ± 34.76 months. The mean AOFAS score was 49.9 ± 7.39 preoperatively and 88.9 ± 5.61 postoperatively. The mean complication rate at final follow-up was 9.02% and the failure rate was 4.23%, with only 2.7% of patient ultimately requiring a further procedure. We also compared outcomes in patient who underwent a Kidner or Modified Kidner procedure (n=245) with those treated with a different surgical technique such as fusion or simple excision (n=275). There was no significant difference in outcome scores, complication rates, failure rates, or secondary surgical procedure rates between these cohorts. Conclusion: This systematic review demonstrated improvement in clinical outcomes following surgical treatment for symptomatic accessory naviculars. The markedly low complication and failure rates further indicate that surgical intervention is beneficial in the management of symptomatic accessory naviculars. Kidner and Modified Kidner procedures resulted in equivocally good outcomes compared with other surgical approaches such as fusion and simple excision. However, the marked heterogeneity between the included studies and few high level comparative studies limits the generation of any robust conclusions for optimal surgical technique. Further research is warranted to determine whether the Kidner procedure confers any particular advantages over other approaches.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate outcomes following polyvinyl alcohol hydrogel implant for the management of hallux rigidus. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies evaluating outcomes in patients who underwent polyvinyl alcohol hydrogel implant for the management of hallux rigidus. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. In total, 15 studies were included in this review. Results: In total, 1536 patients (1578 feet) underwent polyvinyl alcohol hydrogel implant for the management of hallux rigidus at a weighted mean follow-up of 39.4 ± 17.3 months. The weighted mean VAS score improved from a pre-operative score of 6.2 ± 1.3 to a post-operative score of 3.0 ± 1.6. There was limited data regarding improvements in range of motion. The complication rate was 15.7% and the failure rate was 9%. Conclusion: This systematic review demonstrated improvement in subjective clinical outcomes following PVA hydrogel implant for the management of hallux rigidus. A moderate complication rate and failure rate was noted at short term follow-up. Further studies with longer follow-up periods are warranted to elucidate the precise outcomes following PVA hydrogel implant for the management of hallux rigidus.

We explored patterns of COVID-19 vaccination across pediatric visit types using electronic health record data from 7/1/2021 through 7/25/2022 in a pediatric safety-net clinic. We generated frequencies and descriptive statistics for patient demographic and vaccine administration variables. Analyses were stratified into age subgroups of 5-to-11-year-olds and 12- to-17-year-olds. 1,409 children received at least one dose of the COVID-19 vaccine and 2,197 doses were administered in this first year of vaccine delivery. Most vaccines given were first doses in the series (45%), followed by second doses (38%), and then booster doses (17%). First doses tended to be given at well-child (42%) or nurse visits (48%), while second doses were almost entirely given at nurse visits (87%) and booster doses at well-child visits (58%). Efforts to optimize COVID-19 vaccination could leverage clinic workflow systems to provide reminder prompts for vaccination for scheduling future doses and identify strategies to facilitate vaccination at non-well child visits, particularly for booster doses.

