The Development of a Team-Based, Hybrid Inter-university Graduate Certificate Program Focused on Maternal Child Health Professionals.

INTRODUCTION: Pregnancy, childbirth, and child well-being are identified by Healthy People 2030 as priority topics for improving the health of all Americans. New Mexico is the fifth largest state geographically with most of the state's 33 counties considered rural or frontier. Accessing health care services is challenging in this resource-poor environment. The need to provide maternal and child health (MCH) education in the state was the impetus for developing a graduate certificate in maternal and child public health. METHODS: The hybrid MCH graduate certificate engaged professionals in formal training that included a public health approach to addressing MCH issues in the state's diverse communities. Grant funds paid for the tuition, books and travel for students providing an opportunity to individuals who otherwise could not have pursued graduate education and professional development. RESULTS: Over a 4-year period, two cohorts were recruited, educated, and evaluated. The evaluations reflected an increase in competency knowledge scores for all students. DISCUSSION: This model of MCH education was successful at delivering public health graduate education to MCH practitioners and increasing their knowledge and skills. Listening to students and communities as to what their MCH public health needs are and responding with a flexible educational model provided individuals with information and tools that could be used to improve maternal and child health and reduce health disparities in rural, tribal, and underserved communities.

Association of length of hospital stay with delay to surgical fixation of hip fracture.

BACKGROUND: Previous research has shown increases in length of stay (LOS), morbidity and mortality when the standard for surgical fixation of hip fracture of 48 hours is not met. However, few investigators have analyzed LOS as a primary outcome, and most used time of diagnosis as opposed to time of fracture as the reference point. We examined the effect of time to surgical fixation of hip fracture, measured from time of fracture, on length of hospital stay; the secondary outcome was average 1-year mortality. METHODS: We conducted a retrospective cohort study of patients presenting to 1 of 2 tertiary care centres in St. John's, Newfoundland and Labrador, Canada, with a hip fracture from Jan. 1, 2014, to Dec. 31, 2018. We analyzed 3 groups based on timing of surgical fixation after fracture: less than 24 hours (group 1), 24-48 hours (group 2) and more than 48 hours (group 3). We assessed statistical significance using 1-way analysis of variance. RESULTS: Of the 692 patients included in the study, 212 (30.6%) were in group 1, 360 (52.0%) in group 2 and 120 (17.3%) in group 3. A delay to surgical fixation exceeding 48 hours was associated with a significantly longer LOS, by an average of 2.9 and 2.8 days compared to groups 1 and 2, respectively (p = 0.04); there was no significant difference in LOS between groups 1 and 2. A significant difference in average 1-year mortality was observed between groups 1 (11%) and 3 (26%) (p = 0.004), and groups 2 (13%) and 3 (p = 0.009). CONCLUSION: Surgical fixation beyond 48 hours after hip fracture resulted in significantly increased LOS and 1-year mortality. Further research should be conducted to evaluate reasons for delays to surgery and the effects of these delays on time to surgical fixation as measured from time of fracture.

What is in? What is out? Updating the British Society for Cutaneous Allergy facial series.

BACKGROUND: Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012. OBJECTIVES: To review and update the BSCA facial series. METHODS: We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified. RESULTS: Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%. CONCLUSIONS: This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

Recommendation to include hydroxyethyl (meth)acrylate in the British baseline patch test series.

