Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study.

Background: Implementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings. Methods: The mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory. Results: Responders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies. Conclusions: Our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas.

Medical Students' Career Choice and Attitudes Toward Psychiatry: Case of the Czech Republic.

OBJECTIVE: A survey among medical students of all medical schools in the Czech Republic was conducted to investigate attitudes and views of psychiatry and career choice of psychiatry. METHODS: A Czech version of the Attitudes to Psychiatry Scale (APS) and a questionnaire surveying demographic characteristics and choices of future specialty were distributed to all medical students of eight medical schools in the Czech Republic via the schools' internal communication systems in the form of an anonymous online questionnaire. RESULTS: Out of a total of 10,147 medical students in the Czech Republic (academic year 2019/2020), 2418 students participated in the survey (response rate 23.8%). Psychiatry as a non-exclusive career choice was considered by 31.3% respondents; child and adolescent psychiatry was considered by 15.4% respondents. Psychiatry as the only choice was considered by 1.6%, and child and adolescent psychiatry was not considered at all. The interest in both specialties was declining since the first year of study. The status of psychiatry among other medical specialties was perceived as low; students were rather discouraged from entering psychiatry by their families. They did not feel encouraged by their teachers to pursue career in psychiatry despite the fact that they were interested in psychiatry. They also felt uncomfortable with patients with mental illness. CONCLUSIONS: Despite high enthusiasm for psychiatry in the first year of medical school, only a small proportion of medical students consider to choose psychiatry, and especially child and adolescent psychiatry, as a career at the end of medical school.

Optimizing interconception care: Rationale for the IMPLICIT model.

Despite traditional prenatal interventions, the incidence of low birth weight and prematurity in the United States have not significantly decreased. Interconception care for women between pregnancies has been proposed as a method of improving various perinatal outcomes. Although broadly advocated by national groups, interconception care (ICC) has not been widely implemented. We describe best practices for an ICC model based on screening mothers for tobacco use, depression, folic acid intake, and inter-pregnancy interval at well child visits. Because of the model's flexibility, sites can readily customize implementation by incorporating the questions directly into existing workflows and using local service providers already working in maternal-child health. This model has demonstrated promising results and ease of implementation thus far, and offers great potential for improved perinatal outcomes and promotion of health equity.

Latent toxoplasmosis reduces gray matter density in schizophrenia but not in controls: voxel-based-morphometry (VBM) study.

OBJECTIVES: To address the role of latent T. gondii infection in schizophrenia we studied the influence of latent toxoplasmosis on brain morphology. METHODS: An optimized voxel-based morphometry of magnetic resonance imaging was analyzed by analysis of variance with diagnosis and seropositivity as factors in 44 schizophrenic patients (12 T. gondii positive) and 56 controls (13 T. gondii positive). RESULTS: Grey matter (GM) volume was reduced in schizophrenia patients compared with controls in the cortical regions, hippocampus and in the caudate. In the schizophrenia sample we found a significant reduction of GM volume in T. gondii positive comparing with T. gondii-negative patients bilaterally in the caudate, median cingulate, thalamus and occipital cortex and in the left cerebellar hemispheres. T. gondii-positive and -negative controls did not differ in any cluster. Among participants seropositive to T. gondii the reduction of GM in the schizophrenia subjects was located in the same regions when comparing the entire sample (11,660 over-threshold voxels (P ≤ 0.05, FWR corrected). The differences between T. gondii-negative patients and controls consisted only of 289 voxels in temporal regions. CONCLUSIONS: Our study is the first to document that latent toxoplasmosis reduces GM in schizophrenia but not in controls.

Development and evaluation of a multiple-plate fraction collector for sample processing: application to radioprofiling in drug metabolism studies.

Microplate scintillation counters are utilized routinely in drug metabolism laboratories for the off-line radioanalysis of fractions collected during HPLC radioprofiling. In this process, the current fraction collection technology is limited by the number of plates that can be used per injection as well as the potential for sample loss due to dripping or spraying as the fraction collector head moves from well to well or between plates. More importantly, sample throughput is limited in the conventional process, since the collection plates must be manually exchanged after each injection. The Collect PAL, an innovative multiple-plate fraction collector, was developed to address these deficiencies and improve overall sample throughput. It employs a zero-loss design and has sub-ambient temperature control. Operation of the system is completely controlled with software and up to 24 (96- or 384-well) fraction collection plates can be loaded in a completely automated run. The system may also be configured for collection into various-sized tubes or vials. At flow rates of 0.5 or 1.0 mL/min and at collection times of 10 or 15s, the system precisely delivered 83-µL fractions (within 4.1% CV) and 250-µL fractions (within 1.4% CV), respectively, of three different mobile phases into 12 mm × 32 mm vials. Similarly, at a flow rate of 1 mL/min and 10s collection times, the system precisely dispensed mobile phase containing a [(14)C]-radiolabeled compound across an entire 96-well plate (% CV was within 5.3%). Triplicate analyses of metabolism test samples containing [(14)C]buspirone and its metabolites, derived from three different matrices (plasma, urine and bile), indicated that the Collect PAL produced radioprofiles that were reproducible and comparable to the current technology; the % CV for 9 selected peaks in the radioprofiles generated with the Collect PAL were within 9.3%. Radioprofiles generated by collecting into 96- and 384-well plates were qualitatively comparable; however, the peak resolution was greater in the profiles that were collected in 384-well plates due to the collection of a larger number of fractions per minute. In conclusion, this new and innovative fraction collector generated radioprofile results that were comparable to current technology and should provide a major improvement in capacity and throughput for radioprofiling studies.

