No test medical abortion - a review of the evidence on selective use of preabortion testing.

PURPOSE OF REVIEW: The last decade has seen a cascade of different telemedicine models for medical abortion (MA) being tested and implemented. Among these service delivery models is the 'no-test' MA model, in which care is provided remotely and eligibility for the MA is based on history alone. The purpose of this review is to provide an overview of the existing evidence for no-test MA. RECENT FINDINGS: The evidence base for no-test MA relies heavily on cohort and noncomparative studies predominantly from high resource settings. Recent findings indicate that no-test MA is safe, effective, and highly acceptable. Diagnoses of ectopic pregnancy and underestimation of gestational age were rare. Identified advantages included shortening time to access MA and mitigating access barriers such as cost, and geographical barriers. Abortion seekers valued omitting the ultrasound citing reasons such as privacy concerns, costs, more flexibility, and control. The impacts of no-test MA on unscheduled postabortion contacts and visits and on contraceptive use were unclear due to limited evidence. SUMMARY: No-test MA can be provided to complement other care pathways including those with some or no in-person care. Further research is needed to allow for widespread adoption of no-test MA and scale-up in a variety of contexts, including low-resource settings.

The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study.

OBJECTIVES: This prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). METHODS: We recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 µg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. RESULTS: Overall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. CONCLUSIONS: Pretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

Aging Does Not Alter Ankle, Muscle, and Tendon Stiffness at Low Loads Relevant to Stance.

Older adults have difficulty maintaining balance when faced with postural disturbances, a task that is influenced by the stiffness of the triceps surae and Achilles tendon. Age-related changes in Achilles tendon stiffness have been reported at matched levels of effort, but measures typically have not been made at matched loads, which is important due to age-dependent changes in strength. Moreover, there has been limited investigation into age-dependent changes in muscle stiffness. Here, we investigate how age alters muscle and tendon stiffness and their influence on ankle stiffness. We hypothesized that age-related changes in muscle and tendon contribute to reduced ankle stiffness in older adults and evaluated this hypothesis when either load or effort were matched. We used B-mode ultrasound with joint-level perturbations to quantify ankle, muscle, and tendon stiffness across a range of loads and efforts in seventeen healthy younger and older adults. At matched loads relevant to standing and the stance phase of walking, there was no significant difference in ankle, muscle, or tendon stiffness between groups (all p > 0.13). However, at matched effort, older adults exhibited a significant decrease in ankle (27%; p = 0.008), muscle (37%; p = 0.02), and tendon stiffness (22%; p = 0.03) at 30% of maximum effort. This is consistent with our finding that older adults were 36% weaker than younger adults in plantarflexion (p = 0.004). Together, these results indicate that, at the loads tested in this study, there are no age-dependent changes in the mechanical properties of muscle or tendon, only differences in strength that result in altered ankle, muscle, and tendon stiffness at matched levels of effort.

At matched loads, aging does not alter ankle, muscle, or tendon stiffness.

Older adults have difficulty maintaining balance when faced with postural disturbances, a task that is influenced by the stiffness of the triceps surae and Achilles tendon. Age-related changes in Achilles tendon stiffness have been reported at matched levels of effort, but measures typically have not been made at matched loads, which is important due to age-dependent changes in strength. Moreover, age-dependent changes in muscle stiffness have yet to be tested. Here, we investigate how age alters muscle and tendon stiffness and their influence on ankle stiffness. We hypothesized that age-related changes in muscle and tendon contribute to reduced ankle stiffness in older adults and evaluated this hypothesis when either load or effort were matched. We used B-mode ultrasound with joint-level perturbations to quantify ankle, muscle, and tendon stiffness across a range of loads and efforts in seventeen healthy younger and older adults. At matched loads, there was no significant difference in ankle, muscle, or tendon stiffness between groups (all p>0.13). However, at matched effort, older adults exhibited a significant decrease in ankle (27%; p=0.008), muscle (37%; p=0.02), and tendon stiffness (22%; p=0.03) at 30% of maximum effort. This is consistent with our finding that older adults were 36% weaker than younger adults in plantarflexion (p=0.004). Together these results indicate that, at the loads tested in this study, there are no age-dependent changes in the mechanical properties of muscle or tendon, only differences in strength that result in altered ankle, muscle, and tendon stiffness at matched levels of effort.

