System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program.

BACKGROUND: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. METHODS: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. FINDINGS: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. CONCLUSION: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

You just want a break from the hatred of failure: the lived experience of being a student physiotherapist perfectionist and considerations for educators.

Perfectionism is a personality orientation associated with mental health and adjustment problems. Recent evidence demonstrates that perfectionism is widespread among students and on the rise, with recent generations of students placing increasingly more importance on perfection. Whilst the extant literature is vast, it tends to focus on psychopathology and identification of perfectionism correlates rather than the experience of student perfectionism. Furthermore, the education literature is scant and there is a need to understand the deeper processes and nuances of perfectionism, particularly within health professions education where intense study demands, competition to gain entry to educational programmes, and professional cultures may nurture the problem. This phenomenological study explored the lived experiences of ten physiotherapy students as they wrestled with perfectionism in the various facets of their studies. Semi-structured interviews were undertaken, and participants completed log sheets to document perfectionism-related experiences. Idiographic profiles were composed and interview transcripts were analysed, drawing upon features of both phenomenological and thematic analysis. Perfectionism was found to have toxic consequences for the learning experience. Harmful phenomenological experiences included perpetual and excessive achievement striving, punitive self-criticism and health and wellbeing difficulties. A range of sabotaging learning behaviours such as self-handicapping and feedback avoidance was also illuminated, and cultural and organisational influences perceived to foster perfectionism emerged. Findings are discussed in relation to underlying processes and implications for educators. The prospect of findings transferring to other educational contexts is highlighted.

Perinatal Outcomes at Rural Hospitals That Participated in the Rural Surgical and Obstetrical Networks (RSON) of British Columbia (2016-2021).

BACKGROUND: The goal of the Rural Surgical and Obstetrical Networks (RSON) of British Columbia was to support safe and appropriate surgery, operative birth, and perinatal care closer to home for rural communities. Family physicians with enhanced obstetrical and/or surgical skills provide cesarean delivery and family practice anesthetists manage anesthesia for labour pain and operative births at RSON-supported hospitals, with the involvement of a local specialist at one site. OBJECTIVES: The objectives of the study were to: (1) compare perinatal outcomes at hospitals participating in the RSON initiative with outcomes at referral hospitals and (2) examine temporal changes in the proportion of childbearing people who resided in RSON communities and gave birth locally. METHODS: Poisson regression analysis was used to model the effect of hospital type (RSON vs. referral) on perinatal outcomes. We restricted the analysis to singleton births and controlled for differences in maternal characteristics, obstetric history, and pregnancy complications. RESULTS: Childbearing people who gave birth at RSON-supported hospitals (n = 3498) had a 10% lower incidence of adverse maternal-newborn outcomes compared to those who gave birth at referral hospitals (n = 14 772), after controlling for referral bias. We found a small increase (3.2 %) in the proportion of local births over the study period. CONCLUSION: Findings provide evidence that childbearing people can safely give birth at smaller rural hospitals in British Columbia and that investments in rural hospitals contribute to service stability. Stabilizing local birth services in rural communities benefits the whole region because it reduces surgical overload in regional referral centres.

Optimizing rural healthcare through improved team function: a case study of the Rural Surgical Obstetrical Networks programme.

We explored enablers and mechanisms of optimal team function within rural hospital teams, and the impact of these factors on health service sustainability in British Columbia. The data were drawn from interviews and focus groups with healthcare providers and administrators (n = 169) who participated in the Rural Surgical Obstetrical Networks (RSON) initiative to support low-volume rural surgical and obstetrical services in British Columbia, Canada. The 5-year programme (2018-2022) provided evidence-based system interventions across eight rural sites with the objective of providing sustainable, quality health services to meet population needs. To explore the impact of RSON interventions on local team function, we performed a scoping review, to assess the current literature surrounding enablers of effective rural hospital teamwork. Through inductive thematic analysis of interview data, we identified five enablers of good team function at RSON sites, including emphasis on local leadership, shared direction, commitment to sustainability, respect and solidarity among colleagues, and meaningful communication. The RSON project led to a shift in team culture in participating sites, improved team function, and contributed to improved clinical processes and patient outcomes. The findings have implications for rural health policy and practice in British Columbia and other jurisdictions with similar health service delivery models and geographic contexts.

