Impact of the Hunga Tonga volcanic eruption on stratospheric composition.

The explosive eruption of the Hunga Tonga-Hunga Ha'apai (HTHH) volcano on 15 January 2022 injected more water vapor into the stratosphere and to higher altitudes than ever observed in the satellite era. Here, the evolution of the stratospherically injected water vapor is examined as a function of latitude, altitude, and time in the year following the eruption (February to December 2022), and perturbations to stratospheric chemical composition resulting from the increased sulfate aerosols and water vapor are identified and analyzed. The average calculated mass distribution of elevated water vapor between hemispheres is approximately 78% Southern Hemisphere (SH) and 22% Northern Hemisphere in 2022. Significant changes in stratospheric composition following the HTHH eruption are identified using observations from the Aura Microwave Limb Sounder satellite instrument. The dominant features in the monthly mean vertical profiles averaged over 15° latitude ranges are decreases in O3 (-14%) and HCl (-22%) at SH midlatitudes and increases in ClO (>100%) and HNO3 (43%) in the tropics, with peak pressure-level perturbations listed. Anomalies in column ozone from 1.2-100 hPa due to the HTHH eruption include widespread O3 reductions in SH midlatitudes and O3 increases in the tropics, with peak anomalies in 15° latitude-binned, monthly averages of approximately -7% and +5%, respectively, occurring in austral spring. Using a 3-dimensional chemistry-climate-aerosol model and observational tracer correlations, changes in stratospheric composition are found to be due to both dynamical and chemical factors.

Fully synthetic platform to rapidly generate tetravalent bispecific nanobody-based immunoglobulins.

Nanobodies bind a target antigen with a kinetic profile similar to a conventional antibody, but exist as a single heavy chain domain that can be readily multimerized to engage antigen via multiple interactions. Presently, most nanobodies are produced by immunizing camelids; however, platforms for animal-free production are growing in popularity. Here, we describe the development of a fully synthetic nanobody library based on an engineered human VH3-23 variable gene and a multispecific antibody-like format designed for biparatopic target engagement. To validate our library, we selected nanobodies against the SARS-CoV-2 receptor-binding domain and employed an on-yeast epitope binning strategy to rapidly map the specificities of the selected nanobodies. We then generated antibody-like molecules by replacing the VH and VL domains of a conventional antibody with two different nanobodies, designed as a molecular clamp to engage the receptor-binding domain biparatopically. The resulting bispecific tetra-nanobody immunoglobulins neutralized diverse SARS-CoV-2 variants with potencies similar to antibodies isolated from convalescent donors. Subsequent biochemical analyses confirmed the accuracy of the on-yeast epitope binning and structures of both individual nanobodies, and a tetra-nanobody immunoglobulin revealed that the intended mode of interaction had been achieved. This overall workflow is applicable to nearly any protein target and provides a blueprint for a modular workflow for the development of multispecific molecules.

Nipah virus-associated neuropathology in African green monkeys during acute disease and convalescence.

BACKGROUND: Nipah virus is an emerging zoonotic virus that causes severe respiratory disease and meningoencephalitis. The pathophysiology of Nipah virus meningoencephalitis is poorly understood. METHODS: We have collected the brains of African green monkeys during multiple Nipah virus, Bangladesh studies, resulting in 14 brains with Nipah virus-associated lesions. RESULTS: The lesions seen in the brain of African green monkeys infected with Nipah virus, Bangladesh were very similar to those observed in humans with Nipah virus, Malaysia infection. We observed viral RNA and antigen within neurons and endothelial cells, within encephalitis foci and in uninflamed portions of the CNS. CD8+ T cells had a consistently high prevalence in CNS lesions. We developed a UNet model for quantifying and visualizing inflammation in the brain in a high-throughput and unbiased manner. While CD8+ T cells had a consistently high prevalence in CNS lesions, the model revealed that CD68+ cells were numerically the immune cell with the highest prevalence in the CNS of NiV-infected animals. CONCLUSION: Our study provides an in-depth analysis on Nipah virus infection in the brains of primates, and similarities between lesions in patients and the animals in our study validate this model.

Reconstructing curcumin biosynthesis in yeast reveals the implication of caffeoyl-shikimate esterase in phenylpropanoid metabolic flux.