From molecules to behavior: Implications for perineuronal net remodeling in learning and memory.

Perineuronal nets (PNNs) are condensed extracellular matrix (ECM) structures found throughout the central nervous system that regulate plasticity. They consist of a heterogeneous mix of ECM components that form lattice-like structures enwrapping the cell body and proximal dendrites of particular neurons. During development, accumulating research has shown that the closure of various critical periods of plasticity is strongly linked to experience-driven PNN formation and maturation. PNNs provide an interface for synaptic contacts within the holes of the structure, generally promoting synaptic stabilization and restricting the formation of new synaptic connections in the adult brain. In this way, they impact both synaptic structure and function, ultimately influencing higher cognitive processes. PNNs are highly plastic structures, changing their composition and distribution throughout life and in response to various experiences and memory disorders, thus serving as a substrate for experience- and disease-dependent cognitive function. In this review, we delve into the proposed mechanisms by which PNNs shape plasticity and memory function, highlighting the potential impact of their structural components, overall architecture, and dynamic remodeling on functional outcomes in health and disease.

A descriptive study of percutaneous injuries in National Healthcare Group POLYCLINICS dental clinics in Singapore from 2014 to 2020.

INTRODUCTION: All dental staff face risk of percutaneous injuries (PCI)s. Blood-borne diseases may be transmitted to staff via contaminated sharp instruments. Hence there are significant impacts on staff when PCIs occur. Though a PCI is an occupational hazard, it is preventable. AIM: This study aims to identify factors associated with PCIs among dental staff by evaluating the circumstances and staff designations involved. METHODS: PCIs were reported through an electronic incident reporting system from 2014 to 2020. Reports involved their nature and extent. Statistical analysis was carried out to find associations between factors such as injury site, type of instrument and staff designation. RESULTS: A total of 63 PCIs were included in this study. The type of instrument was found to be significantly associated with staff designation (p = 0.04, p < 0.05) with significantly more dental burs causing injury in dentists and more injuries caused by 'other instruments' in health attendants (p = 0.0083). Majority of PCIs occurred in dentists, then dental assistants and health attendants. Staff designation was significantly associated with the instance where PCIs occurred (p < 0.001). Dentists and dental assistants were more likely to sustain injuries during a dental procedure than before procedure and after procedure (p = 0.0167). The mean incidence of PCIs among our dentists was 15.6/100. CONCLUSIONS: All dental staff are at risk of PCIs however dentists sustain the highest number of PCIs. Needles, dental burs and metal matrices are the top three instruments. Targeted interventions might help prevent/reduce PCIs.

Non-linear properties of the Achilles tendon determine ankle impedance over a broad range of activations in humans.

Regulating ankle mechanics is essential for controlled interactions with the environment and rejecting unexpected disturbances. Ankle mechanics can be quantified by impedance, the dynamic relationship between an imposed displacement and the torque generated in response. Ankle impedance in the sagittal plane depends strongly on the triceps surae and Achilles tendon, but their relative contributions remain unknown. It is commonly assumed that ankle impedance is controlled by changing muscle activation and, thereby, muscle impedance, but this ignores that tendon impedance also changes with activation-induced loading. Thus, we sought to determine the relative contributions from the triceps surae and Achilles tendon during conditions relevant to postural control. We used a novel technique that combines B-mode ultrasound imaging with joint-level perturbations to quantify ankle, muscle and tendon impedance simultaneously across activation levels from 0% to 30% of maximum voluntary contraction. We found that muscle and tendon stiffness, the static component of impedance, increased with voluntary plantarflexion contractions, but that muscle stiffness exceeded tendon stiffness at very low loads (21±7 N). Above these loads, corresponding to 1.3% of maximal strength for an average participant in our study, ankle stiffness was determined predominately by Achilles tendon stiffness. At approximately 20% MVC for an average participant, ankle stiffness was 4 times more sensitive to changes in tendon stiffness than to changes in muscle stiffness. We provide the first empirical evidence demonstrating that the nervous system, through changes in muscle activations, leverages the non-linear properties of the Achilles tendon to increase ankle stiffness during postural conditions.

Shear wave ultrasound elastography of the biceps brachii can be used as a precise proxy for passive elbow torque in individuals with hemiparetic stroke.

