A generic approach to estimate airborne concentrations of substances released by indoor spray processes using a deterministic 2-box model.

Sprays are used both in workplace and consumer settings. Although spraying has advantages, such as uniform distribution of substances on surfaces in a highly efficient manner, it is often associated with a high inhalation burden. For an adequate risk assessment, this exposure has to be reliably quantified. Exposure models of varying complexity are available, which are applicable to spray applications. However, a need for improvement has been identified. In this contribution, a simple 2-box approach is suggested for the assessment of the time-weighted averaged exposure concentration (TWA) using a minimum of input data. At the moment, the model is restricted to binary spray liquids composed of a non-volatile fraction and volatile solvents. The model output can be refined by introducing correction factors based on the classification and categorization of two key parameters, the droplet size class and the vapor pressure class of the solvent, or by using a data set of experimentally determined airborne release fractions related to the used spray equipment. A comparison of model results with measured data collected at real workplaces showed that this simple model based on readily available input parameters is very useful for screening purposes. The generic 2-box spray model without refinement overestimates the measurements of the considered scenarios in approximately 50% of the cases by more than a factor of 100. The generic 2-box model performs better for room spraying than for surface spraying, as the airborne fraction in the latter case is clearly overestimated. This conservatism of the prediction was significantly reduced when correction factors or experimentally determined airborne release fractions were used in addition to the generic input parameters. The resulting predictions still overestimate the exposure (ratio tool estimate to measured TWA > 10) or they are accurate (ratio 0.5-10). If the available information on boundary conditions (application type, equipment) does not justify the usage of airborne release fraction, room spraying should be used resulting in the highest exposure estimate. The model scope may be extended to (semi)volatile substances. However, acceptance may be compromised by the limited availability of measured data for this group of substances and thus may have limited potency to evaluate the model prediction.

The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries.

OBJECTIVES: To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS: Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS: A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS: While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Enhanced recovery after cesarean from the patient perspective: a prospective study of the ERAC Questionnaire (ERAC-Q).

OBJECTIVES: To evaluate the impact of an Enhanced Recovery After Cesarean (ERAC) protocol on the post-cesarean recovery experience using a validated ten-item questionnaire (ERAC-Q). METHODS: This is a prospective cohort study of patients completing ERAC quality-of-life questionnaires (ERAC-Q) during inpatient recovery after cesarean delivery (CD) between October 2019 and September 2020, before and after the implementation of our ERAC protocol. Patients with non-Pfannenstiel incision, ICU admission, massive transfusion, bowel injury, existing chronic pain disorders, acute postpartum depression, or neonatal demise were excluded. The ERAC-Q was administered on postoperative day one and day of discharge to the pre- and post-ERAC implementation cohorts, rating aspects of their recovery experience on a scale of 0 (best) to 10 (worst). The primary outcome was ERAC-Q scores. Statistical analysis was performed with SAS software. RESULTS: There were 196 and 112 patients in the pre- and post-ERAC cohorts, respectively. The post-ERAC group reported significantly lower total ERAC-Q scores compared to the pre-ERAC group, reflecting fewer adverse symptoms and greater perceived recovery on postoperative day one (1.6 [0.7, 2.8] vs. 2.7 [1.6, 4.3]) and day of discharge (0.8 [0.3, 1.5] vs. 1.4 [0.7, 2.2]) (p<0.001). ERAC-Q responses did not predict the time to achieve objective postoperative milestones. However, worse ERAC-Q pain and total scores were associated with higher inpatient opiate use. CONCLUSIONS: ERAC implementation positively impacts patient recovery experience. The administration of ERAC-Q can provide real-time feedback on patient-perceived recovery quality and how healthcare protocol changes may impact their experience.

Elevated Radium Activity in a Hydrocarbon-Contaminated Aquifer.