BACKGROUND: (Meth)acrylates are potent sensitizers and a common cause of allergic contact dermatitis (ACD). The frequency of (meth)acrylate ACD has increased with soaring demand for acrylic nails. A preliminary audit has suggested a significant rate of positive patch tests to (meth)acrylates using aimed testing in patients providing a clear history of exposure. To date, (meth)acrylates have not been routinely tested in the baseline patch test series in the U.K. and Europe. OBJECTIVES: To determine whether inclusion of 2-hydroxyethyl methacrylate (2-HEMA) 2% in petrolatum (pet.) in the baseline series detects cases of treatable (meth)acrylate ACD. METHODS: During 2016-2017, 15 U.K. dermatology centres included 2-HEMA in the extended baseline patch test series. Patients with a history of (meth)acrylate exposure, or who tested positive to 2-HEMA, were selectively tested with a short series of eight (meth)acrylate allergens. RESULTS: In total 5920 patients were consecutively patch tested with the baseline series, of whom 669 were also tested with the (meth)acrylate series. Overall, 102 of 5920 (1·7%) tested positive to 2-HEMA and 140 (2·4%) to at least one (meth)acrylate. Had 2-HEMA been excluded from the baseline series, (meth)acrylate allergy would have been missed in 36 of 5920 (0·6% of all patients). The top (meth)acrylates eliciting a positive reaction were 2-HEMA (n = 102, 1·7%), 2-hydroxypropyl methacrylate (n = 61, 1·0%) and 2-hydroxyethyl acrylate (n = 57, 1·0%). CONCLUSIONS: We recommend that 2-HEMA 2% pet. be added to the British baseline patch test series. We also suggest a standardized short (meth)acrylate series, which is likely to detect most cases of (meth)acrylate allergy.

A systematic review of cannabidiol dosing in clinical populations.

AIMS: Cannabidiol (CBD) is a cannabis-derived medicinal product with potential application in a wide-variety of contexts; however, its effective dose in different disease states remains unclear. This review aimed to investigate what doses have been applied in clinical populations, in order to understand the active range of CBD in a variety of medical contexts. METHODS: Publications involving administration of CBD alone were collected by searching PubMed, EMBASE and ClinicalTrials.gov. RESULTS: A total of 1038 articles were retrieved, of which 35 studies met inclusion criteria covering 13 medical contexts. Twenty-three studies reported a significant improvement in primary outcomes (e.g. psychotic symptoms, anxiety, seizures), with doses ranging between <1 and 50 mg/kg/d. Plasma concentrations were not provided in any publication. CBD was reported as well tolerated and epilepsy was the most frequently studied medical condition, with all 11 studies demonstrating positive effects of CBD on reducing seizure frequency or severity (average 15 mg/kg/d within randomised controlled trials). There was no signal of positive activity of CBD in small randomised controlled trials (range n = 6-62) assessing diabetes, Crohn's disease, ocular hypertension, fatty liver disease or chronic pain. However, low doses (average 2.4 mg/kg/d) were used in these studies. CONCLUSION: This review highlights that CBD has a potential wide range of activity in several pathologies. Pharmacokinetic studies as well as conclusive phase III trials to elucidate effective plasma concentrations within medical contexts are severely lacking and highly encouraged.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Background: Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population. Methods: We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group. Results: We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%­30.3%) and 58.1% (95% CI 43.3%­71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care. Conclusion: The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Contexte: Les fractures du bassin chez les personnes âgées sont associées à une morbidité et une mortalité substantielles. La littérature sur les fractures du bassin dans ce groupe d'âge est peu abondante. Le but de cette étude était donc de faire état des taux de mortalité suite à de telles blessures. Nous avons aussi voulu décrire et quantifier l'importante morbidité qui en résulte chez cette population vulnérable. Méhodes: Nous avons effectué une revue rétrospective de tous les cas de fractures du bassin consécutives à un traumatisme de faible énergie chez des patients de plus de 60 ans survenues entre janvier 2000 et décembre 2005. Les données de survie, la durée de l'hospitalisation, le statut ambulatoire et le lieu de résidence ont été notées. À des fins de comparaison, nous avons calculé le taux de mortalité pour un groupe témoin indemme assorti selon l'âge et le sexe en nous servant des données de survie de Statistique Canada. Résultats: Nous avons recensé 43 patients (32 femmes [74 %]; âge moyen 79,4 ans) porteurs de fractures du bassin isolées consécutives à un traumatisme de faible énergie pour la période de l'étude. Les taux de mortalité à 1 an et à 5 ans ont été de 16,3 % (intervalle confiance [IC] de 95 % 7,8 %­30,3 %) et 58,1 % (IC de 95 % 43,3 %­71,6 %), respectivement, tous deux significativement plus élevés que les estimations ponctuelles pour le groupe témoin (6,6 % et 31,3 %, respectivement). Après le traumatisme, 14 patients sur 39 (36 %) ont eu besoin de façon permanente et croissante de dispositifs d'aide à la marche et 8 (20 %) ont eu besoin de façon permanente d'un niveau de soins quotidiens accru. Conclusion: Les résultats donnent à penser que la mortalité et la morbidité pourraient être plus marquées après une fracture de la hanche consécutive à un traumatisme de faible énergie chez la population âgée, comparativement à des témoins assortis selon l'âge et le sexe.