Muscle tissue is prone to changes in composition and architecture following stroke. Changes in muscle tissue of the extremities are thought to increase resistance to muscle elongation or joint torque under passive conditions. These effects likely compound neuromuscular impairments, exacerbating movement function. Unfortunately, conventional rehabilitation is devoid of precise measures and relies on subjective assessments of passive joint torques. Shear wave ultrasound elastography, a tool to measure muscle mechanical properties, may be readily available for use in the rehabilitation setting as a precise measure, albeit at the muscle-tissue level. To support this postulation, we evaluated the criterion validity of shear wave ultrasound elastography of the biceps brachii; we investigated its relationship with a laboratory-based criterion measure for quantifying elbow joint torque in individuals with moderate to severe chronic stroke. Additionally, we evaluated construct validity, with the specific sub-type of hypothesis testing of known groups, by testing the difference between arms. Measurements were performed under passive conditions at seven positions spanning the arc of elbow joint flexion-extension in both arms of nine individuals with hemiparetic stroke. Surface electromyography was utilized for threshold-based confirmation of muscle quiescence. A moderate relationship between the shear wave velocity and elbow joint torque was identified, and both metrics were greater in the paretic arm. Data supports the progression toward a clinical application of shear wave ultrasound elastography in evaluating altered muscle mechanical properties in stroke, while acknowledging that undetectable muscle activation or hypertonicity may contribute to the measurement. Shear wave ultrasound elastography may augment the conventional method of manually testing joint mobility by providing a high-resolution precise value. Tissue-level measurement may also assist in identifying new therapeutic targets for patient-specific impairment-based interventions.

Axial stress determines the velocity of shear wave propagation in passive but not active muscles in vivo.

Ultrasound shear wave elastography can be used to characterize mechanical properties of unstressed tissue by measuring shear wave velocity (SWV), which increases with increasing tissue stiffness. Measurements of SWV have often been assumed to be directly related to the stiffness of muscle. Some have also used measures of SWV to estimate stress, since muscle stiffness and stress covary during active contractions, but few have considered the direct influence of muscle stress on SWV. Rather, it is often assumed that stress alters the material properties of muscle, and in turn, shear wave propagation. The objective of this study was to determine how well the theoretical dependency of SWV on stress can account for measured changes of SWV in passive and active muscles. Data were collected from six isoflurane-anesthetized cats; three soleus muscles and three medial gastrocnemius muscles. Muscle stress and stiffness were measured directly along with SWV. Measurements were made across a range of passively and actively generated stresses, obtained by varying muscle length and activation, which was controlled by stimulating the sciatic nerve. Our results show that SWV depends primarily on the stress in a passively stretched muscle. In contrast, the SWV in active muscle is higher than would be predicted by considering only stress, presumably due to activation-dependent changes in muscle stiffness. Our results demonstrate that while SWV is sensitive to changes in muscle stress and activation, there is not a unique relationship between SWV and either of these quantities when considered in isolation.NEW & NOTEWORTHY Ultrasound shear wave elastography may be an inexpensive way to measure muscle stress in passive muscle. Here, using a cat model we directly measured shear wave velocity (SWV), muscle stress, and muscle stiffness. Our results show that SWV depends primarily on the stress in a passively stretched muscle. In contrast, the SWV in active muscle is higher than would be predicted by considering only stress, presumably due to activation-dependent changes in muscle stiffness.

Envarsus XR® pharmacokinetics in adolescents post-kidney transplantation - A pilot study.

