Ruptured Ovarian Artery Aneurysm in a Postmenopausal Female: Case Report.

Introduction: Ovarian artery aneurysm is a rare diagnosis, primarily associated with late pregnancy and the postpartum period. It can cause life-threatening hemorrhage when ruptured. Even more rare are ovarian artery aneurysms in postmenopausal women. Case Report: We present a case of a postmenopausal female presenting to the emergency department with flank pain. Point-of-care ultrasound showed free fluid in the abdomen. She was diagnosed with an ovarian artery aneurysm on computed tomography angiography and treated successfully with embolization. Conclusion: Ruptured ovarian artery aneurysm is an uncommon cause of intra-abdominal hemorrhage in women.

How to use podcasts in neurology.

Virtual learning resources such as podcasts and social media are increasingly used in medical education. Podcasts are one example of virtual learning, where prerecorded audio files are available to stream or download from the internet, usually without a fee and at any time. This gives listeners flexibility in when and where they engage with the educational material, enabling learning to be better tailored to individual needs. Podcasts are often enjoyed for their relaxed and conversational style. However, listeners must be aware of the lack of external peer review and incomplete coverage of information. There are also risks inherent to distant learning, including depersonalisation of medical education. We describe the roles that podcasts now play in neurological education, exploring some of the ways that they can be used to enhance neurological training both as a learner and educator and giving our top tips, based on our own experiences, for anyone keen to add to the expanding field of available podcasts.

'Would I risk it again?' The long-term impacts of a traumatic birth, as experienced by fathers.

BACKGROUND: Extensive research has explored the impact of traumatic births on mothers, capturing enduring adverse outcomes as well as post-traumatic growth. The literature on fathers' experiences of birth trauma is more limited and little is known of the ongoing impact. The present study aimed to investigate the long-term effects of attending a traumatic birth. METHOD: Semi-structured interviews were completed with fathers who identified as having a traumatic birth experience two or more years ago. Thematic analysis was conducted on eight interview transcripts. RESULTS: Despite the time since the birth trauma, fathers described ongoing impact, which is captured in five themes. Four of these focus on the negative impacts: their attempts to cope by boxing away emotions, which they thought they should not feel; anxieties over having further children; negative effects on parenting; and ongoing distress or negative impact on their wellbeing. The final theme highlighted some positives from the experience, primarily a strengthened relationship with their partner. CONCLUSIONS: Traumatic birth can result in fathers experiencing difficulties beyond the perinatal period, whilst thinking that they should not feel or discuss their distress. As a result of a traumatic birth fathers can experience ongoing guilt and poor mental health, which may lead them to delay subsequent pregnancies. Most participants had not accessed support regarding the traumatic birth, instead coping by trying to avoid their memories and emotional reaction. These findings highlight the need for increased acknowledgement of the impact of birth trauma and intervention for fathers, during and after the perinatal period.

The challenges of open data sharing for qualitative researchers.

'Open Science' advocates for open access to scientific research, as well as sharing data, analysis plans and code in order to enable replication of results. However, these requirements typically fail to account for methodological differences between quantitative and qualitative research, and serious ethical problems are raised by the suggestion that full qualitative datasets can or should be published alongside qualitative research papers. Aside from important ethical concerns, the idea of sharing qualitative data in order to enable replication is conceptually at odds with the underpinnings on most qualitative methodologies, which highlight the importance of the unique interpretative function of the researcher. The question of whether secondary analysis of qualitative data is acceptable is key, and in this commentary we argue that there are good conceptual, ethical and economic reasons to consider how funders, researchers and publishers can make better use of existing data.

Impaired IgM Memory B Cell Function Is Common in Coeliac Disease but Conjugate Pneumococcal Vaccination Induces Robust Protective Immunity.

