The Role of Telemedicine in Rural Specialty Care: Priorities and Recommendations From Rural Primary Care Physicians.

Introduction: The study goal was to understand telemedicine's role in improving access to rural specialty care. Other outcomes included assessing specialty availability and frequency of referrals at rural sites. Methods: This mixed methods study included surveys and semi-structured interviews of rural primary care physicians (PCPs). Survey data were analyzed with summary statistics and cross-tabulations. Interview transcripts were inductively thematically analyzed. Results: Of the 19 PCPs who completed the survey, 37% agreed/strongly agreed current telemedicine practices connected patients to better specialty care; 90% agreed/strongly agreed it had such potential. Interviews revealed telemedicine could improve care when local specialists were unavailable and provided the most benefit in acute care settings or specialist follow-ups. Most survey respondents reported outreach specialists were highly effective in addressing rural specialty care needs. Respondents reported cardiology, general surgery, orthopedic surgery, ENT/otolaryngology, and dermatology as the most frequently referred-to specialties. In-person neurology, gastroenterology, and dermatology were unavailable in many communities. Respondents identified psychiatry as a high priority for telemedicine and discussed clinic-to-clinic visits to optimize telemedicine use. Conclusions: The perceived discrepancy between the current and potential roles of telemedicine in rural specialty care suggests that telemedicine may not fully align with the needs of rural patients and could be optimized for rural practice settings. While local, in-person access to specialists remains a priority, telemedicine can reduce patient burdens and improve care when in-person specialists are unavailable. Telemedicine proponents can identify high-priority areas for implementation through quantitative assessment of specialty care utilization and access as reported by PCPs.

Female reproductive impacts of dietary methylmercury in yellow perch (Perca flavescens) and zebrafish (Danio rerio).

The purpose of this study was to evaluate the effects of environmentally relevant dietary MeHg exposures on adult female yellow perch (Perca flavescens) and female zebrafish (Danio rerio) ovarian development and reproduction. Yellow perch were used in the study for their socioeconomic and ecological importance within the Great Lakes basin, and the use of zebrafish allowed for a detailed analysis of the molecular effects of MeHg following a whole life-cycle exposure. Chronic whole life dietary exposure of F1 zebrafish to MeHg mimics realistic wildlife exposure scenarios, and the twenty-week adult yellow perch exposure (where whole life-cycle exposures are difficult) captures early seasonal ovarian development. For both species, target dietary accumulation values were achieved prior to analyses. In zebrafish, several genes involved in reproductive processes were shown to be dysregulated by RNA-sequencing and quantitative real-time polymerase chain reaction (QPCR), but no significant phenotypic changes were observed regarding ovarian staging, fecundity, or embryo mortality. Yellow perch were exposed to dietary MeHg for 12, 16, or 20 weeks. In this species, a set of eight genes were assessed by QPCR in the pituitary, liver, and ovary, and no exposure-related changes were observed. The lack of genomic resources in yellow perch hinders the characterization of subtle molecular impacts. The ovarian somatic index, circulating estradiol and testosterone, and ovarian staging were not significantly altered by MeHg exposure in yellow perch. These results suggest that environmentally relevant MeHg exposures do not drastically reduce the reproductively important endpoints in these fish, but to capture realistic exposure scenarios, whole life-cycle yellow perch exposures are needed.

Developmental Methylmercury Exposure Affects Swimming Behavior and Foraging Efficiency of Yellow Perch (Perca flavescens) Larvae.

Methylmercury (MeHg) is a pervasive and ubiquitous environmental neurotoxicant within aquatic ecosystems, known to alter behavior in fish and other vertebrates. This study sought to assess the behavioral effects of developmental MeHg exposure on larval yellow perch (Perca flavescens)-a nonmodel fish species native to the Great Lakes. Embryos were exposed to MeHg (0, 30, 100, 300, and 1000 nM) for 20 h and then reared to 25 days post fertilization (dpf) for analyses of spontaneous swimming, visual motor response (VMR), and foraging efficiency. MeHg exposures rendered total mercury (THg) body burdens of 0.02, 0.21, 0.95, 3.14, and 14.93 µg/g (wet weight). Organisms exposed to 1000 nM exhibited high mortality; thus, they were excluded from downstream behavioral analyses. All MeHg exposures tested were associated with a reduction in spontaneous swimming at 17 and 25 dpf. Exposure to 30 and 100 nM MeHg caused altered locomotor output during the VMR assay at 21 dpf, whereas exposure to 100 nM MeHg was associated with decreased foraging efficiency at 25 dpf. For the sake of comparison, the second-lowest exposure tested here rendered a THg burden that represents the permissible level of consumable fish in the United States. Moreover, this dose is reported in roughly two-thirds of consumable fish species monitored in the United States, according to the Food and Drug Administration. Although the THg body burdens reported here were higher than expected in the environment, our study is the first to analyze the effects of MeHg exposure on fundamental survival behaviors of yellow perch larvae and advances in the exploration of the ecological relevance of behavioral end points.

