Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis.

The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.

Pharmacodynamic evaluation of the etonogestrel contraceptive implant initiated midcycle with and without ulipristal acetate: An exploratory study.

OBJECTIVE: To estimate the incidence of ovulation suppression within five days of etonogestrel 68 mg implant insertion in the presence of a dominant follicle with and without same-day ulipristal acetate. STUDY DESIGN: This single site non-masked, exploratory randomized trial recruited people age 18-35 years with regular menstrual cycles, no pregnancy risk, and confirmed ovulatory function. We initiated transvaginal ultrasound examinations on menstrual day 7-9 and randomized participants 1:1 to etonogestrel implant alone or with concomitant ulipristal acetate 30 mg oral when a dominant follicle reached ≥14 mm in diameter. We completed daily sonography and serum hormone levels for up to seven days or transitioned to labs alone if sonographic follicular rupture occurred. We defined ovulation as follicular rupture followed by progesterone >3 ng/mL. We calculated point estimates, risk ratios and 95% confidence intervals for ovulation for each group. Ovulation suppression of ≥44% in either group (the follicular rupture suppression rate with oral levonorgestrel emergency contraception), would prompt future method testing. RESULTS: From October 2020 to October 2022, we enrolled 40 people and 39 completed primary outcome assessments: 20 with etonogestrel implant alone (mean follicular size at randomization: 15.2 mm ± 0.9 mm) and 19 with etonogestrel implant + ulipristal acetate (mean follicular size at randomization: 15.4 mm ± 1.2 mm, p = 0.6). Ovulation suppression occurred in 13 (65%) of etonogestrel implant-alone participants (Risk ratio 0.6 (95% CI: 0.3, 1.1), p = 0.08) and seven (37%) of implant + ulipristal acetate participants. CONCLUSIONS: Ovulation suppression of the etonogestrel implant alone exceeds threshold testing for future research while the implant + ulipristal acetate does not. IMPLICATIONS: Data are lacking on midcycle ovulation suppression for the etonogestrel implant with and without oral ulipristal acetate. In this exploratory study, ovulation suppression occurred in 65% of implant participants and 37% of implant + ulipristal acetate participants. Ovulation suppression of the implant alone exceeds threshold testing for future emergency contraception research.

Efficacy of oral levonorgestrel emergency contraception with same day etonogestrel contraceptive implant: A prospective observational study.

OBJECTIVE: To determine a 1-month pregnancy rate point estimate and 95% confidence interval for guideline-supported, same-day initiation of an etonogestrel implant plus oral levonorgestrel emergency contraception. STUDY DESIGN: In this single-arm, prospective observational study, all emergency contraception clients who presented to four Planned Parenthood Association of Utah clinics from February 2021 to March 2023 received information about oral levonorgestrel with same-day etonogestrel implant insertion. Participants were ≤35 years and reported unprotected intercourse within 5 days with negative pregnancy testing. The primary outcome measure was a 1-month home pregnancy test. We calculated the efficacy using a test of proportions with Yates continuity correction. RESULTS: A total of 160 emergency contraception clients (7.6% of 2106 approached) enrolled and 153 had 1-month pregnancy outcomes. A positive pregnancy test occurred in 2 participants resulting in an overall pregnancy rate of 1.32% (95% confidence interval 0.23%-5.19%). Ultrasound gestational dating assigned conception of the first pregnancy to 8 days before enrollment. For the second pregnancy, ultrasound dating designated conception at 5 days prior to enrollment. Limiting the efficacy rate to the single pregnancy that occurred within 5 days of unprotected intercourse, we report a pregnancy rate of 0.66% (95% confidence interval 0.03%-4.19%). CONCLUSIONS: In this observational study of emergency contraception clients selecting oral levonorgestrel with same-day etonogestrel implant, we identified a pregnancy rate within the established range of oral emergency contraception methods alone. IMPLICATIONS: Clients presenting for emergency contraception may also desire ongoing highly-effective contraception, yet current clinical guidelines serve as a barrier to same-day method initiation for the etonogestrel implant and other hormonal methods. Improving access to contraceptive method initiation will reduce the ongoing risk of unwanted pregnancy for this population. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT04678817; registered 12/16/20.