Electromagnetic Moments of Radioactive

Radioactive ^{136}Te has two valence protons and two valence neutrons outside of the ^{132}Sn double shell closure, providing a simple laboratory for exploring the emergence of collectivity and nucleon-nucleon interactions. Coulomb excitation of ^{136}Te on a titanium target was utilized to determine an extensive set of electromagnetic moments for the three lowest-lying states, including B(E2;0_{1}^{+}→2_{1}^{+}), Q(2_{1}^{+}), and g(2_{1}^{+}). The results indicate that the first-excited state, 2_{1}^{+}, composed of the simple 2p⊕2n system, is prolate deformed, and its wave function is dominated by excited valence neutron configurations, but not to the extent previously suggested. It is demonstrated that extreme sensitivity of g(2_{1}^{+}) to the proton and neutron contributions to the wave function provides unique insight into the nature of emerging collectivity, and g(2_{1}^{+}) was used to differentiate among several state-of-the-art theoretical calculations. Our results are best described by the most recent shell model calculations.

Statin Prescribing in the Elderly: Special Considerations.

PURPOSE OF REVIEW: Our aim was to examine the current evidence behind prescribing statins to individuals over 65 years of age with emphasis on those older than 75. Individuals over 75 years of age may often have multiple comorbidities and take many medications. Additionally, they are often underrepresented in randomized controlled trials (RCTs) of statins in older populations. While results of RCTs demonstrate the benefit of statin therapy in both primary and secondary prevention patients, clinicians must more carefully consider adverse effects and drug-drug interactions before prescribing statin therapy as well as determining the intensity in older individuals. RECENT FINDINGS: Four primary prevention trials support statins for primary prevention following a clinician-patient risk discussion. Of these, JUPITER and HOPE-3 studied participants 70 years of age and over who derived benefit. However, in those over 85 years, available information is inadequate to guide decisions regarding statin therapy. Documented statin adverse effects include new onset diabetes, myopathy, and medication interactions. Although cognitive decline has been reported anecdotally, its incidence was comparable to placebo in two RCTs with validated cognitive evaluations. Concerns about significant liver and kidney injury with statins were not corroborated in RCTs. For most patients, the potential for reducing ASCVD risk outweighs possible adverse effects; however, in the elderly, the impact of drug treatment on cognition, musculoskeletal ability, and independence must be heavily weighed. Given the limited high quality evidence for primary prevention in individuals over 75 years of age, neither the ACC-AHA nor USPSTF cholesterol guidelines recommend statin therapy for primary prevention in this patient population. If prescribed, physician judgment and shared decision-making are crucial. To aid clinicians, imaging studies of subclinical atherosclerosis may improve specificity of statin therapy to prevent ASCVD in the elderly in primary prevention.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series.

BACKGROUND: There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown. OBJECTIVES: To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimize detection of true allergy and to minimize irritant reactions. METHODS: During 2013-2014, 4563 consecutive patients in 12 U.K. centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0·3%, 0·2% and 0·1%, and hydroperoxides of linalool 1·0%, 0·5% and 0·25% pet. Irritant reactions were recorded separately from doubtful reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented. RESULTS: Limonene hydroperoxide 0·3% gave positive reactions in 241 (5·3%) patients, irritant reactions in 93 (2·0%) and doubtful reactions in 110 (2·4%). Linalool hydroperoxide 1·0% gave positive reactions in 352 (7·7%), irritant reactions in 178 (3·9%) and doubtful reactions in 132 (2·9%). A total of 119 patients with crescendo reactions to 0·3% limonene would have been missed if only tested with 0·1% and 131 patients with crescendo reactions to 1·0% linalool would have been missed if only tested with 0·25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series. CONCLUSIONS: We recommend that limonene hydroperoxides be tested at 0·3% and linalool hydroperoxides at 1·0% in the British baseline patch test series.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project.