Mercury-induced epigenetic transgenerational inheritance of abnormal neurobehavior is correlated with sperm epimutations in zebrafish.

Methylmercury (MeHg) is a ubiquitous environmental neurotoxicant, with human exposures predominantly resulting from fish consumption. Developmental exposure of zebrafish to MeHg is known to alter their neurobehavior. The current study investigated the direct exposure and transgenerational effects of MeHg, at tissue doses similar to those detected in exposed human populations, on sperm epimutations (i.e., differential DNA methylation regions [DMRs]) and neurobehavior (i.e., visual startle and spontaneous locomotion) in zebrafish, an established human health model. F0 generation embryos were exposed to MeHg (0, 1, 3, 10, 30, and 100 nM) for 24 hours ex vivo. F0 generation control and MeHg-exposed lineages were reared to adults and bred to yield the F1 generation, which was subsequently bred to the F2 generation. Direct exposure (F0 generation) and transgenerational actions (F2 generation) were then evaluated. Hyperactivity and visual deficit were observed in the unexposed descendants (F2 generation) of the MeHg-exposed lineage compared to control. An increase in F2 generation sperm epimutations was observed relative to the F0 generation. Investigation of the DMRs in the F2 generation MeHg-exposed lineage sperm revealed associated genes in the neuroactive ligand-receptor interaction and actin-cytoskeleton pathways being effected, which correlate to the observed neurobehavioral phenotypes. Developmental MeHg-induced epigenetic transgenerational inheritance of abnormal neurobehavior is correlated with sperm epimutations in F2 generation adult zebrafish. Therefore, mercury can promote the epigenetic transgenerational inheritance of disease in zebrafish, which significantly impacts its environmental health considerations in all species including humans.

Standardizing the initial resuscitation of the trauma patient with the Primary Assessment Completion Tool using video review.

BACKGROUND: Major trauma resuscitations at pediatric trauma centers have an elevated risk for error because of their high acuity and relatively low frequency. The Advanced Trauma Life Support (ATLS) treatment paradigm was established to improve the management of trauma patients during the initial resuscitation phase and has been shown to improve outcomes through a standardized approach. The goal of this quality improvement project was to decrease assessment physician variability and improve the compliance with the ATLS primary assessment for major resuscitations. METHODS: A video review tool was developed to score the assessment physician on completion of the primary survey components using ATLS format. Interrater reliability and content validity were established for the tool. Data were collected through video review of the trauma response team in the emergency department for all Level 1 trauma alert activations with general consent. Chi-square and regression analyses were used to evaluate the data at 30 days, 6 months, and 1 year from the baseline period. RESULTS: A total of 142 patient videos were scored between July 28, 2015, and August 1, 2016. Eleven patients were reviewed during the baseline period, and only 9.1% of the total scores were ≥85. Thirty days following project implementation, 37.5% were ≥ 85. Six months following project implementation, 64.4% scored ≥85. One year following project implementation, 91.5% scored ≥85. These were statistically significant changes (p < .0001) with less variability over time. CONCLUSION: Effective leadership using a standardized approach during the trauma resuscitation has been found to have a positive effect on task completion and the overall functioning of the trauma team. This focused quality improvement project improved compliance with ATLS format and decreased variability by the assessment physician, potentially improving patient safety and outcomes. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Engineered nanomaterials: an emerging class of novel endocrine disruptors.

Over the past decade, engineered nanomaterials (ENMs) have garnered great attention for their potentially beneficial applications in medicine, industry, and consumer products due to their advantageous physicochemical properties and inherent size. However, studies have shown that these sophisticated molecules can initiate toxicity at the subcellular, cellular, and/or tissue/organ level in diverse experimental models. Investigators have also demonstrated that, upon exposure to ENMs, the physicochemical properties that are exploited for public benefit may mediate adverse endocrine-disrupting effects on several endpoints of mammalian reproductive physiology (e.g., steroidogenesis, spermatogenesis, pregnancy). Elucidating these complex interactions within reproductive cells and tissues will significantly advance our understanding of ENMs as an emerging class of novel endocrine disruptors and reproductive toxicants. Herein we reviewed the recent developments in reproductive nanotoxicology and identified the gaps in our knowledge that may serve as future research directions to foster continued advancement in this evolving field of study.

Low-dose gold nanoparticles exert subtle endocrine-modulating effects on the ovarian steroidogenic pathway ex vivo independent of oxidative stress.