Abstract Background Malaria rapid diagnostic tests (mRDTs) have played an important role in the early detection of clinical malaria in an endemic area. While several mRDTs are currently on the market, the availability of mRDTs with high sensitivity and specificity will merit the fight against malaria. We evaluated the field performance of a novel One Step Malaria (P.f/P.v) Tri-line and One Step Malaria (P.f) rapid test kits in Pwani, Tanzania. Methods In a cross-sectional study conducted in Bagamoyo and Kibiti districts in Tanzania, symptomatic patients were tested using the SD BIOLINE, One Step Malaria (P.f/P.v) Tri-line and One Step Malaria (P.f) rapid test kits, microscope, and quantitative Polymerase Chain Reaction (qPCR). An additional qPCR assay was carried out to detect Histidine-Rich Protein 2 (HRP-2) gene deletion on mRDT negative but microscope and qPCR positive samples. Microscope results confirmed by qPCR were used for analysis, where qPCR was used as a reference method. Results The sensitivity and specificity of One Step P.f/P.v Tri-line mRDTs were 96.0% (CI 93.5–97.7%) and 98.3% (CI 96.8–99.2%), respectively. One Step P.f mRDT had sensitivity and specificity of 95.2% (CI 92.5–97.1%) and 97.9% (CI 96.3–99.0%) respectively. Positive predictive value (PPV) was 97.6% (CI 95.4–98.7%) and negative predictive value (NPV) was 96.2% (CI 95.5–98.3%) for the One Step P.f/P.v Tri-line mRDTs respectively, while One Step P.f mRDT had positive predictive value (PPV) and negative predictive value (NPV) of 97.0% (CI 94.8–98.3%) and 96.7 (CI 94.9–97.9%) respectively. 9.8% (CI 7.84–11.76) of all samples tested and reported to be malaria-negative by mRDT had HRP-2 gene deletion. Conclusion One Step Malaria P.f/P.v Tri-line and One Step Malaria P.f rapid test kits have similar sensitivity and specificity as the standard mRDT that is currently in the market, demonstrating the potential to contribute in the fight against malaria in endemic settings. However, the identified malaria parasites population with HRP-2 gene deletion pose a threat to the current mRDT usability in the field and warrants further investigations.

Abstract The development of effective, safe, and acceptable vaccines is a long process. COVID-19 vaccine hesitancy continues to elicit mixed reactions among different quarters despite numerous evidence of their effectiveness. This study aimed to determine the availability and acceptance rates of SARS-CoV-2 vaccines, among Kenyan and Hungarian residing populations and the underlying reasons contributing to the hesitancy of uptake. A non-probability, snowball sampling design was employed, and a survey questionnaire tool link was expeditiously disseminated. Data were carefully analyzed descriptively. Demographic variables, COVID-19 awareness, possible exposure, reasons associated with hesitancy in taking up a vaccine, choice of a vaccine, and availability of vaccines among other important variables were tested to explore their associations with vaccine acceptance rates between the two distinct countries. A total of 1960 participants were successfully enrolled in the research study, while 67 participants were excluded based on the inclusion criterion set. There was, however, no significant difference in COVID-19 public awareness between the Kenyan and Hungarian-residing participants, p = 0.300. Of the respondents, 62.4% were willing and ready to receive vaccines against COVID-19 disease. There was a significant difference (p = 0.014) between the Kenyan and Hungarian-residing respondents concerning vaccine uptake and acceptance rates. The vaccine acceptance rates in Hungary were higher than in Kenya, with mean = 0.27, SD = 0.446, S. E = 0.045 for the Hungarian population sample and mean = 0.40, SD = 0.492, S. E = 0.026, for the Kenyan sample respectively. Concerning gender and vaccine acceptance, there was a notable significant difference between males and females, p = 0.001, where the mean for males and females were 0.29 and 0.46 respectively. Acceptance rates among males were higher than among females. The functions of One-Way ANOVA and Chi-square were used to establish any significant differences and associations between means and variables respectively. Concerns regarding the safety, efficacy, and accuracy of information about the developed vaccines are significant factors that must be promptly addressed, to arrest crises revolving around COVID-19 vaccine hesitancy, especially in Kenya and among females in both populations, where acceptance rates were lower. Expansion of the screening program to incorporate antibody (serology) tests, is also highly recommended in the present circumstance. Equitable distribution of vaccines globally should be encouraged and promoted to adequately cover low- and middle-income countries. To enhance effective combat on vaccination hesitancy and apprehension in different countries, mitigation techniques unique to those countries must be adopted.

Background: Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services. Aim: This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities. Setting: The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020. Methods: This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited. Results: Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients. Conclusion: Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities. Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.

