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Hybrids of Poncirus trifoliata L. Raf. with Citrus have shown degrees of tolerance to the deadly citrus greening disease, hence prompting interest as potential commercial varieties. Although P. trifoliata is known to produce fruit that is inedible, fruit from many advanced hybrid trees have not been evaluated for their quality potential. The sensory quality of selected Citrus hybrids with varying degrees of P. trifoliata in their pedigrees is reported herein. Four Citrus × P. trifoliata hybrids developed through the USDA Citrus scion breeding program-1-76-100, 1-77-105, 5-18-24, and 5-18-31-had acceptable eating quality and sweet and sour taste, with mandarin, orange, fruity-noncitrus, and floral flavors. On the other hand, hybrids with higher proportion of P. trifoliata in their pedigrees, US 119 and 6-23-20, produced a juice characterized by green, cooked, bitter, and Poncirus-like flavor and aftertaste. Partial least square regressions revealed that the Poncirus-like off-flavor is likely due to a combination of higher than typical amounts of sesquiterpene hydrocarbons (woody/green odor), monoterpenes (citrus/pine), and terpene esters (floral) and a lack of aldehydes with typical citrus odor (octanal, nonanal, and decanal). Sweetness and sourness were mostly explained by high sugars and acids, respectively. Further, carvones and linalool contributed to sweetness in the samples from early and late seasons, respectively. In addition to highlighting chemical contributors to sensory descriptors in Citrus × P. trifoliata hybrids, this study provides useful information on sensory quality for future citrus breeding efforts. PRACTICAL APPLICATION: The relationships between the sensory quality and secondary metabolites of Citrus × P. trifoliata hybrids described in this study help identify disease-resistant Citrus scion hybrids with acceptable flavor and help mobilize this resistance in future breeding efforts. It also shows potential of such hybrids to be commercialized., (Published 2023. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Long-lasting insecticidal nets (LLINs) are one of the key interventions in the global fight against malaria. Since 2014, mass distribution campaigns of LLINs aim for universal access by all citizens of Burundi. In this context, we assess the impact of LLINs mass distribution campaigns on malaria incidence, focusing on the endemic highland health districts. We also explored the possible correlation between observed trends in malaria incidence with any variations in climate conditions., Methods: Malaria cases for 2011-2019 were obtained from the National Health Information System. We developed a generalised additive model based on a time series of routinely collected data with malaria incidence as the response variable and timing of LLIN distribution as an explanatory variable to investigate the duration and magnitude of the LLIN effect on malaria incidence. We added a seasonal and continuous-time component as further explanatory variables, and health district as a random effect to account for random natural variation in malaria cases between districts., Results: Malaria transmission in Burundian highlands was clearly seasonal and increased non-linearly over the study period. Further, a fast and steep decline of malaria incidence was noted during the first year after mass LLIN distribution (p<0.0001). In years 2 and 3 after distribution, malaria cases started to rise again to levels higher than before the control intervention., Conclusion: This study highlights that LLINs did reduce the incidence in the first year after a mass distribution campaign, but in the context of Burundi, LLINs lost their impact after only 1 year., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Studies comparing novel collection methods for host seeking and resting mosquitoes A. arabiensis were undertaken in a village in Eritrea. Techniques included an odor baited trap, a novel tent-trap, human landing collection and three methods of resting collection. A technique for the collection of mosquitoes exiting vegetation is also described. Pre-gravid rates were determined by dissection of host seeking insects and post-prandial egg development among insects collected resting., Results: Overall 5,382 host-seeking, 2,296 resting and 357 A. arabiensis exiting vegetation were collected. The Furvela tent-trap was the most efficient, risk-free method for the collection of outdoor host-seeking insects, whilst the Suna trap was the least effective method. Mechanical aspirators (the CDC backpack or the Prokopack aspirator) were superior to manual aspiration in a dark shelter but there was no advantage over manual aspiration in a well-lit one. An estimated two-thirds of newly-emerged mosquitoes went through a pre-gravid phase, feeding twice before producing eggs. Mosquitoes completed gonotrophic development in a dark shelter but left a well-lit shelter soon after feeding. One blood-fed female marked in the village was recaptured 2 days after release exiting vegetation close to the oviposition site and another, shortly after oviposition, attempting to feed on a human host 3 days after release. Exit rates of males from vegetation peaked 3 min after the initial male had left. Unfed and gravid females exited approximately 6 min after the first males., Conclusions: Furvela tent-traps are suitable for the collection of outdoor biting A. arabiensis in Eritrea whilst the Prokopack sampler is the method of choice for the collection of resting insects. Constructing well-lit, rather than dark, animal shelters, may encourage otherwise endophilic mosquitoes to leave and so reduce their survival and hence their vectorial capacity., Competing Interests: The authors declare that they have no competing interests., (© 2021 Charlwood et al.)