Coeliac disease (CD) is associated with hyposplenism, an acquired impairment of spleen function associated with reduced IgM memory B cells and increased susceptibility to serious pneumococcal infection. Little is known about the immune implications of hyposplenism in CD or the optimal pneumococcal vaccination strategy. In this study, the immune effects of hyposplenism in CD, and the accuracy of screening approaches and protective responses induced by two different pneumococcal vaccines were examined. Active and treated CD cohorts, and healthy and surgically splenectomised controls underwent testing for the presence of Howell-Jolly bodies and pitted red cells, spleen ultrasound, and immune assessment of IgM memory B cell frequency and IgM memory B cell responses to T cell-dependent (TD) or T cell-independent (TI) stimulation. Responses following conjugate (TD) and polysaccharide (TI) pneumococcal vaccination were compared using ELISA and opsonophagocytic assays. Although hyposplenism is rare in treated CD (5.1%), functional B cell defects are common (28-61%) and are not detected by current clinical tests. Conjugate pneumococcal vaccination induced superior and sustained protection against clinically relevant serotypes. Clinical practice guidelines in CD should recommend routine pneumococcal vaccination, ideally with a conjugate vaccine, of all patients in lieu of hyposplenism screening.

Stool Gluten Peptide Detection Is Superior to Urinary Analysis, Coeliac Serology, Dietary Adherence Scores and Symptoms in the Detection of Intermittent Gluten Exposure in Coeliac Disease: A Randomised, Placebo-Controlled, Low-Dose Gluten Challenge Study.

Monitoring adherence to a gluten-free diet is an important goal of coeliac disease management. Urine and stool gluten immunogenic peptide (GIP) assays provide an objective readout of gluten ingestion, with the former favoured due to its convenience and acceptability. This study assessed stool GIP excretion after low-dose gluten challenge designed to mimic accidental gluten exposure. A total of 52 coeliac participants undertook a randomised, double-blind gluten (50-1000 mg) or placebo challenge. Stool and urinary GIP, serology, dietary adherence and symptoms were assessed. Stool GIP was 100% sensitive for gluten intake ≥250 mg and 71% for 50 mg. Peak GIP detection was 12-36 h after gluten exposure. The mean stool GIP after 1000 mg gluten ingestion remained above the limit of quantification for 5 days. Urine GIP assessment had poor sensitivity for GIP excretion compared to stool. Serology, dietary adherence score and symptoms did not correlate with gluten excretion during lead-in. We conclude that stool GIP detection is highly sensitive, with levels related to gluten dose and time from ingestion. Weekly or bi-weekly testing will detect low-level exposure more effectively than urine GIP assessments or traditional methods. In this seronegative, apparently well-treated cohort, a high frequency of baseline-positive GIP suggests ongoing gluten exposure, but the assessment of patient behaviour and assay specificity is needed.

'A more human approach I haven't found that really': experiences of hoarding difficulties and seeking help.

BACKGROUND AND AIMS: People with hoarding behaviours often struggle to engage in treatment. This study aimed to explore the experiences of a sample of people who identify as engaging in hoarding behaviours and who are seeking support. Exploring motivation to seek help, the barriers those who hoard face in accessing support and what facilitates accepting help, can aid understanding of how best to intervene. METHOD: Eight individuals who self-identified as seeking help in relation to hoarding behaviours were recruited via social media and support groups. Interviews were conducted by telephone or video call, before being transcribed and analysed using interpretative phenomenological analysis. RESULTS: Participants described complex help-seeking narratives and reported continued ambivalence about addressing their hoarding behaviours. The four group experiential themes identified were Wrestling with identity; Who can I trust?; Services don't fit; and Being overlooked: 'they're too busy looking at the thing, not the person'. Difficulties trusting others and services were identified; services were experienced as rejecting and many participants sought help for problems other than their hoarding. Problems accessing appropriate help for hoarding were predominant in the narratives, although participants who had accessed peer support described this as valuable. CONCLUSIONS: There are both internal (e.g. fear of judgement; feeling overwhelmed) and external (e.g. service gaps) barriers that make finding useful help for hoarding behaviours very difficult. Services may facilitate those seeking help by taking a compassionate and person-centred approach to hoarding problems.

Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services.

BACKGROUND: Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion. METHODS: We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article. RESULTS: Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities. CONCLUSION: Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

The evolution of antimicrobial peptides in Chiroptera.

