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Recent work has shown that perceptual training can be used to improve the performance of novices in real-world visual classification tasks with medical images, but it is unclear which perceptual training methods are the most effective, especially for difficult medical image discrimination tasks. We investigated several different perceptual training methods with medically naïve participants in a difficult radiology task: identifying the degree of hepatic steatosis (fatty infiltration of the liver) in liver ultrasound images. In Experiment 1a (N = 90), participants completed four sessions of standard perceptual training, and participants in Experiment 1b (N = 71) completed four sessions of comparison training. There was a significant post-training improvement for both types of training, although performance was better when the trained task aligned with the task participants were tested on. In both experiments, performance initially improves rapidly, with learning becoming more gradual after the first training session. In Experiment 2 (N = 200), we explored the hypothesis that performance could be improved by combining perceptual training with explicit annotated feedback presented in a stepwise fashion. Although participants improved in all training conditions, performance was similar regardless of whether participants were given annotations, or underwent training in a stepwise fashion, both, or neither. Overall, we found that perceptual training can rapidly improve performance on a difficult radiology task, albeit not to a comparable level as expert performance, and that similar levels of performance were achieved across the perceptual training paradigms we compared.

Docosahexaenoic acid (DHA) is a component of neural tissue. Because its accretion into the brain is greatest during the final trimester of pregnancy, infants born before 29 weeks' gestation do not receive the normal supply of DHA. The effect of this deficiency on subsequent cognitive development is not well understood.We assessed general intelligence at 5 years in children who had been enrolled in a trial of neonatal DHA supplementation to prevent bronchopulmonary dysplasia. In the previous trial, infants born before 29 weeks' gestation had been randomly assigned in a 1:1 ratio to receive an enteral emulsion that provided 60 mg of DHA per kilogram of body weight per day or a control emulsion from the first 3 days of enteral feeds until 36 weeks of postmenstrual age or discharge home, whichever occurred first. Children from 5 of the 13 centers in the original trial were invited to undergo assessment with the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) at 5 years of corrected age. The primary outcome was the full-scale intelligence quotient (FSIQ) score. Secondary outcomes included the components of WPPSI.A total of 1273 infants underwent randomization in the original trial; of the 656 surviving children who had undergone randomization at the centers included in this follow-up study, 480 (73%) had an FSIQ score available - 241 in the DHA group and 239 in the control group. After imputation of missing data, the mean (±SD) FSIQ scores were 95.4±17.3 in the DHA group and 91.9±19.1 in the control group (adjusted difference, 3.45; 95% confidence interval, 0.38 to 6.53; P = 0.03). The results for secondary outcomes generally did not support that obtained for the primary outcome. Adverse events were similar in the two groups.In infants born before 29 weeks' gestation who had been enrolled in a trial to assess the effect of DHA supplementation on bronchopulmonary dysplasia, the use of an enteral DHA emulsion until 36 weeks of postmenstrual age was associated with modestly higher FSIQ scores at 5 years of age than control feeding. (Funded by the Australian National Health and Medical Research Council and Nu-Mega Ingredients; N3RO Australian New Zealand Clinical Trials Registry number, ACTRN12612000503820.).

IntroductionBreastmilk is considered the gold standard for infant nutrition. Breast feeding is recommended as the sole source of nutrition between birth until around 6 months of age and should be continued beyond this age as complementary foods are introduced. While breast feeding initiation is generally high in developed countries, continuation of breast feeding appears to drop rapidly. This is a prospective observational study of life that aims to characterise a current picture of infant feeding practices across the first year, and motivations for feeding practices, and to identify barriers and enablers for breast feeding.Methods and analysisCaregivers with newborn singleton infants of normal birth weight are approached on the postnatal units of three hospitals in South Australia, or through targeted online advertising campaigns promoting the study. Caregivers are asked to complete surveys when their infant reaches 3, 5 and 7 weeks’, and at 3, 4, 5, 6, 9 and 12 months of age. Initially, baseline characteristics, intentions and preferences for infant milk feeds, as well as reasons for preferences are captured. Latter surveys query how infants are being fed, difficulties or barriers to breast feeding, as well as any enablers (if breast feeding). Once infants reach 5 months of age, surveys capture complementary feeding. A large opportunistic sample from the Adelaide community with a minimum of 1000 mother–infant pairs will be enrolled. The data will be analysed descriptively and using regression models.Ethics and disseminationWomen’s and Children’s Health Network Human Research Ethics Committee reviewed and approved the study (approval no HREC/19/WCHN/140, approval date: 22 November 2019). Study results will be disseminated through academic meetings, peer-reviewed journals, in-services for postnatal healthcare services, results letters for participants and social media.Trial registration numberACTRN12620000529943.

The world now has decades of experience with impact assessment and most assessment regimes have undergone revision over time. A positive consequence of the debates about these revisions is a rich b...

