Not a Laughing Matter: When Nitrous Oxide Causes Functional Vitamin B12 Deficiency.

Subacute combined degeneration (SCD) is an acquired neurologic complication from prolonged vitamin B12 deficiency. As a result of dorsal and lateral spinal cord column degeneration, patients present with a range of neurological symptoms, including paresthesias, ataxia, and muscle weakness. Without prompt treatment, irreversible nerve damage occurs. Here we present a young man who developed progressive ascending paresthesias and lower extremity weakness after escalated nitrous oxide use. This case highlights the importance of considering SCD from nitrous oxide toxicity when patients present with progressive ataxia, paresthesia, and lower extremity weakness.

Prospective case study of critical decision making for horses referred for treatment of colic.

BACKGROUND: There is limited evidence on factors affecting critical decision making for horses with colic. This study's aim was to describe the assessment and decision making involved in horses referred for management of colic. METHODS: An in-depth case analysis was used to document case presentation, decision making and outcomes for horses referred for colic to two UK equine veterinary practices over a 12-month period. The data recorded included previous history, presenting signs, response to treatment, case outcome and factors affecting decisions for further treatment or euthanasia. RESULTS: Data were available for 60 cases: 55 were hospitalised for medical or surgical treatment and five horses were euthanased following initial assessment. The main factors affecting treatment decisions were severity of clinical signs (80%, 47/59), financial concerns (10%, 6/59) and ongoing health issues or previous history of colic (5%, 3/59). Factors associated with euthanasia decisions were postoperative complications (5/18), poor prognosis (4/18), deteriorating clinical signs (3/18) and financial concerns (3/18). LIMITATION: The limited study population may affect the extent to which the findings can be generalised. CONCLUSION: The severity of clinical signs was the key factor in treatment decision making. The main factors affecting euthanasia decisions were clinical deterioration, poor prognosis and financial constraints. These findings should be incorporated into clinical case recording to capture the multifactorial nature of decision making.

Diplopia after Sleeve Gastrectomy: The Canary in the Coal Mine.

Wernicke's encephalopathy (WE) is a neurologic emergency requiring timely intravenous thiamine supplementation to prevent permanent neurologic deficits. Historically, the WE diagnosis was limited to individuals with alcohol use disorder. However, it is now widely recognized to occur in patients who are chronically malnourished, post-bariatric surgery, pregnant with hyperemesis gravidarum, and with severe anorexia nervosa. Here we present a young woman who developed WE after undergoing a recent sleeve gastrectomy followed by protracted emesis for several days. This case underscores the importance of performing a thorough neurological review of systems and physical exam in high-risk patients and having a low clinical threshold to initiate appropriate thiamine treatment.

Longitudinal associations between parental reflective functioning and maternal mind-mindedness.

Little work has examined longitudinal associations between parental reflective functioning (PRF) and mind-mindedness (MM), limiting the understanding of separate or bidirectional trajectories of these related but distinct forms of mentalization. We examined cross-lagged associations between PRF, assessed via interview, and MM, coded from play interactions, over 12 months among 90 parents (86% female; 57% White, 43% Black) of infants (Mage = 10.56 months, SD = 8.20) who were participating in The Michigan Model of Infant Mental Health Home Visiting. Data were collected at study enrollment Time 1 (T1) and at 6-month Time 2 (T2) and 12-month Time 3 (T3) postenrollment. Mind-minded comments were coded as appropriate, reflecting accurate interpretation of mental states or nonattuned, characterizing inaccurate interpretations. PRF and appropriate MM each remained stable over time. PRF at the T1 positively predicted appropriate MM at T2. No other cross-lagged associations between PRF and appropriate MM were significant. Concurrent correlations between appropriate MM and PRF were significant only at T3. Nonattuned MM showed stability from T1 to T2 but nonattuned MM at the T2 did not predict nonattuned MM at T3. Greater PRF at T1 predicted less nonattuned MM at T2. No other cross-lagged associations between PRF and nonattuned MM were significant. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Prospective Cohort Study Investigating the Impact of Neutering Bitches Prepubertally or Post-Pubertally on Physical Development.

