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.

Extracts from Dated Lake Sediment Cores in the Athabasca Oil Sands Region Alter Ethoxyresorufin-O-deethylase Activity and Gene Expression in Avian Hepatocytes.

Increases in oil sands mining operations in the Athabasca oil sands region have resulted in increased concentrations of polycyclic aromatic compounds (PACs) and heavy metals in aquatic systems located near surface mining operations. In the present study, sediment cores were collected from 3 lakes with varying proximity to surface mining operations to determine the differences in PAC concentrations. Sediment cores were separated into 2 sections-current mining (top; 2000-2017) and premining (bottom; pre-1945)-and extracts were prepared for in vitro screening using a well-established chicken embryonic hepatocyte (CEH) assay. Concentrations and composition of PACs varied between sites, with the highest ∑PACs in Saline Lake, 5 km from an active oil sands mine site. The proportion of alkylated PACs was greater than that of parent PACs in the top sediment sections compared with the bottom. Ethoxyresorufin-O-deethylase activity in CEH permitted the ranking of lake sites/core sections based on an aryl hydrocarbon receptor-mediated end point; mean median effect concentration values were lowest for the top cores from Saline Lake and another near-mining operations lake, referred to as WF1. A ToxChip polymerase chain reaction (PCR) array was used to evaluate gene expression changes across 43 target genes associated with numerous toxicological pathways following exposure to top and bottom sediment core extracts. The 2 study sites with the greatest ∑PAC concentrations (Saline Lake and WF1) had the highest gene expression alterations on the ToxChip PCR array (19 [top] and 17 [bottom]/43), compared with a reference site (13 [top] and 7 [bottom]/43). The avian in vitro bioassay was useful for identifying the toxicity of complex PAC extracts associated with variably contaminated sediment cores, supporting its potential use for hotspot identification and complex mixture screening. EnvironToxicol Chem 2021;40:1883-1893. © 2021 SETAC.

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).

Prioritized Research for the Prevention, Treatment, and Reversal of Chronic Disease: Recommendations From the Lifestyle Medicine Research Summit.

Declining life expectancy and increasing all-cause mortality in the United States have been associated with unhealthy behaviors, socioecological factors, and preventable disease. A growing body of basic science, clinical research, and population health evidence points to the benefits of healthy behaviors, environments and policies to maintain health and prevent, treat, and reverse the root causes of common chronic diseases. Similarly, innovations in research methodologies, standards of evidence, emergence of unique study cohorts, and breakthroughs in data analytics and modeling create new possibilities for producing biomedical knowledge and clinical translation. To understand these advances and inform future directions research, The Lifestyle Medicine Research Summit was convened at the University of Pittsburgh on December 4-5, 2019. The Summit's goal was to review current status and define research priorities in the six core areas of lifestyle medicine: plant-predominant nutrition, physical activity, sleep, stress, addictive behaviors, and positive psychology/social connection. Forty invited subject matter experts (1) reviewed existing knowledge and gaps relating lifestyle behaviors to common chronic diseases, such as cardiovascular disease, diabetes, many cancers, inflammatory- and immune-related disorders and other conditions; and (2) discussed the potential for applying cutting-edge molecular, cellular, epigenetic and emerging science knowledge and computational methodologies, research designs, and study cohorts to accelerate clinical applications across all six domains of lifestyle medicine. Notably, federal health agencies, such as the Department of Defense and Veterans Administration have begun to adopt "whole-person health and performance" models that address these lifestyle and environmental root causes of chronic disease and associated morbidity, mortality, and cost. Recommendations strongly support leveraging emerging research methodologies, systems biology, and computational modeling in order to accelerate effective clinical and population solutions to improve health and reduce societal costs. New and alternative hierarchies of evidence are also be needed in order to assess the quality of evidence and develop evidence-based guidelines on lifestyle medicine. Children and underserved populations were identified as prioritized groups to study. The COVID-19 pandemic, which disproportionately impacts people with chronic diseases that are amenable to effective lifestyle medicine interventions, makes the Summit's findings and recommendations for future research particularly timely and relevant.

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.

A randomized, blinded, prospective clinical trial of postoperative rehabilitation in dogs after surgical decompression of acute thoracolumbar intervertebral disc herniation.