The aim of the study was to increase the levels of omega-3 fatty acids in eggs, mainly in the form of eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA, 22:6n -3) as EPA and DHA have beneficial health effects. This study tested whether the inclusion of a vegetable source of omega-3 (n-3) fat in the form of alpha-linolenic acid (ALA, 18:3n-3) in the diets of laying hens (Hy-Line brown) would improve n-3 fat accumulation, without altering the product performance or the sensory characteristics of eggs. In this study, the ALA levels of the diets were varied from 0.3 to 6% energy (%en). In order to optimize the conversion of ALA into n-3 long chain polyunsaturated fatty acids (LCPUFA), grain-based diets containing a low linoleic acid (LA, 18:2n-6) level were chosen as a basal diet, and the level of competing substrate, LA, in the dietary treatments was also kept constant. Results showed that increasing the levels of dietary ALA increased all n-3 LCPUFA (EPA, DPA, and DHA) in the eggs. Importantly, diets enriched with ALA did not impair the sensory quality of the eggs. In conclusion, brown laying hens fed ALA enriched diets produced eggs higher in n-3 fatty acids, and met the requirement needed for labelling as n-3 PUFA sources, which provides an alternative n-3 rich food for consumers.

Background Mucosal healing improves clinical outcomes in patients with inflammatory bowel disease (IBD) and is associated with higher infliximab trough levels (ITLs). Transmural healing, assessed by intestinal ultrasound (IUS), is emerging as an objective target in Crohn’s disease (CD) and ulcerative colitis (UC). This study explores the correlation between maintenance ITLs and sonographic transmural healing. Methods Patients on maintenance infliximab therapy were prospectively enrolled to undergo paired IUS examination and serum ITL. Infliximab trough levels were compared between patients with and without sonographic markers of inflammation using the Mann-Whitney U test. Results A prospective cohort of 103 patients (51% male; 79 CD; 24 UC; median duration of disease 8 years) underwent IUS and serum ITL testing. Forty-one percent of CD and 66% of UC patients demonstrated sonographic healing (bowel wall thickening ≤3 mm with no increase in color Doppler signal). Crohn’s disease patients with sonographic healing had higher median ITL compared with those with sonographic inflammation (4.8 μg/mL vs 3.1 μg/mL; P = .049). Additionally, the presence of hyperemia on Doppler was independently associated with lower ITL compared with those without hyperemia (2.1 μg/mL vs 4.2 μg/mL, respectively; P = .003). There was no significant association between ITL and other sonographic markers of inflammation. In UC, lower ITL was associated with hyperemia on Doppler imaging (P = .04). There was no association between ITL and sonographic healing or any other individual sonographic parameter of inflammation. Conclusions Lower maintenance infliximab levels are associated with sonographic parameters of inflammation in UC and CD. Further studies are needed to determine whether targeting higher infliximab levels can increase sonographic healing.

This study aimed to improve the accuracy of Broselow tape (BT) weight prediction by adding midthigh circumference (MTC) and to compare and standardize the methods for measuring MTC.This prospective, observational study was conducted in a pediatric emergency department of a tertiary care children's hospital. Children up to 12 years of age presenting to emergency department were included. Children were excluded if obtaining the data would interfere with their acute management. The data collected included MTC, height, BT weight, and actual weight. Three models were built. Broselow tape-only model and MTC plus BT model used 2 methods for MTC measurements: visual approximation of thigh midpoint (visual MTC1) and Centers for Disease Control and Prevention (CDC)-defined method (CDC MTC2).A total of 430 children were enrolled during pre-coronavirus disease era. Of these, 234 were boys (54.4%) and 196 (45.6%) were girls. Data were categorized into children younger than 2 years (224 [52.1%]) and older than 2 years (206 [47.9%]). African American constituted 250 (58%); White, 136 (31%); and unspecified, 27 (6%). For the entire cohort, both models that included MTC were significantly better at weight prediction with larger adjusted R2 (visual MTC1, 0.921; CDC MTC2, 0.928) and smaller root mean squared (RMSE) (visual MTC1, 2.70; CDC MTC2, 2.56) compared with BT-only model (adjusted R2 = 0.843; RMSE, 3.80). Midthigh circumference plus BT models performed even better in children older than 2 years compared with BT-only model with adjusted R2 (visual MTC1, 0.859; CDC MTC2, 0.872 vs 0.616) and RMSE (visual MTC1, 3.18; CDC MTC2, 3.03 vs 5.27).The inclusion of MTC with BT resulted in a more accurate weight prediction in children especially greater than 2 years old. Midthigh circumference model using CDC-defined method was slightly better predictor of actual weight than visual approximation.

While there is growing optimism for inner transformations to catalyse systemic shifts towards more sustainable ways of being, no study so far has attempted to assess how well current interventions for inner development address core requirements for collective wellbeing. In this article, we apply a novel assessment framework to examine how mindfulness-based interventions address inner and outer sustainability criteria during a global health emergency. This inquiry informs a growing field of study concerned with leveraging inner transformations for systemic shifts towards sustainability progress. Using three prominent online mindfulness-based offerings as a case study, we demonstrate that mindfulness-based interventions have a broad range of potential desirable to detrimental implications for social and biophysical systems. We conclude by discussing how normative conceptions of inner interventions might be contextualised anew to effectively support more viable, just, and inclusive transformations towards long-term viability.