Suitability of new and existing ambient ethylene oxide measurement techniques for cancer inhalation risk assessment.

Ethylene oxide (EtO) is an industrial gas that was recently reassessed to pose significant additional cancer risk at low ambient concentrations. The objective of this study is to evaluate the capabilities of existing and novel techniques to measure ambient EtO at concentrations relevant for assessing cancer risk. We present the first comparison of background ambient EtO measurements between the standard offline TO-15 techniques and two new cavity ringdown spectroscopy (CRDS) instruments, the Picarro G2920 Ethylene Oxide Gas Analyzer and the Entanglement Technologies AROMA-ETO, at a site in Atlanta, GA. Then, we analyzed background EtO measured at EPA NATTS sites across the US. Finally, we used TO-15 measurement data to assess EtO cancer risk at three near-source sites. We find that the TO-15 method has low precision for collocated samples (NME ranges from 24% to 63%), and measurements made with TO-15 pressurized samplers are biased 27% low compared to those from TO-15 passive samplers. Both CRDS methods are biased low compared to TO-15 methods (88% and 31% low bias for Picarro and AROMA, respectively), and TO-15 methods observe a seasonal peak during summer (June to September) whereas Picarro observes no seasonal trend. From our near-source assessment, we find only one site with notable elevation in cancer risk prior to EtO controls installation. Our results suggest that measurement techniques need further development to accurately assess near-source EtO cancer risk. Because different techniques measure distinct EtO trends, EtO cancer risk studies that rely on current measurement capabilities should subtract simultaneous background observations from near-source observations measured by the same method to account for these real or artificial background trends.

Effects of the Dobbs v Jackson Women's Health Organization Decision on Obstetrics and Gynecology Graduating Residents' Practice Plans.

OBJECTIVE: To explore the association of the Dobbs v Jackson Women's Health Organization ( Dobbs ) decision on future practice locations of graduating obstetrics and gynecology residents. METHODS: This is a mixed-methods survey study of obstetrics and gynecology residents graduating from sites with Ryan Program abortion training programs (109 sites) between March 8, 2023, and April 25, 2023. We conducted both univariate and multivariable logistic regression analyses to identify factors that were associated with post- Dobbs change in career plans, particularly location. We also performed a thematic analysis using responses to the survey's optional, open-ended prompt, "Please describe how the Dobbs v Jackson Women's Health Organization decision impacted your professional plans." RESULTS: Of an estimated 724 residents graduating from residencies with Ryan Program abortion training programs, 349 participated in the survey (48.2% response rate); 17.6% of residents indicated that the Dobbs decision changed the location of intended future practice or fellowship plans. Residents who before the Dobbs decision intended to practice in abortion-restrictive states were eight times more likely to change their practice plans than those who planned to practice in protected states before the Dobbs decision (odds ratio 8.52, 95% CI 3.81-21.0). In a thematic analysis of open-ended responses, 90 residents wrote responses related to "not living in a state with abortion restrictions." Of residents pursuing fellowship, 36 indicated that they did not rank or ranked lower programs in restrictive states. CONCLUSION: These findings demonstrate reduced desire of residents in obstetrics and gynecology to practice or pursue fellowship in restrictive states after residency. This reduction in obstetrics and gynecology workforce could significantly exacerbate maternity care deserts.

Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review.

Existing research has found that women who use opioids (WWUO) experience challenges to hormonal and long-acting reversible contraception (HC-LARC) access and use. Facilitators of such use are unclear. We conducted a scoping review to comprehensively map the literature on barriers to and facilitators of HC-LARC access and use in the United States among reproductive-aged WWUO. In accordance with the JBI Manual of Evidence Synthesis, we conducted literature searches for empirical articles published from 1990 to 2021. Independent reviewers screened references, first by titles and abstracts, then by full-text, and charted data of eligible articles. We coded and organized HC-LARC barriers and facilitators according to a four-level social-ecological model (SEM) and categorized findings within each SEM level into domains. We screened 4,617 records, of which 28 articles focusing on HC-LARC (n = 18), LARC only (n = 6), or testing an intervention to increase HC-LARC uptake (n = 4) met inclusion criteria. We identified 13 domains of barriers and 11 domains of facilitators across four SEM levels (individual, relationship, community, societal). The most frequently cited barriers and facilitators were methods characteristics, partner and provider relations, transportation, healthcare availability and accessibility, cost, insurance, and stigma. Future studies would benefit from recruiting participants and collecting data in community settings, targeting more diverse populations, and identifying neighborhood, social, and policy barriers and facilitators. Reducing barriers and improving equity in HC-LARC access and use among WWUO is a complex, multifaceted issue that will require targeting factors simultaneously at multiple levels of the social-ecological hierarchy to effect change.