Objective : Fear of cancer recurrence (FCR) adversely affects quality of life, but health behaviors such as physical activity (PA) and fruit and vegetable intake (FVI) may help alleviate FCR for some survivors. This cross-sectional study tested the common-sense model (CSM) of FCR by investigating associations between constructs from the CSM (perceived illness consequences, control over health, and timeline), and survivors' health behaviors, health self-efficacy, and FCR. Methods : Using wave 3 data from the American Cancer Society Longitudinal Study of Cancer Survivorship-I, path analyses were conducted among mixed-cancer participants ( N = 2,337) who were on average 8.8 mean years post-diagnosis. Results : A final good fitting model [ χ 2 (5, N = 2,337) = 38.12, p < 0.001; SRMR = 0.02; CFI = 0.99; RMSEA = 0.05] indicated that perceiving fewer illness consequences, and greater control over one's health, were directly associated with higher PA ( β = 0.15 and -0.24, p < 0.01, respectively) and higher health self-efficacy ( β = 0.24, -0.38, p < 0.01, respectively). Timeline (i.e., perceiving cancer as chronic) was directly associated with lower health self-efficacy ( β = -0.15, p < 0.01) and higher FCR ( β = 0.51, p < 0.01). Both greater PA and FVI were directly associated with higher health self-efficacy ( β = 0.10 and 0.11, p < 0.01, respectively) which in turn showed a direct association with lower FCR ( β = -0.15, p < 0.01). Conclusion : Increasing survivors' sense of control over health, decreasing perceived chronicity of the illness, and mitigating its consequences may increase their health behaviors and health self-efficacy, which in turn could decrease their FCR. Longitudinal and experimental studies are needed to confirm these findings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Séguin Leclair, Lebel and Westmaas.)

Objective: The objective of this study was to test the severity rating of the signs and architectural changes for interrater reliability among world experts via analysis of lichen sclerosus (LS) photographs., Methods: A recent Delphi consensus exercise established a list of symptoms, signs, and architectural changes, which experts feel are important to include in a severity scale. Photographs of vulvar LS were manually extracted from patient charts and 50 photographs with a range of severity of signs and architectural changes were chosen. Lichen sclerosus experts were invited to take part in the study and 3 dermatologists and 3 gynecologists were selected for their expertise and geographic variety. Raters assessed the photographs for multiple signs and architectural changes as well as an overall impression of disease severity on a 4-point Likert scale. Intraclass correlation coefficients were calculated., Results: The intraclass correlation coefficients were very poor for individual signs and architectural changes as well as for overall disease severity when analyzed for all 6 raters as well as when analyzed with dermatologists' and gynecologists' responses grouped separately. There were no statistically significant correlations found., Conclusions: Global experts were unable to agree on any signs, architectural changes, or an overall global impression to assess vulvar LS disease severity based on analysis of vulvar photographs. Standardized descriptions regarding what constitutes mild, moderate, and severe signs and anatomical changes are required before further scale development can occur.