ObjectivesThe risk factors for prematurity are multifactorial and include low omega-3 status. Omega-3 supplementation in pregnancy has been found to reduce prematurity risk, particularly among women with low omega-3 levels. This study aimed to identify maternal characteristics that predict whether women with a singleton pregnancy will benefit from omega-3 supplementation to reduce their risk of prematurity.DesignExploratory analyses of a multicentre, double-blind randomised trial.Setting6 tertiary care centres in four states in Australia.Participants5328 singleton pregnancies in 5305 women recruited before 20 weeks of gestation.InterventionsFish oil capsules containing 900 mg omega-3 long-chain polyunsaturated fatty acids per day versus vegetable oil capsules consumed from enrolment until 34 weeks’ gestation.Outcome measuresEarly preterm birth (EPTB, ResultsOmega-3 supplementation reduced the odds of EPTB for women with low total omega-3 status in early pregnancy (OR=0.30, 95% CI 0.10–0.93). No additional maternal characteristics influenced whether omega-3 supplementation reduced the odds of EPTB. For PTB, women were more likely to benefit from omega-3 supplementation if they were multiparous (OR=0.65, 95% CI 0.49–0.87) or avoided alcohol in the lead up to pregnancy (OR=0.62, 95% CI 0.45–0.86).ConclusionsOur results support previous findings that women with low total omega-3 levels in early pregnancy are most likely to benefit from taking omega-3 supplements to reduce their risk of EPTB. Understanding how other maternal characteristics influence the effectiveness of omega-3 supplementation on reducing PTB requires further investigation.Trial registration numberACTRN12613001142729.

Projects that undergo environmental impact assessment (EIA) are rarely rejected. Online registries and anecdotal evidence suggest that authorities approve almost all proposed and assessed projects,...

Preterm and sick term infants are commonly fed with expressed breast milk (EBM) that has been subjected to various storage and handling conditions before feeding that may cause lipase-mediated elevation of free fatty acids (FFA). This study was designed to describe the variation, between mothers' and within the same mother over time, in the concentration of FFA in EBM used in an Australian neonatal unit. A total of 256 EBM samples, 149 freshly expressed in the unit cot-side and 87 expressed at home and brought in to the unit, were collected from 32 mothers with an infant admitted to the neonatal intensive and/or special care units at the Women's and Children's Hospital, Adelaide. Among the fresh EBM samples collected cot-side, the average total fat content was 29.78 ± 9.28 mg/mL, and the FFA concentration was 1.70% of total fats (interquartile range [IQR]: 1.17-2.37%). Among the 10 mothers who provided fresh EBM at different stages of lactation, the concentration of FFA remained low overall, with some day-to-day variation (min 0.58% and max 5.0% of total fats within the same mother). The average total fat content of home collected EBM was similar to the cot-side collected samples, at 27.37 ± 8.23 mg/mL, and the FFA concentration was slightly higher at 2.49% of total fats (IQR: 1.74-3.29%). Overall, the FFA concentration of breast milk in the neonatal unit before and even after a short period of cold storage and handling is universally low.

Study objective This was a prospective, pre-post, 13-year observational study documenting the multiyear implementation of an observation unit sickle cell pathway for patients with uncomplicated vaso-occlusive events. Methods The sickle cell pathway begins with rapid triage to identify patients with uncomplicated vaso-occlusive events for immediate transfer to the observation unit and initiation of patient-controlled analgesia followed by repeated evaluations of pain and identification of other complications. Data were abstracted from the electronic medical record or observation unit database. The sickle cell pathway was initiated in April 2006. Major revisions of it were carried out in June 2009 (physician evaluation occurs in sickle cell pathway and only patient-controlled analgesia administration of medications) and October 2010 (multidisciplinary management and individual dosing). Results Annual ED visits ranged between 287 and 528. The preimplementation hospital admission rate was 33% (123/368), 3-day return rate 16% (60/368), and 30-day return rate 67% (248/368). Refinements to the sickle cell pathway have resulted in a decrease in admission rate to 20% (258/1276); 3-day return rate, to 3.6% (46/1,276); and 30-day return rate, to 41% (525/1,276) for the past 3 years. Conclusion The use of a sickle cell pathway for the treatment of uncomplicated vaso-occlusive events has been effective in providing rapid treatment and reducing hospital admissions. However, it was not only the intervention and its refinement that made the sickle cell pathway successful. With the Consolidated Framework for Implementation Research, it was discerned that outer setting factors of organizational commitment to the care of patients with SCD, inner setting factors of learning climate and leadership engagement, individuals, and process contributed to the success of the sickle cell pathway.