No previous large prospective cohort studies have been identified that have investigated the impact of the surgical neutering of bitches before or after known puberty on their growth and physical development. This study was designed to examine the data on physical development, vulval size, and conformation for bitches neutered by ovariohysterectomy before puberty (PPN, n = 155) or after puberty (control, n = 151) using a prospective cohort study design. Data were gathered at six- and 17-months of age using bespoke physical assessment forms and digital images of the vulva. PPN bitches had greater changes in height measurements (mean difference = 2.039, SEM = 0.334, 91% CI = 1.471 to 2.608, p < 0.001) and smaller changes in the measurements of vulval length (mean difference = -0.377, SEM = 0.079, 91% CI = -0.511 to -0.243, p < 0.001) and width (mean difference = -0.221, SEM = 0.063, 91% CI = -0.328 to -0.113, p < 0.001) between six- and 17-months of age than for the control bitches. Although not significant, the PPN bitches were taller (mean 58.5 vs. 56.6 cm) and heavier (mean 28.3 vs. 27.3 kg) with smaller vulval size measurements (mean vulval length 2.8 vs. 3.2 cm, mean vulval width 1.7 vs. 2.1 cm) at 17-months of age. At 17-months of age, significantly more PPN bitches had vulvas that appeared juvenile (Yates' Chi-square = 14.834, D.F. = 1, p < 0.001) and recessed (Yates' Chi-square = 7.792, D.F. = 1, p = 0.005) at the physical assessment, and significantly more PPN bitches had vulvas that appeared 'recessed/inverted' on the examination of digital images (Chi-square = 9.902, D.F. = 1, p = 0.002). The results from this study suggest no contraindications to prepubertal ovariohysterectomy for large breed bitches. However, any longer-term health implications of these differences in physical development need to be investigated and better understood prior to recommendations being made.

Effect of neutering timing in relation to puberty on female dog behaviour-A scoping review.

BACKGROUND: There are contradictory findings in the literature relating to the effects of timing of neutering on bitch behaviour that make decision making regarding neutering timing difficult. METHODS: A scoping review was designed to identify and chart the evidence on the effect of neutering timing in relation to puberty on the behaviour of female domesticated dogs. A protocol was registered, and literature searches were conducted in CAB Abstracts, Medline and Web of Science. Studies were reviewed against the inclusion criteria. Data on study and population characteristics and behavioural outcomes were extracted for the final included studies. RESULTS: A total of 1048 publications were reviewed; 13 were retained for inclusion and charting. Only one of the two studies that classified bitches as pre- or postpubertal presented results for the analysis of behaviours. The remaining 11 studies classified bitches by age at neutering. LIMITATIONS: Since the scoping review searches were conducted, further relevant studies may have become available. The search strategy may not have identified all available literature; however, databases were used that provide high levels of coverage of veterinary literature. CONCLUSION: This scoping review identified a lack of evidence to document the impact of neutering bitches before or after puberty on behaviour.

A prospective cohort study investigating the peri- and postoperative outcomes following ovariohysterectomy in bitches neutered prepubertally or post-pubertally.

