Effect of Body Mass Index on Complications After Vaginal and Laparoscopic Apical Prolapse Surgery.

INTRODUCTION AND HYPOTHESIS: Obesity is increasing worldwide, and data are limited on how body mass index (BMI) affects surgical risk in pelvic organ prolapse. This study is aimed at evaluating the impact of obesity on outcomes after apical pelvic organ prolapse surgery. We hypothesize that obese patients have higher rates of postoperative complications. METHODS: This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2018. Current Procedural Terminology codes identified subjects aged 18-89 who underwent apical prolapse repair, including vaginal colpopexy and laparoscopic or robotic sacrocolpopexy. Minor and major complications were analyzed using the World Health Organization BMI category. Regression analysis was performed to adjust for confounders. RESULTS: The total cohort was 24,718 with 15,137 vaginal colpopexy and 9,581 laparoscopic/robotic sacrocolpopexy. The average age was 60.1, 76.5% were white, 24.2% were American Society of Anesthesiologists (ASA) class 3 or 4, and 44.7% had a major medical comorbidity. Eight hundred and eighty-five patients (5.4%) experienced a minor complication, 324 (2.0%) a major complication, and 1,167 (7.2%) any complication. There was no difference in any, major, or minor complication by BMI and this persisted after adjusting for age, race, ASA class, smoking, and surgical approach. CONCLUSIONS: There is no difference in complication rates after apical prolapse surgery by BMI regardless of age, race, ASA class, smoking use, and surgical approach. Patients and surgeons should be reassured that minimally invasive apical prolapse surgery is safe, with low complication rates. Randomized controlled trials are needed to verify these findings.

Length of Maternity Leave Impact on Mental and Physical Health of Mothers and Infants, a Systematic Review and Meta-analysis.

BACKGROUND: Recent legislative decisions in the United States have encouraged discussion about national parental leave programs. Currently, over 47% of the United States workforce is female. However, the United States is the only nation of the 37 member countries in the Organization for Economic Co-Operation and Development (OECD) to have no national requirement for maternity leave. The first few months of a child's life are vital to their physical and mental development. Likewise, a gradual return to pre-partum functioning is important for a newly postpartum woman. While it has been shown that maternity leave positively impacts various measures of maternal and infant mental and physical health, we lack consensus on the optimal length of paid or unpaid maternity leave. Accordingly, we conducted a systematic review and meta-analysis to evaluate the optimal length of paid or unpaid maternity leave to encourage maternal and infant mental and physical health in the United States. METHODS: A systematic review and meta-analysis were conducted to synthesize and critically evaluate the current research investigating the association between maternity leave and maternal and infant mental and physical health using the Preferred Reporting in Systematic Reviews and Meta-Analyses guidelines. Databases EMBASE, PsycInfo, and PubMed were searched using specific inclusion and exclusion criteria. Methodological Index for Non-Randomized Studies scale assessed the methodological quality of the included eligible studies. The magnitude of heterogeneity between-study was tested using The Cochrane χ2 test and the Moran's I2 statistic. Possible publication bias was assessed through the funnel plot and the Egger regression test. A p-value of < 0.10 will be considered as an indication for the existence of potential publication bias. All statistical analyses were carried out with Stata software version 15. RESULTS: A total of 21 studies were analyzed. It was found that longer maternity leave may decrease rates of maternal mental and physical health complaints. It was also found that longer maternity leave leads to more positive mother-child interactions, decreased infant mortality, and longer periods of breastfeeding. CONCLUSION: Maternity leave of 12 weeks or more confers the greatest benefit for mothers and their infants.

A randomized trial of standard vs restricted opioid prescribing following midurethral sling.

BACKGROUND: Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. OBJECTIVE: This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. STUDY DESIGN: Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. RESULTS: Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval, -∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). CONCLUSION: Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.

Sacrocolpopexy using autologous rectus fascia: Cohort study of long-term outcomes and complications.

