Assessment of Family Medicine Obstetrics Fellowship Websites in the United States: Content and Usability.

INTRODUCTION: The United States is experiencing maternity care shortages. Family physicians can play a role in addressing these shortages. Family medicine obstetrics fellowships train family physicians in obstetrics care. Fellowship websites are important for promoting programs and attracting applicants. However, whether websites provide sufficient program information is unknown. This study aimed to assess completeness and utility of family medicine obstetrics fellowship websites across the United States. METHOD: The study analyzed 46 family medicine obstetrics fellowship websites. The component analysis evaluated the presence of 17 components related to orientation, curriculum, program, personnel, and additional content. The qualitative analysis included ratings for navigation and application, information quality, and esthetics. Analysis included percentages for websites and components and average qualitative ratings. RESULTS: Common components included overviews, training requirements, and contact information. Description of the patient population was the least common component. Usability ratings varied across programs, with higher ratings observed for navigation and application, and information quality. Esthetics and visual appeal received lower ratings. Regional analysis indicated that websites from fellowships in the West and Southwest tended to include more components compared to those in the Southeast. DISCUSSION: Family medicine obstetrics fellowship websites serve as valuable sources of program information for prospective applicants. However, not all websites include essential program details. Some information is rarely provided. Given the shortage of maternity care providers, it is crucial to develop informative and functional websites to attract applicants. Improving website content and design could prove to be a cost-effective strategy to increase the number of applicants.

Introduction of portable computed tomography scanners, in the treatment of acute stroke patients via telemedicine in remote communities.

BACKGROUND: Thrombolysis is an established treatment in selected patients who present early to hospital after symptoms of acute ischaemic stroke. Treatment can only be offered after the patient has been assessed by highly trained physicians and imaging studies have ruled out a brain haemorrhage. This limits the wider availability of thrombolysis to patients in remote communities, especially in countries with limited resources. There has been considerable success with the use of TeleStroke to overcome such barriers. TeleStroke is feasible in remote hospitals provided there is an available computed tomography scanner, a fundamental prerequisite in the assessment of acute stroke and thrombolysis. This is a luxury not widely available, especially in remote sites. Recently, Neurologica introduced a portable computed tomography scanner that can be operated after minimal training. METHODS: We report our preliminary experience with the portable computed tomography scanner in a remote community where Telemedicine was successfully used to evaluate and treat patients presenting with symptoms suggestive of an acute ischaemic stroke. The University of Alberta Hospital in Edmonton, Canada was the 'hub' site and Wainwright Community Hospital was the 'spoke' site. RESULTS: Over a 3-month period, 18 patients were evaluated in the emergency department of the remote hospital where the referring physician felt that symptoms indicated potential for thrombolysis. All patients were evaluated remotely by a stroke neurologist in a TeleStroke service situated 207 km from the rural site. After clinical examination, cranial computed tomography scans were obtained with the portable scanner and evaluated by the stroke neurologist. In three patients, thrombolysis was not offered because the computed tomography showed evidence of brain haemorrhage: two intracerebral haemorrhage and one subarachnoid haemorrhage. Three patients meeting the standard criteria received thrombolysis within 4.5 h from onset of symptoms. There was a significant improvement in two patients. One patient did not make a good recovery. Repeat computed tomography scans showed a small haemorrhagic transformation in one patient. In the remaining 12 subjects, symptoms improved rapidly, were outside the window for thrombolysis, or were not consistent with an acute ischaemic stroke. INTERPRETATIONS: Our preliminary study shows that the portable scanner can be used successfully in the evaluation of patients in remote regions that are not within timely reach of stroke experts or do not have available conventional imaging with computed tomography scans. Telemedicine, in combination with the use of portable scanners, offers hope to a large remote population base that would otherwise not have access to appropriate acute stroke treatment.

Individualized exercise program for the treatment of severe fatigue in patients after allogeneic hematopoietic stem-cell transplant: a pilot study.

Chronic cancer-related fatigue in otherwise asymptomatic post-allogeneic hematopoietic stem cell transplant (HSCT) patients is common and debilitating. This pilot study investigated whether patients with no clinical or psychological abnormalities but severe fatigue would respond to an individually adapted aerobic exercise program. Participants were 12 patients (eight male, and four female patients), median age 47 years and 41 months post-HSCT with a variety of hematopoietic cancer diagnoses. All underwent a 12-week individualized mild aerobic exercise program, preceded by a 4-week introduction and baseline testing phase. Psychological measures included fatigue, mood and depression. Exercise-related physiological outcomes included power output at ventilatory threshold 2 (VT2) and associated changes in stroke volume, heart rate, blood lactate concentration and ratings of perceived exertion. Patients were assessed for fatigue before, immediately after and at 3, 6, 9 and 12 months post-program. Significant improvements were found on both measures of fatigue (both P<0.001), with a very large effect size of 1.82 on the The Functional Assessment of Cancer Therapy - Fatigue Module, which were maintained over the follow-up period. Exercise testing revealed a mean increase (P<0.001) of 28% in power output at VT2 with an increase (P<0.001) in stroke volume and a decrease (P<0.001) in heart rate, blood lactate and perceived exertion at pre-intervention VT2 power output.

