A 3D-Printable, Low-Cost Obturator for Less Invasive Gynecologic Brachytherapy.

The purpose of this report is to design, develop, and evaluate a cost-effective applicator for interstitial brachytherapy (ISBT) to minimize patient morbidity and facilitate access to curative radiation treatment for gynecologic cancers, especially in low-resource settings. A computer-aided design and prototype were developed of a proposed applicator that incorporates 44 slotted channels to gently guide needles, with or without a tandem, through the vaginal canal, effectively eliminating the need for transcutaneous needle insertions typically employed during ISBT of advanced gynecologic cancer and thus reducing the risk of vaginal laceration and bladder or rectal injury. The tested prototype was developed using AutoCAD software (Autodesk, San Francisco, CA) and 3D printed in Accura Xtreme Gray material using stereolithography. Small-scale iterative tests using a gelatin phantom were conducted on this prototype to confirm the efficacy of the applicator through inter-operator usability, needle stability, and needle arrangement. A promising prototype was developed aimed at addressing key issues with traditional perineum-based templates to facilitate ISBT, including being able to cover bulky tumors with parametrial extension reliably, decrease the risk of tissue or organ injury, and treat women with a prior hysterectomy. Results of preclinical testing demonstrated that the applicator met its purpose, suggesting that it may facilitate ISBT without the morbidity typically associated with the procedure, especially by addressing concerns associated with implementing the procedure in low-resource settings. The applicator shows substantial promise in the treatment of advanced gynecologic cancer. While further testing remains necessary to confirm its translatability to the clinical setting, the applicator appears capable of meeting its design objectives, representing its potential for improving upon current methods.

Corrigendum to "Disparities in chronic physical health conditions in sexual and gender minority people using the behavioral risk factor surveillance system" [Prev. Med. Rep. 29 (2022) 101881].

[This corrects the article DOI: 10.1016/j.pmedr.2022.101881.].

Cannabidiol Safety Data: A Systematic Mapping Study.

Robust assessment of potential adverse outcomes is needed to determine a safe cannabidiol (CBD) intake level for consumer use. To assist in identifying knowledge gaps and inform future decision making regarding systematic development of health-based benchmarks, we have developed the first systematic map of the safety-related information available for CBD in the peer-reviewed literature. Literature searching conducted according to a published protocol yielded a total of 4186 unique titles and abstracts published through 2020. These were screened using DistillerSR for studies that evaluated at least one potential health outcome following exposure to CBD and/or other hemp-derived substances. Additional categorization was conducted for a subset of 1001 studies in which CBD was administered alone. Studies that investigated CBD most frequently reported on neurological outcomes (532), carcinogenic outcomes (129), and pharmacokinetics (118). Less frequently studied categories included developmental and reproductive, hepatic, and gastrointestinal outcomes. The primary outcomes associated with the most adverse events reported in the literature were neurological (13) and developmental and reproductive (12). Based on the studies identified, reproductive and developmental toxicity was identified as a data gap that warrants conducting a well-designed, guideline-compliant reproductive toxicity study on CBD. In addition, immune outcomes were noted as a potential emerging research area for CBD. This systematic map provides an important baseline from which to identify topics that may be suitable for further research related to the safe use of CBD. Implications for future potential work and limitations of the mapping exercise are discussed.

Disparities in chronic physical health conditions in sexual and gender minority people using the United States Behavioral Risk Factor Surveillance System.

This study analyzed the physical health status of adults who belong to a sexual or gender minority (SGM) population, and whether health inequities correlate with access to quality healthcare. The Centers for Disease Control and Prevention (CDC) 2014-2020 Behavioral Risk Factor Surveillance System (BRFSS) included data for 64,696 adults who identified as gay, lesbian, bisexual, other, and/or transgender and 1,369,681 adults who identified as cisgender and straight. Multivariable logistic regressions of the weighted sample were conducted to examine associations between demographics and health and access outcomes. After accounting for demographic variables, drinking, and smoking behavior, SGM respondents reported poorer physical and mental health, which worsened after the start of the COVID-19 pandemic. SGM respondents had higher odds than non-SGM of having asthma, arthritis, diabetes, kidney disease, hypertension, cardiovascular disease, heart attack, stroke, and chronic obstructive pulmonary disease (COPD), as well as difficulties "see[ing] the doctor because of cost," particularly after the start of the COVID pandemic. SGM respondents had higher odds of lack of access to healthcare provider, delayed medical care, and issues taking medications due to cost and fewer routine checkups. Thus, the SGM group faced worse health and higher rates of some chronic conditions. This study found a significant relationship with cost barriers attributable to larger societal discrimination regarding SGM individuals, particularly in the workplace. Further research exploring these results is critical, but these findings have identified areas of healthcare inequity to be addressed via preventative health efforts in both public health and primary care settings.