OBJECTIVE: To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery. DESIGN: Ambispective cohort study with retrospective and prospective data. SETTING: A single academic medical centre. POPULATION: Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019. METHODS: Patients were recruited for a follow-up visit, including completing the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse Quantification (POP-Q) examination. Demographic and clinical characteristics were collected. MAIN OUTCOME MEASURES: Composite failure, anatomic failure, symptomatic failure and retreatment. RESULTS: During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. The median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (95% CI 0.1%-5.9%) at 12 months, 3.5% (95% CI 1.1%-10.7%) at 2 years, 13.2% (95% CI 7.0%-24.3%) at 3 years and 28.3% (95% CI 17.0%-44.8%) at 5 years. The anatomic failure rate was 0% at 12 months, 1.4% (95% CI 0.2%-9.2%) at 2 years, 3.1% (95% CI 0.8%-12.0%) at 3 years and 6.8% (95% CI 2.0%-22.0%) at 5 years. The symptomatic failure rate was 0% at 12 months, 1.3% (95% CI 0.2%-9.0%) at 2 years, 2.9% (95% CI 0.7%-11.3%) at 3 years and 13.1% (95% CI 5.3%-30.3%) at 5 years. The retreatment rate was 0.8% (95% CI 0.1%-5.9%) at 12 months and 2 years, 9.4% (95% CI 4.2%-20.3%) at 3 years and 13.0% (95% CI 6.0%-27.2%) at 5 years. CONCLUSION: Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who wish to avoid synthetic mesh. TWEETABLE ABSTRACT: Sacrocolpopexy using autologous rectus fascia is a safe and effective alternative to synthetic mesh.

Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review.

We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m2 (17.2-53.3 kg/m2). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.

Natural history of urinary incontinence from first childbirth to 30-months postpartum.

PURPOSE: The objectives of this study were to determine the incidence of UI in a large cohort of primiparous women before and during pregnancy and over the course of 30-months postpartum, and to identify risk factors for UI during and after pregnancy. METHODS: Nulliparous women aged 18-35 years with singleton pregnancies were interviewed in their third trimester and asked about urinary incontinence before and during pregnancy (n = 3001). After delivery these women were interviewed at 1, 6, 12, 18, 24 and 30-months postpartum and asked about urinary incontinence occurring in the month prior to each interview. Multivariable logistic regression models identified risk factors for UI during pregnancy and during the follow-up period. RESULTS: Overall, 4% reported having urinary incontinence before pregnancy and 36.8% during pregnancy. The strongest predictor of urinary incontinence during pregnancy was urinary incontinence before pregnancy (adjusted OR 13.11, 95% CI 7.43-23.13). Among the women with no subsequent pregnancies, the rate of urinary incontinence increased from 12.5% at 6-months postpartum to 27.4% at 30-months postpartum, 52.1% reported UI at one or more postpartum data collection stages, and the strongest predictors of postpartum UI were UI before pregnancy (adjusted OR 3.95 (95% CI 1.60-9.75) and during pregnancy (adjusted OR 4.36, 95% CI 3.24-5.87). CONCLUSION: Our findings suggest that primiparous women who report UI before and during pregnancy should be monitored for the continuation or worsening of UI over the course of the first 2-3 years postpartum, and treatment options discussed.

Use of Procalcitonin and a Respiratory Polymerase Chain Reaction Panel to Reduce Antibiotic Use via an Electronic Medical Record Alert.

BACKGROUND: Respiratory tract infections are often viral and but are frequently treated with antibiotics, providing a significant opportunity for antibiotic de-escalation in patients. We sought to determine whether an automated electronic medical record best practice alert (BPA) based on procalcitonin and respiratory polymerase chain reaction (PCR) results could help reduce inappropriate antibiotic use in patients with likely viral respiratory illness. METHODS: This multisite, pre-post, quasi-experimental study included patients 18 years and older with a procalcitonin level <0.25 ng/mL and a virus identified on respiratory PCR within 48 hours of each other, and 1 or more systemic antibiotics ordered. In the study group, a BPA alerted providers of the diagnostic results suggesting viral infection and prompted them to reassess the need for antibiotics. The primary outcome measured was total antibiotic-days of therapy. RESULTS: The BPA reduced inpatient antibiotic-days of therapy by a mean of 2.2 days compared with patients who met criteria but did not have the alert fire (8.0 vs 5.8 days, respectively, P < .001). The BPA also reduced the percentage of patients prescribed antibiotics on discharge (20% vs 47.8%, P < .001), whereas there was no difference in need for antibiotic escalation after initial discontinuation (7.6% vs 4.3%, P = .198). CONCLUSIONS: The automated antimicrobial stewardship BPA effectively reduced antibiotic use and discharge prescribing rates when diagnostics suggested viral respiratory tract infection, without a higher rate for reinitiation of antibiotics after discontinuation.