Switching and discontinuation of participant-masked randomization to a copper or levonorgestrel intrauterine device when presenting for emergency contraception.

OBJECTIVES: Examine intrauterine device (IUD) switching or discontinuation up to 6 months after participant-masked randomization to different IUDs. STUDY DESIGN: Participants were randomized 1:1 to the copper T380A or levonorgestrel 52 mg IUD for emergency contraception and informed they could switch IUD type without cost at any time. RESULTS: Of the 327 subjects allocated to the levonorgestrel IUD, 7 (2.1%) switched their IUD type by 6 months versus 18 (5.5%) of the 328 copper IUD users (RR: 0.4 [95% CI: 0.2, 0.9], p = 0.03). Six-month IUD discontinuation occurred in 34 (10.4%) levonorgestrel and 35 (10.7%) copper IUD users. CONCLUSION: Individuals randomly assigned to IUD type at presentation for emergency contraception continue their assigned IUDs at high rates over 6 months. IMPLICATIONS: While many recruited individuals declined enrollment, those who accepted randomization had high continuation rates; the high continuation and low cross-over supports using IUD randomization as a tool for future investigation. Participants' similar rates of and reasons for switching and discontinuation by IUD type over the study period may impact clinical counseling.

Single dose letrozole and misoprostol for termination of pregnancy through 63 days' gestation: A pilot study.

OBJECTIVES: We conducted a pilot study to evaluate a single dose of letrozole 30 mg prior to misoprostol 800 mcg buccally for medication abortion STUDY DESIGN: We enrolled 40 participants seeking medication abortion up to 63 days' gestation at a site in Salt Lake City, UT. Participants received a single dose of letrozole 30 mg in-clinic followed 2 days later by misoprostol 800 mcg buccally at home. They took a second dose of misoprostol if they had no bleeding within 24 hours of the first. Participants returned 7 to 10 days later for assessment of abortion outcome and side effects RESULTS: Thirty-seven participants (93%) returned for follow-up and 2 (5%) went to another facility from which research staff obtained outcome data. Three-fourths (29/39, 74%, 95% CI: 60%-89%) had a complete abortion; 4 (10%, 95% CI: 0.3%-20%) had an incomplete abortion and opted for aspiration, and 6 (15%, 95% CI: 4%-27%) had an ongoing pregnancy. All subjects with follow-up reported taking the first dose of misoprostol. Ten (27%) took the second dose as well; only three did so due to no bleeding. Nineteen participants (51%) reported side effects after letrozole prior to misoprostol and two people (5%) rated these effects as severe. Side effects following misoprostol occurred in 33 participants (89%) and were as expected based on previous literature. No serious adverse events were reported CONCLUSION: A single dose of letrozole 30 mg followed by misoprostol had lower than desirable efficacy and does not warrant further study. IMPLICATIONS: A single dose of letrozole does not appear to be an effective adjunct to misoprostol for medication abortion.

One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial.