Hydrocarbon spills that reach the subsurface can modify aquifer geochemical conditions. Biogeochemical zones typically form proximal to the source zone that include iron (Fe(III)) and manganese (Mn(III/IV)) (hydr)oxide reduction, with potential to release associated geogenic contaminants to groundwater. Here, multi-level monitoring systems are used to investigate radium (226Ra, 228Ra) activities in an aquifer contaminated with a mixture of chlorinated solvents, ketones, and aromatics occurring as a dense non-aqueous phase liquid in the source zone. 226Ra activities are up to 10 times higher than background 60 m downgradient from the source zone, where pH is lower, total dissolved solid concentrations are higher, and conditions are methanogenic. Correlations indicate that Fe and Mn (hydr)oxide reduction and sorption site competition are likely responsible for elevated Ra activities within the dissolved phase plume. 226Ra activities return to background within the Fe(III)/SO42--reducing zone 600 m downgradient from the source, near the middle of the dissolved phase plume. Geochemical models indicate that sorption to secondary phases (e.g., clays) is important in sequestering Ra within the plume. Although maximum Ra activities within the plume are well below the U.S. drinking water standard, elevated activities compared to background emphasize the importance of investigating Ra and other trace elements at hydrocarbon-impacted sites.

Development of the ¡Vamos por Mas! parenting program to prevent substance use among Chilean adolescents.

In Chile, the prevalence of tobacco, alcohol and drug use among adolescents is very high. Decades of research indicate that parenting interventions reduce these risky behaviors. However, there are no parenting interventions validated in Chile to prevent adolescent substance use. This article reports the development of the ¡Vamos por Mas! (¡VxM!) program following the recommendations of the Medical Research Council's framework for designing and evaluating complex interventions. After identifying key intervention components, a preliminary version of a substance-use prevention program was designed. The preliminary intervention targeted families with adolescents in fifth and sixth grade and had four components: personalized feedback, in-person workshops, virtual engagement, and family support, to deliver positive-youth development and family-strengthening content. Then, students, guardians, school staff and community experts from different school systems (N = 111) evaluated the preliminary version of the program through a convergent parallel mixed methods study, including focus groups (N = 14) and surveys (N = 101). In general, all participants had positive perceptions of the program and valued its purpose, strategies, objectives and contents. Suggestions included expanding the purpose to promote healthy relationships, focusing on schools with low and intermediate socioeconomic vulnerability, including self-control content, removing the personalized feedback component and adding two additional components: school partnership and external supervision, among other improvements. With this information, the final version of the ¡VxM! program was developed. After a rigorous intervention development process, the ¡VxM! program is ready to be piloted and evaluated in a randomized trial.

Chile has high rates of tobacco, alcohol and drug use among adolescents. Parenting interventions have shown to reduce these risky behaviors. However, there are no parenting interventions validated in Chile to prevent adolescent substance use. This article reports the development of the ¡Vamos por Mas! (¡VxM!) program to strengthen family relations and prevent adolescent substance use following the recommendations of the Medical Research Council's framework for designing and evaluating complex interventions. In the first phase, key intervention components were identified. Then, a preliminary version of the intervention was designed. In the second phase, perceptions of key stakeholders were collected through focus groups (N = 14) and surveys (N = 101) including adolescents, guardians, school staff and community experts. These participants evaluated the preliminary version of the program and provided feedback. In the final phase of the intervention development process, stakeholder opinions were integrated into the proposal. The final version of the ¡VxM! program included five components: (i) school partnership, (ii) in-person workshops, (iii) virtual engagement, (iv) family support and (v) external supervision. This version is ready to be piloted to evaluate feasibility and preliminary efficacy, before being assessed in a randomized trial.

Fever, Rash, and Cough in a 7-Year-Old Boy.