View from the heart: cardiac fibroblasts in development, scarring and regeneration.

In the adult, tissue repair after injury is generally compromised by fibrosis, which maintains tissue integrity with scar formation but does not restore normal architecture and function. The process of regeneration is necessary to replace the scar and rebuild normal functioning tissue. Here, we address this problem in the context of heart disease, and discuss the origins and characteristics of cardiac fibroblasts, as well as the crucial role that they play in cardiac development and disease. We discuss the dual nature of cardiac fibroblasts, which can lead to scarring, pathological remodelling and functional deficit, but can also promote heart function in some contexts. Finally, we review current and proposed approaches whereby regeneration could be fostered by interventions that limit scar formation.

Postmenopausal endometriosis, where are we now?

PURPOSE OF REVIEW: Postmenopausal endometriosis is a gynecologic disease, affecting 2-5% of postmenopausal woman. Current literature assessing the prevalence, pathogenesis, and treatment of this uncommon condition is limited, stressing the necessity for future research. This review examines the current literature on postmenopausal endometriosis to help inform clinical decision-making and point to novel approaches for treatment and management. RECENT FINDINGS: Although one unifying theory to explain the pathogenesis of endometriotic lesions has not been elucidated, estrogen dependence is central to the pathophysiological process. The total quantity of estrogen production is mediated by multiple enzymes in complex pathways. Recent studies have confirmed the presence of these necessary enzymes in endometriotic lesions thereby suggesting a local source of estrogen and a likely pathogenic contributor. More research is needed to fully elucidate the mechanism of local estrogen biosynthesis; however, the current data provide possible explanations for the presence of postmenopausal endometriosis in an otherwise systemically hypoestrogenic environment. SUMMARY: All suspected endometriosis lesions should be surgically excised for optimization of treatment and prevention of malignant transformation. If hormone replacement therapy is initiated, combined estrogen and progestin is recommended, even in the setting of previous hysterectomy, given the risk of disease reactivation and malignant transformation of endometriotic lesions. Further research is needed to understand the true prevalence, cause, and progression in this patient demographic. Histologic studies evaluating tissue lesions and peritoneal fluid for estrogen receptors, estrogen metabolizing enzymes, immune cells, and nerve fibers will aide in clinical management and treatment planning.

A mixed-methods evaluation of a multidisciplinary point of care ultrasound program.

BACKGROUND: Point of Care Ultrasound (PoCUS) is well established within emergency medicine, however, the availability of formal training for other clinical disciplines is limited. Memorial University has established a cost-efficient, multidisciplinary PoCUS training program focusing on training residents' discipline-specific ultrasound skills. This study evaluates the skills, knowledge, and attitudes of residents who participated in the program. METHODS: Analysis was conducted using a mixed-methods, sequential exploratory approach. Initially, a focus group of seven first year residents was conducted to generate themes that were used to guide development of a survey administered to residents over a two-year period. RESULTS: Thirty residents responded to the survey (response rate 63.8%) with 53.3% meeting the training requirements for focused assessment using sonography in trauma, 43.3% for pleural effusion, 40.0% for aortic aneurysms, and 40.0% for cardiac scans. Early pregnancy assessment was the skill of least interest with 46.6% not interested. Over half the residents (53.6%) agreed or strongly agreed that a multidisciplinary program met their needs while 21.4% disagreed. The focus group found the multidisciplinary approach adequate. CONCLUSIONS: A single PoCUS curriculum has been shown to meet the needs and expectations of a majority of residents from multiple disciplines. It can enhance collaboration and bridge gaps between increasingly compartmentalized practices of medicine.

Adaptation to reef habitats through selection on the coral animal and its associated microbiome.