Mandarins (or tangerines) are mainly consumed as fresh fruits due to the ease of peeling and desirable flavor. Sweetness, acidity, and flavor of mandarin are the most important criteria for consumer preference. The objective of this study was to evaluate the effects of harvest date on sensory and chemical components of four mandarin cultivars (Murcott, 411, Temple, and 'LB8-9' Sugar Belle®). Volatiles were extracted from the headspace of juice samples with solid phase microextraction (SPME) and analyzed using gas chromatography-mass spectrometry (GC-MS). The optimum harvest window for eating quality of 411 was late January to mid-February (soluble solids content [SSC]/titratable acidity [TA]: 11.3 to 14.0), Sugar Belle® fruits were best tasted when harvested from mid- to end of January (SSC/TA: 14.1 to 16.1), and February was the best month for harvesting Murcott (SSC/TA: 13.10 to 18.0) and Temple (SSC/TA:10.3 to 12.50). Sensory perception of sweetness, ripeness, and juiciness increased as SSC/TA increased while sourness and bitterness decreased. Pumpkin flavor, an indicator of overripe fruit, was mainly noticed late in the season. Tangerine flavor tended to decrease, whereas fruity-noncitrus flavor tended to increase with fruit maturity. Monoterpenes were the most abundant volatiles and tended to decrease with fruit maturity, whereas alcohols, esters, and aldehydes increase. Aldehydes, esters, and alcohols were positively correlated with sweetness, ripeness, juiciness, and fruity characteristics, and negatively with sourness and bitterness. On the other hand, monoterpenes were positively correlated with bitterness and tangerine flavor, and negatively correlated with sweetness and fruity-noncitrus flavor. The highest number of esters was found in Temple, whereas Murcott and 411 were high in aldehydes., (© 2020 Institute of Food Technologists®.)

Pain is universal, yet the prevalence of overdose and treatment of pain varies significantly between the United States (US) and Western Europe. Overdose deaths are seven times more common in the US compared to Western Europe. Cultural perceptions of pain, perception and treatment of opioid use disorder, pharmaceutical advertising, and rates and regulation of prescribing of opioids represent examples of factors that may be related to such differences between the US and Western Europe. As Rhode Island continues to battle the devastating and well-documented national opioid overdose epidemic, we should consider how cultural, regulatory differences, and economic factors may influence pain and its treatment.

Background: Fear of cancer recurrence (FCR) adversely affects quality of life. Cigarette smoking increases the risk of recurrence and may exacerbate FCR among survivors who smoke. FCR also may motivate quitting, but research on whether quitting reduces long-term survivors' FCR is lacking. Among long-term survivors of various cancers, the authors investigated relationships between quitting (vs smoking) and FCR, controlling for sociodemographic, cancer-related, and health-related variables., Methods: Data from the American Cancer Society's Longitudinal Study of Cancer Survivors-I were used in generalized estimating equations to compare FCR at 3 waves (T1-T3) after diagnosis between 2 groups; survivors who reported current smoking (n = 196) approximately 9 years after diagnosis (at T3) or who, based on T3 recall of quitting age, had quit smoking after diagnosis (n = 97). T3 cross-sectional analyses among current smokers examined associations of FCR with smoking level and intentions of quitting., Results: A significant smoking status × time interaction (P = .003) indicated that only quitters experienced decreases in FCR from T1 to T3 (P = .007). At T3, FCR was significantly lower among quitters than among current smokers (P = .05), and current smokers reported that FCR caused more functioning impairments (eg, disruption of relationships, everyday activities, mood) than quitters (P = .001). Cross-sectional analyses (T3) among smokers found that heavier smoking predicted less attempts to cope with FCR (P = .04) and that reassurance behaviors (eg, self-examination for cancer) predicted stronger quitting intentions (P = .02)., Conclusions: Quitting smoking lowers FCR, and FCR may disrupt functioning among continuing smokers. Interventions for FCR should be multimodal and should treat both psychological distress and health-related behaviors such as smoking., (© 2019 American Cancer Society.)