3-Carboxy-4-methyl-5-propyl-2-furanpropanoic acid (CMPF) is a metabolite of furan fatty acids found in plasma and urine of humans after consumption of foods containing these fatty acids. Recently, CMPF has been identified as a prominent metabolite following the consumption of either fish oil, fish oil fatty acid-ethyl esters or diets rich in fish. As furan fatty acids are known to occur in fish and fish oils (at a low level), it is possible that in these studies the CMPF in plasma originated from furan fatty acids. We report the plasma CMPF levels in 10 healthy women who consumed 1 gram of pure eicosapentaenoic acid (EPA), or docosapentaenoic acid (DPA) or docosahexaenoic acid (DHA), or olive oil daily for 6 days, in a cross-over study. The supplemented omega 3 fatty acids contained no detectable levels of furan fatty acids. The plasma CMPF and omega 3 fatty acid levels were measured by LC-MS/MS. Consumption of pure omega 3 fatty acids led to a significant increase in the plasma CMPF levels, but not with olive oil (from 1.6 to 2.5-fold compared with baseline). The plasma free fatty acid levels of EPA, DPA and DHA also increased significantly when they were supplemented (p < 0.05). Significant positive correlations existed between the plasma free fatty acid DPA and DHA levels (p < 0.05 and r = +0.49 to +0.81), but not between the EPA and CMPF levels. These data suggest that purified long chain omega 3 fatty acids may be precursors of CMPF; however the metabolic pathway(s) from omega 3 fatty acids to CMPF remain to be elucidated.

Calls for systemic transformations have become prevalent throughout sustainability discourse. Increasingly, these calls point towards consciousness expanding practices and interventions, such as mindfulness, to support the development of individual understandings, skills, and capacities that are conducive to more sustainable ways of being and doing. The growing interest in leveraging inner capacities, including mindsets, worldviews, values, and beliefs for sustainability transformations emerges from concerns that conventional approaches are failing to align social and ecological systems towards long-term viability. Interest in these consciousness-driven transformations is spreading, particularly in governments and prominent organisations. Tempering this enthusiasm are concerns that untethered from moral and ethical guidelines as well as caring understanding of local and global prospects for lasting wellbeing, mindfulness programs, workshops, and interventions for inner transformation can inadvertently strengthen unsustainable systems and deepen inequities. Accordingly, this paper presents an exploratory assessment framework to increase understandings of how events focused on interventions for inner transformation align with broad sustainability requirements. Findings from application of the framework should help to elucidate how these offerings can disrupt normative ways of thinking and doing, and in turn, positively influence multi-scalar transformations. Furthermore, use of the assessment process to plan and/or evaluate inner development offerings is anticipated to help strengthen progress towards sustainability and reduce adverse trade-offs that might undermine positive systemic transformations.

In a Coronavirus disease 2019 (COVID-19) epidemic, management of the emergency department is a difficult task in terms of prevention and control of the disease in general hospitals. On top of meeting urgent needs of patients for medical treatment, the emergency department also has to devote resources into investigation and prevention of COVID-19. At the beginning of the epidemic, with the strategy to intercept the chain of infection, Peking University First Hospital (PKUFH) focused on three important aspects: controlling the source of infection, cutting off the route of transmission, and protecting vulnerable populations, to expeditiously draft scientific and proper management measures for the emergency department, followed by real-time dynamic adjustments based on the development trend of the epidemic. These measures effectively ensured a smooth, orderly and safe operation of the emergency department. As of the writing of this manuscript, there has been no active COVID-19 infection in patients and medical staff in the emergency department, and no infection in patients admitted to PKUFH through the emergency department. This study describes the prevention and control measures in the emergency department of PKUFH during the outbreak of COVID-19, aiming to provide some reference for domestic and international medical institutions.

Individuals with sickle cell disease (SCD) experience neurocognitive decline, low medication adherence, increased unemployment, and difficulty with instrumental activities of daily living (IADL). The relationship between self-perceived cognitive difficulties and IADLs, including employment, school enrollment, independence, engagement in leisure activities, and medication adherence is unknown. We hypothesized that self-reported difficulties across neurocognitive areas would predict lower IADL skills. Adolescent and adult participants of the multi-site Sickle Cell Disease Implementation Consortium (SCDIC) (n=2436) completed patient-reported outcome (PRO) measures of attention, executive functioning, processing speed, learning, and comprehension. Cognitive symptoms were analyzed as predictors in multivariable modeling. Outcome variables included 1) an IADL composite that consisted of employment, participation in school, reliance on others, and leisure pursuits, and 2) hydroxyurea adherence. Participants reported cognitive difficulty across areas of attention (55%), executive functioning (51%), processing speed (57%), and reading comprehension (65%). Executive dysfunction (p