Real-time virtual supports improving health equity and access in British Columbia.

In British Columbia (BC) and across the territories of over 200 First Nations and 39 Métis Nation Chartered communities, the COVID-19 pandemic catalyzed a group of partner organizations to rapidly establish seven virtual care pathways under the Real-Time Virtual Support (RTVS) network. They aimed to address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities, and provide pan-provincial services. Mixed-method evaluation assessed implementation, patient and provider experience, quality improvement, cultural safety, and sustainability. Pathways supported 38,905 patient encounters and offered 29,544 hours of peer-to-peer support from April 2020 to March 2021. Mean monthly encounter growth was 178.0% (standard deviation = 252.1%). Ninety percent of patients were satisfied with the care experience; 94% of providers enjoyed delivering virtual care. Consistent growth suggests that the virtual pathways met the needs of providers and patients in rural, remote, and Indigenous communities, and supported virtual access to care in BC.

Gelatin expression from an engineered Saccharomyces cerevisiae CUP1 promoter in Pichia pastoris.

The methylotrophic yeast Pichia pastoris (reclassified as Komagataella phaffii) is a versatile protein expression system, yet many commonly used promoters have attributes undesirable for fermentation or its optimization. Hence, the copper-inducible CUP1 gene promoter from the related yeast Saccharomyces cerevisiae was used to express human gelatin. Multimerization of a potential copper response element in the CUP1 promoter, a S. cerevisiae Ace1p binding site, significantly increased gelatin expression. Expression was induced by copper in a dose-dependent fashion and was not dependent on cell density. Gelatin was additionally induced in standard copper-containing fermentation basal salts media. Removal of a S. cerevisiae heat shock factor (Hsf1p) binding site reduced copper-dependent gelatin induction suggesting that a similar protein may regulate this promoter in P. pastoris. This engineered copper inducible promoter expands the yeast recombinant protein production tool kit.

Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients.

The development of coronavirus disease 2019 vaccines in the current and planned clinical trials is essential for the success of a public health response. This paper focuses on how physicians should implement the results of these clinical trials when counseling patients who are pregnant, planning to become pregnant, breastfeeding or planning to breastfeed about vaccines with government authorization for clinical use. Determining the most effective approach to counsel patients about coronavirus disease 2019 vaccination is challenging. We address the professionally responsible counseling of 3 groups of patients-those who are pregnant, those planning to become pregnant, and those breastfeeding or planning to breastfeed. We begin with an evidence-based account of the following 5 major challenges: the limited evidence base, the documented increased risk for severe disease among pregnant coronavirus disease 2019-infected patients, conflicting guidance from government agencies and professional associations, false information about coronavirus disease 2019 vaccines, and maternal mistrust and vaccine hesitancy. We subsequently provide evidence-based, ethically justified, practical guidance for meeting these challenges in the professionally responsible counseling of patients about coronavirus disease 2019 vaccination. To guide the professionally responsible counseling of patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed, we explain how obstetrician-gynecologists should evaluate the current clinical information, why a recommendation of coronavirus disease 2019 vaccination should be made, and how this assessment should be presented to patients during the informed consent process with the goal of empowering them to make informed decisions. We also present a proactive account of how to respond when patients refuse the recommended vaccination, including the elements of the legal obligation of informed refusal and the ethical obligation to ask patients to reconsider. During this process, the physician should be alert to vaccine hesitancy, ask patients to express their hesitation and reasons for it, and respectfully address them. In contrast to the conflicting guidance from government agencies and professional associations, evidence-based professional ethics in obstetrics and gynecology provides unequivocal and clear guidance: Physicians should recommend coronavirus disease 2019 vaccination to patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed. To prevent widening of the health inequities, build trust in the health benefits of vaccination, and encourage coronavirus disease 2019 vaccine and treatment uptake, in addition to recommending coronavirus disease 2019 vaccinations, physicians should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, robust educational campaigns, and novel approaches to immunization.