Diplopia and ptosis following injection of local anesthesia without hyaluronidase.

In a university ophthalmology department, a cluster of postoperative diplopia and ptosis cases occurred in the initial 3 months after hyaluronidase (Wydase) became unavailable for use with injection anesthesia. These cases suggest that hyaluronidase, when used with injection anesthesia, may protect extraocular muscles and nerves from the toxic effects of local anesthetic agents. The spreading action of hyaluronidase facilitates uniform diffusion of anesthetic agents. This prevents elevated extracellular tissue pressure, a cause of ischemic damage to extraocular muscles or nerves. Hyaluronidase may also prevent focal accumulations and concentrations of local anesthetic agents, which at high enough levels may cause myotoxic or neurotoxic damage, fibrosis, and contracture of extraocular muscles or nerves.

Transformation of human osteoblast cells to the tumorigenic phenotype by depleted uranium-uranyl chloride.

Depleted uranium (DU) is a dense heavy metal used primarily in military applications. Although the health effects of occupational uranium exposure are well known, limited data exist regarding the long-term health effects of internalized DU in humans. We established an in vitro cellular model to study DU exposure. Microdosimetric assessment, determined using a Monte Carlo computer simulation based on measured intracellular and extracellular uranium levels, showed that few (0.0014%) cell nuclei were hit by alpha particles. We report the ability of DU-uranyl chloride to transform immortalized human osteoblastic cells (HOS) to the tumorigenic phenotype. DU-uranyl chloride-transformants are characterized by anchorage-independent growth, tumor formation in nude mice, expression of high levels of the k-ras oncogene, reduced production of the Rb tumor-suppressor protein, and elevated levels of sister chromatid exchanges per cell. DU-uranyl chloride treatment resulted in a 9.6 (+/- 2.8)-fold increase in transformation frequency compared to untreated cells. In comparison, nickel sulfate resulted in a 7.1 (+/- 2.1)-fold increase in transformation frequency. This is the first report showing that a DU compound caused human cell transformation to the neoplastic phenotype. Although additional studies are needed to determine if protracted DU exposure produces tumors in vivo, the implication from these in vitro results is that the risk of cancer induction from internalized DU exposure may be comparable to other biologically reactive and carcinogenic heavy-metal compounds (e.g., nickel).

Modulation of radiation response of human tumour cells by the differentiation inducers, phenylacetate and phenylbutyrate.

The aromatic fatty acids phenylacetate (PA) and phenylbutyrate (PB) are novel antitumour agents currently under clinical evaluation. Their ability to induce tumour differentiation in laboratory models and their low clinical toxicity profile makes them promising candidates for combination with conventional therapies. In the present studies, we characterized the interactions between these aromatic fatty acids and radiation, using as a model cell lines derived from cancers of the prostate, breast, brain and colon. Analysis of the radiation response of the tumour lines using the linear-quadratic model, demonstrated that cellular exposure to pharmacological, non-toxic concentrations of either PA or PB resulted in time-dependent and contrasting changes in radiation response. While drug pretreatment for 24 h reduced radiation sensitivity (significant alterations in both alpha and beta parameters), pre treatment for 72 h significantly increased radiosensitivity (significant alterations in alpha and beta parameters). In replicating tumour cells, these changes were accompanied by a gradual G1-phase arrest. Cytostasis alone, however, could not explain radiosensitization, as similar alterations in radiation response were documented also in non-cycling cells. Modulation of tumour radiobiology by PA and PB was tightly correlated with early rise followed by decline in intracellular glutathione levels and the activity of antioxidant enzymes such as catalase, superoxide dismutase, glutathione reductase, glutathione peroxidase and glutathione S-transferase. Although in vitro findings identify the aromatic fatty acids PA and PB as a new class of non-toxic modulators of radiation response, the antagonistic effect of these compounds on radiation response needs further examination. Our data strongly suggest that for PA or PB to have a role in clinical radiotherapy, appropriate scheduling of combination therapies must take into account their time-dependent effects in order to achieve clinical radiosensitization.

Effects of anxiety and mood manipulation in autobiographical memory.

In phase 1 of the study subjects high and low in trait anxiety were exposed to a novel mood manipulation technique. This involved the presentation of either pleasant or unpleasant newspaper photographs. Subjects exposed to the positive and negative manipulations reported corresponding state anxiety decreases and increases respectively. In phase 2, subjects were required to recall specific personal memories to anxiety-related and happiness-related cue words. It was found that the high trait anxiety group were faster in response to anxiety-related as compared with happiness-related cue words. Retrieval latencies were not affected by type of cue word for the low trait group. Further analyses showed that the two groups differed in terms of their retrieval latencies rather than their retrieval strategies. Multiple regression analyses revealed that, whereas state anxiety is related to an enhanced retrieval of memories to anxiety-related cue words, depression is associated with a slowing of responses to happiness-related cue words. The content specificity hypothesis is offered as an explanation for this pattern of results.

Physiologically based pharmacokinetic modeling of the lactating rat and nursing pup: a multiroute exposure model for trichloroethylene and its metabolite, trichloroacetic acid.