A 7-year-old boy presented to the emergency department with fever, cough, congestion, abdominal pain, myalgias, and morbilliform rash. Several aspects of the patient's history, including recent travel, living on a farm, exposure to sick contacts, and new medications, resulted in a wide differential diagnosis. Initial laboratory testing revealed leukocytosis with neutrophilia and elevated atypical lymphocytes, but did not reveal any infectious causes of illness. He was discharged from the hospital, but then represented to the emergency department a day later with worsening rash, continued fever, abdominal pain, and poor intake. He was then admitted. A more comprehensive laboratory evaluation was initiated. During this hospital course, the patient's physical examination changed when he developed head and neck edema, and certain laboratory trends became clearer. With the assistance of several specialists, the team was able to reach a more definitive diagnosis and initiate treatment to appropriately manage his condition.

Prenatal diagnosis of Bardet Biedl Syndrome: A case report.

The Bardet-Biedl Syndrome (BBS), also called Laurence-Moon-Bardet-Biedl syndrome is a rare ciliopathic autosomal recessive genetic defect. BBS phenotype develops over the years and diagnosis is usually made in late childhood or early adulthood. Prenatal diagnosis is rare in absence of family history or consanguinity. The major features of this syndrome are cone-rod dystrophy, obesity, polydactyly, learning disabilities, hypogonadism in males, renal anomalies, nystagmus, speech disorders, developmental delay and ataxia. At least 20 BBS genes have been identified and all are involved in primary cilia functioning. Genetic diagnosis includes multigene sequencing technologies. Clinical management includes symptomatic treatment. In our case report, we present a case of a baby born to parents of Bengali Asian ancestry with high clinical suspicion of BBS based on fetal magnetic resonance imaging findings done during antepartum surveillance.

A mixed-methods evaluation of the ¡Vamos por Más! parenting program implementation in Chile.

INTRODUCTION AND AIMS: Substance use is a significant global concern. Strengthening parenting in families with adolescents has been shown to reduce substance use initiation. The ¡Vamos por Más! (¡VxM!) program is a positive-parenting program developed in Chile to improve family relations and reduce adolescent substance use that combines in-person school workshops, multimedia messaging and personalized support. This manuscript reports a mixed-methods evaluation of the pilot implementation of the ¡VxM! program utilizing the Consolidated Framework for Implementation Research and Proctor's taxonomy for process outcomes. METHODS: An explanatory sequential design was used. Quantitative methods evaluated program use, acceptability, appropriateness, and fidelity, and were followed by qualitative focus groups (FGs) to assess the implementation process and understand these outcomes. Thirteen FGs stratified by school and role, including school leaders, program facilitators, participants, and researchers, were conducted. RESULTS: The program was implemented in three schools, reaching 253 families with in-person workshops (40.5% of potential participants), 257 parents who viewed on average 72.1% of sent multimedia messages, and 2 families who used the personalized support (0.3%). Overall, the program was viewed as acceptable and appropriate by participants and implementers due to the high quality of program materials, targeted content, and activities. Implementation differed by schools. Key implementation factors were the outer context, inner school setting, and implementation processes. CONCLUSIONS: This comprehensive evaluation, including both intervention implementers and participants, identified implementation facilitators, barriers, and outcomes. Future ¡VxM! implementations should alter program components of schools with lower engagement to improve program implementation and outcomes.

A New Model Algorithm for Estimating the Inhalation Exposure Resulting from the Spraying of (Semi)-Volatile Binary Liquid Mixtures (SprayEva).