BACKGROUND: Recent evidence demonstrates the effectiveness of the levonorgestrel 52-mg intrauterine device for emergency contraception vs the copper T380A intrauterine device. Of note, 1-year pregnancy and continuation rates after intrauterine device placement for emergency contraception remain understudied. OBJECTIVE: This study compared 1-year pregnancy and intrauterine device continuation rates and reasons for discontinuation among emergency contraception users randomized to the levonorgestrel 52-mg intrauterine device or the copper intrauterine device. STUDY DESIGN: This participant-masked, randomized noninferiority trial recruited emergency contraception individuals desiring an intrauterine device from 6 Utah family planning clinics between August 2016 and December 2019. Participants were randomized 1:1 to the levonorgestrel 52-mg intrauterine device group or the copper T380A intrauterine device group. Treatment allocation was revealed to participants at the 1-month follow-up. Trained personnel followed up the participants by phone, text, or e-mail at 5 time points in 1 year and reviewed electronic health records for pregnancy and intrauterine device continuation outcomes for both confirmation and nonresponders. We assessed the reasons for the discontinuation and used Cox proportional-hazard models, Kaplan-Meier estimates, and log-rank tests to assess differences in the continuation and pregnancy rates between the groups. RESULTS: The levonorgestrel and copper intrauterine device groups included 327 and 328 participants, respectively, receiving the respective interventions. By intention-to-treat analysis at 1 year, the pregnancy rates were similar between intrauterine device types (2.8% [9/327] in levonorgestrel 52-mg intrauterine device vs 3.0% [10/328] in copper intrauterine device; risk ratio, 0.9; 95% confidence interval, 0.4-2.2; P=.82). Most pregnancies occurred in participants after intrauterine device removal, with only 1 device failure in each group. Of note, 1-year continuation rates did not differ between groups with 204 of 327 levonorgestrel 52-mg intrauterine device users (62.4%) and 183 of 328 copper T380A intrauterine device users (55.8%) continuing intrauterine device use at 1 year (risk ratio, 1.1; 95% confidence interval, 1.0-1.2; P=.09). There were differences concerning the reasons for discontinuation between intrauterine device types, with more bleeding and cramping cited among copper intrauterine device users. CONCLUSION: The pregnancy rates were low and similar between intrauterine device types. Of note, 6 of 10 intrauterine device emergency contraception users continued use at 1 year. Moreover, 1-year continuation rates were similar between intrauterine device types.

Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use.

Objectives: We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements. Methods: Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone. Results: Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization. Conclusions: Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.

Light-Dependent Control of Bacterial Expression at the mRNA Level.

Sensory photoreceptors mediate numerous light-dependent adaptations across organisms. In optogenetics, photoreceptors achieve the reversible, non-invasive, and spatiotemporally precise control by light of gene expression and other cellular processes. The light-oxygen-voltage receptor PAL binds to small RNA aptamers with sequence specificity upon blue-light illumination. By embedding the responsive aptamer in the ribosome-binding sequence of genes of interest, their expression can be downregulated by light. We developed the pCrepusculo and pAurora optogenetic systems that are based on PAL and allow to down- and upregulate, respectively, bacterial gene expression using blue light. Both systems are realized as compact, single plasmids that exhibit stringent blue-light responses with low basal activity and up to several 10-fold dynamic range. As PAL exerts light-dependent control at the RNA level, it can be combined with other optogenetic circuits that control transcription initiation. By integrating regulatory mechanisms operating at the DNA and mRNA levels, optogenetic circuits with emergent properties can thus be devised. As a case in point, the pEnumbra setup permits to upregulate gene expression under moderate blue light whereas strong blue light shuts off expression again. Beyond providing novel signal-responsive expression systems for diverse applications in biotechnology and synthetic biology, our work also illustrates how the light-dependent PAL-aptamer interaction can be harnessed for the control and interrogation of RNA-based processes.

Auto-diuresis Predicts Return of Bowel Function.

PURPOSE: Feeding a ventral hernia repair (VHR) patient before the return of bowel function (ROBF) can lead to distention and emesis. Many patients spontaneously diurese after surgery. We hypothesized that this auto-diuresis would signal ROBF. MATERIALS AND METHODS: A total of 395 patients who underwent open, laparoscopic, or mixed VHR were evaluated for correlation between fluid status and ROBF or discharge. ROBF within 24 hours and discharge within 24 hours or 48 hours were used as outcome measures. RESULTS: Patients remained an average 3.59 days after surgery in the hospital and the average ROBF was on day 2.99. The first shift of ≥700 mL of urine predicted ROBF ( P =0.03) and discharge ( P =0.04) within 24 hours. The first shift output of ≥500 mL predicted discharge within 48 hours ( P =0.02). CONCLUSION: Auto-diuresis after surgery is correlated to ROBF and discharge. Accurate fluid measurement can predict bowel function and allow early diet and discharge.