The aim of this prospective cohort study was to investigate perioperative and postoperative outcomes for bitches that were neutered at different times in relation to puberty (rather than age). Three hundred and six Labrador and Golden Retriever crossbreed bitches were neutered before (prepubertal neuter [PPN], n = 155) or after puberty (Control, n = 151) by experienced veterinarians at one of four veterinary practices (VP1-4). Data were gathered from veterinarians at the time of neutering and from bitch caregivers for the 14-day period after neutering using purpose-designed questionnaires. PPN bitches had shorter surgery durations than Control bitches (OR = 0.877, 91% CI = 0.800 to 0.961, P = 0.015). Longer surgery durations were reported for bitches that had intraoperative complications (OR = 1.620, 91% CI = 1.397 to 1.879, P < 0.001). Shorter surgery durations were reported for VP1 compared to all other veterinary practices (OR = 1.189 to 1.534, P < 0.001). There was no difference in the number of PPN or Control bitches that had perioperative complications (PPN: 3.9%, n = 6; Control: 7.7%, n = 11) and no bitch had more than one perioperative complication reported. For the 14-day postoperative period, fewer PPN (1.3%, n = 2) compared to Control bitches (8.9%, n = 13) had wound discharge (Chi-square = 11.151, D.F = 1, P = 0.001) or showed inappetence (PPN: 2.9%, n = 4; Control: 17.3%, n = 19, Chi-square = 14.884, D.F. = 1, P < 0.001). There was no difference in the number of PPN and Control bitches that had redness or swelling of the wound (52 PPN, 48 Control), showed attention to the wound (6 PPN, 6 Control), required veterinary attention (25 PPN, 23 Control), or that showed any other unusual behaviours: discomfort (27 PPN, 16 Control), uncharacteristic irritability (2 PPN, 4 Control), or uncharacteristic licking or chewing of parts of the body (15 PPN, 6 Control). Bitches neutered at VP2-4 were more likely to have wound redness or swelling reported than those neutered at VP1 (OR = 3.109 to 4.076, P = 0.003). Future studies should consider the impact of veterinary practice on results. These results for peri and postoperative complications could suggest that prepubertal ovariohysterectomy may be a suitable option for neutering bitches. However, it is recommended that they be interpreted together with evidence relating to the impacts on other factors including behaviour and longer-term health in order to make fully informed decisions.

A Prospective Cohort Study Investigating the Behavioural Development of Bitches in a Guide Dog Training Programme Neutered Prepubertally or Post-Pubertally.

There are few studies that investigate the effect of neutering bitches before or after puberty. The majority of current literature examining the impact of the timing of neutering on health and behaviour has used age rather than the onset of puberty as the key variable. The aim of this prospective cohort study was to investigate the effects of timing of neutering in relation to puberty on behaviour in female dogs reared and trained in an assistance dog programme. The study examined data for bitches neutered before or after puberty to compare scores for six behavioural factors (training and obedience, aggression, fear and anxiety, excitability, attachment and attention-seeking, and social behaviour) measured at 1 and 3 years of age. Labrador and Golden Retriever crossbreed bitches were neutered before (n = 155) or after (n = 151) puberty. Neutering before or after puberty had no impact on mean scores for the six behavioural factors at 1 or 3 years of age. When examining the change in behavioural factor scores between 1 and 3 years of age, only aggression behavioural factor scores were influenced by neutering before or after puberty. Bitches neutered after puberty were less likely to have aggression factor scores that increased between 1 and 3 years of age (OR = 0.959, 90% CI = 0.924 to 0.995, p = 0.06). However, the majority of bitches scored "0" for aggression at both time points (indicating no aggression behaviours were observed), and the number of bitches for which scores increased between 1 and 3 years of age was low (before puberty = 20, after puberty = 9). This is consistent with very mild aggressive behaviours being observed in a small number of animals and is, therefore, of questionable concern. The results suggest that, for Labrador and Golden Retriever crossbreed bitches, neutering before or after puberty has little to no effect on future behaviour. It is recommended that decisions about the timing of neutering are not informed solely by impacts on behaviour, but that they also consider evidence relating to the impacts on bitch health and well-being.

Scoping review of end-of-life decision-making models used in dogs, cats and equids.

BACKGROUND: End-of-life decisions for companion animals can be stressful for veterinarians and owners, and when delayed result in poor animal welfare. Delayed euthanasia has been identified as a particularly prominent issue for horses. This scoping review aimed to identify the available literature on veterinary decision-making models, which can support end-of-life planning. METHODS: A protocol was preregistered, and a structured literature search was performed on six electronic databases. Publications were reviewed against specifically developed eligibility criteria. Data from original studies and narrative-type reviews were extracted separately, and the components of each model were charted. RESULTS: A total of 2211 publications were identified, 23 met the inclusion criteria and were included in the final review. Eight were original research studies and 15 were narrative reviews or similar. Publications were not indexed uniformly, increasing the difficulty of discovering relevant sources. The end-of-life decision-making process comprised three stages: (1) making the decision, (2) enacting the decision and (3) aftercare. Twenty key components of decision-making models were identified, although no publication reflected all of these. CONCLUSIONS: A lack of original research studies and equine-specific publications was identified. Shared decision-making models for euthanasia in veterinary practice should include all three stages and consider species-specific issues.