Spatially adjacent habitats on coral reefs can represent highly distinct environments, often harbouring different coral communities. Yet, certain coral species thrive across divergent environments. It is unknown whether the forces of selection are sufficiently strong to overcome the counteracting effects of the typically high gene flow over short distances, and for local adaptation to occur. We screened the coral genome (using restriction site-associated sequencing) and characterized both the dinoflagellate photosymbiont- and tissue-associated prokaryote microbiomes (using metabarcoding) of a reef flat and slope population of the reef-building coral, Pocillopora damicornis, at two locations on Heron Island in the southern Great Barrier Reef. Reef flat and slope populations were separated by <100 m horizontally and ~5 m vertically, and the two study locations were separated by ~1 km. For the coral host, genetic divergence between habitats was much greater than between locations, suggesting limited gene flow between the flat and slope populations. Consistent with environmental selection, outlier loci primarily belonged to the conserved, minimal cellular stress response, likely reflecting adaptation to the different temperature and irradiance regimes on the reef flat and slope. The prokaryote community differed across both habitat and, to a lesser extent, location, whereas the dinoflagellate photosymbionts differed by habitat but not location. The observed intraspecific diversity associated with divergent habitats supports that environmental adaptation involves multiple members of the coral holobiont. Adaptive alleles or microbial associations present in coral populations from the environmentally variable reef flat may provide a source of adaptive variation for assisted evolution approaches, through assisted gene flow, artificial cross-breeding or probiotic inoculations, with the aim to increase climate resilience in the slope populations.

The unusual pattern of hereditary bleeding disorders in the province of Newfoundland and Labrador-Canada's most Eastern Province.

Newfoundland and Labrador (NL), the most eastern province of Canada, is characterized by a unique topography and pattern of settlement. The current population is descended from a small founding population of indigenous Innu, Inuit and Mi'kmaq and an estimated 28,000 settlers. These settlers originated from Southwest England and Southeast Ireland and came to invest and work in one of the world's richest fisheries. They settled in bays, coves and islands off the coast, in small settlements called out-ports. These isolated communities developed unusual patterns of genetic disease including an unusual prevalence of some extremely rare Hereditary Bleeding Disorders (HBD). This study was designed to document the prevalence of these rare disorders, at a snapshot in time, using our provincial HBD registry. These diagnoses were verified by reviewing the original initial diagnostic coagulation results to confirm or refute each diagnosis. When available, we also recorded the underlying mutation. Population based prevalence rates were then compared with data published from the World Federation of Hemophilia (WFH) Global Registry. The results are striking. Using the WFH data the per capita prevalence in NL of Hemophilia A, Factors V, XI, and XIII Deficiency are higher than that of mainland Canada minus Labrador by a factor of 2.89, 4.54, 5.44 and 9.22, respectively. The increased prevalence of mild Hemophilia A is explained by a founder effect of the Val 2016 Ala mutation. All the severe FXIII deficient patients are homozygotes for c.691-1 G > A mutation. These results show that NL's unique geography and population distribution led to a genetic drift that increased the prevalence of some rare factor deficiencies. This comparatively high prevalence provides a potential pool of patients for genotype/phenotype research.

Remote Mentoring of Point-of-Care Ultrasound Skills to Inexperienced Operators Using Multiple Telemedicine Platforms: Is a Cell Phone Good Enough?

OBJECTIVES: Telemedicine technology contributes to the teaching of point-of-care ultrasound (US); however, expensive equipment can limit its deployment in resource-challenged settings. We assessed 3 low-cost telemedicine solutions capable of supporting remote US training to determine feasibility, acceptability, and effectiveness. We also explored the value of instructional videos immediately before telementoring. METHODS: Thirty-six participants were randomly assigned to receive US mentoring in 1 of 3 telemedicine conditions: multiple fixed cameras, a smartphone, and traditional audio with a live US stream. Participants were then asked to perform a standardized US examination of the right upper quadrant under remote guidance. We measured observer's global ratings of performance along with the mentor's and student's rating of effort and satisfaction to determine which of the 3 approaches was most feasible, acceptable, and effective. During the second phase, students were randomized to watch an instructional video or not before receiving remote coaching on how to complete a subxiphoid cardiac examination. Effort, satisfaction, and performance from the independent observer's and student's perspective were surveyed. RESULTS: There was no significant difference between the different telemedicine setups from the observer's perspective; however, the mentor rated the smartphone significantly worse (P = .028-.04) than other technologies. Platforms were rated equivalent from the student's perspective. No benefit was detected for watching an instructional video before the mentored task. CONCLUSIONS: Remote US skills can be taught equally effectively by using a variety of telemedicine technologies. Smartphones represent a viable option for US training in resource-challenged settings.