Colorimetric determination of urea using diacetyl monoxime with strong acids.

Urea is a byproduct of the urea cycle in metabolism and is excreted through urine and sweat. Ammonia, which is toxic at low levels, is converted to the safe storage form of urea, which represents the largest efflux of nitrogen from many organisms. Urea is an important nitrogen source in agriculture, is added to many industrial products, and is a large component in wastewater. The enzyme urease hydrolyzes urea to ammonia and bicarbonate. This reaction is microbially mediated in soils, hydroponic solutions, and wastewater recycling and is catalyzed in vivo in plants using native urease, making measurement of urea environmentally important. Both direct and indirect methods to measure urea exist. This protocol uses diacetyl monoxime to directly determine the concentration of urea in solution. The protocol provides repeatable results and stable reagents with good color stability and simple measurement techniques for use in any lab with a spectrophotometer. The reaction between diacetyl monoxime and urea in the presence of sulfuric acid, phosphoric acid, thiosemicarbazide, and ferric chloride produces a chromophore with a peak absorbance at 520 nm and a linear relationship between concentration and absorbance from 0.4 to 5.0 mM urea in this protocol. The lack of detectable interferences makes this protocol suitable for the determination of millimolar levels of urea in wastewater streams and hydroponic solutions.

Use of acceptable daily intake (ADI) as a health-based benchmark in nutrition research studies that consider the safety of low-calorie sweeteners (LCS): a systematic map.

BACKGROUND: It is well-recognized that consumers face many challenges in understanding and applying nutritional guidance for low-calorie sweeteners (LCS). Thus, this research aims to (1) assess how benchmarks for safe levels of consumption of LCS are utilized by researchers, and (2) understand how varying use of such benchmarks may contribute to challenges in understanding and applying nutritional guidance for LCS consumption. METHODS: A systematic mapping exercise was employed to characterize when and how acceptable daily intake (ADI) values are used as health-based benchmarks in nutrition research studies that consider the safety of LCS. RESULTS: Based on results from charting 121 studies, our findings demonstrate that comparisons of LCS intake to an ADI derived by an authoritative body have been made in a diverse set of published literature, varying widely in their objectives, approaches, and populations of interest. The majority of studies compared the ADI to intake in a population under study; these represent the type of comparison that is most consistent with the intent of the ADI. Other applications of the ADI included use as a benchmark in experimental studies, risk-benefit analyses, and metabolism studies. CONCLUSION: Although most instances of ADI use were reasonable within the context of the individual studies' objectives, the diversity in use by original-study authors amplifies the continued need for development of "best practices" regarding the use and interpretation of the ADIs in current research. Using comparisons to the ADI can be a helpful way to provide context to research findings. However, in doing so, it is important that researchers utilize the value in a manner specific with its intent, as the ADI is a metric that represents an estimate of the amount of a substance that can be consumed daily over a lifetime without presenting an appreciable risk to health.

Physician Preceptor Satisfaction and Productivity Across Curricula: A Comparison Between Longitudinal Integrated Clerkships And Traditional Block Rotations.