Are SPECT MPI measures of dyssynchrony dyssynchronous?

BACKGROUND: Assessment of left ventricular mechanical dyssynchrony (LVMD) from gated SPECT myocardial perfusion imaging (MPI) aims to aid selection of patients for cardiac resynchronization therapy (CRT), using either the standard deviation of left ventricular phase (PSD) ≥ 43° or phase histogram bandwidth (HBW) of > 38° and > 30.6° in males and females, respectively. We observed dyssynchrony parameters might be affected by test type and alignment. METHODS: We reviewed 242 patients who underwent gated SPECT MPI with use of the Emory Cardiac Toolbox comparing PSD and HBW at rest and stress for Pearson correlation, and substitutability with Bland-Altman analysis. RESULTS: There is statistically significant difference in the mean PSD and HBW during rest vs stress (33.4 ± 17.4° vs 20.7 ± 13.5° and 97.7 ± 59.6° vs 59.4 ± 45.4°, respectively, P < 0.001). Proper valve plane alignment rendered smaller values (i.e., less dyssynchrony) in both phase SD and HBW (16.8 ± 13.5) vs (22.2 ± 14.7) (P = 0.011), and (47.0 ± 38.2) vs (60.7 ± 48.0) (P = 0.023), respectively. CONCLUSION: Proper alignment and test type, particularly low-dose rest vs high-dose stress, should be considered when assessing LVMD using SPECT MPI.

Effects of two Bisphenol A replacement compounds, 1,7-bis (4-hydroxyphenylthio)-3,5-dioxaheptane and Bisphenol AF, on development and mRNA expression in chicken embryos.

Concerns about the estrogenic properties of Bisphenol A (BPA) have led to increased efforts to find BPA replacements. 1,7-bis(4-Hydroxyphenylthio)-3,5-dioxaheptane (DD-70) and 4,4'-(hexafluoroisopropylidene) diphenol (bisphenol AF, BPAF) are two potential chemical substitutes for BPA; however, toxicity data for these chemicals in avian species are limited. To determine effects on avian embryonic viability, development, and hepatic mRNA expression at two distinct developmental periods (mid-incubation [day 11] and term [day 20]), two egg injection studies were performed. Test chemicals were injected into the air cell of unincubated, fertilized chicken eggs at concentrations ranging from 0-88.2 µg/g for DD-70 and 0-114 µg/g egg for BPAF. Embryonic concentrations of DD-70 and BPAF decreased at mid-incubation and term compared to injected concentrations suggesting embryonic metabolism. Exposure to DD-70 (40.9 and 88.2 µg/g) and BPAF (114 µg/g) significantly decreased embryonic viability at mid-incubation. Exposure to DD-70 (88.2 µg/g) decreased embryo mass and increased gallbladder mass, while 114 µg/g BPAF resulted in increased gallbladder mass in term embryos. Expression of hepatic genes related to xenobiotic metabolism, lipid homeostasis, and response to estrogen were altered at both developmental stages. Given the importance of identifying suitable BPA replacements, the present study provides novel, whole animal avian toxicological data for two replacement compounds, DD-70 and BPAF. DATA AVAILABILITY: Data, associated metadata, and calculation tools are available from the corresponding author (doug.crump@canada.ca).

The Building Blocks of Architecture and Mathematics.

Editor-in-Chief Kim Williams examines the sometimes very sophisticated use of fundamental mathematical elements-curves, grids, simple polygons and polyhedra-in ancient and contemporary architecture and introduces the articles in Nexus Network Journal vol. 23 no. 3 (2021).

Strategies for Improving Nutrition in Inner-City Populations.

PURPOSE OF REVIEW: The social, economic, cultural, and historic reasons for why inner-city communities have struggled with poor nutrition and health outcomes are complex. Creating successful programs to address these problems requires a better understanding of the gaps that exist and formulating solutions to improve access to nutritious food options. RECENT FINDINGS: Studies have demonstrated that aggressive evidence-based nutrition can decrease factors linked to cardiovascular diseases, but improving access to these nutritious resources and prioritizing health literacy and behavior modification related to meal choices are just as essential. Government programs and community interventions have shown promise through creating supermarkets, farmers' markets, and community gardens, but not all inner-city areas have such programs in place. The poor state of inner-city nutrition and health is a true public health crisis. Creation of innovative strategies to improve education on and sustainable access to nutritious foods is essential in order to improve health disparities and outcomes.