Management of Preterm Premature Rupture of Membranes in the Late Preterm Period.

Importance: For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks. Objective: In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM). Evidence Acquisition: Original research articles, review articles, and guidelines on management of late PPROM. Results: Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis. Conclusions and Relevance: We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

In-the-moment ratings on the Early Relational Health Screen: A pilot study of application in home visiting and primary care.

Early infant-parent interaction sets a critical foundation for young children's well-being, and evidence regarding the protective role of secure early relationships has led to increased interest in effective screening and promotion of early relational health in pediatric primary care and home visiting settings. We report findings from two pilot studies conducted in the United States that describe the reliability and validity of a relational health screening tool, the Early Relational Health Screen (ERHS), implemented in two different contexts: an innovative model of relational health promotion in pediatric primary care (Study 1) and an Infant Mental Health Home Visiting (IMH-HV) model (Study 2). Across both studies, a trained clinician rated the ERHS following real-time observation of interaction (i.e., "in-the-moment" ratings). Reliability was assessed by comparing "in-the-moment" ERHS ratings to subsequent coding of the same interaction from video by an independent evaluator. In addition, Study 2 data permitted evaluation of the validity of "in-the-moment" ERHS ratings. Results from both studies indicated reliability of "in-the-moment" ERHS ratings. In addition, Study 2 clinician "in-the-moment" ratings were associated with maternal depression and ratings of child-parent interaction derived from a separate observational task coded by independent evaluators using a different well-validated research-based measure. Discussion highlights the potential of the ERHS as a screening, promotion, and prevention tool that may be feasibly administered by providers across pediatric primary care and home visiting settings.

La temprana interacción infante-progenitor establece una fundación esencial para el bienestar de los niños pequeños, y la evidencia sobre el papel de protección de tempranas relaciones receptivas ha aumentado el interés en la efectiva detección y promoción de la salud de la relación en el cuidado pediátrico primario y los escenarios de visitas a casa. Reportamos los resultados de dos estudios experimentales que describen la confiabilidad y validez de la Temprana Detección de la Salud de la Relación (ERHS) implementada en dos contextos: un modelo innovador de promoción de la salud de la relación en el cuidado primario (Estudio 1) y un modelo de salud mental infantil de visitas a casa (Estudio 2). A lo largo de ambos, un profesional clínico entrenado evaluó ERHS siguiendo una observación de interacción en tiempo real (v.g. puntajes asignados "en el momento"). Se evaluó la confiabilidad por medio de una comparación entre los puntajes del profesional clínico y los subsecuentes puntajes de la misma interacción en video por un evaluador independiente. Adicionalmente, los datos del Estudio 2 permitieron la evaluación de la validez de los puntajes de ERHS. Los resultados de ambos estudios indicaron la confiabilidad de los puntajes ERHS "en el momento." Es más, los puntajes del profesional clínico del Estudio 2 se asociaron con la depresión materna y los puntajes de la interacción niño-progenitor derivados de una tarea separada usando una medida bien validada basada en la investigación. Las discusiones subrayan el potencial de ERHS como una herramienta de detección, promoción y prevención que puede ser administrada factiblemente por los proveedores tanto en el cuidado primario como en los casos de visitas a casa.