Rises in parental vaccine hesitancy, observed during the COVID−19 pandemic, threaten public health. This is especially concerning for vaccines not typically required for school-entry, such as the vaccines for COVID−19 and human papillomavirus (HPV), both of which also have much lower rates of completion compared to other adolescent vaccines. Pediatricians are well-positioned to address vaccine hesitancy and can offer insights into parents’ perspectives in this area. There is evidence that pediatricians’ sharing their own vaccine stories may help to address parents’ concerns; yet we have little information on pediatricians’ or their children’s COVID−19 vaccine uptake. To address these gaps, we conducted a cross-sectional survey about Massachusetts pediatricians’ behaviors and perspectives on vaccines that face significant resistance: HPV and COVID−19 vaccines. A total of 144 people initiated the survey, and 109 participants were eligible and completed the survey. Participants reported high levels of COVID−19 vaccine uptake for themselves (97%) and their children (98%). Similarities in parents’ resistance toward both vaccines were identified: fear of side effects; general vaccine resistance. Pediatricians reported a rise in vaccine hesitancy since the beginning of the COVID−19 pandemic. Future research should focus on identifying strategies to build overall vaccine confidence and streamline these efforts for pediatricians.

Abstract Subanesthetic-dose racemic (R,S)-ketamine (ketamine) produces rapid, robust, and sustained antidepressant effects in major depressive disorder (MDD) and bipolar disorder (BD) and has also been shown to effectively treat neuropathic pain, complex regional pain syndrome, and post-traumatic stress disorder (PTSD). However, to date, its mechanism of action remains unclear. Preclinical studies found that (2 R,6 R;2 S,6 S)-hydroxynorketamine (HNK), a major circulating metabolite of ketamine, elicits antidepressant effects similar to those of ketamine. To help determine how (2 R,6 R)-HNK contributes to ketamine’s mechanism of action, an exploratory, targeted, metabolomic analysis was carried out on plasma and CSF of nine healthy volunteers receiving a 40-minute ketamine infusion (0.5 mg/kg). A parallel targeted metabolomic analysis in plasma, hippocampus, and hypothalamus was carried out in mice receiving either 10 mg/kg of ketamine, 10 mg/kg of (2 R,6 R)-HNK, or saline. Ketamine and (2 R,6 R)-HNK both affected multiple pathways associated with inflammatory conditions. In addition, several changes were unique to either the healthy human volunteers and/or the mouse arm of the study, indicating that different pathways may be differentially involved in ketamine’s effects in mice and humans. Mechanisms of action found to consistently underlie the effects of ketamine and/or (2 R,6 R)-HNK across both the human metabolome in plasma and CSF and the mouse arm of the study included LAT1, IDO1, NAD+, the nitric oxide (NO) signaling pathway, and sphingolipid rheostat.

Abstract Effectively preventing and controlling zoonotic diseases requires a One Health approach that involves collaboration across sectors responsible for human health, animal health (both domestic and wildlife), and the environment, as well as other partners. Here we describe the Generalizable One Health Framework (GOHF), a five-step framework that provides structure for using a One Health approach in zoonotic disease programs being implemented at the local, sub-national, national, regional, or international level. Part of the framework is a toolkit that compiles existing resources and presents them following a stepwise schematic, allowing users to identify relevant resources as they are required. Coupled with recommendations for implementing a One Health approach for zoonotic disease prevention and control in technical domains including laboratory, surveillance, preparedness and response, this framework can mobilize One Health and thereby enhance and guide capacity building to combat zoonotic disease threats at the human–animal–environment interface.