ObjectivesSickle cell disease (SCD) leads to chronic and acute complications that require specialised care to manage symptoms and optimise clinical results. The National Heart Lung and Blood Institute (NHLBI) evidence-based guidelines assist providers in caring for individuals with SCD, but adoption of these guidelines by providers has not been optimal. The objective of this study was to identify barriers to treating individuals with SCD.MethodsThe SCD Implementation Consortium aimed to investigate the perception and level of comfort of providers regarding evidence-based care by surveying providers in the regions of six clinical centres across the USA, focusing on non-emergency care from the providers’ perspective.ResultsRespondents included 105 providers delivering clinical care for individuals with SCD. Areas of practice were most frequently paediatrics (24%) or haematology/SCD specialist (24%). The majority (77%) reported that they were comfortable managing acute pain episodes while 63% expressed comfort with managing chronic pain. Haematologists and SCD specialists showed higher comfort levels prescribing opioids (100% vs 67%, p=0.004) and managing care with hydroxyurea (90% vs 51%, p=0.005) compared with non-haematology providers. Approximately 33% of providers were unaware of the 2014 NHLBI guidelines. Nearly 63% of providers felt patients’ medical needs were addressed while only 22% felt their mental health needs were met.ConclusionsA substantial number of providers did not know about NHLBI’s SCD care guidelines. Barriers to providing care for patients with SCD were influenced by providers’ specialty, training and practice setting. Increasing provider knowledge could improve hydroxyurea utilisation, pain management and mental health support.

ImportanceSARS-CoV-2 enters the nasopharynx to replicate; nasal irrigation soon after diagnosis could reduce viral load and inhibit furin cleavage necessary for cell entry, thereby reducing morbidity and mortality.ObjectiveTo determine whether initiating nasal irrigation after COVID-19 diagnosis reduces hospitalizations and death in high-risk outpatients, and whether irrigant composition impacts severity.DesignUnblinded randomized clinical trial of two nasal irrigation protocols in older outpatients PCR positive for SARS-CoV-2, with an observational arm using laboratory-confirmed cases in the CDC COVID-19 Case Surveillance dataset.SettingSingle-lab community testing facility associated with the emergency department (ED) in Augusta, GA.ParticipantsA consecutive sample of high-risk adults were enrolled within 24 hours of a positive COVID-19 test between September 24 and December 21 of 2020. Patients aged 55 and older were remotely consented. Among 826 screened, 321 of 694 eligible patients were unable to be reached, 294 refused participation, and 79 participants were enrolled.InterventionsParticipants were randomly assigned adding 2.5 mL povidone-iodine 10% or 2.5 mL sodium bicarbonate to 240 mL of isotonic nasal irrigation twice daily for 14 days.Main Outcomes and MeasuresThe primary outcome was hospitalization or death from COVID-19 within 28 days of enrollment by daily self-report confirmed with phone calls and hospital records, compared to the CDC Surveillance Dataset covering the same time. Secondary outcomes compared symptom resolution by irrigant additive.ResultsSeventy-nine high-risk participants were enrolled (mean [SD] age, 64 [8] years; 36 [46%] women; 71% Non-Hispanic White), with mean BMI 30.3. Analyzed by intention-to-treat, by day 28, COVID-19 symptoms resulted in one ED visit and no hospitalizations in 42 irrigating with alkalinization, one hospitalization of 37 in the povidone-iodine group, (1.27%) and no deaths. Of nearly three million CDC cases, 9.47% were known to be hospitalized, with an additional 1.5% mortality in those without hospitalization data. The total risk of hospitalization or death (11%) was 8.57 times that of enrolled patients (SE=2.74; P=.006). 62 completed daily surveys (78%), averaging 1.8 irrigations/day. Eleven had irrigation complaints, and four discontinued. There were no significant differences by additive.ConclusionSARS-CoV-2+ participants initiating nasal irrigation were over 8 times less likely to be hospitalized than the national rate.Trial RegistrationClinicalTrial.gov Identifier: NCT04559035Author ApprovalAll authors have filled out ICMJE and approved submission.Conflict of Interest StatementMaterials were provided by Neilmed Inc. and Rhinosystems Inc. The study was supported by funding from the Bernard and Anne Gray Donor Advised Fund Community Foundation for Greater Atlanta, Neilmed Inc., and Rhinosystems. No authors have conflict of interest.Key PointsQuestionAfter testing positive for COVID-19, will rapidly initiating nasal irrigation reduce the risk of morbidity and mortality compared to a national dataset?FindingsA consecutive sample of 79 high-risk adults (mean age 64, BMI 30.3) were randomized to initiate one of two nasal irrigation protocols within 24 hours of a positive COVID-19 test. Compared to a CDC COVID-19 National Dataset observational arm, 1.27% of participants initiating twice daily nasal irrigation were hospitalized or died, compared to 11%, a significant difference.MeaningIn high-risk outpatients testing positive for SARS-CoV-2 who initiated nasal irrigation rapidly after diagnosis, risk of hospitalization or death was eight times lower than national rates reported by the CDC.

