Barriers to Mental Health Care Identified by Sexual and Gender Minority Individuals in Georgia and South Carolina.

OBJECTIVE: Geographic location can affect access to appropriate, affirming mental health care for sexual and gender minority (SGM) individuals, especially for those living in rural settings. Minimal research has examined barriers to mental health care for SGM communities in the southeastern United States. The objective of this study was to identify and characterize perceived barriers to obtaining mental health care for SGM individuals living in an underserved geographic area. METHODS: Drawing from a health needs survey of SGM communities in Georgia and South Carolina, 62 participants provided qualitative responses describing barriers they encountered to accessing mental health care when needed in the previous year. Four coders used a grounded theory approach to identify themes and summarize the data. RESULTS: Three themes of barriers to care emerged: personal resource barriers, personal intrinsic factors, and healthcare system barriers. Participants described barriers that can inhibit access to mental health care regardless of one's sexual orientation or gender identity, such as finances or lack of knowledge about services, but several of the identified barriers intersect with SGM-related stigma or may be magnified by participants' location in an underserved region of the southeastern United States. CONCLUSIONS: SGM individuals living in Georgia and South Carolina endorsed several barriers to receiving mental health services. Personal resource and intrinsic barriers were the most common, but healthcare system barriers were present as well. Some participants described simultaneously encountering multiple barriers, illustrating that these factors can interact in complex ways to affect SGM individuals' mental health help seeking.

Uterine Hemangioma Presenting as an Endometrial Polyp in a Postmenopausal Woman.

Uterine hemangioma (UH) is a rare benign lesion involving the myometrium and cervix. UH often presents as an endometrial polypoid mass that mimics an endometrial polyp. UH is commonly present in women of reproductive age with menorrhagia or pregnancy-associated complications. However, reported cases in postmenopausal women present with postmenopausal bleeding. The bleeding hemangiomatous polyps are treated with hysteroscopic polypectomy. We report the case of a 65-year-old postmenopausal woman with vaginal bleeding severe enough to seek emergency medical care. Transvaginal ultrasonography showed an endometrial thickness of 10.1mm but was otherwise unremarkable. Hysteroscopic examination revealed two endometrial polyps measuring 2.0cm, and 0.5cm. Surgeons had difficulty removing these polyps using usual methods, ultimately resorting to sharp excision. Microscopic examination showed scant endometrium without hyperplasia and a polypoid lesion with numerous CD31 positive capillaries entirely filling the stroma, supporting the diagnosis of capillary hemangioma. The contributing factor to UH in our case was unclear, which opens the door for future investigation of UH in post-menopausal women.

Parathyroid Carcinoma: Incidence, Survival Analysis, and Management: A Study from the SEER Database and Insights into Future Therapeutic Perspectives.

Introduction: Parathyroid carcinoma (PC) is an extremely rare entity, with a frequency of 0.005% of all malignancies. Most data related to this rare disease are limited to case series and a few database studies. We present a large database study that aims to investigate the demographic, clinical, and pathological factors, prognosis, and survival of PC. Methods: Data of parathyroid carcinoma were extracted from the Surveillance, Epidemiology, and End Results (SEER) diagnosed between 1975 and 2016. Results: PC had a slightly higher incidence in men (52.2%, p < 0.005), the majority of cases affected Caucasians (75.4%, p < 0.005), and the mean age at diagnosis was 62 years. Histologically, 99.7% were adenocarcinomas not otherwise specified (p < 0.005), well-differentiated (p < 0.005), and 2−4 cm (p < 0.001) in size among the patients with available data. In cases with staging provided, most PC were organ-confined (36.8%, p < 0.001). Lymph nodes were positive in 25.2% of cases where lymph node status was reported. The main treatment modality was surgery (97.2%), followed by radiation alone (2%), and very few received chemotherapy alone (0.8%), p < 0.005. Five-year follow-up was available for 82.7% of the cases. Those who underwent surgery only or radiation alone had 5-year survivals of 83.8% and 72.2%, respectively (p < 0.037). Multivariable analysis identified tumor size >4 cm, age > 40 years, male sex, Caucasian race, distant spread, and poorly differentiated grade as independent risk factors for mortality (p < 0.001). Conclusion: PC is a very rare tumor mostly affecting Caucasian individuals in the fifth decade. Older age, poor histologic differentiation, and distant metastasis are associated with a worse prognosis. Surgical resection offers the best survival outcome. To better understand the pathogenesis and factors affecting survival, all PC patients should be enrolled in national and international registries.