INTRODUCTION: Envarsus XR® (LCPT), a once daily dosage formulation of tacrolimus, is an FDA-approved medication in adult renal transplant recipients (RTRs). There are limited data on its pharmacokinetics (PK) in adolescent RTRs. We report here the PK profile of LCPT in adolescent RTRs. METHODS: The dose of LCPT was determined using a dose conversion ratio targeting 0.7 relative to the total daily immediate-release tacrolimus (IR-Tac) dose. On day 7 after converting to LCPT, patients had an abbreviated PK assessment with sampling at: 0 h (pre-dose), 8-, and 12-h post-dose. The PK data analysis was performed using Bayesian estimators. Our results were compared to those of published adult PK data for LCPT and pediatric PK data for IR-Tac and extended release tacrolimus (ER-Tac) formulation (Advagraf). RESULTS: PK data from three adolescent patients on LCPT were evaluated. The mean (±SD) area under the time-concentration curve (AUC) was 240 (±20.22) h*ng/mL. The mean Tmax was 9.01 ± 2.12 h, and the % fluctuation was 77.71 ± 3.96%. The AUC, Tmax , and % fluctuation were similar to reported results in adult patients taking LCPT. The AUC was higher and the Tmax was longer than what has been reported in pediatric patients taking IR-Tac and ER-Tac. In addition, the LCPT group showed a lower % fluctuation than patients receiving ER-Tac. CONCLUSION: The PK evaluation of LCPT in adolescent RTRs showed similar results to adults. Adolescents taking LCPT had a higher AUC, a more attenuated Tmax , and a lower fluctuation than that seen with ER-Tac in pediatrics.

Approximating the influence of external factors on the technical efficiency score of hospital care: evidence from the federal states of Germany.

BACKGROUND: A good health care system and, especially, the provision of efficient hospital care are the goals of national and regional health policies. However, the scope of general hospital care in the 16 federal states in Germany varies considerably from region to region. The objectives of this paper are to evaluate the technical efficiencies of all general hospitals of the 16 federal states for the period from 2015 to 2020, to find out the relation between the exogenous factors and score of efficiency, and also the influence of the COVID-19 pandemic on the results of the technical efficiency of hospital care in the German states. METHODS: A two-step approach was used. First, an input-oriented Data Envelopment Analysis model with constant returns to scale and variable returns to scale was applied for the 6-year period from 2015 to 2020. The calculation of technical efficiency according to the input-oriented DEA model contains the three components-total technical efficiency (TTE), pure technical efficiency (PTE) and scale efficiency (SE). In the second stage, the influence of exogenous variables on the previously determined technical efficiency was evaluated by applying the tobit regression analysis. RESULTS: Although the level of average technical efficiency of about 90% is high, total technical efficiency deteriorated steadily from 2015 to 2020. Its lowest point at around 78%, was in the year 2020. The deterioration of the average technical efficiency is notably influenced by the lower results in the years 2019 and 2020. The decomposition of technical efficiency also revealed that the deterioration of overall average efficiency was influenced by both pure technical efficiency (PTE) and scale efficiency (SE). Based on the tobit regression analysis performed, it was possible to conclude that the change in the efficiency score can be explained by the influence of exogenous factors only from 6.4% for overall efficiency and from 7.1% for scale efficiency. CONCLUSIONS: The results of the analysis of the overall technical efficiency reveal that the aggregated data of all general hospitals of all 16 federal states show a steadily worsening total technical efficiency every year since 2015. Although, especially, the deterioration of the year 2020 with the occurrence of COVID-19 pandemic, contributes to a deteriorated efficiency average, the deterioration of the efficiency values, based on the analysis performed, is also observable between the years 2016 and 2019. Considering the output generated, for inefficient units and the relevant policy authorities in the hospital sector, it can be recommended that the number of beds and in particular the number of physicians, should be reduced as inputs. Based on this study, it is also recommended that decisions to increase the efficiency of general hospitals should be made with consideration of exogenous factors such as the change in the number of general hospitals or the population density in the respective state, as these had explanatory value in connection with the increase in efficiency values. Due to the wide variation in the size of the federal states, the recommendation is more appropriate for federal states with low population density.

Emergency contraception subsidy in Canada: a comparative policy analysis.

BACKGROUND: In Canada, cost prohibits access to emergency contraception (EC) which may assist to prevent unintended pregnancy. The drug, ulipristal acetate (UPA-EC), is more clinically effective and cost-effective than the prior standard levonorgestrel (LNG-EC). We analyzed provincial EC subsidization policies and examined underlying decision-making processes. METHODS: We undertook documentary analysis of provincial EC subsidization policies in publicly available drug formularies. We conducted semi-structured interviews with key informants to explore the processes underlying current policies. RESULTS: Quebec is the only province to subsidize UPA-EC, whilst all ten provinces subsidize LNG-EC. As such, provincial EC subsidization policies do not align with the latest UPA-EC evidence. Interviews revealed that evidence was valued in the policymaking process and formulary decisions were made through interdisciplinary consensus. CONCLUSIONS: We identify a gap between EC subsidization policies and the latest evidence. Institutional structures affect policies reflecting evolving evidence. Increasing interdisciplinary mechanisms may encourage evidence-based policies.