L'interaction précoce nourrisson-parent jette les bases essentielles du bien-être du jeune enfant et l'évidence concernant le rôle protecteur des relations précoces sécures a mené à un intérêt plus grand pour le dépistage efficace et la promotion de la santé relationnelle précoce dans les soins de santé primaire en pédiatrie ainsi que les contextes de visites à domicile. Nous rapportons ici les résultats de deux études pilotes faites aux Etats-Unis d'Amérique, qui décrivent la fiabilité et la validité d'un outil de dépistage de la santé relationnelle, le Dépistage Précoce de Santé Relationnelle (en anglais Early Relational Health Screen dont nous gardons l'abréviation ici, ERHS), mis en place dans deux contextes différents: un modèle innovateur de promotion de la santé relationnelle précoce en soin pédiatrique primaire (Etude 1) et un modèle de visite à domicile pour la santé mentale du nourrisson (Etude 2). Au travers de ces deux études un clinicien entraîné a évalué l'ERHS après une observation en temps réel de l'interaction (c'est-à-dire, des scores "sur le moment"). La fiabilité a été évaluée en comparant l'ERHS "sur le moment" au codage ultérieur de la même interaction à partir d'une vidéo, par un évaluateur indépendant. De plus les données de l'Etude 2 ont permis l'évaluation de la validité des scores ERHS "sur le moment." Les résultats des deux études ont indiqué la fiabilité des scores ERHS "sur le moment." De plus les scores "sur le moment" du clinicien de l'Etude 2 étaient liés à la dépression maternelle et aux scores d'interaction enfant-parent dérivés d'une tâche observationnelle séparée codée par des évaluateurs indépendants en utilisant une mesure basée sur les recherches différente et communément validée. La discussion met en lumière le potentiel de l'ERHS en tant qu'outil de dépistage, de promotion et de prévention qui peut être réalistement utilisé par les professionnels au sein des soins primaires pédiatriques et des contextes de visites à domicile.

Reducing non-surgical readmissions on a gynecologic oncology service.

OBJECTIVE: To assess the effects of a quality improvement (QI) initiative designed to reduce non-surgical readmissions on a gynecologic oncology service. METHODS: A two-phase QI initiative was implemented on an inpatient gynecologic oncology service to reduce non-surgical 30-day readmissions. Phase 1, from July 2018 to June 2020, included trainee education, frequent physical therapy consultation, pharmacy discharge medication review, 72-h post-discharge telephone call, and standardized 10-day clinic follow-up after discharge. Phase 2, from July 2020 to December 2020, incorporated a nurse practitioner to perform discharge navigation and arrange outpatient follow-up. The incidence of non-surgical readmissions during these phases was compared to that of a baseline period (July 2017-June 2018). We also assessed readmissions to identify common indications and evaluate potential demographic and clinical risk factors. RESULTS: Of 390 total non-surgical gynecologic oncology admissions, 100 were readmitted within 30 days (25.6%). Gastrointestinal tract (GI) obstruction, malignancy-associated pain and infection were the most common symptomatic diagnoses at the index admission, and 30% of readmitted patients had an identical indication for readmission. Compared to the baseline period, we observed a reduction in non-surgical readmissions from 34.1% to 22.6% in Phase 1 and to 18.9% in Phase 2 (p < 0.03) based on internal review, and a reduction from 13.9% to 11.9% in Phase 1 and to 4.7% in Phase 2 (p = 0.04) based on healthcare performance tracking data. CONCLUSIONS: 30-day hospital readmission among non-surgical gynecologic oncology patients is common. Implementation of a multifaceted readmissions reduction QI initiative significantly improved readmission rates.

Outcomes and Quality of Care in Rheumatoid Arthritis With or Without Video Telemedicine Follow-Up Visits.