Objective: The aim of the study was to document treatment-seeking experiences of women with chronic vulvar pain, comfort communicating about pain, and test the clinical utility of the screening version of the Vulvar Pain Assessment Questionnaire, screening version (VPAQscreen)., Materials and Methods: Patients scheduled for an appointment with the Program in Vulvar Health at Oregon Health and Science University were invited to complete the VPAQscreen and answer descriptive questions about previous treatment-seeking experiences and communication with health care providers. Clinicians provided provisional diagnoses based on VPAQscreen summaries, final diagnoses based on gynecological examination, and commented on alignment with clinical observations. Patients gave feedback on the accuracy and helpfulness of the VPAQscreen summary, characteristics of the questions asked, and whether their comfort communicating increased., Results: Participants reported previously seeing approximately 5 medical doctors and 2 other health care providers and perceived them as lacking knowledge of vulvar pain syndromes. Providers indicated that VPAQscreen summaries aligned with clinical presentations and suggested provisional diagnoses with more than 80% accuracy. Participants reported that VPAQscreen summaries were helpful and accurate in summarizing symptoms. Most reported that the number, range, and readability of VPAQscreen questions were good or excellent. More than half reported that completing the VPAQscreen increased comfort when speaking with their Oregon Health and Science University physician., Conclusions: Patients with vulvar pain often endure a lengthy process of consulting multiple clinicians before securing care. The VPAQscreen was more than 80% accurate in predicting diagnosis at this specialty clinic and was useful in assisting patients with expressing symptoms. The applicability of the VPAQscreen in general practice is unknown, although it shows promise.

Objective: The goal of this study was to examine fear of cancer recurrence (FCR) and 2 health behaviors, physical activity and fruit and vegetable intake, from early to long-term survivorship in a large cohort of mixed cancer survivors., Method: Group-based trajectory analyses and repeated measures analysis of variance were conducted on data collected in the American Cancer Society's Studies of Cancer Survivorship-I. Two thousand three hundred thirty-seven survivors of 10 cancers completed the survey at 3 time points (M = 1.3, 2.2, and 8.8 years postdiagnosis)., Results: The current study found 3 FCR trajectories clustering cancer survivors by FCR severity: low (33.6%), moderate (58.1%), and high (8.3%). FCR significantly decreased over time and remained distinct for each trajectory group. Patient characteristics prevalent in the high FCR group were being female, of younger age, Hispanic ethnicity, having advanced cancer stage (II to III) and non-Hodgkin lymphoma, and low adherence to physical activity and fruit and vegetable intake recommendations. The high FCR group also reported significantly fewer of these health behaviors compared with the other groups, albeit the effect size was small., Conclusions: Across the survivorship trajectory, FCR severity decreased but remained distinct for the 3 trajectory groups. Future investigations should inquire about the specific needs of each FCR group to subsequently develop targeted interventions. A weak association between FCR and health behaviors was found, with individuals in the high FCR group reporting less health behaviors. Future research should assess the direction of this relationship over time to inform intervention targets within this subgroup. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Periclitoral masses are uncommon disorders in gynecology often leading to pain and distress. With the popularity of female genital hair grooming and depilation, the vulva has been exposed to new insults including contact dermatitis and folliculitis. The unique anatomy of the protective covering of the clitoral hood may subject hair fragments to trapping, inflammation, irritation, and in some cases abscess formation.

The relative efficacy of a mechanical (Prokopack) collection method vs. manual aspiration in the collection of resting mosquitoes was evaluated in northern Tanzania before and after an intervention using indoor residual spraying and longlasting insecticide-treated nets. In smoke-free houses mosquitoes were collected from the roof and walls, but in smoky houses mosquitoes were found predominantly on the walls. Anopheles gambiae (Diptera: Culicidae) constituted 97.7% of the 312 An. gambiae complex specimens identified before but only 19.3% of the 183 identified after the intervention. A single sampling with the Prokopack collected a third of the available insects. Anopheles gambiae completed its gonotrophic development indoors, whereas Anopheles arabiensis did so outdoors. In both species gonotrophic development took 2 days. Most unfed resting An. arabiensis collected outdoors were virgins, whereas the majority of engorged insects were parous (with well-contracted sacs). Daily survival was estimated to be 80.0%. Only 9.4% of the engorged An. arabiensis collected outdoors and 47.1% of those collected indoors had fed on humans. Using the Prokopack sampler is more efficient than manual methods for the collection of resting mosquitoes. Malaria transmission may have been affected by a change in vector composition resulting from a change in feeding, rather than reduced survival. Monitoring the proportions of members of the An. gambiae complex may provide signals of an impending breakdown in control., (© 2018 The Royal Entomological Society.)