High viral tolerance coupled with an extraordinary regulation of the immune response makes bats a great model to study host-pathogen evolution. Although many immune-related gene gains and losses have been previously reported in bats, important gene families such as antimicrobial peptides (AMPs) remain understudied. We built an exhaustive bioinformatic pipeline targeting the major gene families of defensins and cathelicidins to explore AMP diversity and analyze their evolution and distribution across six bat families. A combination of manual and automated procedures identified 29 AMP families across queried species, with α-, ß-defensins, and cathelicidins representing around 10% of AMP diversity. Gene duplications were inferred in both α-defensins, which were absent in five species, and three ß-defensin gene subfamilies, but cathelicidins did not show significant shifts in gene family size and were absent in Anoura caudifer and the pteropodids. Based on lineage-specific gains and losses, we propose diet and diet-related microbiome evolution may determine the evolution of α- and ß-defensins gene families and subfamilies. These results highlight the importance of building species-specific libraries for genome annotation in non-model organisms and shed light on possible drivers responsible for the rapid evolution of AMPs. By focusing on these understudied defenses, we provide a robust framework for explaining bat responses to pathogens.

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program.

INTRODUCTION: Home-based primary care (HBPC) has shown promise in the management of multiple chronic conditions for patients who are homebound or who have limited mobility. The objective of this study was to implement and evaluate an HBPC program that integrates the services of clinical pharmacists and community aging services providers in a community-based setting. METHODS: Mountain Area Health Education Center's (MAHEC) HBPC program brought together an interdisciplinary team including medical providers, pharmacists, and community aging services providers to conduct home visits with older adults (age 50+). A single-arm, prepost analysis was conducted to determine differences from the year before program enrollment to the year postenrollment. We examined the frequency of health care visits, high-cost health care utilization (emergency department [ED] utilization and hospitalizations), and health care costs. Descriptive statistics characterized the study population and outcomes. Fisher's Exact Tests were used to determine if there was a significant difference between years. RESULTS: There were 130 home visits with 62 patients enrolled in the program. The Medicare Annual Wellness Visit (AWV) was completed for 32 (51.6%) patients. There were 13 (21.0%) and 12 (19.4%) individuals who had at least 1 ED visit and hospitalization, respectively, pre-enrollment as compared with 8 (12.9%) and 9 (14.5%) individuals postenrollment (p-value = 0.05, p-value = 0.06). During the postenrollment year, patient enrollees had an average per-member-per-month (PMPM) cost of $1567.96 as compared with $3053.21 in the year prior. CONCLUSIONS: Pharmacist and community agency services-integrated HBPC was implemented in the community setting. There was a decrease in high-cost health care utilization and total health care expenditures for patients as compared with the previous year.

Diet of a threatened rattlesnake (eastern massasauga) revealed by DNA metabarcoding.

Characterizing the diet of imperiled species using minimally invasive methods is crucial to understanding their ecology and conservation requirements. Here, we apply a DNA metabarcoding approach to study the diet of the eastern massasauga rattlesnake (Sistrurus catenatus), a Federally Threatened snake found throughout the Great Lakes region. Eighty-three fecal samples collected across 10 different massasauga populations located in Michigan, USA, were sequenced, with 70 samples containing prey DNA. We used universal metazoan primers and developed a host-specific oligonucleotide blocker to characterize their diet. We identified at least 12 different prey species, with eastern massasaugas exhibiting opportunistic feeding and a strong preference towards small mammals. Meadow voles (Microtus pennsylvanicus) were the most common prey item (70% of diet) followed by the northern short-tailed shrew (Blarina brevicauda) and masked shrew (Sorex cinereus; 15.7% of diet each), along with occasional bird and snake prey. Adult individuals exhibited a more generalized diet, consuming a larger number of prey taxa on average. Younger snakes consumed a smaller variety of prey items and tended to consume smaller-sized mammals such as masked shrews (Sorex cinereus) and northern short-tailed shrews (Blarina brevicauda). We conclude that small mammals are a crucial part of eastern massasauga rattlesnake diet and recommend this be taken into consideration when conservation strategies are developed. The methods developed in this study can be applied to other reptile species, providing an accurate, minimally invasive, and thorough diet assessment for at-risk reptile species.

Complex and alternate consent pathways in clinical trials: methodological and ethical challenges encountered by underserved groups and a call to action.