OBJECTIVE: Telemedicine has been proposed to improve access to care in rheumatology, but few studies of telerheumatology have been published. The objective of this study was to evaluate outcomes and quality of care for rheumatoid arthritis (RA) in patients seen by video telemedicine follow-up compared to in-person only. METHODS: Individuals in the Alaska Tribal Health System with a diagnosis of RA were recruited when seeing a rheumatologist either in-person or by video telemedicine, both of which were offered as part of usual follow-up care. At baseline, participants completed the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire and a telemedicine perception survey and agreed to medical record review. Participants repeated surveys by telephone at 6 and 12 months, and medical record abstraction was performed at 12 months for quality measures. RESULTS: At the 12-month outcome assessment, 63 of 122 RA patients (52%) had ever used telemedicine for RA. In univariate analysis, functional status improved over 12 months in the telemedicine group. In multivariate analysis, RAPID3 score and functional status were associated with telemedicine group (higher), with no statistically significant change over the 12-month period. The only quality measure that differed between groups at 12 months in univariate analysis was the proportion of visits in which disease activity was documented (higher in the in-person group, 40% versus 25%; P = 0.02), but this was not significant after multivariate analysis. CONCLUSION: In short-term follow-up, there was no significant difference in most outcome and quality measures in patients with RA who incorporated telemedicine follow-up in their care compared to in-person only.

Infant Mental Health Home Visiting Mitigates Impact of Maternal Adverse Childhood Experiences on Toddler Language Competence: A Randomized Controlled Trial.

OBJECTIVE: The goal of this study was to test the impact of maternal adverse childhood experiences (ACEs) on subsequent child language competence; higher parental ACEs were expected to predict risk of toddler language delay. Participation in Infant Mental Health Home Visiting (IMH-HV) treatment, which aims to enhance responsive caregiving and improve child social-emotional development, was expected to mitigate this association. METHODS: A randomized controlled trial (RCT) design was used. ACEs data were collected at baseline. Child language screening (using the Preschool Language Scales Screening Test) was conducted 12 months later by masters-level evaluators who were blind to treatment condition. Visits occurred in participants' homes. Participants were community-recruited and were randomized to treatment (psychotherapeutic IMH-HV) or control (treatment as usual). Data come from 62 families who participated in all waves of an RCT testing the efficacy of IMH-HV; mothers were eligible based on child age (<24 mo at enrollment) and endorsement of ≥2 sociodemographic eligibility criteria (economic disadvantage, depression, perceived parenting challenges, and/or high ACEs). RESULTS: The age of mothers enrolled in this ranged from 19 to 44 years (M = 31.91; SD = 5.68); child age at baseline ranged from prenatal to 26 months (M = 12.06; SD = 6.62). The maternal ACE score predicted child language competence (t (5,55) = -3.27, p = 0.002). This effect was moderated by treatment (t (6,54) = 1.73, p = 0.04), indicating no association between maternal ACEs and child language for those randomized to IMH-HV. CONCLUSION: The results highlight that the effects of parent ACEs on early childhood outcomes may be buffered by participation in psychotherapeutic home visiting (trial registration: NCT03175796).

A scoping review of the current evidence on treatment and outcomes following synovial sepsis.

BACKGROUND: Synovial sepsis is a frequent cause of morbidity and mortality in horses. Despite advances in diagnostics and treatments, persistent infection or chronic lameness can occur. OBJECTIVES: To perform a scoping review to identify and evaluate the current evidence on the factors implicated in the success of treatment for synovial sepsis. STUDY DESIGN: Joanna Briggs Institute scoping review. METHODS: A protocol was registered, and a systematic literature search was performed on CAB abstracts, Medline, Scopus and Embase. Inclusion and exclusion criteria were developed and studies systematically reviewed against this. Studies relating to factors affecting treatment success following synovial sepsis were retained and data was extracted on study method, population characteristics and factors significantly associated with treatment outcome. RESULTS: In total, 2338 studies were identified, and 61 were included to full paper analysis. Eight papers reported significant factors, identifying 15 risk factors associated with two measurements of outcome, either survival and/or return to athletic function. The 15 factors were identified and categorised into pre-, intra- and post-operative factors. Risk factors that were identified included the number or type of synovial structures involved, the presence of pannus, tendon and bone pathology, and the use of systemic antimicrobials. There were many discrepancies in inclusion criteria of cases of synovial sepsis as well as measurement and description of outcome variables. MAIN LIMITATIONS: Non-English language studies or conference proceedings were not included. Only small numbers of papers had similar findings. CONCLUSIONS: Standardisation of inclusion criteria is essential to enable comparisons and analysis between studies on synovial sepsis. Future studies should use methodologies to reduce bias including multicentre and multinational studies, prospective study design and robust statistical modelling.