Simultaneous Quantification of Ankle, Muscle, and Tendon Impedance in Humans.

OBJECTIVE: Regulating the impedance of our joints is essential for the effective control of posture and movement. The impedance of a joint is governed mainly by the mechanical properties of the muscle-tendon units spanning it. Many studies have quantified the net impedance of joints but not the specific contributions from the muscles and tendons. The inability to quantify both muscle and tendon impedance limits the ability to determine the causes underlying altered movement control associated with aging, neuromuscular injury, and other conditions that have different effects on muscle and tendon properties. Therefore, we developed a technique to quantify joint, muscle, and tendon impedance simultaneously and evaluated this technique at the human ankle. METHODS: We used a single degree of freedom actuator to deliver pseudorandom rotations to the ankle while measuring the corresponding torques. We simultaneously measured the displacement of the medial gastrocnemius muscle-tendon junction with B-mode ultrasound. From these experimental measurements, we were able to estimate ankle, muscle, and tendon impedance using non-parametric system identification. RESULTS: We validated our estimates by comparing them to previously reported measurements of muscle and tendon stiffness, the position-dependent component of impedance, to demonstrate that our technique generates reliable estimates of these properties. CONCLUSION: Our approach can be used to clarify the respective contributions from the muscle and tendon to the net mechanics of a joint. SIGNIFICANCE: This is a critical step forward in the ultimate goal of understanding how muscles and tendons govern ankle impedance during posture and movement.

Evidence For Cannabidiol Modulation of Serotonergic Transmission in a Model of Osteoarthritis via in vivo PET Imaging and Behavioral Assessment.

Background: Preclinical studies indicate that cannabidiol (CBD), the primary nonaddictive component of cannabis, has a wide range of reported pharmacological effects such as analgesic and anxiolytic actions; however, the exact mechanisms of action for these effects have not been examined in chronic osteoarthritis (OA). Similar to other chronic pain syndromes, OA pain can have a significant affective component characterized by mood changes. Serotonin (5-HT) is a neurotransmitter implicated in pain, depression, and anxiety. Pain is often in comorbidity with mood and anxiety disorders in patients with OA. Since primary actions of CBD are analgesic and anxiolytic, in this first in vivo positron emission tomography (PET) imaging study, we investigate the interaction of CBD with serotonin 5-HT1A receptor via a combination of in vivo neuroimaging and behavioral studies in a well-validated OA animal model. Methods: The first aim of this study was to evaluate the target involvement, including the evaluation of modulation by acute administration of CBD, or a specific target antagonist/agonist intervention, in control animals. The brain 5-HT1A activity/availability was assessed via in vivo dynamic PET imaging (up to 60 min) using a selective 5-HT1A radioligand ([18F]MeFWAY). Tracer bindings of 17 ROIs were evaluated based on averaged SUVR values over the last 10 min using CB as the reference region. We subsequently examined the neurochemical and behavioral alterations in OA animals (induction with monosodium iodoacetate (MIA) injection), as compared to control animals, via neuroimaging and behavioral assessment. Further, we examined the effects of repeated low-dose CBD treatment on mechanical allodynia (von Frey tests) and anxiety-like (light/dark box tests, L/D), depressive-like (forced swim tests, FST) behaviors in OA animals, as compared to after vehicle treatment. Results: The tracer binding was significantly reduced in control animals after an acute dose of CBD administered intravenously (1.0 mg/kg, i.v.), as compared to that for baseline. This binding specificity to 5-HT1A was further confirmed by a similar reduction of tracer binding when a specific 5-HT1A antagonist WAY1006235 was used (0.3 mg/kg, i.v.). Mice subjected to the MIA-induced OA for 13-20 days showed a decreased 5-HT1A tracer binding (25% to 41%), consistent with the notion that 5-HT1A plays a role in the modulation of pain in OA. Repeated treatment with CBD administered subcutaneously (5 mg/kg/day, s.c., for 16 days after OA induction) increased 5-HT1A tracer binding, while no significant improvement was observed after vehicle. A trend of increased anxiety or depressive-like behavior in the light/dark box or forced swim tests after OA induction, and a decrease in those behaviors after repeated low-dose CBD treatment, are consistent with the anxiolytic action of CBD through 5HT1A receptor activation. There appeared to be a sex difference: females seem to be less responsive at the baseline towards pain stimuli, while being more sensitive to CBD treatment. Conclusion: This first in vivo PET imaging study in an OA animal model has provided evidence for the interaction of CBD with the serotonin 5-HT1A receptor. Behavioral studies with more pharmacological interventions to support the target involvement are needed to further confirm these critical findings.