Abstract Background Zoonotic diseases pose a significant threat to human, animal, and environmental health. The Economic Community of West African States (ECOWAS) has endured a significant burden of zoonotic disease impacts. To address zoonotic disease threats in ECOWAS, a One Health Zoonotic Disease Prioritization (OHZDP) was conducted over five days in December 2018 to prioritize zoonotic diseases of greatest regional concern and develop next steps for addressing these priority zoonoses through a regional, multisectoral, One Health approach. Methods The OHZDP Process uses a mixed methods prioritization process developed by the United States Centers for Disease Control and Prevention. During the OHZDP workshop, representatives from human, animal, and environmental health ministries from all 15 ECOWAS Member States used a transparent and equal process to prioritize endemic and emerging zoonotic diseases of greatest regional concern that should be jointly addressed by One Health ministries and other partners. After the priority zoonotic diseases were identified, participants discussed recommendations and further regional actions to address the priority zoonoses and advance One Health in the region. Results ECOWAS Member States agreed upon a list of seven priority zoonotic diseases for the region – Anthrax, Rabies, Ebola and other viral hemorrhagic fevers (for example, Marburg fever, Lassa fever, Rift Valley fever, Crimean-Congo Hemorrhagic fever), zoonotic influenzas, zoonotic tuberculosis, Trypanosomiasis, and Yellow fever. Participants developed recommendations and further regional actions that could be taken, using a One Health approach to address the priority zoonotic diseases in thematic areas including One Health collaboration and coordination, surveillance and laboratory, response and preparedness, prevention and control, workforce development, and research. Conclusions ECOWAS was the first region to use the OHZDP Process to prioritize zoonotic disease of greatest concern. With identified priority zoonotic diseases for the region, ECOWAS Member States can collaborate more effectively to address zoonotic diseases threats across the region using a One Health approach. Strengthening national and regional level multisectoral, One Health Coordination Mechanisms will allow ECOWAS Member States to advance One Health and have the biggest impact on improving health outcomes for both people and animals living in a shared environment.

Vaccine hesitancy is a long-standing public health issue. The present work describes parental perceptions of COVID-19 vaccination for 5- to 11-year-old children, to aid in vaccination efforts. Parents of 5- to 11-year-old children residing in Worcester, Massachusetts, were recruited through community partner outreach to participate in semi-structured focus groups. Focus groups were conducted via Zoom in English (n = 4) and Spanish (n = 3) with a total of 67 parents. Rapid qualitative analysis was used. Most participants were female and of Hispanic ethnicity. Themes included: (1) Trusted sources and influential types of information (e.g. personal COVID-19 vaccine stories from peers and healthcare providers), (2) Motivations for vaccination: health (i.e. protecting children, families, and communities from COVID-19), (3) Motivations for vaccination: social, emotional, and educational (i.e. mitigating related negative effects of COVID-19), (4) Drivers of vaccine hesitancy (e.g. frustration, uncertainty, and confusion), (5) Differentiating vaccine acceptance, hesitancy, and resistance, (6) Needed information. Although this context may be unique to parents of 5- to 11-year-old children from Central Massachusetts, especially those who may be Spanish-speaking, or of Hispanic ethnicity, this work reinforces the need for effective and persistent communication to combat vaccine hesitancy. In describing parents’ perceptions toward COVID-19 vaccination in their 5- to 11-year-old children, we contextualize vaccine hesitancy and highlight opportunities for existing evidence-based communication strategies to increase vaccine confidence and uptake in pediatric populations.