Curcumin is a polyphenolic natural product from the roots of turmeric (Curcuma longa). It has been a popular coloring and flavoring agent in food industries with known health benefits. The conventional phenylpropanoid pathway is known to proceed from phenylalanine via p-coumaroyl-CoA intermediate. Although hydroxycinnamoyl-CoA: shikimate hydroxycinnamoyl transferase (HCT) plays a key catalysis in the biosynthesis of phenylpropanoid products at the downstream of p-coumaric acid, a recent discovery of caffeoyl-shikimate esterase (CSE) showed that an alternative pathway exists. Here, the biosynthetic efficiency of the conventional and the alternative pathway in producing feruloyl-CoA was examined using curcumin production in yeast. A novel modular multiplex genome-edit (MMG)-CRISPR platform was developed to facilitate rapid integrations of up to eight genes into the yeast genome in two steps. Using this MMG-CRISPR platform and metabolic engineering strategies, the alternative CSE phenylpropanoid pathway consistently showed higher titers (2-19 folds) of curcumin production than the conventional pathway in engineered yeast strains. In shake flask cultures using a synthetic minimal medium without phenylalanine, the curcumin production titer reached up to 1.5 mg/L, which is three orders of magnitude (∼4800-fold) improvement over non-engineered base strain. This is the first demonstration of de novo curcumin biosynthesis in yeast. Our work shows the critical role of CSE in improving the metabolic flux in yeast towards the phenylpropanoid biosynthetic pathway. In addition, we showcased the convenience and reliability of modular multiplex CRISPR/Cas9 genome editing in constructing complex synthetic pathways in yeast.

Update on ischemic hepatitis.

PURPOSE OF REVIEW: Ischemic hepatitis (IH) refers to diffuse liver injury secondary to hypoperfusion. The condition is usually seen in the critical care setting and is associated with significant mortality. IH typically occurs in the setting of systemic hypotension superimposed on some form of underlying cardiac dysfunction. This review aims to report what is known and what is new about the etiology, pathophysiology, and clinical features associated with IH. RECENT FINDINGS: In recent years, studies on IH have largely confirmed earlier reports regarding etiologies, comorbid conditions, and associated mortality. Recent study has also shed light on the potential treatment of IH with N -acetyl-cysteine (NAC). SUMMARY: IH is typically associated with underlying cardiac disease, and patients with IH have a very high mortality rate. Treatment remains largely supportive, although the utility of agents such as NAC are being explored.

Interests and Barriers to Medical Students Participation in a Dedicated Global Surgery Curriculum.

INTRODUCTION: Despite many institutions establishing global surgery (GS) programs to support clinical care and education in resource-limited settings, few have established a specific curriculum in GS. This study's objective was to assess medical student interest in such a curriculum and prospects for future careers in GS/global health (GH), and to define the barriers to pursuing an international rotation. METHODS: We conducted an anonymous online survey of all 495 medical students at a major academic medical center in the mid-South that collected demographic data, country of origin, interest in a GS/GH elective, and barriers to pursuing a GS/GH rotation abroad. The data were analyzed using SPSS software. RESULTS: Prior international experience increased the likelihood of a student's involvement in GS/GH and more preclinical (years 1 & 2) students (90%) than clinical students. (years 3 & 4) (70%) felt strongly about the value of a GS/GH experience. Of the 163 students who completed the survey, 80% expressed interest in a GS/GH elective, with preclinical students expressing more interest (90%) than clinical students (71%). This interest strongly correlated with an interest in pursuing a career in GH (94%) and/or GS (100%). Identified barriers to engagement in a GS/GH experience abroad included financing (74%), scheduling (58%), family obligations (23%), and personal safety (19%). CONCLUSIONS: The students we surveyed were very interested in a GS/GH curriculum that included a rotation abroad, especially if they were to receive financial support. Preclinical students expressed more willingness to self-fund such experiences. The findings of this survey further strengthen the need to incorporate GS/GH in medical school curricula.

Mast cell distribution and prevalence in the murine urinary bladder.