A physiologically based pharmacokinetic (PB-PK) model was developed to describe trichloroethylene (TCE) kinetics in the lactating rat and nursing pup. The lactating dam was exposed to TCE either by inhalation or by ingestion in drinking water. The nursing pup's exposure to TCE was by ingestion of maternal milk containing TCE. The kinetics of trichloroacetic acid (TCA), a metabolite of TCE, were described in the lactating dam and developing pup by a hybrid one-compartment model. The lactating dam's exposure to TCA was from metabolism of TCE to TCA. The pup's exposure to TCA was from metabolism of TCE ingested in suckled milk and from direct ingestion of TCA in maternal milk. For the PB-PK model, partition coefficients (PCs) were determined by vial equilibration, and metabolic constants for TCE oxidation, by gas uptake methods. The blood/air and the fat/blood PCs for the dam were 13.1 and 34.2, and for the pup, 10.6 and 42.3, respectively. The milk/blood PC for the dam was 7.1. In lactating rats and rat pups (19-21 days old) the maximum velocities of oxidative metabolism were 9.26 +/- 0.073 and 12.94 +/- 0.107 mg/kg/hr. The plasma elimination rate constant (K = 0.063 +/- 0.004 hr-1) and apparent volume of distribution (Vd = 0.568 liter/kg) for TCA in the lactating dam were estimated from both intravenous dosing studies and an inhalation study with TCE. For the pup, K (0.014 +/- hr-1) and Vd (0.511 liter/kg) were estimated from a single 4-hr inhalation exposure with TCE. The dose-rate-dependent stoichiometric yield of TCA from oxidative metabolism of TCE in the lactating rat is 0.17 for a low-concentration inhalation exposure (27 ppm TCE) and 0.27 for an exposure above metabolic saturation (about 600 ppm TCE). For the pup, the stoichiometric yield of TCA is 0.12. With changing physiological values during lactation for compartmental volumes, blood flows, and milk yields obtained from the published literature and kinetic parameters and PCs determined by experimentation, a PB-PK model was constructed to predict maternal and pup concentrations of TCE and TCA. To test the fidelity of the PB-PK lactation model, a multiday inhalation exposure study was conducted from Days 3 to 14 of lactation and a drinking water study, from Days 3 to 21 of lactation. The inhalation exposure was 4 hr/day, 5 days/week, at 610 ppm. The TCE concentration in the drinking water was 333 micrograms/ml. Prediction compared favorably with limited data obtained at restricted time points during the period of lactation.

Physiologically based pharmacokinetic modeling of the pregnant rat: a multiroute exposure model for trichloroethylene and its metabolite, trichloroacetic acid.

A physiologically based pharmacokinetic (PB-PK) model was developed to describe trichloroethylene (TCE) kinetics in the pregnant rat exposed to TCE by inhalation, by bolus gavage, or by oral ingestion in drinking water. The kinetics of trichloroacetic acid (TCA), an oxidative metabolite of TCE, were described by a classical one-compartment pharmacokinetic model. Among the required model parameters for TCE, partition coefficients (PCs) and kinetic constants for oxidation were determined by vial equilibration and gas uptake methods, respectively. The fat:blood PC was 33.9; the blood:air PC was 13.2; and the fetal tissue:fetal blood PC was 0.51. TCE was readily metabolized with high substrate affinity. In naive and pregnant female rats the maximum velocities of oxidative metabolism were 10.98 +/- 0.155 and 9.18 +/- 0.078 mg/kg/hr, while the estimated Michaelis constant for the two groups of rats was very low, 0.25 mg/liter. The first-order rate constant for oral absorption of TCE from water was 5.4 +/- 0.42/hr-1 in naive rats. With TCA, the volume of distribution (0.618 liter/kg) and the plasma elimination rate constant (0.045 +/- 0.0024/hour) were estimated both from intravenous dosing studies with TCA and from an inhalation study with TCE. By comparison of the two routes of administration, the stoichiometric yield of TCA from TCE was estimated to be 0.12 in pregnant rats. To develop a data base for testing the fidelity of the PB-PK model, inhalation and bolus gavage exposures were conducted from Day 3 to Day 21 of pregnancy and a drinking water exposure from Day 3 to Day 22 of pregnancy. Inhalation exposures with TCE vapor were 4 hr/day at 618 ppm. The TCE concentration in drinking water was 350 micrograms/ml and the gavaged rats received single daily doses of 2.3 mg TCE/kg. Time varying physiological parameters for compartment volumes and blood flows during pregnancy were obtained from the published literature. Using the kinetic parameters determined by experimentation, TCE concentrations in maternal and fetal blood and TCA concentrations in maternal and fetal plasma were predicted from the PB-PK model by computer simulation and compared favorably with limited data obtained at restricted time points during pregnancy for all three routes of exposure. On the basis of the PB-PK model, fetal exposure to TCE, as area-under-the-curve, ranged from 67 to 76% of maternal exposure. For TCA the fetal exposure was 63 to 64% of the maternal exposure. The fetus is clearly at risk both to parent TCE and its TCA metabolite.(ABSTRACT TRUNCATED AT 400 WORDS)