PURPOSE: To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT). METHODS: An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results. RESULTS: mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers. CONCLUSIONS: The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Rapid infrared mapping for highly accurate automated histology in Barrett's oesophagus.

Barrett's oesophagus (BE) is a premalignant condition that can progress to oesophageal adenocarcinoma. Endoscopic surveillance aims to identify potential progression at an early, treatable stage, but generates large numbers of tissue biopsies. Fourier transform infrared (FTIR) mapping was used to develop an automated histology tool for detection of BE and Barrett's neoplasia in tissue biopsies. 22 oesophageal tissue samples were collected from 19 patients. Contiguous frozen tissue sections were taken for pathology review and FTIR imaging. 45 mid-IR images were measured on an Agilent 620 FTIR microscope with an Agilent 670 spectrometer. Each image covering a 140 µm × 140 µm region was measured in 5 minutes, using a 1.1 µm2 pixel size and 64 scans per pixel. Principal component fed linear discriminant analysis was used to build classification models based on spectral differences, which were then tested using leave-one-sample-out cross validation. Key biochemical differences were identified by their spectral signatures: high glycogen content was seen in normal squamous (NSQ) tissue, high glycoprotein content was observed in glandular BE tissue, and high DNA content in dysplasia/adenocarcinoma samples. Classification of normal squamous samples versus 'abnormal' samples (any stage of Barrett's) was performed with 100% sensitivity and specificity. Neoplastic Barrett's (dysplasia or adenocarcinoma) was identified with 95.6% sensitivity and 86.4% specificity. Highly accurate pathology classification can be achieved with FTIR measurement of frozen tissue sections in a clinically applicable timeframe.

Multi-centre Raman spectral mapping of oesophageal cancer tissues: a study to assess system transferability.

The potential for Raman spectroscopy to provide early and improved diagnosis on a wide range of tissue and biopsy samples in situ is well documented. The standard histopathology diagnostic methods of reviewing H&E and/or immunohistochemical (IHC) stained tissue sections provides valuable clinical information, but requires both logistics (review, analysis and interpretation by an expert) and costly processing and reagents. Vibrational spectroscopy offers a complimentary diagnostic tool providing specific and multiplexed information relating to molecular structure and composition, but is not yet used to a significant extent in a clinical setting. One of the challenges for clinical implementation is that each Raman spectrometer system will have different characteristics and therefore spectra are not readily compatible between systems. This is essential for clinical implementation where classification models are used to compare measured biochemical or tissue spectra against a library training dataset. In this study, we demonstrate the development and validation of a classification model to discriminate between adenocarcinoma (AC) and non-cancerous intraepithelial metaplasia (IM) oesophageal tissue samples, measured on three different Raman instruments across three different locations. Spectra were corrected using system transfer spectral correction algorithms including wavenumber shift (offset) correction, instrument response correction and baseline removal. The results from this study indicate that the combined correction methods do minimize the instrument and sample quality variations within and between the instrument sites. However, more tissue samples of varying pathology states and greater tissue area coverage (per sample) are needed to properly assess the ability of Raman spectroscopy and system transferability algorithms over multiple instrument sites.

Energy-dispersive X-ray diffraction using an annular beam.

We demonstrate material phase identification by measuring polychromatic diffraction spots from samples at least 20 mm in diameter and up to 10 mm thick with an energy resolving point detector. Within our method an annular X-ray beam in the form of a conical shell is incident with its symmetry axis normal to an extended polycrystalline sample. The detector is configured to receive diffracted flux transmitted through the sample and is positioned on the symmetry axis of the annular beam. We present the experiment data from a range of different materials and demonstrate the acquisition of useful data with sub-second collection times of 0.5 s; equating to 0.15 mAs. Our technique should be highly relevant in fields that demand rapid analytical methods such as medicine, security screening and non-destructive testing.