Rare Lower Extremity Fibrosarcomatous Variant of Dermatofibrosarcoma With Myxoid Features Treated With Transtibial Amputation.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor originating from the dermis, with high rates of local recurrence and invasive growth but low likelihood of distant metastasis. Fibrosarcomatous transformation (FS-DFSP) of DFSP accounts for approximately 5-15% of DFSP tumors, is a higher-grade tumor, with higher chances of metastasis and poorer prognosis. We present a case of a 66-year-old female presented with a large fungating mass on the left dorsal foot. Ultrasound-guided core needle biopsy with immunohistochemistry suggested a spindle cell neoplasm, favoring myxofibrosarcoma with intermediate grade. The patient elected for below-knee amputation over limb salvage with wide resection and free flap reconstruction. Based on clinical presentation, radiologic, histologic features and fluorescence in situ hybridization (FISH) studies confirmed the diagnosis of fibrosarcomatous variant of dermatofibrosarcoma protuberans with myxoid change. FS-DFSP with myxoid change is a rare soft tissue tumor that requires aggressive treatment due to its high rates of recurrence. This case presents a rare tumor in a unique location that was successfully treated with limb amputation, which is not documented in current literature.

Near Infrared Spectroscopy Measurements of Mitochondrial Capacity Using Partial Recovery Curves.

BACKGROUND: Near-infrared spectroscopy (NIRS) has been used to measure muscle mitochondrial capacity (mVO2max) as the recovery rate constant of muscle metabolism after exercise. The current method requires as many as 50 short ischemic occlusions to generate two recovery rate constants. PURPOSE: To determine the validity and repeatability of using a 6-occlusion protocol versus one with 22 occlusions to measure muscle mitochondrial capacity. The order effect of performing multiple Mito6 test was also evaluated. METHOD: In two independent data sets (bicep n = 7, forearm A n = 23), recovery curves were analyzed independently using both the 6 and 22 occlusion methods. A third data set (forearm B n = 16) was generated on the forearm muscles of healthy subjects using four 6-occlusion tests performed in succession. Recovery rate constants were generated using a MATLAB routine. RESULTS: When calculated from the same data set, the recovery rate constants were not significantly different between the 22 occlusion and 6 occlusion methods for the bicep (1.43 ± 0.33 min-1, 1.43 ± 0.35 min-1, p = 0.81) and the forearm A (1.97 ± 0.40 min-1, 1.97 ± 0.43 min-1, p = 0.90). Equivalence testing showed that the mean difference was not different than zero and the 90% confidence intervals were within 5% of the average rate constant. This was true for the Mito6 and the Mito5∗ approaches. Bland-Altman analysis showed a slope of 0.21 min-1 and an r of 0.045 for the bicep dataset and a slope of -0.01 min-1 and an r of 0.045 for the forearm A dataset. When performing the four 6-occlusion tests; recovery rate constants showed no order effects (1.50 ± 0.51 min-1, 1.42 ± 0.54 min-1, 1.26 ± 0.41 min-1, 1.29 ± 0.47 min-1, P > 0.05). CONCLUSION: The Mito6 analysis is a valid and repeatable approach to measure mitochondrial capacity. The Mito6 protocol used fewer ischemic occlusion periods and multiple tests could be performed in succession in less time, increasing the practicality of the NIRS mitochondrial capacity test. There were no order effects for the rate constants of four repeated 6-occlusion tests of mitochondrial capacity, supporting the use of multiple tests to improve accuracy.

Design, delivery and evaluation of a simulation-based workshop for health professional students on falls prevention in acute care settings.

AIMS AND OBJECTIVES: To describe the design, delivery and evaluation outcomes of a simulation-based educational workshop to teach a patient-centred falls prevention strategy to health professional students tasked with implementing the strategy during clinical placement. BACKGROUND: Falls are among the most common and costly threat to patient safety. The Safe Recovery Programme (SRP) is an evidence-based, one-to-one communication approach with demonstrated efficacy at preventing falls in the postgraduate context. Simulation-based education (SBE) is commonly used to address issues of patient safety but has not been widely incorporated into falls prevention. METHODS: This study was a Pre-Post-test intervention design. Health professional students were taught how to deliver the SRP in an SBE workshop. The workshop incorporated content delivery, role-play simulations and interactions with a simulated patient. Students completed surveys immediately before and after the workshop and after clinical placement. Linear and logistic regression analysis was undertaken to identify differences within each pairwise comparison at the three time points. Qualitative free text responses underwent content analysis. RESULTS: There were 178 students trained. The educational design of the programme described in this paper was highly valued by students. Following the workshop, students' falls knowledge increased and they correctly identified evidence-based strategies except bedrail use and patient sitters. Following clinical placement, fewer SBE students correctly identified evidence surrounding bed alarm use. Students became more confident about falls communication post-SBE; however, this confidence decreased postclinical placement. Motivation to implement the SRP decreased between postworkshop and postclinical placement time points. CONCLUSIONS: Falls research often includes educational components but previous studies have failed to adequately describe educational methods. Students learnt about best evidence falls prevention strategies using interactive educational methodologies with a workshop viewed by students as being well-designed and assisting their learning from theory to practice.While students valued the delivery of the SRP using SBE, confidence and motivation to implement falls strategies were not sustained following clinical placement. A programme of education including SBE can be used to support the delivery of falls-based education, but further research is needed to identify what factors may influence student's motivation and confidence to implement falls prevention strategies during clinical placement.

