The Association Between Sexual Initiation and Membership in Dyadic Profiles of Perceived Shared Power.

There is scarce empirical evidence examining whether sexual initiation and power are associated with each other. Utilizing latent profile analyses, we examined in a nationally representative sample of US newlywed heterosexual couples (N = 1,948 couples) whether wives' and husbands' sexual initiation patterns and satisfaction with these patterns were associated with membership in different profiles of wives' and husbands' perceptions of shared relational power while accounting for both partner's satisfaction with sexual frequency. We found four profiles of wives' and husbands' perceptions of power. The most common profile was when both wives and husbands perceived high levels of power compared to other profiles, but wives had significantly higher reports of perceived power than husbands (High Power, Wife Higher; 40.8%). Husbands' sexual initiation patterns were not associated with profile membership. Wives who reported equal sexual initiation patterns had a higher probability of being in the High Power, Wife Higher profile compared to the Wife Low Power, Husband Moderate Power profile. Both wives' and husbands' satisfaction with sexual initiation patterns were associated with profile membership. Wives and husbands that were satisfied with sexual initiation patterns had a higher probability of being in the High Power, Wife Higher profile compared to the profile where both wives and husbands had high perceptions of shared relational power compared to other profiles, but their scores were not significantly different from each other (High Power, Equal).

A comparative national-level analysis of government food system resilience activities across four developed countries at varying stages of planning.

BACKGROUND: The COVID-19 pandemic, extreme weather events, and the Russian invasion of Ukraine have highlighted global food system vulnerabilities and a lack of preparedness and prospective planning for increasingly complex disruptions. This has spurred an interest in food system resilience. Despite the elevated interest in food system resilience, there is a lack of comparative analyses of national-level food system resilience efforts. An improved understanding of the food system resilience landscape can support and inform future policies, programs, and planning. METHODS: We conducted a cross-country comparison of national-level food system resilience activities from Australia, Aotearoa New Zealand, Sweden, and the United States. We developed upon and adapted the resilience framework proposed by Harris and Spiegel to compare actions derived from thirteen national food system resilience documents. We coded the documents based on the actions taken by the governments including: the food system resilience attributes utilized, the part of the food supply chain, the specific shocks or stressors, the implementation level, the temporal focus of action, and the expected impact on food security. We analyzed and compared countries' coded categories and subcategories, and category combinations. RESULTS: The results showed that these countries are addressing some of the same issues, are using multi-pronged policy actions to address food system resilience issues, and are focused on both retrospective reviews and prospective models of disruptive events to inform their decisions. Some work has been done towards preparing for climate change and other natural disasters, and less preparing has been done for other shocks or stressors. CONCLUSIONS: This paper develops and applies a framework rooted in literature to understand the content of national-level food system resilience documents. The analysis identified potential gaps, concentrations, and themes in national food systems resilience. The framework can be applied to augment existing policy, create new policy, as well as to supplement and complement other existing frameworks.

Predicting Breastfeeding Intentions: A Test and Extension of the Theory of Normative Social Behavior with African American Social Identity.

Breastfeeding is a health promoting social behavior but statistics suggest a persistent disparity of lower rates among African American mothers. The Theory of Normative Social Behavior (TNSB) explains when and how norms influence behaviors, but has produced inconsistent results with respect to proposed moderators group identity and injunctive norms (IN), limiting its predictive value in diverse cultural groups. Cultural norms are one of many influences on breastfeeding behaviors, yet little is known about their mechanisms of influence. The TNSB has not been tested in the breastfeeding context or within an exclusively African American cultural group. Given this knowledge gap, a survey of 528 African American mothers in the Washington, D.C. area was conducted to test the moderating effects of IN and subjective norms (SN) and social identity on the descriptive norms (DN) to intentions relationship as predicted by the TNSB. Structural equation modeling was used to show that when controlling for education and breastfeeding history, norms significantly predicted 26.4% of the variance in breastfeeding intentions. SN and DN interacted negatively to enhance breastfeeding intentions. Latent profile analysis using ethnic pride, collectivism, and religiosity scales detected four profiles of African American social identity. Social identity profile membership was a significant moderator on the DN to intentions pathway in the structural equation model. Profiles with the highest ethnic pride were significantly influenced by DN to intend to breastfeed. Implications from this study for public health intervention and communication messaging are discussed.