Nutrition, risk factors, prevention, and imaging: The 2018 Mario Verani Lecture.

Heart disease has been the leading cause of death in the United States since 1918. Cardiac mortality rates have dramatically decreased in this era of advanced medical and interventional therapies. However, this has been aptly described as "mopping up the floor instead of turning off the faucet." With this recognition, prevention in cardiology is poised to become a central focus. Within prevention, dietary intervention is recognized as the single largest opportunity for improved cardiovascular outcomes, including improvement or elimination of cardiac risk factors, prevention of myocardial infarction, stroke and cardiovascular death, and reduction of plaque burden and myocardial ischemia. Cardiac imaging, particularly nuclear perfusion and coronary computed tomographic angiography, plays a critical role in early diagnosis and serial evaluation of myocardial ischemia and coronary artery disease. These techniques have the potential to help refine research protocols and evaluate their success by providing intermediate markers of improved myocardial blood flow and coronary plaque morphology.

Extracts of Passive Samplers Deployed in Variably Contaminated Wetlands in the Athabasca Oil Sands Region Elicit Biochemical and Transcriptomic Effects in Avian Hepatocytes.

Recent contaminant monitoring in boreal wetlands situated in Alberta's Athabasca oil sands region revealed increased concentrations of polycyclic aromatic compounds (PACs) in passive sampling devices deployed in wetlands close to bitumen surface mining operations. In this study, graded concentrations of semipermeable membrane device (SPMD) extracts, collected from 4 wetlands with variable burdens of PACs, were administered to chicken and double-crested cormorant (DCCO) embryonic hepatocytes to determine effects on 7-ethoxyresorufin-O-deethylase (EROD) activity and mRNA expression. Concentrations and composition of PACs detected in SPMDs varied among sites, and the proportion of alkyl PACs was greater than parent compounds at all sites. ΣPACs was the highest in SPMDs deployed within 10 km of mining activity (near-site wetland [5930 ng SPMD-1]) compared to those ∼50 km south (far-site wetland [689 ng SPMD-1]). Measures of EROD activity and Cyp1a4 mRNA expression allowed the ranking of wetland sites based on aryl hydrocarbon receptor-mediated end points; EROD activity and Cyp1a4 mRNA induction were the highest at the near-site wetland. ToxChip PCR arrays (one chicken and one DCCO) provided a more exhaustive transcriptomic evaluation across multiple toxicological pathways following exposure to the SPMD extracts. Study sites with the greatest PAC concentrations had the most genes altered on the chicken ToxChip (12-15/43 genes). Exposure of avian hepatocytes to SPMD extracts from variably contaminated wetlands highlighted traditional PAC-related toxicity pathways as well as other novel mechanisms of action. A novel combination of passive sampling techniques and high-throughput toxicity evaluation techniques shows promise in terms of identifying hotspots of chemical concern in the natural environment.

Athabasca Oil Sands Petcoke Extract Elicits Biochemical and Transcriptomic Effects in Avian Hepatocytes.

