Exploring online reproductive health promotion in Canada: a focus on behavioral and environmental influences from a sex and gender perspective.

BACKGROUND: Reproductive health promotion can enable early mitigation of behavioral and environmental risk factors associated with adverse pregnancy outcomes, while optimizing health of women + (all genders that can gestate a fetus) and babies. Although the biological and social influences of partners on pregnancy are well established, it is unknown whether online Canadian government reproductive health promotion also targets men and partners throughout the reproductive lifespan. METHODS: Reproductive health promotion, designed for the general public, was assessed in a multi-jurisdictional sample of Canadian government (federal, provincial/territorial, and municipal) and select non-governmental organization (NGO) websites. For each website, information related to environmental and behavioral influences on reproductive health (preconception, pregnancy, postpartum) was evaluated based on comprehensiveness, audience-specificity, and scientific quality. RESULTS: Government and NGO websites provided sparse reproductive health promotion for partners which was generally limited to preconception behavior topics with little coverage of environmental hazard topics. For women + , environmental and behavioral influences on reproductive health were well promoted for pregnancy, with content gaps for preconception and postpartum stages. CONCLUSION: Although it is well established that partners influence pregnancy outcomes and fetal/infant health, Canadian government website promotion of partner-specific environmental and behavioral risks was limited. Most websites across jurisdictions promoted behavioral influences on pregnancy, however gaps were apparent in the provision of health information related to environmental hazards. As all reproductive stages, including preconception and postpartum, may be susceptible to environmental and behavioral influences, online health promotion should use a sex- and gender-lens to address biological contributions to embryo, fetal and infant development, as well as contributions of partners to the physical and social environments of the home.

Mobilizing community-driven health promotion through community granting programs: a rapid systematic review.

BACKGROUND: Effective health promotion responds to the unique needs of communities. Community granting programs that fund community-driven health promotion initiatives are a potential mechanism to meet those unique needs. While numerous community health-focused programs are available, the various strategies used by granting programs to foster engagement, administer grants and support awardees have not been systematically evaluated. This rapid systematic review explores the administration of community granting programs and how various program components impact process and population health outcomes. METHODS: A systematic search was conducted across three databases: Medline, SocINDEX, and Political Science Database. Single reviewers completed screening, consistent with a rapid review protocol. Studies describing or evaluating community granting programs for health or public health initiatives were included. Data regarding program characteristics were extracted and studies were evaluated for quality. A convergent integrated approach was used to analyze quantitative and qualitative findings. RESULTS: Thirty-five community granting programs, described in 36 studies, were included. Most were descriptive reports or qualitative studies conducted in the USA. Program support for grant awardees included technical assistance, workshops and training, program websites, and networking facilitation. While most programs reported on process outcomes, few reported on community or health outcomes; such outcomes were positive when reported. Programs reported that many funded projects were likely sustainable beyond program funding, due to the development of awardee skills, new partnerships, and securing additional funding. From the perspectives of program staff and awardees, facilitators included the technical assistance and workshops provided by the programs, networking amongst awardees, and the involvement of community members. Barriers included short timelines to develop proposals and allocate funds. CONCLUSIONS: This review provides a comprehensive overview of health-related community granting programs. Grant awardees benefit from technical assistance, workshops, and networking with other awardees. Project sustainability is enhanced by the development of new community partnerships and grant-writing training for awardees. Community granting programs can be a valuable strategy to drive community health, with several key elements that enhance community mobilization. REGISTRATION: PROSPERO #CRD42023399364.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation.

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

The effects of α-lactalbumin supplementation and handgrip contraction on soleus motoneuron excitability.

INTRODUCTION: We tested two strategies that hypothetically increase serotonin availability (α-lactalbumin consumption and a remote submaximal handgrip contraction) on estimates of persistent inward currents (PICs) amplitude of soleus muscle in healthy participants. METHODS: With a randomised, double-blind, and cross-over design, 13 healthy participants performed triangular-shaped ramp contractions with their plantar flexors (20% of maximal torque), followed by a 30-s handgrip sustained contraction (40% of maximal force) and consecutive repeated triangular-shaped contractions. This was performed before and after the consumption of either 40 g of α-lactalbumin, an isonitrogenous beverage (Zein) or an isocaloric beverage (Corn-starch). Soleus motor units discharge rates were analysed from high-density surface electromyography signals. PICs were estimated by calculating the delta frequency (ΔF) of motor unit train spikes using the paired motor unit technique. RESULTS: ΔF (0.19 pps; p = 0.001; d = 0.30) and peak discharge rate (0.20 pps; p < 0.001; d = 0.37) increased after the handgrip contraction, irrespective of the consumed supplement. No effects of α-lactalbumin were observed. CONCLUSIONS: Our results indicate that 40 g of α-lactalbumin was unable to modify intrinsic motoneuron excitability. However, performing a submaximal handgrip contraction before the plantar flexion triangular contraction was capable of increasing ΔF and discharge rates on soleus motor units. These findings highlight the diffused effects of serotonergic input, its effects on motoneuron discharge behaviour, and suggest a cross-effector effect within human motoneurons.