Phenomenon: Physicians are under intense pressure to improve clinical productivity. High clinical load, limited availability, and decreased clinical efficiency are well-documented barriers to precepting medical students and threaten clinical productivity. In an era of increasing medical student enrollment, these barriers have already led to a decreased availability of clinical teachers and training sites across the United States. Improved preceptor satisfaction could have a great impact on recruitment and retention of medical student preceptors and is likely linked to changes in productivity. Curriculum structure could impact both preceptor productivity and satisfaction. Comparing productivity and satisfaction of physician preceptors teaching in longitudinal integrated clerkships (LICs) to those teaching in traditional block rotations (TBRs), or in both settings (LIC-TBR), could lead to a better understanding of the impact of curriculum structure on preceptor productivity and satisfaction. Approach: Data were collected through a quantitative cross-sectional survey of outpatient physician preceptors in North Carolina in 2017. Preceptor satisfaction and student influence on productivity-related aspects of practice were analyzed with bivariate chi-square statistics and multivariate logistic regression. Findings: Analyses included 338 physician preceptors: 79 LIC (23%), 50 LIC-TBR (15%), and 209 TBR preceptors (62%). LIC preceptors were more likely to indicate being "very satisfied" with precepting than either their LIC-TBR or TBR counterparts. There were no differences in perceived productivity-related aspects of practice across the different curricula, such as patient flow, income, or physician working hours. Logistic regressions controlling for potential confounding variables suggested that those teaching in LICs were almost 3 times more likely to be "very satisfied" relative to those teaching in LIC-TBR and TBR settings and that the negative influence of students on patient flow and physician working hours had an adverse effect on preceptor satisfaction. Insights: Preceptor satisfaction was high overall, though satisfaction was significantly higher among preceptors who teach in LICs. The perceived impact of students on clinical productivity was stable across the different curricula. In an era of increasing need for physician preceptors, the higher satisfaction of those who teach in LICs should be considered in curricular design and for preceptor recruitment and retention.

Family medicine residents' perspectives on curricular messaging surrounding enhanced skills fellowship programs.

OBJECTIVE: To better understand the messages that family medicine residents receive about enhanced skills fellowship programs throughout their training. DESIGN: Phenomenologic approach using structured qualitative interviews. SETTING: Postgraduate family medicine program in Ontario. PARTICIPANTS: Eleven family medicine residents (5 first-year and 6 second-year residents) from 4 separate training sites. METHODS: Interviews were audiotaped and codes were developed by the study investigators. Themes arose from the data via the immersion and crystallization technique. MAIN FINDINGS: Themes emerged in 3 categories: perception of purpose, sources of messaging, and formal or informal versus hidden curricular messages. Fellowship programs were viewed by residents in terms of their personal and professional benefits. Residents learned about fellowship programs through word of mouth and from role models. The formal curriculum remained neutral about fellowship training. The hidden curriculum highlighted a number of messages: a) to maximize chances of acceptance into some fellowship programs, one should focus most of his or her elective time in that clinical area; b) many fellowships graduate subspecialists to the exclusion of family medicine; c) a fellowship is required to practise in a large urban centre but is not required to practise in rural communities; and d) those without fellowship training are less well regarded. CONCLUSION: Residents receive mixed messages regarding fellowship training. This might be a phenomenon isolated to a larger urban centre in Ontario. Decision making at the individual level in terms of career path seems to be affected and might have implications at the larger system level.

The North Carolina Community Preceptor Experience: Third Study of Trends Over 12 Years.

PURPOSE: To measure community-based preceptors' overall satisfaction and motivations, the influence of students on preceptors' practices, and compare with 2005 and 2011 studies. METHOD: North Carolina primary care preceptors across disciplines (physicians, pharmacists, advanced practice nurses, physician assistants) received survey invitations via e-mail, fax, postcard, and/or full paper survey. Most questions in 2017 were the same as questions used in prior years, including satisfaction with precepting, likelihood to continue precepting, perceived influence of teaching students in their practice, and incentives for precepting. A brief survey or phone interview was conducted with 62 nonresponders. Chi-square tests were used to examine differences across discipline groups and to compare group responses over time. RESULTS: Of the 2,786 preceptors contacted, 893 (32.1%) completed questionnaires. Satisfaction (816/890; 91.7%) and likelihood of continuing to precept (778/890; 87.4%) remained unchanged from 2005 and 2011. However, more preceptors reported a negative influence for patient flow (422/888; 47.5%) in 2017 than in 2011 (452/1,266; 35.7%) and 2005 (496/1,379; 36.0%) (P < .0001), and work hours (392/889; 44.1%) in 2017 than in 2011 (416/1,268; 32.8%) and 2005 (463/1,392; 33.3%) (P < .0001). Importance of receiving payment for teaching increased from 32.2% (371/1,152) in 2011 to 46.4% (366/789) in 2017 (P < .0001). CONCLUSIONS: This 2017 survey suggests preceptor satisfaction and likelihood to continue precepting have remained unchanged from prior years. However, increased reporting of negative influence of students on practice and growing value of receiving payment highlight growing concerns about preceptors' time and finances and present a call to action.