Women with low n-3 (omega-3) status in pregnancy can reduce their risk of early preterm birth (34 weeks' gestation) through n-3 long chain polyunsaturated fatty acid (LCPUFA) supplementation. As investigators measure fatty acid status in different blood fractions, equations are needed to compare results across studies. Similarly, derived cut-points for defining low and replete n-3 status are needed to assist clinical interpretation during early pregnancy. Our aims were to develop equations to convert the percentage of total n-3 fatty acids, EPA+DHA and DHA between whole blood, plasma and red blood cells (RBC), and to derive cut-points for defining low and replete total n-3 fatty acid status in plasma and RBC from those already established in whole blood. Using blood samples from 457 pregnant women in a multicentre randomised controlled trial, equations for these interconversions were developed using simple linear regression models. Measures of n-3 fatty acid status in whole blood and plasma were strongly related (R

Introduction A 2018 Cochrane review found that omega-3 supplementation in pregnancy was associated with a risk reduction of early preterm birth of 0.58; prompting calls for universal supplementation. Recent analysis suggests the benefit may be confined to women with a low baseline omega-3 fatty acid status. However, the contemporary omega-3 fatty acid status of pregnant women in the UK is largely unknown. This is particularly pertinent for women with a previous preterm birth, in whom a small relative risk reduction would have a larger reduction of absolute risk. This study aimed to assess the omega-3 fatty acid status of a UK pregnant population and determine the association between the long-chain omega-3 fatty acids and recurrent spontaneous early preterm birth. Material and methods A total of 283 high-risk women with previous early preterm birth were recruited to the prospective observational study in Liverpool, UK. Additionally, 96 pregnant women with previous term births and birth ≥39+0 weeks in the index pregnancy provided a low-risk population sample. Within the high-risk group we assessed the odds ratio of recurrent early preterm birth compared with birth at ≥37+0 weeks of gestation according to plasma eicosapentaenoic acid plus docosahexaenoic acid (EPA+DHA) at 15-22 weeks of gestation. Results Our participants had low EPA+DHA; 62% (143/229) of women with previous preterm birth and 69% (68/96) of the population sample had levels within the lowest two quintiles of a previously published pregnancy cohort. We found no association between long-chain omega-3 status and recurrent early preterm birth (n = 51). The crude odds ratio of a recurrent event was 0.91 (95% CI 0.38-2.15, p = 0.83) for women in the lowest, compared with the highest three quintiles of EPA+DHA. Conclusions In the majority of our participants, levels of long-chain omega-3 were low; within the range that may benefit from supplementation. However, levels showed no association with risk of recurrent early spontaneous preterm birth. This could be because our population levels were too low to show benefit in being omega-3 "replete"; or else omega-3 levels may be of lesser importance in recurrent early preterm birth.

Introduction During the last trimester of pregnancy, the fetal brain undergoes a rapid growth spurt and accumulates essential nutrients including docosahexaenoic acid (DHA). This takes place ex-utero for infants born

Optic nerve sheath diameter (ONSD) is used clinically as a noninvasive measure for elevated intracranial pressure (ICP). This study had two purposes: to investigate the immediate effects optic nerve sheath (ONS) dilation post-ICP increase on trabecular fibers connecting the optic nerve to the ONS and to document any changes in these fibers 30 days post-increased ICP. In a swine model, ICP was increased by inflating a Foley catheter balloon in the epidural space. Three control pigs received the catheter insertion without inflation (no increase in ICP) and four experimental pigs received the catheter with inflation (increased ICP). The control and two randomly selected pigs with increased ICP were euthanized immediately after the procedure. The two other pigs were euthanized 30 days post-catheter inflation. For all pigs, the ONS was removed and imaged using a scanning electron microscope, calculating percent porosity values. Porosity values for the experimental groups (Immediately measured [IM] μ = 0.5749; Delayed measured [DM] μ = 0.5714) were larger than the control group (μ = 0.4336) and statistically significant (IM vs. Control

Background Oxidized derivatives of polyunsaturated fatty acids, collectively known as oxylipins, are labile bioactive mediators with diverse roles in human physiology and pathology. Oxylipins are increasingly being measured in plasma collected in clinical studies to investigate biological mechanisms and as pharmacodynamic biomarkers for nutrient-based and drug-based interventions. Whole blood is generally stored either on ice or at room temperature prior to processing. However, the potential impacts of delays in processing, and of temperature prior to processing, on oxylipin concentrations are incompletely understood. Objective To evaluate the effects of delayed processing of blood samples in a timeframe that is typical of a clinical laboratory setting, using typical storage temperatures, on concentrations of representative unesterified oxylipins measured by liquid chromatography-tandem mass spectrometry. Design Whole blood (drawn on three separate occasions from a single person) was collected into 5 mL purple-top potassium-EDTA tubes and stored for 0, 10, 20, 30, 60 or 120 min at room temperature or on wet ice, followed by centrifugation at 4 °C for 10 min with plasma collection. Each sample was run in duplicate, therefore there were six tubes and up to six data points at each time point for each oxylipin at each condition (ice/room temperature). Representative oxylipins derived from arachidonic acid, docosahexaenoic acid, and linoleic acid were quantified by liquid chromatography tandem mass spectrometry. Longitudinal models were used to estimate differences between temperature groups 2 h after blood draw. Results We found that most oxylipins measured in human plasma in traditional potassium-EDTA tubes are reasonably stable when stored on ice for up to 2 h prior to processing, with little evidence of auto-oxidation in either condition. By contrast, in whole blood stored at room temperature, substantial time-dependent increases in the 12-lipoxygenase-derived (12-HETE, 14-HDHA) and platelet-derived (thromboxane B2) oxylipins were observed. Conclusion These findings suggest that certain plasma oxylipins can be measured with reasonable accuracy despite delayed processing for up to 2 h when blood is stored on ice prior to centrifugation. 12-Lipoxygenase- and platelet-derived oxylipins may be particularly sensitive to post-collection artifact with delayed processing at room temperature. Future studies are needed to determine impacts of duration and temperature of centrifugation on oxylipin concentrations.