Petroleum coke or "petcoke" is a granular carbonaceous material produced during the upgrading of heavy crude oils, including bitumen. Petcoke dust was recently reported as an environmental contaminant in the Athabasca oil sands region, but the ecotoxicological hazards posed by this complex bitumen-derived material-including those to avian species-have not been characterized. In this study, solvent extracts (x) of delayed and fluid petcoke (xDP and xFP) were prepared and dissolved in dimethyl sulfoxide. A water-accommodated fraction of delayed petcoke (waDP) was also prepared. Graded concentrations of xDP, xFP, and waDP were administered to chicken and double-crested cormorant hepatocytes to determine effects on 7-ethoxyresorufin-O-deethylase (EROD) activity, porphyrin accumulation, and mRNA expression. Polycyclic aromatic compounds (PACs) were characterized, and xDP, xFP, and waDP had total PAC concentrations of 93 000, 270, and 5.3 ng/mL. The rank order of biochemical and transcriptomic responses was xDP > xFP > waDP (e.g., EROD EC50s were lower for xDP compared to xFP and waDP). A total of 22, 18, and 4 genes were altered following exposure to the highest concentrations of xDP, xFP, and waDP, respectively, using a chicken PCR array comprising 27 AhR-related genes. To provide more exhaustive coverage of potential toxicity pathways being impacted, two avian ToxChip PCR arrays-chicken and double-crested cormorant-were utilized, and xDP altered the expression of more genes than xFP. Traditional PAC-related toxicity pathways and novel mechanisms of action were identified in two avian species following petcoke extract exposure. Extrapolation to real-world exposure scenarios must consider the bioavailability of the extracted PACs compared to those in exposed organisms.

Plant-Based Nutrition: An Essential Component of Cardiovascular Disease Prevention and Management.

PURPOSE OF REVIEW: This review aims to summarize and discuss the role of plant-based nutrition as an adjunct to the management of cardiovascular disease (CVD). Discussion of nutrition and the benefits of a plant-based diet should be highlighted during healthcare provider visits as an essential part of the overall CVD prevention and management care plan. RECENT FINDINGS: Evidence from prospective cohort studies indicates that a high consumption of predominantly plant-based foods, such as fruit and vegetables, nuts, and whole grains, is associated with a significantly lower risk of CVD. The protective effects of these foods are likely mediated through their multiple beneficial nutrients, including mono- and polyunsaturated fatty acids, omega-3 fatty acids, antioxidant vitamins, minerals, phytochemicals, fiber, and plant protein. In addition, minimizing intake of animal proteins has been shown to decrease the prevalence of CVD risk factors. Substantial evidence indicates that plant-based diets can play an important role in preventing and treating CVD and its risk factors. Such diets deserve more emphasis in dietary recommendations.

Complications of subdural and depth electrodes in 269 patients undergoing 317 procedures for invasive monitoring in epilepsy.

OBJECTIVE: Intracranial monitoring is fundamental to epilepsy surgery, with reported complication rates of 3-17%. We aimed to assess the differences in complication rates between subdural and depth electrodes. METHODS: We conducted a retrospective review of 317 electrode implantation procedures. All documented abnormal postoperative findings were recorded in our study. Those that resulted in a significant alteration of treatment course, including neurologic deficit, long-term medication use, reoperation, or hospital readmission, were deemed clinically significant. When possible, findings were attributed to a particular electrode type based on relative location to each electrode. RESULTS: Postoperative abnormalities were associated with SDE placement in 152 (47.9%) procedures and 40 (25.2%) DE placements (p < 0.001). Twenty-nine (9.1%) clinically significant complications were seen in the subdural electrode (SDE) group compared to 10 associated with DEs (6.3%, p = 0.37). SDEs were associated with increased rates of any postoperative hemorrhage (p < 0.001) or extraaxial collection (p = 0.007). Subdural grid placement was associated with an increased risk of any extraaxial collection (odds ratio [OR 2.42), as well as clinically significant collections (OR 9.47). Previous craniotomy was found to be associated with any abnormal postoperative finding (OR 1.71) as well as radiographic hemorrhage (OR 1.99). Concurrent resection is also associated with abnormal findings (OR 1.83) and extraaxial collections (OR 2.37). The overall complication rate was 9.1%, with 13 procedures (4.1%) resulting in neurologic deficit. However, only two patients (0.6%) had permanent neurologic sequelae resulting from lead placement. SIGNIFICANCE: Subdural electrodes appear to have an increased rate of abnormal postoperative findings, including hemorrhage and extraaxial collections; however, there was no difference in clinically significant findings. Subdural grids also appear to be associated with symptomatic extraaxial collections, and previous craniotomy increases the risk of hemorrhage. Overall, intracranial monitoring remains a safe and effective procedure for localization of operative seizure foci. Patient selection and risk education for various modalities is an essential aspect of preoperative evaluation.