BACKGROUND: Mast cells have been implicated in the pathology of various urinary bladder disorders. However, the distribution of mast cells throughout urinary bladder tissue remains uncertain despite mast cell prevalence being relatively well-defined. Using a mouse tissue model, this study aims to characterise the prevalence and distribution of mast cells throughout the urinary bladder. METHODS: Bladder tissues were collected from six C57BL/6J female mice. Mast cell prevalence was quantified by flow cytometry, based on the expression of the following characteristic markers: CD45, CD117 and FcɛRIα. The toluidine blue stain assessed mast cell distribution, size, and proximity to vasculature. A repeated measures one-way ANOVA was used to evaluate the density of mast cells between the discrete layers of the urinary bladder, and an ordinary one-way ANOVA was used to assess potential differences between mast cell size across the urinary bladder wall. RESULTS: It was determined that mast cells compose less than 4% of all live leukocytes in the urinary bladder. They were also found to be more prominent in the lamina propria and detrusor muscle layers, compared to the urothelium and adventitia. In addition, 20.89% of mast cells were located near vasculature, which may be an important factor in consideration of their function and potential to contribute to various bladder pathologies, such as cystitis or overactive bladder. CONCLUSION: These findings provide a baseline understanding of mast cell prevalence and distribution throughout the urinary bladder.

Method for the production of a compact source of atomic line spectra in the vacuum ultraviolet.

Atomic emission spectra provide a means to identify and to gain insight into the electronic structure of emitting or absorbing matter. Detailed procedures are provided for the construction of low-pressure electrodeless discharge lamps that yield targeted emission in the vacuum ultraviolet for the spectroscopic study of water vapor and halogen species aboard an array of airborne observation platforms in the upper atmosphere, as well as in laboratory environments. While specific to the production of Lyman-alpha, atomic chlorine, and atomic bromine emissions in this study, the configuration of the lamps and their interchangeability with respect to operation lend these procedures to constructing sources engaging a wide selection of atomic and molecular spectra with straightforward modifications. The features and limitations of each type of lamp are discussed, as well as methods to improve spectral purity and factors affecting operational lifetime.

Associations between hospital organizational features, person-centred care and nurse-sensitive outcomes for persons with dementia in acute care: A systematic literature review.

AIM(S): The aim of this systematic literature review was to determine the extent and quality of quantitative evidence regarding associations between hospital organizational features, person-centred care (PCC) and nursing-sensitive outcomes among persons with dementia in the acute care setting. DESIGN: Systematic review. METHODS: Key terms were utilized to guide searches in four databases. The two reviewers deduplicated articles and came to a consensus for the final sample using inclusion and exclusion criteria. DATA SOURCES: MEDLINE/OVID, CINHAL, COCHRANE and WEB OF SCIENCE. RESULTS: There were 10 studies included. PCC was associated with better outcomes for persons with dementia (i.e. decreased restraint use, decreased length of stay, increased involvement with families and the patient, and increased nurse confidence and competence in caring for this population). Of the studies, none explicitly identified an association between nursing-sensitive outcomes, PCC and hospital organizational features in the acute care setting among persons with dementia. CONCLUSION: This review highlights a clinically significant gap in knowledge regarding associations between hospital organizational features, PCC and nursing sensitive outcomes. The impact of face-to-face dementia competency training as a standard practice among acute care facilities, the importance of leadership engagement, support and involvement to improve nurse confidence and competence in caring for persons with dementia needs to be explored. IMPACT STATEMENT: These findings support future research to understand the relationship between organization features and patient-centred care and how these collectively impact nursing-sensitive outcomes, specifically in persons with dementia in acute care settings.

"They're scared that somebody's gonna judge them": Female African American youth in foster care's perspectives on sexual and reproductive health communication with caregivers.

BACKGROUND: Obtaining accurate information is critical for youth's sexual and reproductive health (SRH). Youth not in foster care often learn about SRH from their biological parents. Separated from their biological parents, youth in care depend on healthcare providers and caregivers for SRH information. However, they often receive insufficient information and feel unsupported in meeting their needs for SRH information. PURPOSE: This study explored female African American adolescents in foster care's perspectives on effective SRH communication with caregivers to help them avoid sexual risks. METHODS: A qualitative study was conducted using semi-structured interviews. We used purposive sampling to recruit 16 adolescents aged 18 to 20 years old with a history of foster care placement. The transcribed interviews underwent inductive thematic analysis. The Positive Youth Development theory underpinned this research. RESULTS: Two prominent themes emerged: establishing a relationship and preferred communication approach. Youth reported that for caregivers to engage in effective SRH communication, they must first establish a relationship by being aware of the youth's childhood trauma, building trust, having patience, and being vulnerable. Youth also appreciated caregivers who ensured comfortability and were honest and straightforward. DISCUSSION: Caregivers should be trained on adverse childhood experiences, trauma-informed approaches, SRH knowledge, and communication. IMPLICATIONS TO PRACTICE: Healthcare providers should make use of the time spent with youth and discuss SRH topics during clinical encounters. This time spent with youth may be their only chance to obtain accurate SRH information. Youth's perspectives regarding communication about SRH should be implemented in future SRH communication interventions.