BACKGROUND: Informed consent is considered a fundamental requirement for participation in trials, yet obtaining consent is challenging in a number of populations and settings. This may be due to participants having communication or other disabilities, their capacity to consent fluctuates or they lack capacity, or in emergency situations where their medical condition or the urgent nature of the treatment precludes seeking consent from either the participant or a representative. These challenges, and the subsequent complexity of designing and conducting trials where alternative consent pathways are required, contribute to these populations being underserved in research. Recognising and addressing these challenges is essential to support trials involving these populations and ensure that they have an equitable opportunity to participate in, and benefit from, research. Given the complex nature of these challenges, which are encountered by both adults and children, a cross-disciplinary approach is required. DISCUSSION: A UK-wide collaboration, a sub-group of the Trial Conduct Working Group in the MRC-NIHR Trial Methodology Research Partnership, was formed to collectively address these challenges. Members are drawn from disciplines including bioethics, qualitative research, trials methodology, healthcare professions, and social sciences. This commentary draws on our collective expertise to identify key populations where particular methodological and ethical challenges around consent are encountered, articulate the specific issues arising in each population, summarise ongoing and completed research, and identify targets for future research. Key populations include people with communication or other disabilities, people whose capacity to consent fluctuates, adults who lack the capacity to consent, and adults and children in emergency and urgent care settings. Work is ongoing by the sub-group to create a database of resources, to update NIHR guidance, and to develop proposals to address identified research gaps. CONCLUSION: Collaboration across disciplines, sectors, organisations, and countries is essential if the ethical and methodological challenges surrounding trials involving complex and alternate consent pathways are to be addressed. Explicating these challenges, sharing resources, and identifying gaps for future research is an essential first step. We hope that doing so will serve as a call to action for others seeking ways to address the current consent-based exclusion of underserved populations from trials.

Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

The impact of prehabilitation interventions on affective and functional outcomes for young to midlife adult cancer patients: A systematic review.

OBJECTIVE: Cancer remains one of the most enduring health crises of the modern world. Prehabilitation is a relatively new intervention aimed at preparing individuals for the stresses associated with treatment from diagnosis. Prehabilitation can include exercise, psychological and nutrition-based interventions. The present systematic review aimed to assess the efficacy of prehabilitation on affective and functional outcomes for young to midlife adult cancer patients (18-55 years). Outcomes of interest included prehabilitation programme composition, duration, mode of delivery and measures used to determine impact on affective and functional outcomes. METHODS: The following databases were searched with controlled and free text vocabulary; Psychological Information database (PsychINFO), Culmunated Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE) and Public MEDLINE (PubMed). Abstract and full-text screening was conducted with a secondary reviewer and final texts were subject to risk of bias analysis. RESULTS: Thirteen texts were included at full-text. These included data of 797 prehabilitation participants (mean age 53 years) and a large representation of female participants (71% average). Evidence was found for the efficacy of psychological prehabilitation for anxiety reduction. Prehabilitation did not significantly affect health related quality of life. Findings moderately supported the therapeutic validity of exercise prehabilitation for functional outcomes, both in terms of clinical and experimental improvement with respect to the quality of evidence. Variation between all prehabilitation types was observed. There was insufficient evidence to support the efficacy of psychological prehabilitation on stress, distress or depression. CONCLUSION: Implications for future research are highlighted and then discussed with respect to this young to midlife age group.

Trial Forge Guidance 3: randomised trials and how to recruit and retain individuals from ethnic minority groups-practical guidance to support better practice.

Randomised trials, especially those intended to directly inform clinical practice and policy, should be designed to reflect all those who could benefit from the intervention under test should it prove effective. This does not always happen. The UK National Institute for Health and Care Research (NIHR) INCLUDE project identified many groups in the UK that are under-served by trials, including ethnic minorities.This guidance document presents four key recommendations for designing and running trials that include the ethnic groups needed by the trial. These are (1) ensure eligibility criteria and recruitment pathway do not limit participation in ways you do not intend, (2) ensure your trial materials are developed with inclusion in mind, (3) ensure staff are culturally competent and (4) build trusting partnerships with community organisations that work with ethnic minority groups. Each recommendation comes with best practice advice, public contributor testimonials, examples of the inclusion problem tackled by the recommendation, or strategies to mitigate the problem, as well as a collection of resources to support implementation of the recommendations.We encourage trial teams to follow the recommendations and, where possible, evaluate the strategies they use to implement them. Finally, while our primary audience is those designing, running and reporting trials, we hope funders, grant reviewers and approvals agencies may also find our guidance useful.