Background: The determination of parous rates in mosquitoes, despite numerous shortcomings, remains a tool to evaluate the effectiveness of control programs and to determine vectorial capacity in malaria vectors. Two dissection techniques are used for this. For one, the tracheoles of dried ovaries are examined with a compound microscope and in the other the follicular stalk of ovaries is examined, wet, with a stereomicroscope. The second method also enables the sac stage of parous insects (which provides information on the duration of the oviposition cycle) and the mated status of insects to be determined. Despite widespread use the two techniques have not previously been compared., Methods: We compared the two dissection techniques using Anopheles arabiensis , collected with a tent-trap in Eritrea. The paired ovaries were removed in water and one was examined by each method. From a separate set of dissections from Tanzania, we also determined if the sac stages of Anopheles gambiae s.l. (83% of 183 identified by PCR being Anopheles arabiensis the remainder being A. gambiae ) that were alive on collection were different to those that died on collection and what the implications for vectorial capacity estimation might be., Results: Seven per cent of the dry ovaries could not be classified due to granulation (yolk) in the ovariole that obscured the tracheoles. The sensitivity of the dry dissection was 88.51% (CI [79.88-94.35%]) and the specificity was 93.55% (CI [87.68-97.17%]) among the 211 ovaries that could be classified by the dry technique and compared to the ovaries dissected wet. 1,823 live and 1,416 dead from Furvela tent-traps, CDC light-trap and window-trap collections were dissected 'wet' from Tanzania. In these collections parous insects were more likely to die compared to nulliparous ones. The proportion of parous mosquitoes with 'a' sacs (indicative of recent oviposition) was significantly greater in insects that were dead (0.36) on collection in the morning compared to those that were alive (0.12) (Chi square 138.93, p  < 0.001). There was a preponderance of newly emerged virgin insects in the outdoor collection (Chi sq = 8.84, p  = 0.003)., Conclusions: In anophelines the examination of mosquito ovaries using transmitted light in a 'wet' dissection is a more useful and informative technique than examination of dry ovaries. In order to correctly estimate the duration of the oviposition cycle mosquitoes should be dissected as soon as possible after collection. Younger insects were more likely to attempt to feed outdoors rather than indoors., Competing Interests: The authors declare there are no competing interests.

Background: Mosquito nets containing synergists designed to overcome metabolic resistance mechanisms in vectors have been developed. These may enhance excitability in the mosquitoes and affect how they respond to CDC light-traps. Investigating the behaviour of vectors of disease in relation to novel mosquito nets is, therefore, essential for the design of sampling and surveillance systems., Methods: In an initial experiment in Muleba, Tanzania, nine bedrooms from three housing clusters were sampled. CDC light-traps were operated indoors next to occupied untreated nets (UTN), Olyset ® long lasting insecticidal net (LLIN) and Olyset Plus ® LLIN containing piperonyl butoxide (PBO) synergist. Nets were rotated daily between the nine rooms over nine nights. A further series of experiments using the nets on alternate nights in a single room was undertaken during the short rains. Anopheles gambiae s.l. were collected in CDC light-traps, a window-trap and Furvela tent-trap. Anopheles gambiae s.l. were identified to species by polymerase chain reaction (PCR)., Results: In the initial experiment 97.7% of the 310 An. gambiae s.l. were An. gambiae s.s., the remainder being Anopheles arabiensis. The number of mosquitoes collected from 81 light-trap collections was greater in the presence of an Olyset [density rate ratio 1.81, 95% CI (1.22-2.67), p = 0.003] relative to an UTN. In a second experiment, in the wet season 84% of the 180 An. gambiae s.l. identified were An. arabiensis. The number of An. gambiae s.l. collected from a light-trap compared to a tent-trap was significantly higher when an Olyset Plus net was used compared to an UTN. Survival of the mosquitoes in the window trap was not reduced by the use of an Olyset Plus net in the bedroom relative to an Olyset net., Conclusion: Mosquitoes entering bedrooms, even those susceptible to pyrethroids, were not killed by contact with an Olyset Plus LLIN. The enhanced numbers of An. gambiae or An. arabiensis collected in light-traps when a treated net is used requires further experimentation and may be because of a heightened escape reaction on the part of the mosquito.