The spraying of liquid multicomponent mixtures is common in many professional and industrial settings. Typical examples are cleaning agents, additives, coatings, and biocidal products. In all of these examples, hazardous substances can be released in the form of aerosols or vapours. For occupational and consumer risk assessment in regulatory contexts, it is therefore important to know the exposure which results from the amount of chemicals in the surrounding air. In this research, a mechanistic mass balance model has been developed that covers the spraying of (semi)-volatile substances, taking into account combined exposure to spray mist, evaporation from droplets, and evaporation from surfaces as well as the nonideal behaviour of components in liquids and backpressure effects. For wall-spraying scenarios, an impaction module has been developed that quantifies the amount of overspray and the amount of material that lands on the wall. Mechanistically, the model is based on the assumption that continuous spraying can be approximated by a number of sequentially released spray pulses, each characterized by a certain droplet size, where the total aerosol exposure is obtained by summation over all release pulses. The corresponding system of differential equations is solved numerically using an extended Euler algorithm that is based on a discretisation of time and space. Since workers typically apply the product continuously, the treated area and the corresponding evaporating surface area grows over time. Time-dependent concentration gradients within the sprayed liquid films that may result from different volatilities of the components are therefore addressed by the proposed model. A worked example is presented to illustrate the calculated exposure for a scenario where aqueous solutions of H2O2 are sprayed onto surfaces as a biocidal product. The results reveal that exposure to H2O2 aerosol reaches relevant concentrations only during the spraying phase. Evaporation from sprayed surfaces takes place over much longer time periods, where backpressure effects caused by large emission sources can influence the shape of the concentration time curves significantly. The influence of the activity coefficients is not so pronounced. To test the plausibility of the developed model algorithm, a comparison of model estimates of SprayExpo, SprayEva, and ConsExpo with measured data is performed. Although the comparison is based on a limited number (N = 19) of measurement data, the results are nevertheless regarded as supportive and acceptable for the plausibility and predictive power of SprayEva.

Exposure modelling in Europe: how to pave the road for the future as part of the European Exposure Science Strategy 2020-2030.

Exposure models are essential in almost all relevant contexts for exposure science. To address the numerous challenges and gaps that exist, exposure modelling is one of the priority areas of the European Exposure Science Strategy developed by the European Chapter of the International Society of Exposure Science (ISES Europe). A strategy was developed for the priority area of exposure modelling in Europe with four strategic objectives. These objectives are (1) improvement of models and tools, (2) development of new methodologies and support for understudied fields, (3) improvement of model use and (4) regulatory needs for modelling. In a bottom-up approach, exposure modellers from different European countries and institutions who are active in the fields of occupational, population and environmental exposure science pooled their expertise under the umbrella of the ISES Europe Working Group on exposure models. This working group assessed the state-of-the-art of exposure modelling in Europe by developing an inventory of exposure models used in Europe and reviewing the existing literature on pitfalls for exposure modelling, in order to identify crucial modelling-related strategy elements. Decisive actions were defined for ISES Europe stakeholders, including collecting available models and accompanying information in a living document curated and published by ISES Europe, as well as a long-term goal of developing a best-practices handbook. Alongside these actions, recommendations were developed and addressed to stakeholders outside of ISES Europe. Four strategic objectives were identified with an associated action plan and roadmap for the implementation of the European Exposure Science Strategy for exposure modelling. This strategic plan will foster a common understanding of modelling-related methodology, terminology and future research in Europe, and have a broader impact on strategic considerations globally.

SCAT5 Sex Differences: Normative Data, Clinical Thresholds, and Relevance for Identification of Concussion.

OBJECTIVE: This study evaluated sex differences in performance on the Sport Concussion Assessment Tool-5 (SCAT5) Standardized Assessment of Concussion (SAC) and in baseline SCAT5 symptom reporting. It established clinically relevant cut points for low performance on the SAC based on both reliable chance indices (RCIs) and normative performance. This study also evaluated the diagnostic utility of the sex-adjusted SCAT5 SAC for identification of suspected concussion in collegiate athletes. METHOD: In total, 671 uninjured collegiate athletes were administered the SCAT5 and 264 of these athletes also completed SCAT5 testing ~1 year later. Fifty-four athletes were administered the SCAT5 after being removed from play due to suspected concussion. Sex differences in cognitive performance and symptom reporting at baseline were evaluated and sex-specific clinically relevant cut points were provided. Chi square and logistic regression models were used to evaluate if SAC performance was a significant predictor of concussion status. RESULTS: Female athletes outperformed male athletes on the SCAT 5 SAC and showed minimally higher symptom endorsement. Use of sex-corrected normative data improved performance of the SAC in identification of suspected concussion when a low score cut point was used. Logistic regression models showed that sex-corrected SAC change from baseline (RCI) improved the predictive value of the model after first accounting for other elements of the SCAT5. CONCLUSIONS: Present results support the use of sex-specific normative data for the SCAT5 SAC, particularly if using low performance without comparison to a baseline; however, reliable change from a pre-injury baseline may have somewhat higher diagnostic utility.