PT or cervical collar for cervical radiculopathy?

To shorten recovery time for adults with acute cervical radiculopathy, recommend either physical therapy (PT) and a home exercise plan or a cervical collar and rest. Both are more effective than a wait-and-see strategy.

Primary care and the early phases of schizophrenia in the Czech Republic.

AIM: To explore knowledge, treatment setting, attitudes and needs associated with patients in early phases of psychosis among general practitioners (GPs) in Prague, and to compare results with GPs from 6 countries participating in the International GP Study (IGPS) on Early Psychosis (Canada, Australia, New Zealand, England, Norway, Austria). METHODS: Survey questionnaires were mailed to 648 GPs in the city of Prague. RESULTS: The response rate was 19.9%. Prague GPs showed significantly lower diagnostic knowledge of early phases of psychosis compared to their international colleagues. They frequently indicated depression/anxiety and somatic complaints as early warnings of psychosis. They more often considered their behaviour to be problematic and more commonly handed them over to specialists. The majority of Prague GPs wished specialized outpatient services for low-threshold referrals of such patients. CONCLUSIONS: Along the mental health reforms in the Czech Republic which emphasis the role of primary care, GPs' knowledge of the early warning signs of psychosis needs to be improved.

The International Study on General Practitioners and Early Psychosis (IGPS).

BACKGROUND: In much of the world, general practitioners (GPs) are the health professionals most frequently initially contacted when a young person is developing psychosis. However little is known about their expertise in assessing psychosis and its risk. METHODS: To assess the diagnostic patterns and treatment practices related to psychosis of GPs working in a range of health care systems, questionnaires were mailed to 12,516 randomly selected GPs in seven countries: Canada, Australia, New Zealand, England, Norway, Austria and the Czech Republic. Sites were defined as gatekeeping or non-gatekeeping, based on the primary care health system in effect at each site. A gatekeeping system (GK) is one which mandates that patients see a GP before in order to be referred to a specialist. By contrast, in a non-gatekeeping (nGK) system, individuals can seek help directly from specialists without authorization by a GP. RESULTS: Twenty-two percent (n=2784) GPs responded to the mailed questionnaire. They reported low prevalence of early psychosis seen in general practice. Using awareness of functional decline as a prognostic sign as a proxy, gatekeeping (GK) GPs were found to be superior in their knowledge of the signs and symptoms of early psychosis than were non-gatekeeping GPs. GP's with less knowledge as to early psychosis were more likely to refer individuals with suspected psychosis to specialists. GP's reported a preference for access to specialized outpatient services as compared with obtaining continuous medical education relevant to early psychosis. The duration of maintenance treatment recommended by GP's was less than that recommended in international guidelines. GP's also underestimated the risk for relapse after a first episode of psychosis. CONCLUSIONS: As GPs were largely unaware of features of early psychosis, such as functional decline, this should be the target of educational programs for GP's. However, the incidence of psychosis is low and GP's express a preference for access to appropriate referral over continuing medical education. Therefore, the development of specialized services for the assessment and care of patients who are in the early stages of developing schizophrenia may be warranted.

Stereocontrolled synthesis of (-)-macrolactin A.

The total synthesis of (-)-macrolactin A, a 24-membered macrolide, has been achieved using a newly developed 1,3-diol synthon for the introduction of two key stereogenic centers. The synthon was derived from sequential use of the Noyori asymmetric reduction followed by chiral sulfoxide methodology. Tellurium-derived cuprate organometallics offered an efficient and highly stereoselective means for installation of the C8 Z/E-diene, while the C15 E/E-segment was derived from a Julia-Lythgoe olefination. Yamaguchi lactonization was used to secure the macrocycle in a convergent approach with the longest linear sequence of 19 steps from Noyori alcohol 6.