Evaluating the Impact of Chemical Complexity and Horizontal Resolution on Tropospheric Ozone Over the Conterminous US With a Global Variable Resolution Chemistry Model.

A new configuration of the Community Earth System Model (CESM)/Community Atmosphere Model with full chemistry (CAM-chem) supporting the capability of horizontal mesh refinement through the use of the spectral element (SE) dynamical core is developed and called CESM/CAM-chem-SE. Horizontal mesh refinement in CESM/CAM-chem-SE is unique and novel in that pollutants such as ozone are accurately represented at human exposure relevant scales while also directly including global feedbacks. CESM/CAM-chem-SE with mesh refinement down to ∼14 km over the conterminous US (CONUS) is the beginning of the Multi-Scale Infrastructure for Chemistry and Aerosols (MUSICAv0). Here, MUSICAv0 is evaluated and used to better understand how horizontal resolution and chemical complexity impact ozone and ozone precursors over CONUS as compared to measurements from five aircraft campaigns, which occurred in 2013. This field campaign analysis demonstrates the importance of using finer horizontal resolution to accurately simulate ozone precursors such as nitrogen oxides and carbon monoxide. In general, the impact of using more complex chemistry on ozone and other oxidation products is more pronounced when using finer horizontal resolution where a larger number of chemical regimes are resolved. Large model biases for ozone near the surface remain in the Southeast US as compared to the aircraft observations even with updated chemistry and finer horizontal resolution. This suggests a need for adding the capability of replacing sections of global emission inventories with regional inventories, increasing the vertical resolution in the planetary boundary layer, and reducing model biases in meteorological variables such as temperature and clouds.

Impact of Circular, Waste-Heat Reuse Pathways on PM2.5-Air Quality, CO2 Emissions, and Human Health in India: Comparison with Material Exchange Potential.

India is home to 1.3 billion people who are exposed to some of the highest levels of ambient air pollution in the world. In addition, India is one of the fastest-growing carbon-emitting countries. Here, we assess how two strategies to reuse waste-heat from coal-fired power plants and other large sources would impact PM2.5-air quality, human health, and CO2 emissions in 2015 and a future year, 2050, using varying levels of policy adoption (current regulations, proposed single-sector policies, and ambitious single-sector strategies). We find that power plant and industrial waste-heat reuse as input to district heating systems (DHSs), a novel, multisector strategy to reduce local biomass burning for heating emissions, can offset 71.3-85.2% of residential heating demand in communities near a power plant (9.3-12.4% of the nationwide heating demand) with the highest benefits observed during winter months in areas with collocated industrial activity and higher residential heating demands (e.g., New Delhi). Utilizing waste-heat to generate electricity via organic Rankine cycles (ORCs) can generate an additional 22 (11% of total coal-fired generating capacity), 41 (8%), 32 (13%), and 6 (5%) GW of electricity capacity in the 2015, 2050-current regulations, 2050-single-sector, and 2050-ambitious-single-sector scenarios, respectively. Emission estimates utilizing these strategies were input to the GEOS-Chem model, and population-weighted, simulated PM2.5 showed small improvements in the DHS (0.2-0.4%) and ORC (0.3-3.4%) scenarios, where the minimal DHS PM2.5-benefit is attributed to the small contribution of biomass burning for heating to nationwide PM2.5 emissions (much of the biomass burning activity is for cooking). The PM2.5 reductions lead to ∼130-36,000 mortalities per year avoided among the scenarios, with the largest health benefits observed in the ORC scenarios. Nationwide CO2 emissions reduced <0.04% by DHSs but showed larger reductions using ORCs (1.9-7.4%). Coal fly-ash as material exchange in cement and brick production was assessed, and capacity exists to completely reutilize unused fly-ash toward cement and brick production in each of the scenarios.

Implementation of piglet castration under inhalation anaesthesia on farrowing farms.