Evaluating and implementing an opportunity for diversity and inclusion in case-based learning.

Problem-based learning (PBL) and case-based learning (CBL) often mention social identities only if this information is directly relevant to diagnosis, which can inadvertently perpetuate stereotypes in trainee learning. Using a student-developed resource entitled "Portraying Social Identities in Medical Curriculum: A Primer," we analyzed cases for social identities, identified gaps, and proposed changes, including use of a validated name bank to reflect diversity as represented by local census data. Through this innovation, suggestions were provided to represent the social determinants of health in CBL cases. Other medical schools can use our innovation to improve the social diversity of their medical curriculums.

Bien souvent, l'apprentissage par résolution de problèmes (ARP) et l'apprentissage par les cas (APC) ne touchent aux identités sociales que si ce type d'information contribue directement au diagnostic, ce qui peut involontairement perpétuer les stéréotypes dans l'apprentissage des étudiants. À l'aide d'une ressource élaborée par les étudiants, intitulée « Portraying Social Identities in Medical Curriculum : A Primer ¼ (la représentation des identités sociales dans les programmes d'études médicales : une introduction), nous avons analysé des cas d'identités sociales, identifié des lacunes et proposé des changements, notamment l'utilisation d'une banque de noms validée reflétant la diversité qui ressort des données du recensement local. Grâce à cette innovation, des suggestions ont été faites pour représenter les déterminants sociaux de la santé dans les cas étudiés dans l'APC. Nous invitons les facultés de médecine à se servir de notre ressource pour mieux rendre compte de la diversité sociale dans leurs programmes d'études.

Owners' Knowledge and Approaches to Colic in Working Equids in Honduras.

In Honduras, many families are reliant on working equids in their daily life. The aim of this study was to evaluate knowledge about, and approaches to colic used by owners of working equids in Choluteca, Honduras using a phenomenological approach. Semi-structured, verbal questionnaires were conducted with ninety-three owners from eleven different communities in the Choluteca region on equid horse owners' knowledge of colic and treatments. Additional context was gained through observations and verbal questionnaires with three veterinary practitioners and eight agricultural pharmacy (agrovet) store owners. Working equids were commonly used for firewood collection 31% (40/126), transportation 24% (30/126), and carrying crops 13% (17/126). Thirty-eight percent of owners (35/92) said they did not know what colic was, 27% (24/89) could not name any clinical signs, and 46% (42/92) could not name any causes. Most owners with previous experience of colic had treated it themselves 79% (53/67), typically using herbal remedies. Colic was a major concern for owners of working equids who had prior experience or knowledge of the condition. Knowledge and understanding of colic varied, and access to evidence-based treatments was very limited. The findings will be used to inform the development of educational resources on colic in working equids.

Optimizing Household Water Decisions for Managing Intermittent Water Supply in Mexico City.

One billion people worldwide experience intermittent water supply (IWS), in which piped water is delivered for limited durations. Households with IWS must invest in water storage infrastructure and often rely on multiple sources of water; therefore, these household-level purchasing and infrastructure decisions is a critical component of water access. Informed by interviews with IWS households, we use radial basis function networks, a type of artificial neural network, to determine optimal household water management decisions that maximize reliability of water supply while minimizing costs for a representative household in Mexico City that uses municipal piped water, trucked water, and rainwater. We find that securing reliable water supply for IWS households is greatly assisted by installation of household storage tanks of at least 2500 L. In the case of IWS households with limited storage options, the overall cost for water supply is reduced by scheduling water deliveries on nonconsecutive days. Rainwater harvesting systems were shown to be economically viable for households with limited water supply. This study demonstrates the importance of considering the management of multiple sources and household storage infrastructure when evaluating water investments in cities with IWS.