Development of nutrition counselling resources for family medicine using the knowledge to action framework.

BACKGROUND: Obesity within the USA is a public health crisis. Nutrition counselling in primary care is an effective yet underutilized intervention because of both health care professional (HCP) barriers and patient barriers. OBJECTIVE: The purpose of this study was to: (i) identify HCP and patient perceptions, needs and barriers surrounding nutrition counselling, (ii) develop nutrition resources for HCPs and patients and (iii) assess utility of the approach. METHODS: Paper surveys were completed by 48 HCPs (response rate: 63.2%) and 185 patients in five family medicine clinics. Based on results, nutrition resources were developed and integrated into the electronic medical record. To assess utility, paper surveys were completed by 25 HCPs (response rate: 32.9%) after 4 weeks. Results were presented as descriptive statistics. RESULTS: Both HCPs and patients indicated that nutrition counselling is necessary to improve dietary behaviours, but barriers prevented HCPs from providing counselling and patients from improving dietary behaviours. HCPs indicated that improved patient handouts (74.5%), community nutrition classes (72.3%) and community cooking classes (63.8%) could enhance nutrition counselling. Patients identified that coupons and discounts (45.5%), sample meal plans and recipes (44.3%) and websites for recipes, grocery guides, and cooking videos (35.9%) would help them to consume a healthy diet. Patient education handouts, patient resource guides and HCP education were created. Following receipt, most HCPs (85%) indicated that the resources enhanced their nutrition counselling. CONCLUSIONS: HCP and patient barriers to nutrition counselling are multiple and varied. Design and implementation of an approach tailored to stakeholders' needs have potential to improve nutrition counselling in primary care.

Rigorous evaluation of a substance use and teen pregnancy prevention program for American Indian girls and their female caregivers: a study protocol for a randomized controlled trial.

BACKGROUND: Early sexual initiation is associated with higher risk for sexually transmitted infection, teen pregnancy, domestic violence and substance use in later adolescence and early adulthood. Native American adolescents are more likely to have early sexual initiation compared to other racial/ethnic groups. Few programs designed with and for Native adolescents to delay sexual initiation and substance use have been tested through rigorous evaluations. This is the protocol for the randomized controlled trial of the Asdzáán Be'eena' program, a teen pregnancy and substance use prevention program for young Native girls and their female caregivers. METHODS: N = 410 female adolescents ages 10-14 and their female caregivers will be enrolled in the study and randomized to the intervention or control arm. The intervention consists of the 11-session Asdzáán Be'eena' program. The control arm consists of mailed non-monetary incentives. All participants will complete evaluations at baseline and 3 follow-up timepoints (immediate, 6 and 12 months post intervention). Evaluations include measures to assess protective factors associated with delayed sexual initiation and substance use. DISCUSSION: This is one of the first rigorous evaluations of a gender-specific, culturally tailored teen pregnancy and substance use primary prevention program for Native girls and their female caregivers. If proven efficacious, Native communities will have a culturally appropriate program for promoting protective factors associated with delayed substance use and sexual risk taking. TRIAL REGISTRATION: NCT04863729 ; April 27, 2021.

Feasibility, Acceptability, and Preliminary Impact of Asdzáán Be'eená: An Intergenerational, Strength-Based, and Culturally Grounded Program to Improve the Health of Navajo Families.

Native American youth endure a complex interplay of factors that portend greater risk-taking behaviors and contribute to marked health disparities experienced in adolescence. The Asdzáán Be'eená ("Female Pathways" in Navajo) program was developed as a primary prevention program to prevent substance use and teen pregnancy among Navajo girls. The Asdzáán Be'eená program consists of 11 lessons delivered to dyads of girls ages 8 to 11 years and their female caregivers. Feasibility, acceptability, and preliminary impact on risk and protective factors were assessed through a pre-/post study design. Data were collected from girls and their female caregivers at baseline, immediate, and 3 months postprogram completion. Forty-seven dyads enrolled in the study, and 36 completed the 3-month evaluation. At 3 months postprogram, girls reported significant increases in self-esteem, self-efficacy, parent-child relationship, social support, cultural, and sexual health knowledge. Caregivers reported increased family engagement in Navajo culture and parent-child communication and improved child functioning (fewer internalizing and externalizing behaviors). Findings suggest Asdzáán Be'eená has potential to break the cycle of substance use and teen pregnancy in Native communities by improving protective and reducing risk factors associated with these adverse health outcomes. Additional rigorous efficacy trials are necessary to establish program effectiveness.