BACKGROUND: Since 01.01.2021, suckling piglets may no longer be castrated without anaesthesia in Germany. Previous studies showed castration using isoflurane anaesthesia in combination with a suitable analgesic, meet the requirements of the German Animal Welfare Act. It can be carried out independently by farmers and other qualified persons with an automated and certified isoflurane device. Therefore, the aim of the present field study was to implement the use of three different anaesthetic devices for surgical castration of male piglets under automated isoflurane anaesthesia on 15 conventional pig farms in southern Germany. In addition, the depth of anaesthesia based on defensive movements, the labour time required in contrast to anaesthetic-free castration, castration-related anaesthetic incidents and the piglet mortality rate as well as occupational safety were investigated. For this purpose, farrowing batches of 11,574 piglets castrated under isoflurane anaesthesia (IA) were compared with the results of the 1568 piglets of anaesthetic-free farrowing batches (AF). RESULTS: In total, 80.1% of the castrated piglets showed sufficient depth of anaesthesia, although this varied significantly between devices. 1.7% of the piglets suffered an anaesthetic incident, of which 0.1% died during or within 24 h after anaesthesia. The required time for the complete working process differed significantly between AF (1.7 ± 0.8 min/piglet) and IA batches (2.2 ± 0.8 min/piglet) but not for castration itself. The mean isoflurane consumption was 0.57 ± 0.27 ml/piglet and differed significantly between the devices (p < 0.001). The isoflurane concentration in the ambient air of the person-related workplace safety measurements was below the internationally lowest value of 15 mg/m3 from Ontario and Israel. CONCLUSION: In conclusion, 2 of the 3 types of devices used, a sufficient depth of anaesthesia during castration under isoflurane was achieved in 85% of castrated piglets. Anaesthetic incidents occurred in 1.7% of the animals, of which 0.1% died. Castration under isoflurane is more time-consuming than anaesthetic-free castration, but the castration time itself did not differ significantly. The occupational exposure limits were below the internationally lowest limit value of 15 mg/m3 for the persons involved. Even though castration under isoflurane is more time consuming than anaesthetic-free castration, it is a well-establishable method for practice and a dear improvement for animal welfare.

Signal transduction in light-oxygen-voltage receptors lacking the active-site glutamine.

In nature as in biotechnology, light-oxygen-voltage photoreceptors perceive blue light to elicit spatiotemporally defined cellular responses. Photon absorption drives thioadduct formation between a conserved cysteine and the flavin chromophore. An equally conserved, proximal glutamine processes the resultant flavin protonation into downstream hydrogen-bond rearrangements. Here, we report that this glutamine, long deemed essential, is generally dispensable. In its absence, several light-oxygen-voltage receptors invariably retained productive, if often attenuated, signaling responses. Structures of a light-oxygen-voltage paradigm at around 1 Å resolution revealed highly similar light-induced conformational changes, irrespective of whether the glutamine is present. Naturally occurring, glutamine-deficient light-oxygen-voltage receptors likely serve as bona fide photoreceptors, as we showcase for a diguanylate cyclase. We propose that without the glutamine, water molecules transiently approach the chromophore and thus propagate flavin protonation downstream. Signaling without glutamine appears intrinsic to light-oxygen-voltage receptors, which pertains to biotechnological applications and suggests evolutionary descendance from redox-active flavoproteins.

Investigating the Sources of Urban Air Pollution Using Low-Cost Air Quality Sensors at an Urban Atlanta Site.

Advances in low-cost sensors (LCS) for monitoring air quality have opened new opportunities to characterize air quality in finer spatial and temporal resolutions. In this study, we deployed LCS that measure both gas (CO, NO, NO2, and O3) and particle concentrations and co-located research-grade instruments in Atlanta, GA, to investigate the capability of LCS in resolving air pollutant sources using non-negative matrix factorization (NMF) in a moderately polluted urban area. We provide a comparison of applying the NMF technique to both normalized and non-normalized data sets. We identify four factors with different temporal trends and properties for both normalized and non-normalized data sets. Both normalized and non-normalized LCS data sets can resolve primary organic aerosol (POA) factors identified from research-grade instruments. However, applying normalization provides factors with more diverse compositions and can resolve secondary organic aerosol (SOA). Results from this study demonstrate that LCS not only can be used to provide basic mass concentration information but also can be used for in-depth source apportionment studies even in an urban setting with complex pollution mixtures and relatively low aerosol loadings.