Major Depressive Disorder (MDD) is a major cause of disability worldwide and is associated with serious lasting impairment. A leading hypothesis of the pathophysiology of MDD is the monoamine deficiency hypothesis which suggests that depression is caused by depletion of serotonin, norepinephrine, or dopamine in the central nervous system. Serotonin is the most widely studied neurotransmitter in the pathophysiology of depression, with studies showing that reduced central serotonin synthesis leads to depressive symptoms in individuals at risk for depression. Selective Serotonin Reuptake Inhibitors (SSRI) inhibit serotonin reuptake and subsequently increase the amount of serotonin available in synapses. Common side effects of SSRIs include increased suicidality of patients under the age of 25, sexual dysfunction, anxiety, dizziness, weight gain, gastrointestinal distress, and headache. Other side effects include prolonging the QT interval, coagulopathy, and the risk of serotonin syndrome, as well as SSRI discontinuation syndrome. Sites of increased bleeding related to SSRI use have been reported to occur in the upper gastrointestinal tract, as well as intracranially. Based on the current literature, three studies have found that SSRIs are not associated with increased bleeding and/or increased perioperative risk, while others have demonstrated that SSRIs are associated with an increased risk in perioperative use. The inhibition of serotonin reuptake can affect platelet aggregation since platelets also express the serotonin transporter. SSRIs can result in decreased storage of serotonin in platelet dense granules. Increased serotonin can also increase gastric acid secretion, which increases the risk for ulceration. SSRIs in combination with NSAIDs also show a significantly increased risk of upper GI bleeding. Some studies show an increased bleeding risk from 30% to 70% when taking a combination of vitamin K antagonists and SSRIs in hospitalized patients. Related to the high prevalence of conditions that are treated with SSRIs, the bleeding risk associated with this class of medication merits further study.

Proprioception of all animals is important in being able to have coordinated locomotion. Stretch activated ion channels (SACs) transduce the mechanical force into electrical signals in the proprioceptive sensory endings. The types of SACs vary among sensory neurons in animals as defined by pharmacological, physiological and molecular identification. The chordotonal organs within insects and crustaceans offer a unique ability to investigate proprioceptive function. The effects of the extracellular environment on neuronal activity, as well as the function of associated SACs are easily accessible and viable in minimal saline for ease in experimentation. The effect of extracellular [Ca2+] on membrane properties which affect voltage-sensitivity of ion channels, threshold of action potentials and SACs can be readily addressed in the chordotonal organ in crab limbs. It is of interest to understand how low extracellular [Ca2+] enhances neural activity considering the SACs in the sensory endings could possibly be Ca2+ channels and that all neural activity is blocked with Mn2+. It is suggested that axonal excitability might be affected independent from the SAC activity due to potential presence of calcium activated potassium channels (K(Ca)) and the ability of Ca2+ to block voltage gated Na+ channels in the axons. Separating the role of Ca2+ on the function of the SACs and the excitability of the axons in the nerves associated with chordotonal organs is addressed. These experiments may aid in understanding the mechanisms of neuronal hyperexcitability during hypocalcemia within mammals.

We explored perspectives of clinicians in central and western Massachusetts about efforts to vaccinate pediatric patients against COVID-19 as well as best practices and challenges for vaccine delivery. We conducted semi-structured qualitative interviews (n = 16) with family practice and pediatric clinicians between late October and early December 2021. Our interviews addressed: process for vaccination and vaccine promotion, parental receptivity to COVID-19 vaccination, receptivity to other pediatric vaccines, resources needed to support vaccine promotion, and best practices developed to encourage hesitant parents. Using a multi-prong recruitment strategy we invited clinicians to participate in telephone interviews, which were audio-recorded and transcribed. We used rapid qualitative analysis to produce summary templates for each interview which were ultimately combined into a matrix summary. The majority of participants (n = 10) were offering the vaccine in their own clinics, while the remainder cited challenges related to staffing, logistics, and space that prevented them from offering the vaccine. Clinicians reported parents fall into three groups: vaccine-accepting, hesitant but potentially accepting, and refusers. Strategies they identified that worked to encourage hesitant parents were sharing personal vaccine stories, acknowledging parents’ fears about the vaccine, and being persistent with the most hesitant parents. Yet resources are needed including educational materials and training in how to have these conversations. While challenges related to staffing and space will be difficult to overcome for clinics to be able to offer vaccination on-site, our results highlight the importance of developing effective messaging strategies and training clinicians in how to integrate them into routine practice.