Use of the Pelvic Organ Quantification System (POP-Q) in published articles of peer-reviewed journals.

INTRODUCTION AND HYPOTHESIS: The Pelvic Organ Quantification (POP-Q) system is a standardized technique used for staging POP. This study aimed to examine POP-Q use in peer-reviewed publications. METHODS: Nine journals representative of urogynecology were reviewed for articles describing POP staging from January to December 2012 and 2015. Review articles, editorials, letters and articles with or without retractions in manuscript form were excluded. The primary outcome was frequency of POP-Q use. Secondary outcomes were POP-Q use by journal specialty, specialty of primary author, country of origin, and an anatomic definition of failure. Data were evaluated using chi-square tests. Results yielding p < 0.05 were deemed statistically significant. RESULTS: Two hundred and nineteen articles were reviewed. POP-Q was used in 88.4% in 2012 and 80% in 2015(not significant; p = 0.296). Urologists used the POP-Q least frequently, although its use was greater in 2015 (63.6%) than in 2012 (50%). In 2012, a definition for anatomic failure was present in 27% of articles; 23% of authors in the 2012 time frame reported using the POP-Q, and 17.8% used a specific POP-Q point. Between 2012 and 2015, the use of a specific point significantly decreased (17.8 vs. 7.8%, p = 0.033). CONCLUSION: POP-Q is the most common staging system used in published articles across studied subgroups. When used as an outcome measure, a greater number of authors use the recommended staging system rather than specific points.

Augmented Reality as a Telemedicine Platform for Remote Procedural Training.

Traditionally, rural areas in many countries are limited by a lack of access to health care due to the inherent challenges associated with recruitment and retention of healthcare professionals. Telemedicine, which uses communication technology to deliver medical services over distance, is an economical and potentially effective way to address this problem. In this research, we develop a new telepresence application using an Augmented Reality (AR) system. We explore the use of the Microsoft HoloLens to facilitate and enhance remote medical training. Intrinsic advantages of AR systems enable remote learners to perform complex medical procedures such as Point of Care Ultrasound (PoCUS) without visual interference. This research uses the HoloLens to capture the first-person view of a simulated rural emergency room (ER) through mixed reality capture (MRC) and serves as a novel telemedicine platform with remote pointing capabilities. The mentor's hand gestures are captured using a Leap Motion and virtually displayed in the AR space of the HoloLens. To explore the feasibility of the developed platform, twelve novice medical trainees were guided by a mentor through a simulated ultrasound exploration in a trauma scenario, as part of a pilot user study. The study explores the utility of the system from the trainees, mentor, and objective observers' perspectives and compares the findings to that of a more traditional multi-camera telemedicine solution. The results obtained provide valuable insight and guidance for the development of an AR-supported telemedicine platform.

Using local clinical educators and shared resources to deliver simulation training activities across rural and remote South Australia and south-west Victoria: A distributed collaborative model.

PROBLEM: There is a lack of access to simulation-based education (SBE) for professional entry students (PES) and health professionals at rural and remote locations. DESIGN: A descriptive study. SETTING: Health and education facilities in regional South Australia and south-west Victoria. KEY MEASURES FOR IMPROVEMENT: Number of training recipients who participated in SBE; geographical distribution and locations where SBE was delivered; number of rural clinical educators providing SBE. STRATEGIES FOR CHANGE: A distributed model to deliver SBE in rural and remote locations in collaboration with local health and community services, education providers and the general public. Face-to-face meetings with health services and education providers identified gaps in locally delivered clinical skills training and availability of simulation resources. Clinical leadership, professional development and community of practice strategies were implemented to enhance capacity of rural clinical educators to deliver SBE. EFFECTS OF CHANGE: The number of SBE participants and training hours delivered exceeded targets. The distributed model enabled access to regular, localised training for PES and health professionals, minimising travel and staff backfill costs incurred when attending regional centres. The skills acquired by local educators remain in rural areas to support future training. LESSONS LEARNT: The distributed collaborative model substantially increased access to clinical skills training for PES and health professionals in rural and remote locations. Developing the teaching skills of rural clinicians optimised the use of simulation resources. Consequently, health services were able to provide students with flexible and realistic learning opportunities in clinical procedures, communication techniques and teamwork skills.