Multisite study of Aggressive Behavior Risk Assessment Tool in emergency departments.

Objective: Violence is a major preventable problem in emergency departments (EDs), and validated screening tools are needed to identify potentially violent patients. We aimed to test the utility of the Aggressive Behavior Risk Assessment Tool (ABRAT) for screening patients in the ED. Methods: A prospective cohort study was conducted among adult and pediatric patients aged ≥10 years visiting 3 emergency departments in Michigan between May 1, 2021, and June 30, 2021. Triage nurses completed the 16-item checklist using electronic health records (EHRs), and the occurrence of violent incidents were collected before ED disposition. A multivariate logistic regression model was applied to select a parsimonious set of items. Results: Among 10,554 patients, 127 had ≥1 violent incidents (1.2%). The regression model resulted in a 7-item ABRAT for EDs, including history of aggression and mental illness and reason for visit, as well as 4 violent behavior indicators. Receiver operating characteristics analysis showed that the area under the curve was 0.91 (95% confidence interval [CI], 0.87-0.95), with a sensitivity of 84.3% (95% CI, 76.5%-89.9%) and specificity of 95.3% (95% CI, 94.8%-95.7%) at the optimal cutoff score of 1. An alternative cutoff score of 4 for identifying patients at high risk for violence had a sensitivity and specificity of 70.1% and 98.9%, respectively. Conclusion: The ABRAT for EDs appears to be a simple yet comprehensive checklist with a high sensitivity and specificity for identifying potentially violent patients in EDs. The availability of such a screening checklist in the EHR may allow rapid identification of high-risk patients and implementation of focused mitigation measures to protect emergency staff and patients.

Leveraging Implementation Science to Achieve Empirical Outcomes.

Organizations are often challenged to demonstrate the evidence of empirical outcomes required for Magnet® application and designation. Theoretically, the application of evidence-based guidelines to the clinical setting leads to empirical outcomes. However, successful integration of guidelines into practice remains problematic. This article explains how organizations can leverage implementation science to promote the effective uptake of best practice standards to achieve the outcomes necessary to improve care and demonstrate Magnet standards.

Quantitative and qualitative impact of One Key Question on primary care providers' contraceptive counseling at routine preventive health visits.

OBJECTIVES: One Key Question (OKQ) is a clinical screening tool to assess pregnancy desire in the next year. We aimed to 1) describe the effect of OKQ implementation on contraceptive counseling rates at preventive health visits and 2) evaluate primary care providers' perception of OKQ implementation on their contraceptive counseling practices. STUDY DESIGN: We performed a quantitative retrospective chart review of preventive health visits at eight federally qualified health centers in Utah between 2014 and 2017. Implementation of OKQ included a brief training and inclusion of OKQ in the electronic medical record. Providers received OKQ training in August 2015 and re-training in March 2017. We assessed OKQ and contraceptive counseling documentation rates using interrupted-time-series analysis. We then conducted semi-structured interviews with providers and queried them about the impact of OKQ. We identified dominant themes using modified grounded theory to create an explanatory framework. RESULTS: Abstracting 6634 charts yielded 9840 visits with 56 unique providers (51% physician assistant, 34% physician, 14% nurse practitioner). Interrupted-time-series analysis showed a documentation increase of OKQ in late 2015 (2.6%) and again in spring 2017 (9%), however rates remained low. Contraceptive counseling rates (39.7%) did not change after OKQ implementation. Charts with evidence of a current contraceptive method were less likely to have a OKQ response documented. Interviewees reported OKQ's algorithm did not alter their contraceptive counseling. CONCLUSIONS: OKQ did not change documented rates of contraceptive counseling and uptake was low in quantitative and qualitative analyses. Our study suggests limited usefulness of OKQ in the primary care setting. IMPLICATIONS: Implementation of the One Key Question tool through training and optional EHR field did not increase documented rates of contraceptive counseling in a large federally qualified health center or affect provider contraceptive counseling. Our study suggests limited usefulness of OKQ as a robust screening tool in this primary care setting.