Theoretical Background of Occupational-Exposure Models-Report of an Expert Workshop of the ISES Europe Working Group "Exposure Models".

On 20 October 2020, the Working Group "Exposure Models" of the Europe Regional Chapter of the International Society of Exposure Science (ISES Europe) organised an online workshop to discuss the theoretical background of models for the assessment of occupational exposure to chemicals. In this report, participants of the workshop with an active role before and during the workshop summarise the most relevant discussion points and conclusions of this well-attended workshop. ISES Europe has identified exposure modelling as one priority area for the strategic development of exposure science in Europe in the coming years. This specific workshop aimed to discuss the main challenges in developing, validating, and using occupational-exposure models for regulatory purposes. The theoretical background, application domain, and limitations of different modelling approaches were presented and discussed, focusing on empirical "modifying-factor" or "mass-balance-based" approaches. During the discussions, these approaches were compared and analysed. Possibilities to address the discussed challenges could be a validation study involving alternative modelling approaches. The wider discussion touched upon the close relationship between modelling and monitoring and the need for better linkage of the methods and the need for common monitoring databases that include data on model parameters.

Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia.

OBJECTIVE: SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS: This is an observational study of 61 pregnant women with confirmed SARS-CoV-2 infection who delivered and had a placental histological evaluation at NYU Langone Health between March 19, 2020 and June 30, 2020. Primary outcomes were the prevalence of placental histopathologic features and their association with maternal-fetal comorbidities and severity of COVID-19 related hypoxia. Analysis was performed using Fisher's exact test and t-test with p < 0.05 considered significant. RESULTS: Sixty-one placentas were included in the study cohort, 71% from pregnancies complicated by at least one maternal-fetal comorbidity. Twenty-five percent of placentas were small for gestational age and 77% exhibited at least one feature of maternal vascular malperfusion. None of the histopathologic features in the examined placentas were associated with the presence of any specific maternal-fetal comorbidity. Thirteen percent of the cohort required maternal respiratory support for COVID-19 related hypoxia. Villous trophoblast necrosis was associated with maternal supplemental oxygen requirement (67 vs. 33%, p = 0.04) and intubation (67 vs. 33%, p = 0.01). CONCLUSION: In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.

Head Trauma in a Community-Based Sample of Victims of Intimate Partner Violence: Prevalence, Mechanisms of Injury and Symptom Presentation.

OBJECTIVE: The present study aimed to explore the prevalence of subconcussive head trauma, traumatic brain injury (TBI), potential hypoxic events, and hypoxic brain injury (HBI) in victims of physical intimate partner violence (IPV). The study also aimed to characterize the injury presentation and mechanisms of injury in this population. METHOD: A group of 47 female participants with a history of at least one relationship that included physical violence completed a structured interview assessing for subconcussive hits, TBI, and HBI. Participants ranged in age from 19 to 55, and had an average of 15.3 years of education. Forty-four participants completed the structured interview in person and three participants completed the interview over the phone. RESULTS: The majority of participants reported sustaining at least one impact to the head and approximately half of the participants sustained at least one impact that resulted in a mild TBI. Approximately half of the participants experienced at least one incident of having difficulty breathing due to a violent act from their partner, and approximately one-third of participants reported symptoms consistent with mild HBI. The most common mechanisms of injury were being hit with a closed fist and being strangled. CONCLUSIONS: The high levels of head trauma observed in this study highlight the need for clinical and community providers to screen victims of physical IPV for head trauma. The unique characteristics of this population (female sex, high frequency of injuries, and presence of HBIs) indicate that research evaluating the cognitive effects of injuries in this population is needed.