Caring for Children With Congenital Upper Extremity Differences.

The purpose of this article is to provide information about the changing landscapes in research, treatment, civil rights' protection, disability awareness, and accepted terminology in the care of children with congenital upper limb differences. This knowledge can guide clinical and nonclinical conversations between patients and their families.

Development of a Group Curriculum for Children With Congenital Upper Limb Difference (CULD) and Their Caregivers.

Caring for patients with congenital upper limb differences (CULD) requires an understanding of unique psychosocial challenges. The study purpose was to describe the needs of children with CULD and their caregivers to develop a group curriculum. This mixed-method study included 13 mothers and one father of children with CULD (age 3 months to 14 years; mean 7.2 ± 4.3 years) using Patient-Reported Outcomes Measurement Information System Parent Proxy Reports and caregiver interviews. Patient-Reported Outcomes Measurement Information System Peer Relationships (M = 48.1 ± 10.9) and Pain Interference (M = 44.5 ± 7.5) T-scores were average with below average scores for Physical Function: Upper Extremity (M = 31.9 ± 12.1). Caregivers expressed high interest in groups to create community and mutual support covering themes of responding to questions from strangers, social and coping skills, building self-confidence, accessing resources, advocacy skills, and advice from adults with CULD. Access to a support group with a curriculum addressing CULD-related patient and family needs may improve care.

Republished: going glass to digital: virtual microscopy as a simulation-based revolution in pathology and laboratory science.

The recent technological advance of digital high resolution imaging has allowed the field of pathology and medical laboratory science to undergo a dramatic transformation with the incorporation of virtual microscopy as a simulation-based educational and diagnostic tool. This transformation has correlated with an overall increase in the use of simulation in medicine in an effort to address dwindling clinical resource availability and patient safety issues currently facing the modern healthcare system. Virtual microscopy represents one such simulation-based technology that has the potential to enhance student learning and readiness to practice while revolutionising the ability to clinically diagnose pathology collaboratively across the world. While understanding that a substantial amount of literature already exists on virtual microscopy, much more research is still required to elucidate the full capabilities of this technology. This review explores the use of virtual microscopy in medical education and disease diagnosis with a unique focus on key requirements needed to take this technology to the next level in its use in medical education and clinical practice.

Utility of postmortem bacterial culture of abdominal organs at autopsy of young calves.

Postmortem bacterial culture is controversial in human medicine, and veterinary-specific research in this area is lacking. To address this knowledge gap, we cultured liver, kidney, and spleen individually from on-farm calf mortalities to determine the number of bacterial species present, concordance between organ cultures, and agreement with gross and histologic findings. We hypothesized that the spleen, a filtering organ, would be the most useful organ with the least amount of postmortem contamination given that it does not have a direct conduit to a bacterial population. Fresh liver, kidney, and spleen were collected for culture from 30 calves 5-28-d-old with various causes of mortality. Bacterial growth of ≥2 species was observed in ~48% of cultures, with Escherichia coli and Streptococcus spp. being most frequent. One bacterial species was present in 20% of cultures, with E. coli predominating. No growth was observed in ~32% of cultures. In 43% of cases, there was agreement in the culture results for all 3 organs; however, the majority were mixed bacterial growth. The best agreement was observed when there were no gross and/or histologic septic lesions in target organs and no bacterial growth on culture. The spleen was not helpful in determining bacterial significance in comparison to kidney or liver.

The ACTIV-6 Stakeholder Advisory Committee: a model for virtual engagement in decentralized clinical trials.

Introduction: Engaging patients, caregivers, and other stakeholders to help guide the research process is a cornerstone of patient-centered research. Lived expertise may help ensure the relevance of research questions, promote practices that are satisfactory to research participants, improve transparency, and assist with disseminating findings. Methods: Traditionally engagement has been conducted face-to-face in the local communities in which research operates. Decentralized platform trials pose new challenges for the practice of engagement. We used a remote model for stakeholder engagement, relying on Zoom meetings and blog communications. Results: Here we describe the approach used for research partnership with patients, caregivers, and clinicians in the planning and oversight of the ACTIV-6 trial and the impact of this work. We also present suggestions for future remote engagement. Conclusions: The ACTIV-6 experience may inform proposed strategies for future engagement in decentralized trials.