Although co-payments and deductibles are means of keeping health expenditures low, they have also been cited as barriers that inhibit patients from accessing necessary healthcare. We aimed to evaluate Rhode Island residents' experiences with cost-related access challenges within the state's healthcare system. We conducted a cross-sectional survey of resident experiences with healthcare in Rhode Island. Our survey instrument was composed of the RAND Corporation "Short-Form Patient Satisfaction Questionnaire (PSQ-18)", questions developed by the Rhode Island Office of the Health Insurance Commissioner, and ranking of health priorities based on prior community assessments conducted by the Rhode Island Department of Health. Data were collected at venues across the state as part of the Rhode Island Department of Health 2015 Statewide Health Inventory. From July to August 2015, 404 surveys were completed. We found that 40% of respondents had a co-pay of $20-$50, while 35.7% of respondents had a deductible of greater than $500. Further, one-third of respondents delayed receiving care due to financial barriers. This decision resulted in a worsening condition or hospital visit for nearly half of those respondents. Co-pays and deductibles pose challenges to Rhode Islanders accessing health care. Cost-related barriers to healthcare access should continue to be addressed, especially in the context of preventive care services, which are now being built into health insurance premiums through the Patient Protection and Affordable Care Act. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Purpose: Fear of cancer recurrence (FCR) is a common experience for cancer survivors. However, it remains unclear what characteristics differentiate non-clinical from clinical levels of FCR. The goal of this study was to investigate the potential hallmarks of clinical FCR., Methods: A convenience sample of 40 participants (n = 19 female) was drawn from another study (Lebel et al. in Qual Life Res 25:311-321. doi: 10.1007/s11136-015-1088-2 , 2016). The semi-structured interview for fear of cancer recurrence (Simard and Savard in J Cancer Surviv 9:481-491. doi: 10.1007/s11764-015-0424-4 , 2015) was used to identify participants with non-clinical and clinical FCR and qualitative analysis of these interviews was performed., Results: Individuals with clinical FCR reported the following features: death-related thoughts, feeling alone, belief that the cancer would return, experiencing intolerance of uncertainty, having cancer-related thoughts and imagery that were difficult to control, daily and recurrent, lasted 30 minutes or more, increased over time, caused distress and impacted their daily life. Triggers of FCR and coping strategies did not appear to be features of clinical FCR as they were reported by participants with a range of FCR scores., Conclusions: While features of clinical FCR found in this analysis such as intrusive thoughts, distress and impact on functioning confirmed previous FCR research, other features spontaneously emerged from the interviews including "death-related thoughts," "feeling alone," and "belief that the cancer will return." The participants' descriptions of cancer-specific fear and worry suggest that FCR is a distinct phenomenon related to cancer survivorship, despite similarities with psychological disorders (e.g., Anxiety Disorders). Future research investigating the construct of FCR, and the distinguishing features of clinical FCR across a range of cancer types and gender is required.