Effects of α-lactalbumin on strength, fatigue and psychological parameters: a randomised double-blind cross-over study.

PURPOSE: The neurotransmitter serotonin has a strong effect on behaviour and motor control. Regarding motor control, serotonin contributes to the development of fatigue and is also involved in the ability of motor neurones to operate across a large range of forces (gain control). The consumption of tryptophan-rich supplements (such as α-lactalbumin) is of interest because this amino acid is the only precursor for brain serotonin synthesis. Therefore, the purpose of this study was to determine the effects of α-lactalbumin supplementation on neuromuscular performance. METHODS: Using a randomised double-blind cross-over design, 16 healthy participants performed plantar flexor and handgrip maximal voluntary contractions, a 30-s submaximal handgrip contraction, and a plantar flexor fatigue protocol before and 90 min after consuming either 40 g of α-lactalbumin, an isonitrogenous beverage (Zein) or an isocaloric beverage (corn-starch). Sleepiness, mood, and cognition were assessed to evaluate any psychological effects. RESULTS: α-Lactalbumin decreased force steadiness by 25% during the sustained submaximal handgrip contraction (p < 0.01) and induced greater fatigue (15% reduction in total torque-time integral, p = 0.01) during the fatigue protocol. These effects were not observed for the other control beverages. No effects were found for maximal or explosive strength, or psychological measurements. CONCLUSIONS: 40 g of α-lactalbumin increased handgrip force variability and reduced performance during fatiguing muscle contractions but did not influence brief maximal contractions or psychological parameters in healthy individuals. These findings support the hypothesis that the consumption of α-lactalbumin can increase motor neurone input-output gain and exacerbate central fatigue during sustained maximal exercise.

The pandemic experiences of Ontario perinatal providers: a qualitative study.

BACKGROUND: The COVID-19 pandemic has produced widespread disruptions for healthcare systems across Canada. Perinatal care in Ontario, Canada was subject to province-wide public health restrictions, reallocation of hospital beds and human health resources. To better understand the impacts of the pandemic on Ontario perinatal care, this study explored the perspectives of perinatal care providers about their clinical COVID-19 pandemic experiences. METHODS: Semi-structured key informant virtual interviews were conducted between August 2021 and January 2022 with 15 Ontario-based perinatal care providers. Recorded interviews were transcribed, and thematic content analysis used to identify major themes and subthemes. RESULTS: Participants were mainly women, practicing in Eastern and Central Ontario as health providers (obstetricians, nurses, midwives), allied regulated health professionals (social worker, massage therapist), and perinatal support workers (doula, lactation consultant). Major themes and subthemes were identified inductively as follows: (1) Impacts of COVID-19 on providers (psychosocial stress, healthcare system barriers, healthcare system opportunities); (2) Perceived impacts of COVID-19 on pregnant people (psychosocial stress, amplification of existing healthcare barriers, influences on reproductive decision making; minor theme- social and emotional support roles); (3) Vaccine discourse (provider empathy, vaccines and patient family dynamics, minor themes- patient vaccine hesitancy, COVID-19 misinformation); and (4) Virtual pregnancy care (benefits, disadvantages, adaptation of standard care practices). CONCLUSIONS: Perinatal care providers reported significant stress and uncertainty caused by the COVID-19 pandemic and evolving hospital protocols. Providers perceived that their patients were distressed by both the pandemic and related reductions in pregnancy healthcare services including hospital limits to support companion(s). Although virtual pregnancy care impaired patient-provider rapport, most providers believed that the workflow efficiencies and patient convenience of virtual care is beneficial to perinatal healthcare.

Comparison of anticoagulation with left atrial appendage closure after atrial fibrillation ablation: Rationale and design of the OPTION randomized trial.