Sleep disturbances and depression are bidirectionally associated among college student athletes across COVID-19 pandemic exposure classes.

College athletes may be vulnerable to sleep disturbances and depression during the COVID-19 pandemic as a result of large shifts in social and athletic obligations. In a national sample of college athletes, we examined the associations between sleep disturbances and depression across two timepoints, using COVID-19 exposure as a moderator. Data were collected from 2098 NCAA Division I, II, and III college athletes during two timepoints, from April 10 to May 23, and from August 4 to September 15, 2020. First, a latent class analysis was conducted with five indicators of levels of COVID-19 exposure to determine different exposure profiles. Second, to examine the directionality of associations between sleep disturbance and depression, a cross-lagged panel model was added to the latent class membership structural equation model; this allowed for testing of moderation by COVID exposure class membership. Four highly homogeneous, well-separated classes of COVID-19 exposure were enumerated: Low Exposure (57%); Quarantine Only (21%); High Other, Low Self Exposure (14%); and High Exposure (8%). COVID-19 exposure class membership did not significantly moderate associations between sleep disturbances and depression. However, student athletes significantly differed in T2 depression by their COVID-19 exposure class membership. Depression and sleep disturbances were positively correlated at both timepoints (r T1 = 0.39; r T2 = 0.30). Additionally, cross-lagged associations were found such that T2 depression was associated with T1 sleep disturbances (ß = 0.14) and vice versa (ß = 0.11). These cross-lagged associations were not significantly affected by athletes' level of COVID-19 exposure during the beginning of the pandemic.

The Relationship of Resilience, Self-Compassion, and Social Support to Psychological Distress in Women Collegiate Athletes During COVID-19.

Given how COVID-19 had caused significant increases in collegiate athletes' psychological distress, we examined the extent to which such distress may have been ameliorated by the athletes' psychosocial resources (e.g., resilience). We used structural equation modeling to examine the direct and indirect relationships of resilience, self-compassion, and social support to women collegiate athletes' (N = 3,924; 81.2% White) psychological distress; athletes completed measures of these constructs from mid-April to mid-May 2020. Analyses revealed significant direct effects: More supported (ß = -0.12 to -0.19), self-compassionate (ß = -0.48 to -0.53), and resilient (ß = -0.21 to -0.35) athletes experienced less psychological distress (R2 = .61-.65). Further, self-compassion and social support were related indirectly (and inversely) to psychological distress through higher levels of resilience. These psychosocial resources appear to have played a positive role in how athletes coped with the pandemic, being associated with less psychological distress. These findings have application beyond the pandemic, providing direction for how sport psychology professionals may assist athletes in maintaining their well-being.

A Model of Perfectionism, Moral Disengagement, Altruism, and Antisocial and Prosocial Behaviors in Wheelchair Athletes.

Two forms of perfectionism were examined in the present study to see whether they predicted prosocial and antisocial behaviors in sport through moral disengagement and altruism in a sample of 327 wheelchair basketball and rugby athletes (M = 33.57 years, SD = 10.51; 83% male). Using structural equation modeling, the following significant direct and indirect effects were found. First, perfectionistic strivings positively predicted perceived prosocial behaviors and altruism. Second, perfectionistic concerns negatively predicted altruism and prosocial behaviors and positively predicted moral disengagement. Third, antisocial behaviors were positively predicted by moral disengagement and altruism. Furthermore, perfectionistic concerns indirectly predicted antisocial behaviors positively through moral disengagement and negatively through altruism. Finally, perfectionistic strivings positively predicted antisocial behaviors through altruism. Results provided partial support for the role of perfectionism in predicting prosocial and antisocial behaviors through moral disengagement among athletes with a disability.

Factor Structure of the Barriers to Physical Activity Scale for Youth With Visual Impairments.

Youth with visual impairments (VIs) often experience unique barriers to physical activity compared with their sighted peers. A psychometrically sound scale for assessing barriers to physical activity for youth with VI is needed to facilitate research. The purpose of this study was to confirm the ability of the previously identified three-factor structure of the Physical Activity Barriers Questionnaire for youth with Visual Impairments (PABQ-VI) to produce scores considered to be valid and reliable that perform equally well across age, VI severity, and gender. Our results supported the three-factor structure and that the PABQ-VI produces scores considered valid and reliable. Mean, variance, and correlation differences were found in personal, social, and environmental barriers for age and VI severity, but not gender. Researchers can use the PABQ-VI to test and evaluate ways to reduce barriers for this population.