Background: Mandarins and mandarin hybrids have excellent flavor and color attributes, making them good candidates for consumption as fresh fruit. When processed into juice, however, they are less palatable, as they develop delayed bitterness when stored for a period of time. In this study the kinetics of delayed bitterness in two citrus mandarin hybrid siblings, 'Ambersweet' and USDA 1-105-106, was explored by sensory and instrumental analyses. In addition to the bitter limonoids, other quality factors (i.e. sugars, acids, pH, soluble solids content (SSC), titratable acidity (TA) and the ratio SSC/TA) were also measured., Results: The two citrus hybrid siblings had different chemical profiles, which were perceived by taste panels. USDA 1-105-106 developed delayed bitterness when the juice was stored for more than 4 h, similar to juice from 'Navel' oranges, but 'Ambersweet' did not. Bitterness in 'Ambersweet' was more affected by harvest maturity, as juice from earlier harvest had lower SSC but higher TA and bitter limonoids., Conclusion: Since juice of USDA 1-105-106 shows delayed bitterness when stored for more than 4 h, this cultivar is not suitable for juice processing. Our finding that siblings can differ in chemical and sensory properties emphasize the importance of post-processing storage studies before releasing cultivars for juice., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: The study aimed to describe a case of low-grade fibromyxoid sarcoma arising from the vulva and to discuss the diagnostic challenges, clinical management, and epidemiology of this rare malignancy., Case: A 36-year-old woman presented to 3 separate emergency departments with complaints of a painful and slowly enlarging vulvar mass. Eventual gynecologic referral resulted in excision of a 6-cm, noncystic vulvar mass. Pathological diagnosis revealed low-grade fibromyxoid sarcoma. Later, a right radical hemivulvectomy ensured adequate margins, and 2 years later, the patient is free of recurrent and metastatic disease., Conclusions: Low-grade fibromyxoid sarcoma is a rare malignancy that may present in the lower genital tract. Definitive diagnosis is essential because low-grade fibromyxoid sarcoma may metastasize many years after diagnosis, thereby requiring indefinite clinical surveillance.

Objectives: We conducted a validation study on use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (N=3633). This survey sought to identify potential facilitators and barriers to an implementation policy that would allow nurses to clinically clear the c-spine of minor trauma patients., Methods: We conducted a prospective quantitative survey of ED nurses in six hospitals. Questions were developed from a previous qualitative survey at the same validation study EDs., Results: 158 ED nurses were surveyed and 137 (86.7%) responded. Nurses strongly endorsed potential facilitators for nursing clearance of the c-spine, including 'Like to try new things at work' (96.4%) and 'Easy for me to take on new responsibilities' (96.4%). Most respondents were comfortable applying the rule (89.1%). Nurses endorsed potential barriers but at much lower rates, with the most common being 'Heavy workload makes it difficult to use the rule' (37.2%). Variation existed among hospitals for the facilitator 'Use of the rule would be useful to my practice', ranging from 81.8% to 100% endorsement (P=0.004)., Conclusions: This survey was an important step towards the goal of empowering ED nurses to clinically clear the c-spine of alert and stable trauma patients. There was a high rate of endorsement of facilitators and a low rate of endorsement of barriers. We found variation between hospitals, emphasizing the importance of understanding local beliefs when seeking to change clinical practice. We are conducting an implementation trial based on this feedback., (Copyright © 2009 Elsevier Ltd. All rights reserved.)

Objectives: The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses., Methods: We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form., Results: Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%-100.0%) and specificity of 43.4% (95% CI 42.0%-45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases., Conclusion: Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.

Partial liver graft transplantation is a surgical advance developed to overcome severe donor shortage. Survival of these grafts involves recovery from cold ischemia and reperfusion (CIR) injury, immediate regeneration and maintenance of function. Here we examined the outcome of partial liver grafts in comparison to whole grafts following CIR injury. Lewis rats subjected to orthotopic liver transplantation (OLT) with whole grafts preserved in Viaspan were compared to rats receiving 50% and 30% grafts. Outcome was analyzed by survival and regeneration. Transplantation was associated with 100% survival for all grafts, whereas 16 h preservation resulted in 100%, 20% and 0% survival in animals receiving whole, 50% and 30% grafts, respectively. CIR induced increased IL-6 levels in 50% and 30% grafts, and activation of STAT3. Cell cycle progression (cyclin D1) and regeneration (BrdU) was initiated in all livers preserved for 1 or 8 h, but not in partial grafts preserved for 16 h. In conclusion, partial grafts recover from CIR injury through similar molecular pathways to whole grafts. Partial grafts with severe injury fail to achieve cellular proliferation despite the early initiating signals. This failure could be attributed to the impaired ability of the parenchyma to respond to initiating signals for regeneration.