VISIONET: intuitive visualisation of overlapping transcription factor networks, with applications in cardiogenic gene discovery.

BACKGROUND: Existing de novo software platforms have largely overlooked a valuable resource, the expertise of the intended biologist users. Typical data representations such as long gene lists, or highly dense and overlapping transcription factor networks often hinder biologists from relating these results to their expertise. RESULTS: VISIONET, a streamlined visualisation tool built from experimental needs, enables biologists to transform large and dense overlapping transcription factor networks into sparse human-readable graphs via numerically filtering. The VISIONET interface allows users without a computing background to interactively explore and filter their data, and empowers them to apply their specialist knowledge on far more complex and substantial data sets than is currently possible. Applying VISIONET to the Tbx20-Gata4 transcription factor network led to the discovery and validation of Aldh1a2, an essential developmental gene associated with various important cardiac disorders, as a healthy adult cardiac fibroblast gene co-regulated by cardiogenic transcription factors Gata4 and Tbx20. CONCLUSIONS: We demonstrate with experimental validations the utility of VISIONET for expertise-driven gene discovery that opens new experimental directions that would not otherwise have been identified.

Progress towards the elimination of trachoma in Nigeria.

Trachoma is targeted for elimination as a public health problem worldwide by 2030. In Nigeria, elimination activities are implemented at the local government area (LGA) level. They started in 2002 by conducting baseline population-based prevalence surveys (PBPSs), which continued in a systematic manner with engagement from the Global Trachoma Mapping Project in 2013, and subsequently Tropical Data. The results led to the development of Nigeria's first trachoma action plan and its subsequent revision with additional information. Following 449 baseline PBPSs, 122 LGAs had an active trachoma prevalence above the elimination threshold, requiring interventions, while 231 LGAs required community-based interventions for trichiasis management. By 2021, >34 million antibiotic treatments had been provided in 104 LGAs, with 89 LGAs eliminating active trachoma. Nationally, water and sanitation coverages increased by 3% and 18%, respectively, in 7 y. Systematic trichiasis case finding and management were carried out in 231 LGAs, resulting in the management of 102 527 people. Fifty-four LGAs decreased trichiasis prevalence unknown to the health system to <0.2% in persons ≥15 y of age. Where this elimination prevalence threshold was reached, trichiasis services were transitioned to routine eye/healthcare systems. Such progress relied on strong leadership and coordination from the national trachoma program and tremendous support provided by partners. Attaining elimination of trachoma as a public health problem in Nigeria by 2030 is feasible if funding support is sustained.

Software support for SBGN maps: SBGN-ML and LibSBGN.

MOTIVATION: LibSBGN is a software library for reading, writing and manipulating Systems Biology Graphical Notation (SBGN) maps stored using the recently developed SBGN-ML file format. The library (available in C++ and Java) makes it easy for developers to add SBGN support to their tools, whereas the file format facilitates the exchange of maps between compatible software applications. The library also supports validation of maps, which simplifies the task of ensuring compliance with the detailed SBGN specifications. With this effort we hope to increase the adoption of SBGN in bioinformatics tools, ultimately enabling more researchers to visualize biological knowledge in a precise and unambiguous manner. AVAILABILITY AND IMPLEMENTATION: Milestone 2 was released in December 2011. Source code, example files and binaries are freely available under the terms of either the LGPL v2.1+ or Apache v2.0 open source licenses from http://libsbgn.sourceforge.net. CONTACT: sbgn-libsbgn@lists.sourceforge.net.