Background and Aims Gastrointestinal ultrasound is useful in the assessment of patients with Crohn’s disease, but its application in ulcerative colitis [UC] is less well established. Here we systematically review the role of gastrointestinal ultrasound in patients with UC. Methods Searches of the PUBMED and EMBASE databases were performed with the following search strategy: [ultrasound OR sonography] AND [intestinal OR bowel] AND [ulcerative colitis OR inflammatory bowel disease]. The final search was performed in August 2019. Results Of 6769 studies identified in the search with a further two studies found from other sources, 50 studies met the inclusion criteria. Increased bowel wall thickness and detection of increased blood flow by colour Doppler were the most often applied criteria for defining disease activity and distribution. When compared with other reference investigations, gastrointestinal ultrasound accurately determined disease extent, severity and response to medical therapy. While further information can be obtained from haemodynamic measurements of the abdominal vessels and contrast-enhanced ultrasound, their clinical value was uncertain. Likewise, hydrocolonic sonography has few advantages over standard gastrointestinal ultrasound examination. Of several scoring systems proposed, there is disparity between the measures and a general lack of validation. There has been limited application of gastrointestinal ultrasound in acute severe ulcerative colitis with toxic megacolon, and, while performing well in children, normal limits differ from those in adults. Conclusion Current evidence indicates that gastrointestinal ultrasound has utility in the non-invasive assessment of patients with UC. Continued advances in technology with better image resolution, validation of scoring systems and application at the point of care by gastroenterologists are likely to contribute to increased use of gastrointestinal ultrasound in routine clinical practice.

Lipid emulsions used to support nutrition in preterm infants contain long-chain polyunsaturated fatty acids (LCPUFAs) as a source of essential fatty acids; these LCPUFAs and their parent polyunsaturated fatty acid (PUFA) can be oxidized by a variety of mechanisms to bioactive molecules called oxylipins, which are signaling molecules that initiate and/or resolve inflammation. The aim of this study was to explore levels of free LCPUFA and their related oxylipins in 3 commercially available lipid emulsions (Intralipid, SMOFlipid, and ClinOleic) using ultra high-performance liquid chromatography mass spectroscopy. Free LCPUFA were detected in all lipid emulsions tested. Seven, 8, and 9 different oxylipin compounds were detected in the 3 emulsions, respectively. The oxylipins detected were mainly derived from omega-6 PUFAs; these included 13-hydroxyoctadecadienoic acid from linoleic acid and 5-hydroxyeicosatetraenoic acid derived from arachidonic acid. It may be clinically important to know that oxylipins exist in lipid emulsions and to evaluate their potential effects on preterm infants.

Aim This study qualitatively explored the impact mentoring relationships had on the professional socialization of novice clinical nurse leader. Background Professional socialization entails acquisition of the skills, knowledge and values associated with nursing. Model C clinical nurse leaders have completed a bachelor's degree before graduate-level nursing programme acceptance. Thereby, the mentoring needs of model C clinical nurse leaders may differ from that of traditionally educated novice nurses. Method Focus groups were conducted with seven novice model C clinical nurse leaders during their first year of employment. Qualitative data were analysed via a grounded theory approach. Results The participants described an intense focus on patient care and how multiple mentoring relationships motivated them to become competent bedside clinicians. They described how the mentors' actions enabled them to deal with negative feelings, which increased their confidence, comfort and competence with clinical skills. Conclusions Clinical skills improved when a novice model C clinical nurse leader worked with multiple mentors. The qualitative data did not show that the model C clinical nurse leaders needed different mentoring relationships than traditionally educated nurses. Implication for nursing management The results suggest multiple mentors should be used to develop the clinical competences of novice model C clinical nurse leaders.

BACKGROUND: Docosahexaenoic acid (DHA, 22:6n-3) supplementation in the prenatal period is associated with a reduction in the incidence of some symptoms of allergic disease. Infants born preterm are at increased risk of allergic disease, but it is unknown if DHA supplementation reduces the risk of childhood allergies. OBJECTIVES: The aim of this study was to determine if supplementation of infants born at

This article explores the diversity of strategic environmental assessment (SEA) practice in Canada and lessons for improving the effectiveness of SEA. There are multiple dimensions to effec...