Hepatocyte growth/scatter factor (HGF/SF) is a pleiotropic cytokine originally identified as a potent mitogen for rat hepatocytes. Two HGF/SF knockout mouse models have been reported, both of which exhibit developmental abnormalities causing embryonic lethality. To circumvent this limitation, we created a mouse conditionally deficient in liver expression of HGF/SF to specifically investigate the role of this mitogen in the process of adult liver regeneration. Gene targeting technology was used to generate a mouse with loxP sites flanking exon 5 of the HGF/SF gene (ex5-flox). In the absence of cre recombinase activity, mice homozygous for ex5-flox were indistinguishable from wild-type littermates. To ablate HGF/SF gene expression in vitro, primary hepatocytes established from homozygous HGF(ex5-flox) mice were infected with a recombinant adenoviral vector coding for cre recombinase (AdCre1). PCR analyses of genomic DNA demonstrated greater than 90% ablation of the ex5-floxed gene sequence. In vivo, HGF(ex.5-flox) mice were administered AdCre1 vector and the ablation of the HGF gene confirmed by Southern blot analysis. To induce liver regeneration, mice were injected with the hepatotoxin carbon tetrachloride. The regenerative capacity of hepatocytes in mice administered cre recombinase was shown to be significantly reduced when compared with mice injected with an adenovirus expressing LacZ. A similar reduction in hepatocyte regeneration was observed in HGF(ex.5.flox) mice carrying the cre transgene under the control of the interferon-inducible (pI:pC) Mx1 promoter, as an alternative strategy to ablate the HGF/SF gene in liver. Our results confirm the mitogenic role of HGF/SF in liver regeneration.

Providing anesthesia for office endometrial procedures is a clinical challenge. The available techniques include the traditional paracervical block, the deep paracervical block, intrauterine lidocaine, topical spray lignocaine, and conscious sedation. Each offers some benefit in providing anesthesia during these procedures and can contribute to a more comfortable experience for the patient.

Polycystic ovary syndrome (PCOS) affects approximately 6% of women in their reproductive years. The symptoms of the syndrome are chronic anovulation and androgen excess. Infertility due to ovulatory dysfunction is a common problem for women with PCOS. Metformin, an antihyperglycemic agent, can correct the metabolic dysfunction that occurs with PCOS, and also stimulate folliculogenesis. The drug is effective alone and in combination with clomiphene citrate. An alternative option, ovarian diathermy, also promotes ovulation through changes in the intraovarian hormonal environment. Both techniques provide promising and effective alternatives for women with PCOS who do not respond to traditional oral ovulation induction agents.

The innate immune response to intraportally infused adenoviral vector was evaluated in rhesus monkeys. A first-generation adenovirus-expressing lacZ (Ad-lacZ) was administered at a dose just below that which causes severe morbidity. The response to vector was evaluated for the initial 24 h following infusion. Clinical findings during this time were primarily limited to petechiae, consistent with the development of thrombocytopenia and biochemical evidence of disseminated intravascular coagulation. Serum transaminases were elevated and a lymphopenia developed. Tracking of fluorescent-labeled vector demonstrated distribution to macrophages and dendritic cells of the spleen and Kupffer cells of the liver. A systemic release of the cytokine IL-6 occurred soon after vector infusion. Analysis of splenic cells revealed acute activation of macrophages and dendritic cells followed by massive apoptosis. Bone marrow cultures demonstrated normal erythroid and primitive progenitors with a significant decrease in myeloid progenitors. Similar findings, except the abnormality in bone marrow cultures, were observed in monkeys who received an identical dose of Ad-lacZ in which vector genes were inactivated with psoralen and UV irradiation. These data suggest that inadvertent targeting of antigen-presenting cells following intraportal infusion of vector leads to a systemic cytokine syndrome which may be triggered by the viral capsid proteins.

Improving outcomes while maintaining quality and satisfaction in today's healthcare environment is a challenge. This article shares some of the foundation work and the results of an interdisciplinary team effort toward that goal. Changes in care practices and their impact on outcomes can promote the welfare of the patient, institution, and the nation's health.

Developing a patient-focused unit is necessary to attain the highest standards of patient care. It is only when we can view our unit through the eyes of a patient that we will be able to see ourselves as others see us. Professionally, we have committed ourselves to creating caring environments that promote healing. We cannot meet this goal until we make a commitment to be patient-focused and give up being nurse-focused or facility-focused.