Coronavirus disease 2019 (COVID-19) is a pandemic whose adverse effects have been felt all over the world. As of August 2022, reports indicated that over 500 million people in the world had been infected and the number of rising deaths from the disease were slightly above 6.4 million. New variants of the causative agent, SARS-CoV-2 are emanating now and then and some are more efficacious and harder to manage. SARS-CoV-2 main protease (Mpro) has essential functions in viral gene expression and replication through proteolytic cleavage of polyproteins. Search for SARS-CoV-2 Mpro inhibitors is a vital step in the treatment and management of COVID-19. In this study, we investigated whether alkaloids with antiviral and myriad other bioactivities from the genus Lycoris can act as SARS-CoV-2 Mpro inhibitors. We conducted a computer-aided drug design study through screening optimal ligands for SARS-CoV-2 Mpro from a list of over 150 Lycoris alkaloids created from online databases such as ChEMBL, PubChem, ChemSpider, and published journal papers. The In silico study involved molecular docking of Lycoris alkaloids to SARS-CoV-2 Mpro active site, absorption, distribution, metabolism, elimination and toxicity (ADMET) screening and finally molecular dynamic (MD) simulations of the most promising ligand-SARS-CoV-2 Mpro complexes. The study identified 3,11-dimethoxy-lycoramine, narwedine, O-demethyllycoramine and epilycoramine as drug-like and lead-like Lycoris alkaloids with favorable ADMET properties and are very likely to have an inhibition activity on SARS-CoV-2 Mpro and may become potential drug candidates. DOI: http://dx.doi.org/10.5281/zenodo.7041808

Introduction: Rates of human papillomavirus (HPV) vaccination remain low and missed opportunities for HPV vaccination are widespread. Researchers have identified factors related to HPV vaccination, but less is known about missed opportunities. Methods: We used medical claims data from a large Midwestern insurance provider to explore relationships between adolescent and provider characteristics and missed opportunities for HPV vaccination. We stratified models by initiation status with adolescents who had received one or more HPV vaccinations in one group (n = 6,123) and adolescents with no record of an HPV vaccination in the other (n = 8,107). Results: There were significant differences in comparisons of all variables between initiators and non-initiators. Notably, non-initiators had lower rates of vaccination for HPV and other adolescent vaccinations, and fewer well-child visits. For all adolescents, birth year, having other recommended vaccines, and number of well-child visits were significantly associated with missed opportunities. Additionally, among initiators, pediatrician as a primary care provider and being in a rural area were significantly associated. Discussion: Overall, adolescents with greater healthcare utilization had more missed opportunities, indicating that, despite increased numbers of visits, providers are not taking advantage of these opportunities to vaccinate. Future research should prioritize developing a deeper understanding of why these missed opportunities are occurring and implementing new and existing strategies to prevent them. Reducing missed opportunities will help to prevent future HPV-related cancers and the significant morbidity and mortality that they can cause.

Abstract Background Hikikomori is a phenomenon describing people who exhibit behaviors of self-secluding themselves at home for long durations of time and usually only having face-to-face social interactions with none other than family. Existing interventions for hikikomori are inconclusive and the majority are absent in using a theoretical framework to guide its components. Therefore, applicability of the psychosocial recovery framework of Connectedness, Hope and Optimism, Identity, Meaning in Life, and Empowerment (CHIME) towards hikikomori care was reviewed. Method Five databases were searched in April 2020 with the search formula from a published systematic review on hikikomori combined with search terms specific to domains of the CHIME framework. Articles included in the review were of the English language, of all publication years, peer-reviewed, quantitative or qualitative research studies and case studies, included study designs that were observational or interventional in nature, and involved populations of socially withdrawn youth. Results CHIME’s comprehensive structure and organized approach could guide researchers or service providers in determining areas needing assessments, measurement, and areas of focus. It is suggested that the CHIME framework is applicable after modifying a specific dimension—‘meaning of mental illness experiences’ into ‘meaning of the hikikomori experience’. Thematic overlap occurred between the domains of connectedness, identity, and meaning. Yet, additional dimensions or domains such as trust building, non-linearity, and spatiality can be included for addressing specific limitations in this application, which would help towards catering services to help hikikomori in recovery or in increasing quality-of-life of those individuals’ while entrapped in this withdrawn lifestyle. Conclusion CHIME framework could be applicable towards hikikomori care after applying the suggested modifications. Additionally, many knowledge gaps were found in literature during this review that warrants further investigation to improve hikikomori care.