Feasibility and Acceptability of Virtual Implementation of a Sexual Reproductive Health Teen Pregnancy Prevention Program for Native Youth.

American Indian/Alaska Native (Native) youth face high rates of substance use, teen pregnancy and sexually transmitted infections. In response to the COVID-19 pandemic, Respecting the Circle of Life (RCL), a sexual reproductive health and teen pregnancy prevention program for Native youth and their trusted adult, was adapted and delivered in a virtual format with Native youth in a rural, reservation-based Native community. This manuscript describes the adaptation process, feasibility, and acceptability of virtual program implementation. The manuscript describes the process of rapidly shifting the RCL program into a virtual format. In addition, a mixed-methods process evaluation of implementation forms, program feedback forms, in-depth interviews with participants, and staff debriefing sessions was completed. Results show virtual implementation of RCL is both feasible and acceptable for Native youth and their trusted adults. A key benefit of virtual implementation is the flexibility in scheduling and ability to have smaller groups of youth, which offers greater privacy for youth participants compared to in-person implementation with larger groups. However, internet connectivity did present a challenge for virtual implementation. Ultimately, sexual and reproductive health programs seeking to reach Native youth and families should consider virtual implementation methods, both during and outside of pandemic situations.

Natural history of a bighorn sheep pneumonia epizootic: Source of infection, course of disease, and pathogen clearance.

A respiratory disease epizootic at the National Bison Range (NBR) in Montana in 2016-2017 caused an 85% decline in the bighorn sheep population, documented by observations of its unmarked but individually identifiable members, the subjects of an ongoing long-term study. The index case was likely one of a small group of young bighorn sheep on a short-term exploratory foray in early summer of 2016. Disease subsequently spread through the population, with peak mortality in September and October and continuing signs of respiratory disease and sporadic mortality of all age classes through early July 2017. Body condition scores and clinical signs suggested that the disease affected ewe groups before rams, although by the end of the epizootic, ram mortality (90% of 71) exceeded ewe mortality (79% of 84). Microbiological sampling 10 years to 3 months prior to the epizootic had documented no evidence of infection or exposure to Mycoplasma ovipneumoniae at NBR, but during the epizootic, a single genetic strain of M. ovipneumoniae was detected in affected animals. Retrospective screening of domestic sheep flocks near the NBR identified the same genetic strain in one flock, presumptively the source of the epizootic infection. Evidence of fatal lamb pneumonia was observed during the first two lambing seasons following the epizootic but was absent during the third season following the death of the last identified M. ovipneumoniae carrier ewe. Monitoring of life-history traits prior to the epizootic provided no evidence that environmentally and/or demographically induced nutritional or other stress contributed to the epizootic. Furthermore, the epizootic occurred despite proactive management actions undertaken to reduce risk of disease and increase resilience in this population. This closely observed bighorn sheep epizootic uniquely illustrates the natural history of the disease including the (presumptive) source of spillover, course, severity, and eventual pathogen clearance.

Variations in Awareness of Association Between Adverse Pregnancy Outcomes and Cardiovascular Risk by Specialty.

INTRODUCTION: Cardiovascular disease (CVD) remains the leading cause of death among women. Adverse pregnancy outcomes (APOs), including pre-eclampsia (PE), gestational diabetes mellitus (GDM) and pre-term birth (PTB) are associated with future maternal CVD risk. However, data on awareness of the association between APOs and long-term CVD risk among physicians in different specialties are lacking. This study assessed awareness of this association and whether this knowledge varies by specialty. METHODS: An anonymous web-based voluntary survey was sent to physicians in internal medicine (IM), family medicine (FM), obstetrics-gynecology (Ob-Gyn) and cardiology. The questions aimed to assess a physician's knowledge regarding identification of APOs and their association with future CVD risk and knowledge of CVD risk factor screening in women with APOs and future CVD risk. RESULTS: The survey was completed by 53 physicians, of whom 21% were in IM, 26% in FM, 23% in Ob-Gyn and 30% in cardiology. Based on the responses, cardiologists screened most frequently for APOs, with 56% always screening a female patient and 31% often screening. Only half of the IM and FM physicians acknowledged awareness of the association between APOs and CVD risk. Respondents in all specialties recognized PE and GDM as APOs linked to long-term maternal CVD risk, but failed to associate PTB as an APO. The majority of physicians in IM, FM and cardiology also lacked the knowledge of how often to appropriately screen for CVD risk factors associated with APOs. CONCLUSION: Awareness of the association between APO and future maternal CVD risk varies by specialty. A significant percentage of the physicians who responded to the survey did not routinely ask about APOs when assessing CVD risk and failed to identify PTB as a risk factor for APOs. Education on this topic and targeted efforts to improve screening for APOs are needed within all specialties to help reduce CVD morbidity and mortality.