Development of a School Health Policy Implementation Survey: A Delphi Study.

Data on school health policy implementation are limited due to the absence of a validated measurement tool. The purpose of this study was to create and pilot a school health policy implementation survey. A modified, four-round Delphi process was used to achieve consensus on content and format of the survey. The final 76-item survey was piloted in 655 schools with a return rate of 57.1% (n = 378). Seven schools participated in environmental audits. Based on the audits, survey responses represented an accurate description of school practices for 84.2% (n = 64) of questions. The remaining 15.8% (n = 12) of survey items were eliminated or revised. This measurement tool begins to fill the research gap between the evaluation of written school health policy and implementation. Further, this tool may be used by school nurses in alignment with the Framework for 21st Century School Nursing Practice.

The Five Nations model for prison health surveillance: lessons from practice across the UK and Republic of Ireland.

BACKGROUND: Prison populations experience an increased burden of physical, mental and social health needs compared to the community, further impacted by the prison environment. Surveillance systems to monitor health and well-being trends in prisons are lacking, presenting a challenge to services planners, and policy makers who often lack evidence to inform decisions. METHOD: The Five Nations Health and Justice Collaboration, a body of experts on prison health across the UK and Republic of Ireland (ROI), met to share and discuss challenges and opportunities to developing robust prison health surveillance systems that could inform local provision, guide national policy and enable cross-border comparisons. RESULTS: Challenges to robust prison health surveillance systems were shared across the UK and ROI. Methods of surveillance differed across nations and included performance indicators and outcome measures as part of local or national programs. All nations had strong public health infectious disease notification systems. CONCLUSIONS: The Five Nations Health and Justice Collaboration is proposing a new model for prison health surveillance, based on established guidelines for public health surveillance but with additional features that recognize the uniqueness of the prison environment and need for a whole prison approach, built on collaboration and sharing of data between health and justice sectors.

Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention.

BACKGROUND: Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes. METHODS: A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines. DISCUSSION: This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period.

BACKGROUND: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care. METHODS: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62). RESULTS: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58). CONCLUSION: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Looking behind the bars: emerging health issues for people in prison.

Introduction: There are more than 10 million people imprisoned worldwide. These individuals experience a higher burden of communicable and non-communicable disease, mental health and substance misuse problems than the general population and often come from marginalized and underserved groups in the community. Prisons offer an important opportunity for tackling health problems in a way that can deliver benefits to the individual and to the community. This paper focuses specifically on emerging health issues for prisons across the world. Sources of data: This paper uses sources of international data from published systematic reviews and research studies, the Ministry of Justice for England and Wales, the Prisons and Probations Ombudsmen Review and other United Kingdom government briefing papers. Areas of agreement: Deaths in custody are a key concern for the justice system as well as the health system. Areas of controversy: Suicide is the leading cause of mortality in prisons worldwide but non-communicable diseases, such as cardiovascular disease, are increasing in importance in high-income countries and are now the leading cause of mortality in prisons in England and Wales. Growing points: The prison population is ageing in most high-income countries. Older people in prison typically have multiple and complex medical and social care needs including reduced mobility and personal care needs as well as poor health. Areas timely for developing research: Further research is needed to understand the complex relationship between sentencing patterns, the ageing prison population and deaths in custody; to model its impact on prisons and healthcare provision in the future and to determine effective and cost-effective models of care. Research into the health of prisoners is important in improving the health of prisoners but there is considerable variation in quantity and quality between countries. Recent innovations seek to address this disparity and facilitate the sharing of good practice.

Building healthy communities: A comprehensive school health program to prevent obesity in elementary schools.