BACKGROUND: For patients with symptomatic atrial fibrillation (AF), physicians typically offer AF ablation for symptom relief; however, patients often anticipate/expect a life free from anticoagulation. This belief puts patients at increased risk of stroke due to the potential for asymptomatic AF postablation if anticoagulation is ceased contrary to clinical guidelines. Although the WATCHMAN device has been FDA-approved to decrease the risk of thromboembolism from the left atrial appendage (LAA) in patients with an appropriate rationale to avoid oral anticoagulation, it has not been well-studied following AF ablation. Additionally, there are limited data comparing the WATCHMAN device to direct oral anticoagulants. The OPTION study will investigate whether LAA closure with the WATCHMAN FLX device is a reasonable alternative to oral anticoagulation following percutaneous catheter ablation for nonvalvular AF. TRIAL DESIGN: OPTION is a multinational, multicenter, prospective randomized clinical trial. Patients with a CHA2DS2-VASc of ≥2 in men or ≥3 in women and who underwent a AF catheter ablation procedure between 90 and 180 days prior to randomization (sequential) or are planning to have catheter ablation within 10 days of randomization (concomitant) will be randomized in a 1:1 allocation of WATCHMAN FLX vs control. Control patients will start or continue market-approved oral anticoagulation for the duration of the trial. A total of 1600 patients were randomized from 130 global investigational sites. Follow-up for both device and control patients will occur at 3, 12, 24, and 36 months. The primary effectiveness noninferiority endpoint is stroke (ischemic or hemorrhagic), all-cause death, or systemic embolism at 36 months. The primary safety superiority endpoint is nonprocedural bleeding through 36 months (International Society on Thrombosis and Haemostasis [ISTH] major bleeding or clinically relevant nonmajor bleeding). The secondary noninferiority endpoint is ISTH major bleeding through 36 months (including procedural bleeding). CONCLUSIONS: This trial will assess the safety and efficacy of WATCHMAN FLX in a postablation contemporary clinical AF patient population at risk of stroke.

Sexual behaviors at home and abroad: an online survey of Canadian young adult travelers.

BACKGROUND: For young adults, travel- an accessible and aspirational experience- may be accompanied by high-risk lifestyle behaviors abroad, which in turn, increases the risk of sexually transmitted and blood-borne infections (STBBI). This study aimed to examine sexual and risk behaviors of young Canadian adults both at-home and during international travel. METHODS: Sexually-active Canadians, aged 18-25 years (N = 646) who travelled abroad in 2016, completed an online, cross-sectional survey analyzed by descriptive statistics. Outcome measures included young Canadian adults' lifestyle risk and sexual behaviors at-home and abroad. RESULTS: Sexual behaviors, both penetrative and non-penetrative activities, decreased significantly (p < 0.001; McNemar test) abroad compared to at-home. International travel elicited a statistically significant increase in alcohol consumption compared to at-home (Wilcoxon, z = - 11.341, p < 0.001). Partner type (new trip-acquired partner) abroad was associated with a greater number of travel-acquired sexual partners (Mann-Whitney, U = 4901, p < 0.001), inconsistent condom use during penetrative sex (U = 7215, p = 0.009), and sex under the influence of alcohol (Test of Two Proportions, p < 0.001). CONCLUSIONS: Although many young Canadian respondents practiced abstinence in their 2016 travel, for sexually-active travelers, new partner-type was related to high risk sexual behaviors. Young Canadians exhibited sexual risk behaviors both at-home and while travelling; suggesting the need for both domestic and pre-travel sexual health interventions.

Public health perinatal promotion during COVID-19 pandemic: a social media analysis.

BACKGROUND: Canadian public health agencies, both municipal/regional and provincial/territorial, are responsible for promoting population health during pregnancy and the early postnatal period. This study examines how these agencies use web-based and Facebook channels to communicate perinatal health promotion during the emergence of the COVID-19 pandemic. METHODS: Perinatal health promotion content of websites and Facebook posts from a multijurisdictional and geographically diverse sample of government and non-governmental organizations (NGO) were evaluated using thematic content analysis in 2020. RESULTS: Major Facebook perinatal health promotion themes included breastfeeding, infant care, labor/delivery, parenting support and healthy pregnancy. Facebook COVID-19-themed perinatal health promotion peaked in the second quarter of 2020. Websites emphasized COVID-19 transmission routes, disease severity and need for infection control during pregnancy/infant care, whereas Facebook posts focussed on changes to local health services including visitor restrictions. NGO perinatal health promotion reflected organizations' individual mandates. CONCLUSIONS: Canadian government use of Facebook to disseminate perinatal health promotion during the COVID-19 pandemic varied in terms of breadth of topics and frequency of posts. There were missed opportunities to nuance transmission/severity risks during pregnancy, thereby proactively countering the spread of misinformation.