Nurses' moral distress and leadership communication in hospitals serving Black patients during COVID-19.

BACKGROUND: Poorer leadership communication during COVID-19 may have contributed to the moral distress of nurses in hospitals where Black patients predominantly access their care (BSH). PURPOSE: To compare nurse moral distress and leadership communication during the COVID-19 pandemic in hospitals that serve disproportionately many or few patients of Black race. METHODS: In a national hospital sample (n = 90), nurse survey data were collected (March 2021). Nurse moral distress was analyzed in linear regression models. The key covariates were BSH category (Medicare Black patient percentage) and leadership communication. DISCUSSION: Nurses in high-BSH had significantly greater moral distress and more difficulty accessing personal protective equipment than nurses in low-BSH. The percentage of nurses in high-BSHs with high moral distress was double that of nurses in low-BSHs. Poorer leadership communication in BSHs accounted for the nurses' greater moral distress. CONCLUSION: Policies should improve leadership communication, mitigate distress, and support nurses in under-resourced settings.

Decreasing Multiple Sclerosis Treatment Expenditures and Improving Quality at the Health System Level.

OBJECTIVE: This study was undertaken to evaluate a multicomponent health system intervention designed to reduce escalating disease-modifying treatment (DMT) expenditures and improve multiple sclerosis (MS) outcomes by increasing use of preferred formulary and highly effective DMTs (HETs). METHODS: We conducted a trend study of treatment utilization and expenditure outcomes prior to (2009-2011) and during (2012-2018) MS Treatment Optimization Program (MSTOP) implementation in Kaiser Permanente Southern California (KPSC) compared to a Kaiser Permanente region of similar size. Annual relapse rates (ARRs) were obtained from KPSC's electronic health records. RESULTS: Adherence to preferred formulary DMTs increased from 25.4% in 2011 to 72.2% in 2017 following MSTOP implementation in KPSC and 22.1% to 43.8%, respectively, in the comparator. KPSC's annual DMT expenditures in 2018 were less than in 2011 despite an 11.3% increase in DMT-treated members. The decline in average per patient per year of treatment expenditures from a peak of $43.1 K in 2014 to $26.3 K in 2018 in KPSC was greater than the comparator, which peaked at $52.1 K and declined to $40.0 K in 2018. Over the 7 years following initiation of MSTOP, cumulative MS DMT expenditures were $161.6 million less than the comparator. HET use increased to 62.5% of per patient treatment-years versus 32.4% in the comparator. This corresponded to a 69% decline in adjusted ARR (95% confidence interval = 64.1-73.2%; p < 0.0001) among DMT-treated patients in KPSC. INTERPRETATION: A novel, expert-led health system intervention reduced MS DMT expenditures despite rising prices while simultaneously reducing MS relapse rates. Our focus on health system progress toward meaningful, measurable targets could serve as a model to improve quality and affordability of MS care in other settings. ANN NEUROL 2022;92:164-172.

Blood-brain barrier penetration of non-replicating SARS-CoV-2 and S1 variants of concern induce neuroinflammation which is accentuated in a mouse model of Alzheimer's disease.

COVID-19 and especially Long COVID are associated with severe CNS symptoms and may place persons at risk to develop long-term cognitive impairments. Here, we show that two non-infective models of SARS-CoV-2 can cross the blood-brain barrier (BBB) and induce neuroinflammation, a major mechanism underpinning CNS and cognitive impairments, even in the absence of productive infection. The viral models cross the BBB by the mechanism of adsorptive transcytosis with the sugar N-acetylglucosamine being key. The delta and omicron variants cross the BB B faster than the other variants of concern, with peripheral tissue uptake rates also differing for the variants. Neuroinflammation induced by icv injection of S1 protein was greatly enhanced in young and especially in aged SAMP8 mice, a model of Alzheimer's disease, whereas sex and obesity had little effect.

Large Community Outbreak of Legionnaires Disease Potentially Associated with a Cooling Tower - Napa County, California, 2022.