Impact of Diabetes Medication Therapy Adherence Clinic (DMTAC) appointment intervals on glycemic control in public health clinics across Perak, Malaysia.

Introduction: Frequent diabetes medication therapy adherence clinic (DMTAC) appointments may lead to more rapid glycaemic control. This study aimed to evaluate the association between appointment intervals and glycaemic control (haemoglobin A1c [HbA1c] level) along with blood pressure (BP) and lipid profile (LP) during DMTAC appointments. Method: This study retrospectively reviewed all recorded baseline and completed DMTAC data, including HbA1c level, LP and BP, of 318 eligible participants from 29 DMTACs across Perak. The participants were divided into shorter appointment interval (SAI) (≤30 days) and longer appointment interval (LAI) groups. Results: The majority of the baseline socio-demographic and clinical characteristics did not significantly differ between the SAI and LAI groups (p>0.05). Ischaemic heart disease (Odds ratio, OR=3.457; 95% CI= 1.354-8.826; p=0.009) and hypertension (OR=0.521; 95% CI=0.276-0.992; p=0.044) were significantly associated with the appointment intervals. Upon completion of eight DMTAC visits, the HbA1c and FBS levels and DBP significantly improved (p<0.05). However, the mean HbA1c level (1.35±2.18% vs 0.87±2.11%, p=0.548), FBS level (1.25±4.82mmol/L vs 2.29±6.23mmol/L, p=0.538), SBP (3.28±21.82mmHg vs 3.65±18.35mmHg, p=0.343) and LDL level (0.09±0.98mmol/L vs 0.07±1.13mmol/L, p=0.246) did not significantly differ between the SAI and LAI groups. Conclusion: Longer DMTAC appointment intervals had similar improvement in glycaemic controls, blood pressure and lipid profiles as compared to shorter appointment intervals. A longer interval can be scheduled for lower-risk patients to optimise the use of human resources and minimise costs.

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy.

OBJECTIVE: To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists. METHODS: Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH). RESULTS: Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits. CONCLUSION: Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

A Retrospective Study of Clinical Encounters for Pelvic Inflammatory Disease: Missed Opportunities to Screen for Syphilis and HIV?

OBJECTIVE: Missed screening opportunities may contribute to the rising rates of sexually transmitted and blood borne infections (STBBIs) in Manitoba. This study sought to determine the proportion of women who are screened for syphilis and human immunodeficiency virus (HIV) when admitted with pelvic inflammatory disease (PID). METHODS: We performed a retrospective analysis of all inpatient admissions for PID over 3 discrete years (fiscal years 2007, 2012, 2017) at a single tertiary care centre. Data extracted from medical records included STBBI screening performed, clinical signs at presentation, and history of PID or STBBI. To improve the accuracy of our estimates, we complemented the records data with population data from Manitoba. We evaluated predictive factors influencing any or concurrent STBBI screening using bivariate analysis for significance (P < 0.05). RESULTS: One hundred and five admissions met inclusion criteria. Syphilis and HIV screening was ordered concurrently with chlamydia and gonorrhoea screening in 6 (6%) of encounters and was ordered at any point during admission for PID in 28 (27%). A history of substance abuse (odds ratio [OR] 4.94 [95% CI 1.62-15.05] for syphilis screening and OR 6.94 [95% CI 2.38-20.23] for HIV screening) and a positive gonorrhea result while admitted (OR 3.40 [95% CI 1.06-10.88] for syphilis screening) were strongly associated with receiving any screening. Reporting multiple sexual partners was also strongly associated with receiving any STBBI screening while admitted (OR 19.44 [95% CI 2.01-187.92] and OR 15.00 [95% CI 1.58-142.70] for syphilis and HIV screening, respectively). CONCLUSION: A minority of patients were screened for syphilis and HIV while admitted for PID. This study highlights a missed opportunity to screen for STBBI among sexually active women.