Monitoring insulin aggregation via capillary electrophoresis.

Early stages of insulin aggregation, which involve the transient formation of oligomeric aggregates, are an important aspect in the progression of Type II diabetes and in the quality control of pharmaceutical insulin production. This study is the first to utilize capillary electrophoresis (CE) with ultraviolet (UV) detection to monitor insulin oligomer formation at pH 8.0 and physiological ionic strength. The lag time to formation of the first detected species in the aggregation process was evaluated by UV-CE and thioflavin T (ThT) binding for salt concentrations from 100 mM to 250 mM. UV-CE had a significantly shorter (5-8 h) lag time than ThT binding (15-19 h). In addition, the lag time to detection of the first aggregated species via UV-CE was unaffected by salt concentration, while a trend toward an increased lag time with increased salt concentration was observed with ThT binding. This result indicates that solution ionic strength impacts early stages of aggregation and ß-sheet aggregate formation differently. To observe whether CE may be applied for the analysis of biological samples containing low insulin concentrations, the limit of detection using UV and laser induced fluorescence (LIF) detection modes was determined. The limit of detection using LIF-CE, 48.4 pM, was lower than the physiological insulin concentration, verifying the utility of this technique for monitoring biological samples. LIF-CE was subsequently used to analyze the time course for fluorescein isothiocyanate (FITC)-labeled insulin oligomer formation. This study is the first to report that the FITC label prevented incorporation of insulin into oligomers, cautioning against the use of this fluorescent label as a tag for following early stages of insulin aggregation.

Intrapartum predictors of uterine rupture.

This case-controlled study reviewed 26 cases of uterine rupture at an academic medical center. Controls were selected in a 2:1 design by reviewing the immediate successful vaginal birth after cesarean delivery (VBAC) before and after each case of uterine rupture. At less than 2 hours before delivery or acute uterine rupture, mild and severe variable decelerations, persistent abdominal pain, and hyperstimulation were more common in cases of uterine rupture as compared to controls and had statistically significant positive likelihood ratios (LR). Mild and severe variable fetal heart rate decelerations, especially in the presence of persistent abdominal pain, may predict uterine rupture in patients attempting VBAC.

Prolonged mild fetal hypoxia up-regulates type I nitric oxide synthase expression in discrete areas of the late-gestation fetal sheep brain.

OBJECTIVE: Our purpose was to study the effects of prolonged mild hypoxemia on type I nitric oxide synthase (NOS) messenger RNA, protein, and enzymatic activity in the fetal sheep brain. STUDY DESIGN: Pregnant sheep were randomly allocated to receive maternal nitrogen (n = 8) or compressed air (controls, n = 5) to reduce fetal brachial artery PO(2) by 25% for 5 days. Type I NOS mRNA (determined by ribonuclease protection assay) protein (determined by Western blot) and enzymatic activity (determined by citrulline assay) were measured in the hippocampus, striatum, cerebellum, and frontal cortex. Data are presented as mean +/- SEM and were compared by means of one-way analysis of variance or two-sample t test. RESULTS: The reduction in maternal inspired oxygen concentration decreased fetal PO(2) by 26% and oxygen content by 25% without an associated change in PCO(2) or pH. Fetal hypoxemia increased type I NOS mRNA by threefold in the striatum and by 2-fold in the frontal cortex and cerebellum, but it did not change mRNA expression in the hippocampus (P <.05). Type I NOS protein and catalytic activity increased only in the striatum (P <.05). CONCLUSION: Prolonged mild hypoxemia has a differential effect on type I NOS mRNA in fetal sheep brain areas. Type I NOS protein and catalytic activity significantly increased only in the striatum. Our data suggest that fetal type I NOS gene expression is regulated at transcriptional, post-transcriptional, and translational levels.