BACKGROUND: Experimental evidence shows benefit of rehabilitation after spinal cord injury (SCI) but there are limited objective data on the effect of rehabilitation on recovery of dogs after surgery for acute thoracolumbar intervertebral disc herniations (TL-IVDH). OBJECTIVE: Compare the effect of basic and intensive post-operative rehabilitation programs on recovery of locomotion in dogs with acute TL-IVDH in a randomized, blinded, prospective clinical trial. ANIMALS: Thirty non-ambulatory paraparetic or paraplegic (with pain perception) dogs after decompressive surgery for TL-IVDH. METHODS: Blinded, prospective clinical trial. Dogs were randomized (1:1) to a basic or intensive 14-day in-house rehabilitation protocol. Fourteen-day open field gait score (OFS) and coordination (regulatory index, RI) were primary outcomes. Secondary measures of gait, post-operative pain, and weight were compared at 14 and 42 days. RESULTS: Of 50 dogs assessed, 32 met inclusion criteria and 30 completed the protocol. There were no adverse events associated with rehabilitation. Median time to walking was 7.5 (2 - 37) days. Mean change in OFS by day 14 was 6.13 (confidence intervals: 4.88, 7.39, basic) versus 5.73 (4.94, 6.53, intensive) representing a treatment effect of -0.4 (-1.82, 1.02) which was not significant, P=.57. RI on day 14 was 55.13 (36.88, 73.38, basic) versus 51.65 (30.98, 72.33, intensive), a non-significant treatment effect of -3.47 (-29.81, 22.87), P = .79. There were no differences in secondary outcomes between groups. CONCLUSIONS: Early postoperative rehabilitation after surgery for TL-IVDH is safe but doesn't improve rate or level of recovery in dogs with incomplete SCI.

A Deficiency of Nutrition Education and Practice in Cardiology.

BACKGROUND: Nutrition is one of the foundations of cardiovascular guidelines for risk reduction and treatment. However, little is known about whether cardiologists, cardiology fellows-in-training, and cardiovascular team members have the nutrition education and knowledge necessary to implement these guidelines. The aim of this study was to describe the educational experiences, attitudes, and practices relating to nutrition among cardiovascular professionals. METHODS: Surveys completed by cardiologists, fellows-in-training, and cardiovascular team members inquired about their personal dietary habits, history of nutrition education, and attitudes regarding nutrition interventions. RESULTS: A total of 930 surveys were completed. Among cardiologists, 90% reported receiving no or minimal nutrition education during fellowship training, 59% reported no nutrition education during internal medicine training, and 31% reported receiving no nutrition education in medical school. Among cardiologists, 8% described themselves as having "expert" nutrition knowledge. Nevertheless, fully 95% of cardiologists believe that their role includes personally providing patients with at least basic nutrition information. The percentage of respondents who ate ≥5 servings of vegetables and fruits per day was: 20% (cardiologists), 21% (fellows-in-training), and 26% (cardiovascular team members). CONCLUSIONS: A large proportion of cardiovascular specialists have received minimal medical education and training in nutrition, and current trainees continue to experience significant education and training gaps.

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.

In-hospital statin underutilization among high-risk patients: delayed uptake of the 2013 cholesterol guidelines in a U.S. cohort.

OBJECTIVES: Clinician utilization of the 2013 cholesterol lowering guidelines remains variable and unknown. We sought to examine statin prescribing patterns and compare rates among specialists who treat high-risk cardiovascular patients admitted to the hospital. METHODS: We retrospectively (via chart review) examined four specialty groups: (i) Cardiology, (ii) Cardiovascular or Vascular (CV) Surgery, (iii) Neurology, and (iv) Internal Medicine. Adult patients were included based on a discharge diagnosis of acute coronary syndrome, coronary artery bypass graft surgery, carotid endarterectomy, acute ischemic stroke, transient ischemic attack, or high-risk chest pain. Prescribing patterns were evaluated 6 months and 18 months after the release of the 2013 guidelines. High-intensity statin was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg per day. RESULTS: 632 patients were included in our study. The following percentages of patients were discharged on high-intensity statin (6 months; 18 months): (i) Cardiology (80%; 85%), (ii) CV Surgery (52%, 65%), (iii) Neurology (59%; 66%), and (iv) Internal Medicine (45%; 48%). Among the four groups, Cardiology was the most likely to discharge patients on high-intensity statin (p < 0.001) in 2014 and in 2015. Cardiology, CV Surgery, and Neurology significantly increased the percentage of patients on high-intensity statin from pre-admission to time of discharge in both years. CONCLUSION: High-intensity statin therapy is underutilized among high-risk cardiovascular patients admitted to the hospital. Variations exist in prescribing patterns of different specialties who manage high-risk populations. This data can be used to test quality improvement interventions to improve rates of high-intensity statin utilization among high-risk patients prior to hospital discharge.

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.

Satisfaction and sustainability: a realist review of decentralized models of perinatal surgery for rural women.