Case Report: Can Inhaled Adenosine Attenuate COVID-19?

This case report demonstrates a small repetition of the case series carried out in Italy wherein inhaled adenosine was administered to patients experiencing severe and worsening coronavirus disease-2019 (COVID-19). The two cases are important not only because they were the first of their type in the United States, but also because both patients were DNR/DNI and were therefore expected to die. Study repetition is vitally important in medicine. New work in pharmacology hypothesizes that adenosine-regulator proteins may play a role in the pathogenesis of COVID-19 infection. Furthermore, adenosine, by interacting with cell receptor sites, has pluripotent effects upon inflammatory cells, is anti-inflammatory, and is important in tissue hypoxia signaling. Inhaled adenosine is potentially safe; thousands have received it for asthmatic challenge testing. The effects of adenosine in these two cases were rapid, positive, and fit the pharmacologic hypotheses (as seen in prior work in this journal) and support its role as a therapeutic nucleoside.

Community Engagement Mental Health Model for Home Treatment of Psychosis in Jamaica.

Economic constraints in low- and middle-income countries like Jamaica challenge health care services to identify efficient methods of mental health care. This column describes the community engagement mental health (CEMH) model in Kingston, Jamaica, for patients with mental disorders, including psychosis. The CEMH uses a task sharing methodology to deliver acute psychiatric treatment within a community setting. Preliminary results suggest high service user and provider satisfaction and good clinical outcomes. The authors discuss challenges and benefits of the CEMH in terms of its potential as a cost-effective service innovation.

A pilot study of the effects of Mycoplasma ovipneumoniae exposure on domestic lamb growth and performance.

Mycoplasma ovipneumoniae is a globally distributed pathogen that has been associated with pneumonia in both domestic and wild Caprinae. It is closely related to M. hyopneumoniae, a respiratory pathogen of swine that is associated with decreased growth rates of pigs as well as clinical respiratory disease. In order to assess the effects of M. ovipneumoniae on lamb performance, we generated a cohort of lambs free of M. ovipneumoniae by segregation of test negative ewes after lambing, then compared the growth and carcass quality traits of M. ovipneumoniae-free and -colonized lambs from weaning to harvest. Some signs of respiratory disease were observed during the feeding trial in both lamb groups, but the M. ovipneumoniae-exposed group included more affected lambs and higher average disease scores. At harvest, lungs of lambs in both groups showed few grossly visible lesions, although the M. ovipneumoniae-exposed group did exhibit increased microscopic lung lesions (P<0.05). In addition, M. ovipneumoniae exposed lambs produced lower average daily gains (P<0.05), and lower yield grade carcasses (P<0.05) compared to those of non-exposed lambs. The results demonstrated the feasibility of test and segregation for elimination of M. ovipneumoniae from groups of sheep and suggested that this pathogen may impair lamb growth and productivity even in the absence of overt respiratory disease.

Detection of Mycoplasma ovipneumoniae in Pneumonic Mountain Goat ( Oreamnos americanus) Kids.