Legionnaires disease is a serious infection acquired by inhalation of water droplets from human-made building water systems that contain Legionella bacteria. On July 11 and 12, 2022, Napa County Public Health (NCPH) in California received reports of three positive urinary antigen tests for Legionella pneumophila serogroup 1 in the town of Napa. By July 21, six Legionnaires disease cases had been confirmed among Napa County residents, compared with a baseline of one or two cases per year. NCPH requested assistance from the California Department of Public Health (CDPH) and CDC to aid in the investigations. Close temporal and geospatial clustering permitted a focused environmental sampling strategy of high-risk facilities which, coupled with whole genome sequencing results from samples and investigation of water system maintenance, facilitated potential linking of the outbreak with an environmental source. NCPH, with technical support from CDC and CDPH, instructed and monitored remediation practices for all environmental locations that tested positive for Legionella. The investigation response to this community outbreak illustrates the importance of interdisciplinary collaboration by public health agencies, laboratory support, timely communication with the public, and cooperation of managers of potentially implicated water systems. Timely identification of possible sources, sampling, and remediation of any facility testing positive for Legionella is crucial to interrupting further transmission.

Maternal precarious employment and child overweight/obesity in the United States.

Precarious employment has increased in the United States and is now recognized as an important social determinant of health. Women are disproportionately employed in precarious jobs and are largely responsible for caretaking, which could deleteriously affect child weight. We utilized data from the National Longitudinal Survey of Youth adult and child cohorts (1996-2016; N = 4453) and identified 13 survey indicators to operationalize 7 dimensions of precarious employment (score range: 0-7, 7 indicating the most precarious): material rewards, working-time arrangements, stability, workers' rights, collective organization, interpersonal relations, and training. We estimated the association between maternal precarious employment and incident child overweight/obesity (BMI ≥85th percentile) using adjusted Poisson models. Between 1996 and 2016, the average age-adjusted precarious employment score among mothers was 3.7 (Standard Error [SE] = 0.02) and the average prevalence of children with overweight/obesity was 26.2% (SE = 0.5%). Higher maternal precarious employment was associated with a 10% higher incidence of children having overweight/obesity (Confidence Interval: 1.05, 1.14). A higher incidence of childhood overweight/obesity may have important implications at the population-level, due to the long-term health consequences of child obesity into adulthood. Policies to reduce employment precariousness should be considered and monitored for impacts on childhood obesity.

Labour agentry and subsequent adverse mental health outcomes: A follow-up study of the ARRIVE Trial.

OBJECTIVE: Labour can be traumatic for women who perceive they are not involved in decisions affecting their care during labour. Our objective was to assess the relation between labour agentry and subsequent mental health. DESIGN: Follow-up cohort study. SETTING: U.S. Tertiary care center. POPULATION: Participants from Utah who participated in the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial. METHODS: During the ARRIVE trial, participants completed the Labor Agentry Scale twice, a validated questionnaire measuring perceived control of patients during childbirth. ARRIVE participants from Utah subsequently were asked to complete questions about mental health history and stressful events occurring since the trial, as well as surveys including the Primary Care Posttraumatic Stress Disorder (PC-PTSD) screen, Edinburgh Postnatal Depression Scale (EPDS) and Generalised Anxiety Disorder-7 (GAD-7) screen. The lower quartile of both agentry measurements defined a person's ordinal agentry category, used for assessing cohort characteristics by exposure category. Continuous minimum agentry was included in adjusted modelling. MAIN OUTCOME MEASURES: The primary outcome was a mental health composite including a positive screen for depression, anxiety, or PTSD or self-report of a diagnosis or exacerbation since their delivery. RESULTS: In all, 766 of 1042 (74%) people responded to the survey (median 4.4, range 2.5-6.4 years after delivery) and 753 had complete data for analysis. In unadjusted comparisons across ordinal agentry category, lower agentry was significantly associated with the primary composite endpoint, and depressive symptoms (test of trend p = 0.003 primary, p = 0.004 depression). Lower labour agentry scores were associated with incremental odds of the primary endpoint (1 SD [24 units], adjusted odds ratio [aOR] 1.21, 95% CI 1.41-1.03), driven by depressive symptoms or self-reported diagnosis (aOR 1.25, 95% CI 1.47-1.05). CONCLUSIONS: Lower labour agentry at the time of birth was associated with a greater risk for mental health conditions years after delivery, indicating a potential opportunity for primary prevention of subsequent depression.

The impact of COVID-19 on medium term weight loss and comorbidities in patients undergoing bariatric surgery and its association with psychological wellbeing.