Predictors of severe and critical disease in pregnant women with SARS-CoV-2.

BACKGROUND/OBJECTIVE: SARS-CoV-2 continues to spread widely in the US and worldwide. Pregnant women are more likely to develop severe or critical illness than their non-pregnant counterparts. Known risk factors for severe and critical disease outside of pregnancy, such as asthma, diabetes, and obesity have not been well-studied in pregnancy. We aimed to determine which clinical and pregnancy-related factors were associated with severe and critical COVID illness in pregnancy. STUDY DESIGN: This was a retrospective cohort study of women with confirmed intrauterine pregnancy and positive nasopharyngeal swab for SARS-CoV-2 who presented to an academic medical center in New York City from 1 March 2020 to 1 July 2020. Severe and critical COVID-19 disease was defined by World Health Organization criteria. Women with severe/critical disease were compared to women with asymptomatic/mild disease. Continuous variables were compared with Mann-Whitney or t-test and categorical variables were compared using chi-square and Fisher's exact. Statistical significance was set at p < .05. Multivariable logistic regression was performed including variables that were significantly different between groups. RESULTS: Two hundred and thirty-three patients were included, 186 (79.8%) with asymptomatic/mild disease and 47 (20.2%) with severe/critical disease. Women with asymptomatic/mild disease were compared to those with severe/critical disease. Women with severe/critical disease were more likely to have a history of current or former smoking (19.6 vs. 5.4%, p = .004), COVID-19 diagnosis in the 2nd trimester (42.6 vs. 11.8%, p = .001), and asthma or other respiratory condition (21.3 vs. 7.0%, p = .01). Women with severe/critical disease were more likely to have cesarean delivery (35.5 vs. 15.6%, p < .01) and preterm delivery <37 weeks (25.8 vs. 3.8%, p < .01). After adjustment, history of smoking remained significantly predictive of severe/critical disease [aOR 3.84 (95% CI, 1.25-11.82)]. CONCLUSION: Pregnant women with a history of smoking, asthma, or other respiratory condition, and COVID-19 diagnosis in the second trimester of pregnancy were more likely to develop severe/critical disease. These findings may be useful in counseling women on their individual risk of developing the severe or critical disease in pregnancy and may help determine which women are good candidates for vaccination during pregnancy.

The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women.

OBJECTIVE: To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS: Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS: Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION: Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.

Increasing Access to Medications for Opioid Use Disorder in Primary Care: Removing the Training Requirement May Not Be Enough.

BACKGROUND: Substance use disorders, including opioid use disorder (OUD), are understood as chronic diseases with a relapsing and remitting course and no known cure. Medications for OUD (MOUD) are well established with decades of evidence supporting their safety and efficacy; however, treatment access remains poor and inequitable. Buprenorphine is an MOUD that can be prescribed in a primary care outpatient setting, although regulatory and administrative challenges are a barrier to prescribing it. Recent regulatory changes offer an opportunity to expand the number of family doctors who treat OUD. METHODS: We offered free, easily accessible buprenorphine "x-waiver training" led by a team of primary care clinicians. In addition, we provided wrap-around support for MOUD clinical questions and administrative needs with experienced family medicine mentors. RESULTS: More than 400 clinicians attended our trainings, including medical students, residents, and attending physicians. Of the 101 attending physicians who completed our trainings, only 30 went on to apply for an x-wavier, and of those only 7 were currently prescribing when contacted 12 months later. CONCLUSION: Our experience indicates that removing the training requirement is a necessary first step but is unlikely to result in major changes to rates of prescribing without other significant cultural changes.