Background: Unicompartmental knee arthroplasty (UKA) treats arthritis involving only one compartment of the knee. Lateral UKA is mainly performed through medial parapatellar or lateral parapatellar approaches to the knee. This technique article introduces a medial subvastus approach to lateral UKA, discusses the clinical rationale behind its use, and offers a preliminary retrospective study on short-term outcomes of lateral UKAs using the lateral vs medial subvastus approaches. Methods: A description of the medial subvastus approach is included. In addition, we reviewed 32 and 30 lateral UKAs performed using the lateral and medial subvastus approaches, respectively. Minimum follow-up duration was 1 year. Knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR) knee scores were used for comparison. Results: Age and body mass index were similar between the 2 cohorts. Mean KOOS, JR. scores for the subvastus approach group were significantly higher than those for the lateral approach group at 81.41 ± 2.0 for medial subvastus and 74.19 ± 2.9 for lateral (P = .02). One deep infection and 2 revision total knee arthroplasties occurred in the lateral approach group. Neither occurred in the subvastus group. The mean follow-up duration was significantly longer for the lateral approach group than that for the subvastus group at 749 vs 410 days (P < .001). Literature on time-dependence of patient-reported outcomes supports usage of the data, despite follow-up discrepancies. Conclusions: A subvastus approach for lateral UKA may offer improved visualization, easier conversion to total knee arthroplasty, and faster recovery, based on clinical observation. Preliminary results suggest improved short-term knee scores compared to a lateral approach.

Abstract Interventions to reduce tremor in essential tremor (ET) and Parkinson’s disease (PD) clinical populations often utilize pharmacological or surgical therapies. However, there can be significant side effects, decline in effectiveness over time, or clinical contraindications for these interventions. Therefore, alternative approaches must be considered and developed. Some non-pharmacological strategies include assistive devices, orthoses and mechanical loading of the tremorgenic limb, while others propose peripheral electrical stimulation. Specifically, peripheral electrical stimulation encompasses strategies that activate motor and sensory pathways to evoke muscle contractions and impact sensorimotor function. Numerous studies report the efficacy of peripheral electrical stimulation to alter tremor generation, thereby opening new perspectives for both short- and long-term tremor reduction. Therefore, it is timely to explore this promising modality in a comprehensive review. In this review, we analyzed 27 studies that reported the use of peripheral electrical stimulation to reduce tremor and discuss various considerations regarding peripheral electrical stimulation: the stimulation strategies and parameters, electrodes, experimental designs, results, and mechanisms hypothesized to reduce tremor. From our review, we identified a high degree of disparity across studies with regard to stimulation patterns, experimental designs and methods of assessing tremor. Having standardized experimental methodology is a critical step in the field and is needed in order to accurately compare results across studies. With this review, we explore peripheral electrical stimulation as an intervention for tremor reduction, identify the limitations and benefits of the current state-of-the-art studies, and provide ideas to guide the development of novel approaches based on the neural circuitries and mechanical properties implied in tremor generation.

Abstract The COVID-19 pandemic has disrupted traditional global point-of-care ultrasound (POCUS) education and training, as a result of travel restrictions. It has also provided an opportunity for innovation using a virtual platform. Tele-ultrasound and video-conferencing are alternative and supportive tools to augment global POCUS education and training. There is a need to support learners and experts to ensure that maximum benefit is gained from the use of these innovative modalities.