INTRODUCTION: This article was developed as part of a larger realist review investigating the viability and efficacy of decentralized models of perinatal surgical services for rural women in the context of recent and ongoing service centralization witnessed in many developed nations. The larger realist review was commissioned by the British Columbia Ministry of Health and Perinatal Services of British Columbia, Canada. Findings from that review are addressed in this article specific to the sustainability of rural perinatal surgical sites and the satisfaction of providers that underpins their recruitment to and retention at such sites. METHODS: A realist method was used in the selection and analysis of literature with the intention to iteratively develop a sophisticated understanding of how perinatal surgical services can best meet the needs of women who live in rural and remote environments. The goal of a realist review is to examine what works for whom under what circumstances and why. The high sensitivity search used language (English) and year (since 1990) limiters in keeping with both a realist and rapid review tradition of using reasoned contextual boundaries. No exclusions were made based on methodology or methodological approach in keeping with a realist review. Databases searched included MEDLINE, PubMed, EBSCO, CINAHL, EBM Reviews, NHS Economic Evaluation Database and PAIS International for literature in December 2013. RESULTS: Database searching produced 103 included academic articles. A further 59 resources were added through pearling and 13 grey literature reports were added on recommendation from the commissioner. A total of 42 of these 175 articles were included in this article as specific to provider satisfaction and service sustainability. Operative perinatal practice was found to be a lynchpin of sustainable primary and surgical services in rural communities. Rural shortages of providers, including challenges with recruitment and retention, were found to be a complex issue, with scope of practice and contextual support as the key factors. Targeted educational programs, exposure to rural practice and living environments, accessible and appropriate continuing medical education, and strong clinical support (including locum coverage and sustainable on-call schedules) were all found to be areas of important consideration in rural service sustainability. CONCLUSIONS: Rural practice was found to be a site to actualize personal goals and values for providers. A broad and challenging scope of practice and the opportunity to participate in community level health improvements were seen as critical to the retention of providers. Without proper support, however, providers reported a feeling of being 'in too deep'. Common themes were a lack of health human resource redundancies, compromised access to specialist support and technology, and a lack of work-life balance. Burnout and attrition in perinatal surgical services threaten to destabilize other aspects of rural community health services, making the need to address sustainability of rural providers urgent.

Impact of Appropriate Use on the Estimated Radiation Risk to Men and Women Undergoing Radionuclide Myocardial Perfusion Imaging.

UNLABELLED: The impact of appropriate use criteria (AUC) for myocardial perfusion imaging (MPI) with SPECT on the estimated lifetime attributable risk (LAR) of cancer is unknown. METHODS: A cohort of 1,511 consecutive patients who underwent clinically indicated (99m)Tc-setamibi MPI were categorized into appropriate/uncertain (n = 823) versus inappropriate (n = 688) use groups according to the 2009 AUC and were prospectively followed for 27 ± 10 mo. Logistic regression models were used to determine the annualized probability of major adverse cardiac events (MACE) of cardiac death or myocardial infarction and the probability of revascularization within 6 mo of MPI, accounting for relevant covariates. We determined LAR for each subject on the basis of accepted risk estimates. We calculated MPI's benefit-to-risk ratios, defined by the annualized predicted MACE-to-LAR ratio and the predicted 6-mo-revascularization-to-LAR ratio. RESULTS: During follow-up, there were 22 MACE and 29 6-mo revascularizations. The administered radioactivity and effective radiation doses absorbed were similar between the study groups. Patients with inappropriate MPI had significantly higher LAR (median, 0.08% vs. 0.06%, P < 0.001), lower predicted MACE-to-LAR ratio (median, 1.5 vs. 4.3, P < 0.001), and lower predicted 6-mo-revascularization-to-LAR ratio (median, 5.4 vs. 15.5, P < 0.001). Women had higher LAR (median, 0.08% vs. 0.07%, P < 0.001) and lower predicted MACE-to-LAR ratio (median, 1.9 vs. 3.3, P < 0.001) and 6-mo-revascularization-to-LAR ratio (median, 4.4 vs. 17.5, P < 0.001). However, appropriate/uncertain use negated the difference between men and women in LAR (P = 0.94) and the predicted MACE-to-LAR ratio (P = 0.97). CONCLUSION: Inappropriate MPI use is associated with excess cancer risk and lower MPI's benefit-to-risk ratio. Appropriate/uncertain use neutralizes the sex gap in LAR with MPI.

A comparative assessment of coronary artery calcification on chest CT scans of patients referred to a cardio-oncology clinic.

BACKGROUND: The presence and burden of coronary artery calcium (CAC) is a strong predictor of cardiovascular events. In an effort to gain insight into the utility of CAC for coronary artery disease (CAD) screening in cancer patients with heart disease, we sought to determine the presence and burden of CAC detected on routine chest CT in patients referred to a cardio-oncology clinic, comparing them to a conventional cardiology clinic with the general population as controls. METHODS: Patients from the cardio-oncology clinic, general cardiology clinic, and the general clinic population at Rush University Medical Center who had a chest CT as part of their previous treatment were identified. Each CT scan was evaluated for presence, extent, and severity of CAC by 3 independent readers. RESULTS: In multivariate analysis, when compared with cardio-oncology clinic, CAC was more prevalent in the CT scans of cardiology patients (p = 0.04), but not the general clinic population (p = 0.5); CAC extent (p = 0.05) and severity (p = 0.05) was significantly higher in the cardiology patients but the extent (p = 0.05) and severity (p = 0.92) was similar in the general clinic population. CONCLUSION: Despite being matched by age and sex, controlling for other major cardiovascular risk factors, patients referred to our cardio-oncology clinic had similar and less prevalent/severe CAC burden compared with the general population and conventional cardiology clinics respectively. Whether this translates to less utility of CAC for CAD screening, or to less overall coronary events in a cardio-oncology clinic, is of interest.