BACKGROUND: The COVID-19 epidemic imposed significant stressors on individuals and changed how medical care is delivered. The affect that this stress has placed on the field of bariatric surgery and the associated outcomes is not well established. METHODS: A retrospective review of a prospectively collected database from a single academic institution was conducted. Weight loss and comorbidity outcomes were compared between a cohort of patients operated on during the pandemic and a matched group operated on prior to COVID-19. GAD-7 and PHQ-9 questionnaires were used to assess for anxiety and depression, respectively. RESULTS: A total of 329 and 155 patients were enrolled in the pre-pandemic and COVID-19 groups respectively. There were no significant differences in pre-operative BMI (p = 0.437) or comorbidities: Type II DM (p = 0.810), hypertension (p = 0.879), sleep apnea (p = 0.502), and hyperlipidemia (p = 0.227). Post-operatively, weight loss was comparable at all time points out to 1 year. Type II DM resolution rates were higher in the control cohort at 6 months (p = 0.007), but not at 12 months (p = 1.000). There was no statistically significant difference in resolution rates between the control group and the COVID-19 group for the other measured comorbidities. There was no difference in objective measures of anxiety and depression when comparing the two groups (both p > 0.05). CONCLUSIONS: The COVID-19 pandemic has fundamentally changed how society and medical systems function. Focusing on pre-operative dietary training and screening for inadequately managed psychological comorbidities yielded similar weight loss outcomes notwithstanding the significant societal and individual stressors with which patients were faced.

A critical review of hot executive functioning in youth attention-deficit/hyperactivity disorder: Methodological limitations, conceptual considerations, and future directions.

Hot executive functioning (EF) - EF under emotionally or motivationally salient conditions - is a putative etiology of attention-deficit/hyperactivity disorder (ADHD), disruptive behavior problems (DBPs), and their related impairments. Despite two decades of research, the present study is the first review of the construct in youth ADHD, with a particular focus on the role of task design, age, and DBPs, as well as relevant conceptual and methodological considerations. While certain hot EF tasks have been investigated extensively (e.g., choice impulsivity), substantial inconsistency in measurement of the broader construct remains, severely limiting conclusions. Future research should a) consider the extent to which various hot EF tasks relate to one another, a higher order factor, and other related constructs; b) further investigate task design, particularly the elicitation of emotion or motivation and its anticipated effect on EF; and c) incorporate multiple levels of analysis to validate similarities and differences among tasks with regard to the affective experiences and cognitive demands they elicit. With improved measurement and conceptual clarity, hot EF has potential to advance the literature on etiological pathways to ADHD, DBPs and associated impairments and, more broadly, may represent a useful tool for understanding the influence of emotion and motivation on cognition.

Association between health care access and food insecurity among lower-income older adults with multiple chronic conditions in Washington State, USA.

OBJECTIVE: Lower-income older adults with multiple chronic conditions (MCC) are highly vulnerable to food insecurity. However, few studies have considered how health care access is related to food insecurity among older adults with MCC. The aims of this study were to examine associations between MCC and food insecurity, and, among older adults with MCC, between health care access and food insecurity. DESIGN: Cross-sectional study data from the 2019 Behavioral Risk Factor Surveillance System survey. SETTING: Washington State, USA. PARTICIPANTS: Lower-income adults, aged 50 years or older (n 2118). MCC was defined as having ≥ 2 of 11 possible conditions. Health care access comprised three variables (unable to afford seeing the doctor, no health care coverage and not having a primary care provider (PCP)). Food insecurity was defined as buying food that did not last and not having money to get more. RESULTS: The overall prevalence of food insecurity was 26·0 % and was 1·50 times greater (95 % CI 1·16, 1·95) among participants with MCC compared to those without MCC. Among those with MCC (n 1580), inability to afford seeing a doctor was associated with food insecurity (prevalence ratio (PR) 1·83; 95 % CI 1·46, 2·28), but not having health insurance (PR 1·49; 95 % CI 0·98, 2·24) and not having a PCP (PR 1·10; 95 % CI 0·77, 1·57) were not. CONCLUSIONS: Inability to afford healthcare is related to food insecurity among older adults with MCC. Future work should focus on collecting longitudinal data that can clarify the temporal relationship between MCC and food insecurity.

Guideline No. 437: Diagnosis and Management of Adenomyosis.

OBJECTIVE: To describe the current evidence-based diagnosis and management of adenomyosis. TARGET POPULATION: All patients with a uterus of reproductive age. OPTIONS: Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy). OUTCOMES: Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes). BENEFITS, HARMS, AND COSTS: This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options. EVIDENCE: Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows. TWEETABLE ABSTRACT: Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available. SUMMARY STATEMENTS: RECOMMENDATIONS.