Key informant perspectives on sexual health services for travelling young adults: a qualitative study.

BACKGROUND: International travel has become increasingly popular among young adults. Young adults often engage in casual sexual relationships abroad, exhibit sexual risk behaviours and may thus be at risk of contracting sexually transmitted and blood-borne infections. Pre-travel interventions and consultations may mitigate this risk. At present, we know little about sexual health-related pre-travel interventions. The aim of this study was therefore to document key informants' experiences, perceptions and recommendations in the context of sexual health of young adult travellers. METHODS: Key informants were professionals working in Ottawa, Canada travel clinics, travel organizations or sexual health clinics with a young adult clientele. This study used a qualitative approach and consisted of 13 in-person or Skype semi-structured interviews with key informants. Thematic content analysis was informed by a sexual health framework, with themes emerging both inductively and deductively. RESULTS: Sexual health was not common in pre-travel interventions described by key informants. Risk-assessment, and practical or purpose-driven pre-travel interventions were identified, resulting in risk mitigation strategies tailored to the destination region and/or mission/culture of the travel organization. Dissemination (e.g. limited time, lack of training) and uptake (e.g. young adults' embarrassment, provider discomfort, financial constraints) barriers limited in-depth discussions of pre-travel interventions related to sexual health. Key informants acknowledged the importance of early sexual health education, and recommended ongoing, comprehensive sexual education for both youth and young adults. CONCLUSION: The findings of this study suggest that more time and resources should be allocated to the topic of sexual health during pre-travel interventions with young adults. Professionals who guide and prepare young adults for travel must develop concomitant skills in sexual health promotion. Early, comprehensive sexual education is recommended to improve overall sexual health in young adults and mitigate risk behaviours during travel.

Communication skills training and assessment of food animal production medicine veterinarians: A component of a voluntary Johne's disease control program.

In food animal production medicine (FAPM), the success of control programs for infectious diseases that have serious animal health and economic consequences frequently rely on the veterinarian's effective communication and producer adherence to veterinary recommendations. However, little research has been conducted on communication skills of practicing FAPM veterinarians. During this study, we developed a communication training workshop intervention to support the Atlantic Johne's Disease Initiative. Seventeen FAPM veterinarians across 10 clinics practicing within Maritime Canada participated in a pre-post intervention study design. Communication skills were evaluated utilizing 3 assessment tools; an objective structured clinical exam (OSCE), standardized client feedback, and an instrument designed for veterinary participants to assess their self-efficacy. Study results showed that before training, communication skills of participating veterinarians had limitations, including skill deficits in communication tasks strongly associated with increased adherence to veterinary recommendations. Based on the 3 assessment tools, communication skills of participating veterinarians improved with the training provided. Significant increases were detected in pre- to postintervention self-efficacy percentage scores, OSCE percentage and global scores from expert raters, and OSCE percentage and global scores from standardized client feedback. These improvements emphasize the importance of communication skills training specific to FAPM.

Dairy producer satisfaction and knowledge transfer with the veterinary-administered risk assessment and management plan in a voluntary Johne's disease control program.

The Atlantic Johne's Disease Initiative (AJDI) aims to control Mycobacterium avium ssp. paratuberculosis infection by using veterinary-administered risk assessments to identify high-risk management practices and prompt changes in management behavior. Objectives for this study were to measure producer satisfaction with the veterinary-administered risk assessment and management plan (RAMP) process in a voluntary Johne's disease (JD) control program, compare RAMP-specific satisfaction results based on herd JD status, and measure knowledge transfer from certified veterinarians to producers during the RAMP. A satisfaction questionnaire was adapted to the RAMP process in the AJDI to measure producer satisfaction. The questionnaire included 9 RAMP-specific producer satisfaction items, 1 global RAMP satisfaction item, and 16 questions to assess producer knowledge and knowledge translation about JD, bovine viral diarrhea (BVD), and bovine leukosis virus (BLV) during the RAMP (BVD and BLV used for comparison purposes). A total of 133 dairy producers in the AJDI (79.6% response rate) completed the questionnaire by telephone. The RAMP-specific satisfaction was high among the AJDI producers surveyed, and these results were not found to differ based on herd JD status. The lowest satisfaction scores and the highest number of "unable to assess" responses were for the item relating to cost. Factors that contributed to RAMP-specific producer satisfaction were not identified from the demographic and herd information available in this study. The knowledge scores indicated moderate knowledge about JD and fair knowledge about BVD and BLV. Evidence of knowledge translation from the RAMP was mixed in this study. Bovine viral diarrhea knowledge scores were not found to differ based on whether or not the certified veterinarian discussed BVD during the preceding RAMP, but BLV knowledge scores were higher among dairy producers that discussed BLV during the preceding RAMP. Strengths and gaps in producer knowledge about these 3 infectious diseases were identified. By using this producer questionnaire, interventions aimed at improving the content, delivery, and satisfaction of RAMP in JD control programs, such as the AJDI, can be developed.

Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk.

BACKGROUND: Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF. METHODS: A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk. RESULTS: In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk. CONCLUSIONS: In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.

Impact of anticoagulation strategy after left atrial appendage occlusion in patients requiring direct current cardioversion.

INTRODUCTION: Current guidelines recommend adequate anticoagulation for at least 3 weeks pre- and 4 weeks post-direct current cardioversion (DCCV) to reduce thrombo-embolic risk in patients with atrial fibrillation (AF) lasting greater than 48 h. No specific recommendations exist for DCCV in patients that have undergone left atrial appendage occlusion (LAAO), many of whom are ineligible for anticoagulation. This study aims to observe the efficacy and safety of DCCV post-LAAO in everyday clinical practice. METHODS: This prospective multicenter registry included DCCVs in patients post-LAAO. Imaging strategy or anticoagulation treatment around DCCV were analyzed. Complications during 30-day follow-up were registered. DCCVs performed in accordance with current guidelines for the general AF population were compared to DCCVs performed deviating from these guidelines. RESULTS: In 93 patients (age 65 ± 17 years, CHA2 DS2 -VASC 3.0 ± 1.3) 284 DCCVs were performed between 2010 and 2018, in 271 sinus rhythm was restored. A wide variety of imaging or anticoagulation strategies around DCCV was observed; in 128 episodes strategies deviated from current guidelines. No thrombo-embolic events were observed after any DCCV during 30-day follow-up. In 34 DCCVs trans-esophageal echocardiography (TOE) was performed before DCCV to exclude cardiac thrombi and/or (re-)verify adequate device positioning. In two patients without post-LAAO imaging before DCCV, a device rotation or embolization was observed during scheduled TOE after LAAO. CONCLUSION: DCCV in AF patients after LAAO is highly effective. No thrombo-embolic events were observed in any patient in this observational cohort, regardless of the periprocedural anticoagulation or imaging strategy. Confirmation of adequate device positioning at least once before DCCV seems recommendable.

Maternal perceptions and concerns about children's weight status and diet quality: a study among Black immigrant families.

OBJECTIVE: To identify factors influencing Black immigrant mothers' perceptions and concerns about child weight and to compare children's diet quality according to these perceptions and concerns. DESIGN: Mothers' perceptions and concerns about child weight were assessed with sex-specific figure rating scales and the Child Feeding Questionnaire, respectively. Participants' weights and heights were measured and characterised using WHO references. Children's dietary intakes were estimated using a 24-h dietary recall. Children's diet quality was evaluated using the relative proportion of their energy intake provided by ultra-processed products, which were identified with the NOVA classification. χ2 tests, multivariate logistic regressions and t tests were performed. SETTING: Ottawa, Ontario, Canada. PARTICIPANTS: Black immigrant mothers of Sub-Saharan African and Caribbean origin (n 186) and their 6-12-year-old children. RESULTS: Among mothers, 32·4 % perceived their child as having overweight while 48·4 % expressed concerns about child weight. Girls and children with overweight or obesity were significantly more likely to be perceived as having overweight by their mothers than boys and normal-weight children, respectively. Mothers of children living with obesity, but not overweight, were significantly more likely to be concerned about their child's weight than mothers of normal-weight children. Children's diet quality did not differ according to mothers' perceptions and concerns. CONCLUSIONS: Children's gender and weight status were major determinants of perceptions and concerns about child weight among Black immigrant mothers. Including knowledge about mothers' perceptions and concerns about child weight will help nutrition professionals develop interventions tailored to specific family needs within the context of their cultural backgrounds.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy.

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO2 of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10-12 cm H2O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

Combining left atrial appendage closure and catheter ablation for atrial fibrillation: 2-year outcomes from a multinational registry.