The agenda for Universal Health Coverage has driven the exploration of various innovative approaches to expanding health services to the general population. As more African countries have adopted digital health tools as part of the strategic approach to expanding health services, there is a need for defining a standard framework for implementation across board. Therefore, there is a need to review and employ an evidence-based approach to inform managing challenges, adopting best approaches, and implement informed recommendations. We reviewed a variety of digital health tools applied to different health conditions in primary care settings and highlighted the challenges faced, approaches that worked and relevant recommendations. These include limited coverage and network connectivity, lack of technological competence, lack of power supply, limited mobile phone usage and application design challenges. Despite these challenges, this review suggests that mHealth solutions could attain effective usage when healthcare workers receive adequate onsite training, deploying applications designed in an intuitive and easy to understand approach in a manner that fits into the users existing workflows, and involvement of the stakeholders at all levels in the design, planning, and implementation stages of the interventions.

Aspergillus fumigatus is a potentially deadly opportunistic human pathogen. A. fumigatus has evolved a variety of mechanisms to evade detection by the immune system. For example, the conidium surface is covered in a layer of 1,8-dihydroxynaphthalene (DHN) melanin which masks the antigen macrophages use for recognition. DHN melanin also protects conidia from ultraviolet radiation and gives A. fumigatus conidia their characteristic green-grayish color. Here, we conducted genomic analysis of two closely related white-spore natural variants of A. fumigatus in comparison to two closely related green-spore isolates to identify a genetic basis of the white-spore phenotype. Illumina whole-genome resequencing data of the four isolates was used to identify variants that were shared in the white-spore isolates and different from both the green-spore isolates and the Af293 reference genome (which is also a green-spore isolate). We identified 4,279 single nucleotide variants and 1,785 insertion/deletions fitting this pattern. Among these, we identified 64 variants predicted to be high impact, loss-of-function mutations. One of these variants is a single nucleotide deletion that results in a frameshift in pksP (Afu2g17600), the core biosynthetic gene in the DHN melanin encoding gene cluster. The frameshift mutation in the white-spore isolates leads to a truncated protein in which a phosphopantetheine attachment site (PP-binding domain) is interrupted and an additional PP-binding domain and a thioesterase domain are omitted. Growth rate analysis of white-spore and green-spore isolates at 37°C and 48°C revealed that white-spore isolates are thermosensitive. Growth rate of A. fumigatus Af293 and a pksP null mutant in the Af293 background suggests pksP is not directly involved in the thermosensitivity phenotype. Further, our study identified a mutation in a gene (Afu4g04740) associated with thermal sensitivity in yeasts which could also be responsible for the thermosensitivity of the white-spore mutants. Overall, we used comparative genomics to identify the mutation and protein alterations responsible for the white-spore phenotype of environmental isolates of A. fumigatus.

Osteoid osteomas are benign, typically intracortical lesions most often affecting the diaphyses of long bones. We describe a case involving a 26-year-old male laborer who presented with the insidious onset of ulnar-sided wrist pain. He was diagnosed with and successfully treated with surgical excision for an osteoid osteoma involving the hook of the hamate.

Bin/Amphiphysin/RVS (BAR) domain proteins belong to a superfamily of coiled-coil proteins influencing membrane curvature in eukaryotes and are associated with vesicle biogenesis, vesicle-mediated protein trafficking, and intracellular signaling. Here, we report a bacterial protein with BAR domain-like activity, BdpA, from Shewanella oneidensis MR-1, known to produce redox-active membrane vesicles and micrometer-scale outer membrane extensions (OMEs). BdpA is required for uniform size distribution of membrane vesicles and influences scaffolding of OMEs into a consistent diameter and curvature. Cryo-TEM reveals that a strain lacking BdpA produces lobed, disordered OMEs rather than membrane tubules or narrow chains produced by the wild-type strain. Overexpression of BdpA promotes OME formation during planktonic growth of S. oneidensis where they are not typically observed. Heterologous expression results in OME production in Marinobacter atlanticus and Escherichia coli. Based on the ability of BdpA to alter membrane architecture in vivo, we propose that BdpA and its homologs comprise a newly identified class of bacterial BAR domain-like proteins.