Cefepime-induced neurotoxicity: a systematic review.

BACKGROUND: Cefepime is a widely used antibiotic with neurotoxicity attributed to its ability to cross the blood-brain barrier and exhibit concentration-dependent ϒ-aminobutyric acid (GABA) antagonism. Neurotoxic symptoms include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. Data suggest that up to 15% of ICU patients treated with cefepime may experience these adverse effects. Risk factors include renal dysfunction, excessive dosing, preexisting brain injury, and elevated serum cefepime concentrations. We aimed to characterize the clinical course of cefepime neurotoxicity and response to interventions. METHODS: A librarian-assisted search identified publications describing cefepime-associated neurotoxicity from January 1980 to February 2016 using the CINAHL and MEDLINE databases. Search terms included cefepime, neurotoxicity, encephalopathy, seizures, delirium, coma, non-convulsive status epilepticus, myoclonus, confusion, aphasia, agitation, and death. Two reviewers independently assessed identified articles for eligibility and used the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) for data reporting. RESULTS: Of the 123 citations identified, 37 (representing 135 patient cases) were included. Patients had a median age of 69 years, commonly had renal dysfunction (80%) and required intensive care (81% of patients with a reported location). All patients exhibited altered mental status, with reduced consciousness (47%), myoclonus (42%), and confusion (42%) being the most common symptoms. All 98 patients (73% of cohort) with electroencephalography had abnormalities, including non-convulsive status epilepticus (25%), myoclonic status epilepticus (7%), triphasic waves (40%), and focal sharp waves (39%). As per Food and Drug Administration (FDA)-approved dosing guidance, 48% of patients were overdosed; however, 26% experienced neurotoxicity despite appropriate dosing. Median cefepime serum and cerebrospinal fluid (CSF) concentrations were 45 mg/L (n = 21) and 13 mg/L (n = 4), respectively. Symptom improvement occurred in 89% of patients, and 87% survived to hospital discharge. The median delay from starting the drug to symptom onset was 4 days, and resolution occurred a median of 2 days after the intervention, which included cefepime discontinuation, antiepileptic administration, or hemodialysis. CONCLUSIONS: Cefepime-induced neurotoxicity is challenging to recognize in the critically ill due to widely varying symptoms that are common in ICU patients. This adverse reaction can occur despite appropriate dosing, usually resolves with drug interruption, but may require additional interventions such as antiepileptic drug administration or dialysis.

Nursing associate role is a better than spending on agency nurses.

I'm training on the new nursing associate scheme. It is a pilot scheme, therefore it is trial and error, but as nursing associates we could go on to become trained nurses.

Reporting Melanoma: A Nationwide Surveillance of State Cancer Registries.

The goal of our study was to determine current melanoma reporting methods available to dermatologists and dermatopathologists and quantify changes in reporting methods from 2012 to 2014. A cross-sectional study design was utilized consisting of website perusal of reporting procedures, followed up by telephone and email inquiry of reporting methods from every state cancer registry. This study was conducted over a six-month period from February to August 2014. A previous similar survey was conducted in 2012 over the same time frame and results were compared. Kansas state cancer registry provided no data. As of August 2014, 96% of 49 state cancer registries had electronic methods available to all designated reporters. Seven (14%) states required an electronic-only method of reporting melanoma cases. Eighty-six percent allowed hard copy pathology report submission. Compared to the 2012 survey, 2 additional states were found to have initiated electronic reporting methods by 2014. In conclusion, a variety of methods exist for reporting diagnosed melanoma cases. Although most state cancer registries were equipped for electronic transmission of cases for mandated reporters, a number of states were ill-equipped for electronic submission from outpatient dermatologists. There was a general trend towards electronic versus nonelectronic reporting from 2012 to 2014.

Delivering away from home: the perinatal experiences of First Nations women in northwestern Ontario.