Buprenorphine alters microglia and astrocytes acutely following diffuse traumatic brain injury.

Traumatic brain injury (TBI) is a common phenomenon, accounting for significant cost and adverse health effects. While there is information about focal pathologies following TBI, knowledge of more diffuse processes is lacking, particularly regarding how analgesics affect this pathology. As buprenorphine is the most commonly used analgesic in experimental TBI models, this study investigated the acute effects of the opioid analgesic buprenorphine (Bup-SR-Lab) on diffuse neuronal/glial pathology, neuroinflammation, cell damage, and systemic physiology. We utilized a model of central fluid percussion injury (CFPI) in adult male rats treated with a single subcutaneous bolus of Bup-SR-Lab or saline 15 min post-injury. Microscopic assessments were performed at 1 day post-injury. Cell impermeable dextran was infused intraventricularly prior to sacrifice to assess neuronal membrane disruption. Axonal injury was assessed by investigating labeling of the anterogradely transported amyloid precursor protein. Neuroinflammation was assessed by analyzing Iba-1 + microglial and GFAP + astrocyte histological/morphological features as well as cytokine levels in both regions of interest (ROIs). Myelin pathology was assessed by evaluating the expression of myelin basic protein (MBP) and the propensity of MBP + myelin debris. Acute physiologic data showed no difference between groups except for reduction in weight loss following cFPI in Bup treated animals compared to saline. There were no discernable differences in axonal injury or membrane disruption between treatment groups. Cytokine levels were consistent between Bup and saline treated animals, however, microglia and astrocytes revealed region specific histological changes at 1d following Bup treatment. Myelin integrity and overall MBP expression showed no differences between Bup and saline treated animals, but there were significant regional differences in MBP expression between the cortex and thalamus. These data suggest effects of Bup treatment on weight following CFPI and potential regional specificity of Bup-associated microglial and astrocyte alterations, but very little change in other acute pathology at 1-day post-injury. Overall, this preliminary study indicates that use of Bup-SR-Lab in preclinical work does have effects on acute glial pathology, however, longer term studies will be needed to assess potential effects of Bup treatment on more chronic pathological progressions.

Low-Intensity Steady Background Noise Enhances Pitch Fusion Across the Ears in Normal-Hearing Listeners.

Binaural pitch fusion is the perceptual integration of stimuli that evoke different pitches between the ears into a single auditory image. This study was designed to investigate how steady background noise can influence binaural pitch fusion. The binaural fusion ranges, the frequency ranges over which binaural pitch fusion occurred, were measured with three signal-to-noise ratios (+15, +5, and -5dB SNR) of the pink noise and compared with those measured in quiet. The preliminary results show that addition of an appropriate amount of noise can reduce binaural fusion ranges, an effect called stochastic resonance. This finding increases the understanding of how specific noise levels can sharpen binaural pitch fusion in normal hearing individuals. Furthermore, it elicits more pathways for research to explore how this benefit can practically be used to help improve binaural auditory perception.

Simultaneous in vivo Estimation of Muscle, Tendon, and Ankle Impedance.

Appropriate regulation of joint impedance is required to successfully navigate our environment. Joint impedance is strongly dependent upon the mechanical properties of the muscles and tendons spanning it. While the impedance of the joint has been well characterized, methods to determine the individual contribution from the muscles and tendons are limited. This is a crucial gap as muscle and tendon impedance can be selectively altered by aging, pathology, or injury. Therefore, we developed an innovative in vivo method that allows for the simultaneous quantification of joint, muscle, and tendon impedance. Stochastic perturbations of ankle angle were applied while a B-mode ultrasound was used to image the displacement of the medial gastrocnemius muscle-tendon junction. Non-parametric system identification was used to quantify ankle impedance and the frequency response function between ankle rotations and muscle-tendon junction displacements. The latter represents, when scaled by Achilles tendon moment arm, the ratio between the net musculotendon impedance and the impedance of the muscle, a relationship we refer to as the impedance ratio. Muscle and tendon impedance can be calculated from these experimental estimates. The ability to simultaneously quantify joint, muscle, and tendon impedance will provide a clearer understanding their respective roles in our ability to navigate our environment, and how changes in those roles may contribute to functional impairments.