We documented bronchopneumonia in seven mountain goat ( Oreamnos americanus) kid mortalities between 2011 and 2015 following a pneumonia epizootic in bighorn sheep ( Ovis canadensis) and sympatric mountain goats in the adjacent East Humboldt Range and Ruby Mountains in Elko County, Nevada, US. Gross and histologic lesions resembled those described in bighorn lambs following all-age epizootics, and Mycoplasma ovipneumoniae was detected with real-time PCR in the lower and upper respiratory tracts of all kids. Mannheimia haemolytica, with one isolate being leukotoxigenic, was cultured from the upper respiratory tract of five kids, and in one kid, a leukotoxigenic strain of Mannheimia glucosida was isolated from both upper and lower respiratory tracts. During this same period, 75 mountain goats within the two populations were marked and sampled for respiratory pathogens, and M. ovipneumoniae, leukotoxigenic Bibersteinia trehalosi, and Mannheimia haemolytica were identified. The M. ovipneumoniae recovered from the kid mortalities shared the same DNA sequence-based strain type detected in the adult goats and sympatric bighorn sheep during and after the 2009-10 pneumonia outbreak. Clinical signs in affected kids, as well as decreased annual kid recruitment, also resembled reports in bighorn lambs from some herds following all-age pneumonia-associated die-offs. Mycoplasma ovipneumoniae, Pasteurellaceae spp., and other respiratory bacterial pathogens should be considered as a cause of pneumonia with potential population-limiting effects in mountain goats.

Evidence for persistent Bovine viral diarrhea virus infection in a captive mountain goat (Oreamnos americanus).

Bovine viral diarrhea (BVD) viruses are pestiviruses that have been isolated from domestic and wild ruminants. There is serologic evidence of pestiviral infection in more than 40 species of free-range and captive mammals. Vertical transmission can produce persistently infected animals that are immunotolerant to the infecting strain of Bovine viral diarrhea virus (BVDV) and shed virus throughout their lives. Seven species (white-tailed deer, mouse deer, eland, domestic cattle, alpaca, sheep, and pigs) have been definitively identified as persistently infected with BVDV. This study provides serological, molecular, immunohistochemical, and histological evidence for BVDV infection in 2 captive mountain goats from a zoological park in Idaho. The study was triggered by isolation of BVDV from tissues and immunohistochemical identification of viral antigen within lesions of a 7-month-old male mountain goat (goat 1). Blood was collected from other mountain goats and white-tailed and mule deer on the premises for BVDV serum neutralization, viral isolation, and reverse transcription polymerase chain reaction. One 3-month-old mountain goat (goat 2) was antibody negative and BVDV positive in serum samples collected 3 months apart. This goat subsequently died, and though still antibody negative, BVDV was isolated from tissues and identified by immunohistochemistry within lesions. Sequencing and phylogenetic analysis identified the isolates as BVDV-2. These findings provide evidence of persistent infection in a mountain goat, underscoring the need for pestivirus control strategies for wild ruminants in zoological collections.

Transitional care management in the outpatient setting.

Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required.

Calling at the highway: The spatiotemporal constraint of road noise on Pacific chorus frog communication.

Loss of acoustic habitat due to anthropogenic noise is a key environmental stressor for vocal amphibian species, a taxonomic group that is experiencing global population declines. The Pacific chorus frog (Pseudacris regilla) is the most common vocal species of the Pacific Northwest and can occupy human-dominated habitat types, including agricultural and urban wetlands. This species is exposed to anthropogenic noise, which can interfere with vocalizations during the breeding season. We hypothesized that Pacific chorus frogs would alter the spatial and temporal structure of their breeding vocalizations in response to road noise, a widespread anthropogenic stressor. We compared Pacific chorus frog call structure and ambient road noise levels along a gradient of road noise exposures in the Willamette Valley, Oregon, USA. We used both passive acoustic monitoring and directional recordings to determine source level (i.e., amplitude or volume), dominant frequency (i.e., pitch), call duration, and call rate of individual frogs and to quantify ambient road noise levels. Pacific chorus frogs were unable to change their vocalizations to compensate for road noise. A model of the active space and time ("spatiotemporal communication") over which a Pacific chorus frog vocalization could be heard revealed that in high-noise habitats, spatiotemporal communication was drastically reduced for an individual. This may have implications for the reproductive success of this species, which relies on specific call repertoires to portray relative fitness and attract mates. Using the acoustic call parameters defined by this study (frequency, source level, call rate, and call duration), we developed a simplified model of acoustic communication space-time for this species. This model can be used in combination with models that determine the insertion loss for various acoustic barriers to define the impact of anthropogenic noise on the radius of communication in threatened species. Additionally, this model can be applied to other vocal taxonomic groups provided the necessary acoustic parameters are determined, including the frequency parameters and perception thresholds. Reduction in acoustic habitat by anthropogenic noise may emerge as a compounding environmental stressor for an already sensitive taxonomic group.