INTRODUCTION: Our objective was to understand the perinatal knowledge and experiences of First Nations women from northwestern Ontario who travel away from their remote communities to give birth. METHODS: A systematic review of MEDLINE, HealthSTAR, HAPI, Embase, AMED, PsycINFO and CINAHL was undertaken using Medical Subject Headings and keywords focusing on Canadian Aboriginal (First Nations, Metis and Inuit) prenatal education and care, and maternal health literacy. This qualitative study using semistructured interviews was conducted in a rural hospital and prenatal clinic that serves First Nations women. Thirteen women from remote communities who had travelled to Sioux Lookout, Ont., to give birth participated in the study. RESULTS: We identified 5 other qualitative studies that explored the birthing experiences of Aboriginal women. The studies documented a negative experience for women who travelled to access intrapartum maternity care. While in Sioux Lookout to give birth, our participants also experienced loneliness and missed their families. They were open to the idea of a culturally appropriate doula program and visits in hospital by First Nations elders, but they were less interested in access to tele-visitation with family members back in their communities. We found that our participants received most of their prenatal information from family members. CONCLUSION: First Nations women who travel away from home to give birth often travel great cultural and geographic distances. Hospital-based maternity care programs for these women need to achieve a balance of clinical and cultural safety. Programs should be developed to lessen some of the negative consequences these women experience.

Traditional First Nations birthing practices: interviews with elders in Northwestern Ontario.

OBJECTIVES: Traditionally, First Nations maternity care was provided by community-based midwives trained through apprenticeship. Obstetrical practices and beliefs were integrated to provide holistic care. The Sioux Lookout Meno Ya Win Health Centre has a mandate to be a centre of excellence for Aboriginal health care. We undertook a literature review and performed a qualitative research study to understand some of the traditional practices in maternity care. METHODS: We conducted qualitative semi-structured interviews in English and Oji-Cree with 12 elders who had knowledge and experience of historical birthing practices in their home communities. Research team members included nursing and medical personnel and Anishinabe First Nation members. Interviews were analyzed and themes developed and verified by member checking and triangulation. RESULTS: The hands-on training for a community-based midwife often began in her teenage years with observation of childbirth practices. Practices were handed down by oral tradition and included prescriptions for healthy diet and moderate exercise during pregnancy; intrapartum care with preparation of clean cloths, moss, and scissors; the involvement of certain supportive family and community members; careful attention to the sacred handling of the placenta and umbilical cord; and careful wrapping of the newborn in fur. Complications, sometimes fatal, included retained placentas and stillbirths. CONCLUSION: The provision of modern maternity care to Aboriginal patients should include acknowledgement of, and respect for, traditional birthing practices. Facilities providing care for these patients should consult with the relevant Aboriginal communities to understand their needs and initiate appropriate programming.

First Nations women's knowledge of menopause: experiences and perspectives.

OBJECTIVE: To understand and describe the menopause experiences and perspectives of First Nations women residing in northwestern Ontario. DESIGN: Phenomenologic approach using in-depth qualitative interviews. SETTING: Sioux Lookout, Ont, and 4 surrounding First Nations communities. PARTICIPANTS: Eighteen perimenopausal and postmenopausal First Nations women, recruited by convenience and snowball sampling techniques. METHODS: Semistructured interviews were audiotaped and transcribed. Themes emerged through a crystallization and immersion analytical approach. Triangulation of methods was used to ensure reliability of findings. MAIN FINDINGS: This study confirms the hypothesis that menopause is generally not discussed by First Nations women, particularly with their health care providers. The generational knowledge gained by the women in this study suggests that a variety of experiences and symptoms typical of menopause from a medical perspective might not be conceptually linked to menopause by First Nations women. The interview process and initial consultation with translators revealed that there is no uniform word in Ojibway or Oji-Cree for menopause. A common phrase is "that time when periods stop," which can be used by caregivers as a starting point for discussion. Participants' interest in the topic and their desire for more information might imply that they would welcome the topic being raised by health care providers. CONCLUSION: This study speaks to the importance of understanding the different influences on a woman's menopause experience. Patient communication regarding menopause might be enhanced by providing women with an opportunity or option to discuss the topic with their health care providers. Caregivers should also be cautious of attaching preconceived ideas to the meaning and importance of the menopause experience.