Obesity among children is highly prevalent and can lead to risk factors for chronic disease in adulthood. Key organizations have called on schools to play a larger role by increasing children's physical activity and nutrition by adopting an overall culture of health. This study examined the impact of a socioecological theory driven school-wide nutrition and physical activity intervention on 5th graders' central adiposity and obesity level. In 2015-2016, in the Midwest region of U.S., four treatment and two control schools, including 628 (377 treatment) 5th grade children participated in an eight-month intervention. Children in the treatment schools participated in a comprehensive healthy school transformation program consisting of six components. Waist-to-Height Ratio (WHtR) and Body Mass Index (BMI) was calculated and used as the measure of obesity. ANCOVA revealed a significant difference in WHtR among treatment and control groups at time two (T2) FMI(1,6148.14) = 4.43, p = .035, R2 = 0.64, R2Treament = 0.01, with no significant differences based on age, sex, and race. Additionally, the ANCOVA for BMI revealed a marginally significant lower BMI among the treatment than comparison group students FMI(1, 614) = 3.575, p = .059, R2 = 0.01 (Mdiff = -0.23, 95%CI upper boundary: -0.03). The healthy school intervention led to significant differences in obesity levels, regardless of age, sex, or race, across the 8-month program between 5th grade children in treatment and non-treatment schools. This supports the ability of schoolwide programs to significantly and positively impact student health and chronic disease prevention.

Observational multi-centre, prospective study to characterize novel pathogen-and host-related factors in hospitalized patients with lower respiratory tract infections and/or sepsis - the "TAILORED-Treatment" study.

BACKGROUND: The emergence and spread of antibiotic resistant micro-organisms is a global concern, which is largely attributable to inaccurate prescribing of antibiotics to patients presenting with non-bacterial infections. The use of 'omics' technologies for discovery of novel infection related biomarkers combined with novel treatment algorithms offers possibilities for rapidly distinguishing between bacterial and viral infections. This distinction can be particularly important for patients suffering from lower respiratory tract infections (LRTI) and/or sepsis as they represent a significant burden to healthcare systems. Here we present the study details of the TAILORED-Treatment study, an observational, prospective, multi-centre study aiming to generate a multi-parametric model, combining host and pathogen data, for distinguishing between bacterial and viral aetiologies in children and adults with LRTI and/or sepsis. METHODS: A total number of 1200 paediatric and adult patients aged 1 month and older with LRTI and/or sepsis or a non-infectious disease are recruited from Emergency Departments and hospital wards of seven Dutch and Israeli medical centres. A panel of three experienced physicians adjudicate a reference standard diagnosis for all patients (i.e., bacterial or viral infection) using all available clinical and laboratory information, including a 28-day follow-up assessment. Nasal swabs and blood samples are collected for multi-omics investigations including host RNA and protein biomarkers, nasal microbiota profiling, host genomic profiling and bacterial proteomics. Simplified data is entered into a custom-built database in order to develop a multi-parametric model and diagnostic tools for differentiating between bacterial and viral infections. The predictions from the model will be compared with the consensus diagnosis in order to determine its accuracy. DISCUSSION: The TAILORED-Treatment study will provide new insights into the interplay between the host and micro-organisms. New host- or pathogen-related biomarkers will be used to generate a multi-parametric model for distinguishing between bacterial and viral infections. This model will be helpful to better guide antimicrobial therapy for patients with LRTI and sepsis. This study has the potential to improve patient care, reduce unnecessary antibiotic prescribing and will contribute positively to institutional, national and international healthcare economics. TRIAL REGISTRATION: NCT02025699 . Registration Date: January, 1, 2014.

Youth Program Adult Leader's Directive Assistance and Autonomy Support and Development of Adolescents' Agency Capacity.

Developing a capacity for exercising agency is an important developmental task of adolescence. Many organized youth programs provide adolescents opportunities to build their capacity to exercise agency. The researchers tested hypotheses that adult youth program leader's directive assistance and autonomy support would promote adolescents' capacity for agency. They surveyed 441 high school adolescents and 11 adult advisors from 10 Future Farmers of America chapters twice over 2 years. Adolescents self-reported on their capacity for agency and advisors reported on each adolescent's capacity. Directive assistance and autonomy support correlated with the capacity for agency within both time points. Only autonomy support predicted adolescents' capacity for agency over time. Implications of leader's support for adolescents' capacity for exercising agency are discussed.

Uncommonly isolated clinical Pseudomonas: identification and phylogenetic assignation.