Gold nanoparticles (GNPs) have gained considerable attention for application in science and industry. However, the untoward effects of such particles on female fertility remain unclear. The objectives of this study were to (1) examine the effects of 10-nm GNPs on progesterone and estradiol-17ß accumulation by rat ovaries ex vivo and (2) to identify the locus/loci whereby GNPs modulate steroidogenesis via multiple-reference gene quantitative real-time RT-PCR. Regression analyses indicated a positive relationship between both Star (p < 0.05, r(2) = 0.278) and Cyp11a1 (p < 0.001, r(2) = 0.366) expression and P4 accumulation upon exposure to 1.43 × 10(6) GNPs/mL. Additional analyses showed that E2 accumulation was positively associated with Hsd3b1 (p < 0.05, r(2) = 0.181) and Cyp17a1 (p < 0.01, r(2) = 0.301) expression upon exposure to 1.43 × 1(3) and 1.43 × 10(9) GNPs/mL, respectively. These results suggest a subtle treatment-dependent impact of low-dose GNPs on the relationship between progesterone or estradiol-17ß and specific steroidogenic target genes, independent of oxidative stress or inhibin.

Gene expression and pathologic alterations in juvenile rainbow trout due to chronic dietary TCDD exposure.

The goal of this project was to use functional genomic methods to identify molecular biomarkers as indicators of the impact of TCDD exposure in rainbow trout. Specifically, we investigated the effects of chronic dietary TCDD exposure on whole juvenile rainbow trout global gene expression associated with histopathological analysis. Juvenile rainbow trout were fed Biodiet starter with TCDD added at 0, 0.1, 1, 10 and 100 ppb (ngTCDD/g food), and fish were sampled from each group at 7, 14, 28 and 42 days after initiation of feeding. 100 ppb TCDD caused 100% mortality at 39 days. Fish fed with 100 ppb TCDD food had TCDD accumulation of 47.37 ppb (ngTCDD/g fish) in whole fish at 28 days. Histological analysis from TCDD-treated trout sampled from 28 and 42 days revealed that obvious lesions were found in skin, oropharynx, liver, gas bladder, intestine, pancreas, nose and kidney. In addition, TCDD caused anemia in peripheral blood, decreases in abdominal fat, increases of remodeling of fin rays, edema in pericardium and retrobulbar hemorrhage in the 100 ppb TCDD-treated rainbow trout compared to the control group at 28 days. Dose- and time-dependent global gene expression analyses were performed using the cGRASP 16,000 (16K) cDNA microarray. TCDD-responsive whole body transcripts identified in the microarray experiments have putative functions involved in various biological processes including growth, cell proliferation, metabolic process, and immune system processes. Nine microarray-identified genes were selected for QPCR validation. CYP1A3 and CYP1A1 were common up-regulated genes and HBB1 was a common down-regulated gene among each group based on microarray data, and their QPCR validations are consistent with microarray data for the 10 and 100 ppb TCDD treatment groups after 28 days exposure (p<0.05). In addition, in the 100 ppb group at 28 days, expression of complement component C3-1 and trypsin-1 precursor have a more than 10-fold induction from the microarray experiments, and their QPCR validations are consistent and showed significant induction in the 100 ppb group at 28 days (p<0.05). Overall, lesion in nasal epithelium is a novel and significant result in this study, and TCDD-responsive rainbow trout transcripts identified in the present study may lead to the development of new molecular biomarkers for assessing the potential impacts of environmental TCDD on rainbow trout populations.

Effective use of the air ambulance for pediatric trauma.

BACKGROUND: The purpose of this study was to compare outcomes of pediatric trauma patients transported by helicopter from the injury scene (IS group) to a trauma center and those transported by air after hospital stabilization (HS group). METHODS: A retrospective analysis of pediatric trauma patients (<19 years of age) transported by air ambulance and admitted to a pediatric trauma center was conducted. Outcomes compared were mortality and length of stay. Patients were subdivided into minor (Injury Severity Score [ISS] < 15) and major (ISS > 15) trauma. TRISS analysis was performed to verify the overall quality of the care. RESULTS: Eight hundred forty-two HS and 379 IS patients were included. The mean age, median ISS, and distribution of penetrating and blunt injuries did not differ significantly between the groups. The overall death rate was significantly lower for the interfacility transfer patients (HS group, 5.5%; IS group, 8.7%; p < 0.05). Mean intensive care unit (ICU) and hospital length of stay did not differ significantly. HS patients with major trauma had significantly less mortality (HS group, 15.5%; IS group, 26.7%; p < 0.05) and shorter mean ICU stays (HS group, 118.3 hours; IS group, 149.1 hours; p < 0.05) than IS major trauma patients. No differences were seen in patients with minor trauma. TRISS analysis showed improved survival for all patients compared with Major Trauma Outcome Study norms. CONCLUSION: Retrospective analysis was not able to demonstrate any benefit to direct transport from the scene to a trauma center. Hospital stabilization before transfer by air ambulance may improve survival and shorten ICU stays for patients with major trauma.

Case report: solitary pelvic osteochondroma presenting with L3 nerve root compression.

Osteochondroma is the most common benign bone tumor, comprising 40% of benign bone tumors. Typically they are found in adolescents growing on long bones such as the femur or radius and are clinically obvious. Very rarely, osteochondromas grow in the pelvis where they can reach a large size and present in more subtle ways. We describe an unusual case of a solitary osteochondroma in an otherwise healthy 29 year-old male presenting with signs and symptoms of an L3 nerve root compression.