Objective To determine whether initiating saline nasal irrigation after COVID-19 diagnosis reduces hospitalization and death in high-risk outpatients compared with observational controls, and if irrigant composition impacts severity. Methods Participants 55 and older were enrolled within 24 hours of a + PCR COVID-19 test between September 24 and December 21, 2020. Among 826 screened, 79 participants were enrolled and randomly assigned to add 2.5 mL povidone-iodine 10% or 2.5 mL sodium bicarbonate to 240 mL of isotonic nasal irrigation twice daily for 14 days. The primary outcome was hospitalization or death from COVID-19 within 28 days of enrollment by daily self-report confirmed with phone calls and hospital records, compared to the CDC Surveillance Dataset covering the same time. Secondary outcomes compared symptom resolution by irrigant additive. Results Seventy-nine high-risk participants were enrolled (mean [SD] age, 64 [8] years; 36 [46%] women; 71% Non-Hispanic White), with mean BMI 30.3. Analyzed by intention-to-treat, by day 28, COVID-19 symptoms resulted in one ED visit and no hospitalizations in 42 irrigating with alkalinization, one hospitalization of 37 in the povidone-iodine group, (1.27%) and no deaths. Of nearly three million CDC cases, 9.47% were known to be hospitalized, with an additional 1.5% mortality in those without hospitalization data. Age, sex, and percentage with pre-existing conditions did not significantly differ by exact binomial test from the CDC dataset, while reported race and hospitalization rate did. The total risk of hospitalization or death (11%) was 8.57 times that of enrolled nasal irrigation participants (SE = 2.74; P = .006). Sixty-two participants completed daily surveys (78%), averaging 1.8 irrigations/day. Eleven reported irrigation-related complaints and four discontinued use. Symptom resolution was more likely for those reporting twice daily irrigation ( X2 = 8.728, P = .0031) regardless of additive. Conclusion SARS-CoV-2+ participants initiating nasal irrigation were over 8 times less likely to be hospitalized than the national rate.

Infants born very preterm miss out on the in utero transfer of the omega-3 and omega-6 long-chain polyunsaturated fatty acids that occurs during the third trimester. A number of studies have explored the impact of increasing the enteral intakes of omega-3 +/- omega-6 long-chain polyunsaturated fatty acids to match fetal accretion rates in such infants. These studies have shown early transient improvements in vision and development with both strategies, but with the use of omega-3 supplementation alone appearing to increase the incidence of bronchopulmonary dysplasia. A recent study of omega-3 + omega-6 supplementation demonstrated a significant reduction in the incidence of severe retinopathy of prematurity in a high-risk population, without apparent adverse effects; a larger study is needed to confirm the observed benefits, to assess safety, and to determine long-term developmental outcomes of this strategy.

STUDY OBJECTIVES: This study investigated risk factors and estimated rates of acute insomnia disorder in health care workers at the onset of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A Qualtrics survey of more than 2,300 health care providers was conducted in a single academic health system on May 15, 2020, including practicing attending physicians, residents and fellows in training, advanced practice providers, and nurses. Six hundred and sixty-eight responded (29% response rate). The survey employed the Research Diagnostic Criteria for insomnia disorder to diagnose acute insomnia disorder. RESULTS: Five hundred seventy-three respondents had no missing data pertaining to sleep, with a mean age of 43.4 ± 12.5 years and 72% women. The rate of insomnia disorder before COVID-19 was 44.5%, while after COVID-19 it was 64.0%. Of persons with insomnia disorder before COVID-19 10.2% stated it had resolved during COVID-19, while 43.4% of persons who did not have insomnia disorder before COVID-19 developed acute insomnia disorder during COVID-19 (χ(2) = 145.2; df = 1; P < .0001). New cases of acute insomnia disorder were related positively to female sex, advancing age, and less time spent in direct patient care. CONCLUSIONS: Acute insomnia disorder was exceptionally common in this sample of tertiary care health care workers. The effects of sex and age were similar to what has been generally described as risk factors for insomnia. The surprising finding that less time spent in direct patient care was associated with more cases of acute insomnia disorder might be explained by the poorly understood stresses of working from home during COVID-19. CITATION: McCall WV, Mensah-Bonsu D, Withers AE, Gibson RW. Short-term insomnia disorder in health care workers in an academic medical center before and during COVID-19: rates and predictive factors. J Clin Sleep Med. 2021;17(4):749–755.

Background Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. Objective This study will implement an electronic health record–embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record–embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. Methods A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute–funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record–embedded individualized pain plans will be written by the patient’s sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record–embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. Results The study is currently enrolling study participants. The active implementation period is 18 months. Conclusions This study proposes a structured, framework-informed approach to implement electronic health record–embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record–embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. Trial Registration ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. International Registered Report Identifier (IRRID) DERR1-10.2196/24818