AIMS: Clinical practice guidelines do not recommend discontinuation of long-term oral anticoagulation in patients with a high stroke risk after catheter ablation for atrial fibrillation (AF). Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the long-term outcomes of combining catheter ablation procedures for AF and LAAC from multicentre registries. METHODS AND RESULTS: Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 142 subjects at 11 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful LAAC was achieved in 99.3% of patients. The 30-day device and/or procedure-related serious adverse event rate was 2.1%. After a mean follow-up time of 726 ± 91 days, 92% of patients remained off oral anticoagulation. The rates of the composite endpoint of ischaemic stroke/transient ischaemic attack/systemic thromboembolism were 1.09 per 100 patient-years (100-PY); and for non-procedural major bleeding were 1.09 per 100-PY. These represent relative reductions of 84% and 70% vs. expected rates per risk scores. CONCLUSION: The long-term outcomes from these international, multicentre registries show efficacy for all-cause stroke prevention and a significant reduction in late bleeding events in a population of high stroke risk post-ablation patients who have been withdrawn from oral anticoagulation.

Best Practices for the Design, Implementation and Evaluation of Prenatal Health Programs.

Introduction Prenatal health programs provide health education, reproductive care and related services to women. Programs may be administered individually or collaboratively by agencies including public health units, hospitals, health clinics, community and non-governmental organizations. Prenatal health disparities among populations at-risk may be reduced through the provision of accessible health education, services and resources to help women mitigate modifiable risks to pregnancy. Although standardized guidelines inform clinical screening, testing and maternity care, gaps exist regarding the design, implementation and evaluation for comprehensive prenatal health programs. Methods Using a multijurisdictional approach, prenatal health guidance documents released by clinical associations and regional governments across Canada, Australia, the United States, the United Kingdom and Ireland were systematically evaluated to identify standards and practices regarding the design, implementation and evaluation of prenatal health programs. Results Evidence-based, surveillance/monitoring, and expert/stakeholder collaborations were principles affirmed by guidance documents across all jurisdictions. Each jurisdiction described tailored strategies to optimize prenatal health in their respective communities. Divergence between jurisdictions was noted for patient care models and promotion of providers and companions of choice. Discussion A best practices model is proposed describing recommendations as follows: prenatal health programs should be grounded in a theoretical approach, fundamentally woman-centered and designed to address interacting prenatal health determinants across the lifespan. Accessible and inclusive prenatal health care can be achieved through provider training and community stakeholder collaborations. Identification of best practices for prenatal health program design, implementation and evaluation ensures that service standards are harmonized across communities, thereby optimizing maternal and child health.

Public Awareness of Low-Risk Alcohol Use Guidelines.

Objective. To evaluate the effectiveness of a population-based, public education campaign designed to increase awareness of the Canadian Low-Risk Alcohol Drinking Guidelines (LRDG). Method. A province-wide mass media campaign was introduced. To measure campaign effectiveness, we completed a cross-sectional study using pre- and postcampaign surveys. Measurements included awareness of the LRDG, specific knowledge of the LRDG, and beliefs toward drinking and behavior change. Results. Postsurvey respondents were more likely to be aware of the LRDG (19.2% vs. 25.8%). However, increased awareness was largely driven by females being significantly more aware of the guidelines after the campaign (odds ratio = 1.74; 95% confidence interval = [1.38, 2.19]). Men were not found to be more aware postcampaign. The results did not show a significant increase in specific knowledge of the LRDG or change in beliefs toward drinking and behavior change after the campaign. Independent of the survey cycle, males and those aged 19 to 25 years were less likely to be aware of the LRDG, select the correct drink limit or less, and believe that consuming alcohol in excess has short- and long-term health consequences when compared to females and those aged 56 to 70 years. Conclusions. A provincial public health education campaign was effective at increasing awareness of the LRDG, though uptake was lowest among those at highest risk for heavy drinking.

The effect of limited English proficiency and interpreter service use on clinical outcomes in psychiatric inpatient units.

OBJECTIVE: The effects of limited English and interpreter use on clinical outcomes in mental health are poorly understood. This paper describes an exploratory study examining those effects across three adult inpatient psychiatric units, predicting it would lead to increased length of stay. METHODS: Forty-seven patients with limited English proficiency (LEP) were retrospectively identified and compared with 47 patients with proficient English. Length of stay, number of consultant reviews and discharge diagnosis were recorded and compared. RESULTS: An increased length of stay for those with LEP was not statistically significant (p=0.155). The LEP group did undergo more consultant reviews (p=0.036), however, and attracted different discharge diagnoses, with no primary discharge diagnoses of personality disorder made (p=0.018). CONCLUSIONS: This study provides evidence of significant effects of limited English on both service burden and outcome.