Fifty-two Pseudomonas strains that were difficult to identify at the species level in the phenotypic routine characterizations employed by clinical microbiology laboratories were selected for genotypic-based analysis. Species level identifications were done initially by partial sequencing of the DNA dependent RNA polymerase sub-unit D gene (rpoD). Two other gene sequences, for the small sub-unit ribosonal RNA (16S rRNA) and for DNA gyrase sub-unit B (gyrB) were added in a multilocus sequence analysis (MLSA) study to confirm the species identifications. These sequences were analyzed with a collection of reference sequences from the type strains of 161 Pseudomonas species within an in-house multi-locus sequence analysis database. Whole-cell matrix-assisted laser-desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) analyses of these strains complemented the DNA sequenced-based phylogenetic analyses and were observed to be in accordance with the results of the sequence data. Twenty-three out of 52 strains were assigned to 12 recognized species not commonly detected in clinical specimens and 29 (56 %) were considered representatives of at least ten putative new species. Most strains were distributed within the P. fluorescens and P. aeruginosa lineages. The value of rpoD sequences in species-level identifications for Pseudomonas is emphasized. The correct species identifications of clinical strains is essential for establishing the intrinsic antibiotic resistance patterns and improved treatment plans.

Health service changes to address diabetes in pregnancy in a complex setting: perspectives of health professionals.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women have high rates of gestational and pre-existing type 2 diabetes in pregnancy. The Northern Territory (NT) Diabetes in Pregnancy Partnership was established to enhance systems and services to improve health outcomes. It has three arms: a clinical register, developing models of care and a longitudinal birth cohort. This study used a process evaluation to report on health professional's perceptions of models of care and related quality improvement activities since the implementation of the Partnership. METHODS: Changes to models of care were documented according to goals and aims of the Partnership and reviewed annually by the Partnership Steering group. A 'systems assessment tool' was used to guide six focus groups (49 healthcare professionals). Transcripts were coded and analysed according to pre-identified themes of orientation and guidelines, education, communication, logistics and access, and information technology. RESULTS: Key improvements since implementation of the Partnership include: health professional relationships, communication and education; and integration of quality improvement activities. Focus groups with 49 health professionals provided in depth information about how these activities have impacted their practice and models of care for diabetes in pregnancy. Co-ordination of care was reported to have improved, however it was also identified as an opportunity for further development. Recommendations included a central care coordinator, better integration of information technology systems and ongoing comprehensive quality improvement processes. CONCLUSIONS: The Partnership has facilitated quality improvement through supporting the development of improved systems that enhance models of care. Persisting challenges exist for delivering care to a high risk population however improvements in formal processes and structures, as demonstrated in this work thus far, play an important role in work towards improving health outcomes.

OPAT for cellulitis: its benefits and the factors that predispose to longer treatment.

This retrospective study investigated the demographics and treatment outcomes of patients with cellulitis receiving outpatient parenteral antibiotic therapy (OPAT) between 2010 and 2014 in Cambridge University Hospitals. The rate of treatment failure (as indicated by the readmission to hospital) was low, at 5.5%. Risk factors associated with a longer duration of OPAT treatment included: immunosuppression, peripheral vascular disease, obesity, lymphoedema, previous cellulitis and diabetes.

Metabolomics of AS-5 RBC supernatants following routine storage.

BACKGROUND AND OBJECTIVES: The safety and efficacy of stored red blood cells (RBCs) transfusion has been long debated due to retrospective clinical evidence and laboratory results, indicating a potential correlation between increased morbidity and mortality following transfusion of RBC units stored longer than 14 days. We hypothesize that storage in Optisol additive solution-5 leads to a unique metabolomics profile in the supernatant of stored RBCs. MATERIALS AND METHODS: Whole blood was drawn from five healthy donors, RBC units were manufactured, and prestorage leucoreduced by filtration. Samples were taken on days 1 and 42, the cells removed, and mass spectrometry-based metabolomics was performed. RESULTS: The results confirmed the progressive impairment of RBC energy metabolism by day 42 with indirect markers of a parallel alteration of glutathione and NADPH homeostasis. Moreover, oxidized pro-inflammatory lipids accumulated by the end of storage. CONCLUSION: The supernatants from stored RBCs may represent a burden to the transfused recipients from a metabolomics standpoint.

Nerve localization techniques for peripheral nerve block and possible future directions.

BACKGROUND: Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block. METHODS: This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem. RESULTS: To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques. CONCLUSIONS: Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.