The impact of COVID-19 on general surgical trainees' surgical exposure in Australia.

BACKGROUND: The COVID-19 pandemic disrupted the provision of surgical services in Australia. To prepare for a surge of COVID-19 patients, elective surgery was mandatorily reduced or ceased at multiple timepoints in Australian states between 2020 and 2022. Operative exposure is a critical component of surgical training in general surgery, and readiness for practice is an ongoing priority. However, the impact of COVID-19 on operative exposure in Australian General Surgical Trainees (AGST) has not been quantified. METHODS: This study was a retrospective longitudinal cohort study using de-identified operative logbook data for Australian General surgical Trainees (AGST) from the Royal Australasian College of Surgeons (RACS) Morbidity and Audit Logbook Tool (MALT) system between February 2019 and July 2021. Bivariate analysis was used to determine the impact of COVID-19 on general surgical trainees' exposure to operative surgery and trainees' operative autonomy. RESULTS: Data from 1896 unique 6-month training terms and 543 285 surgical cases was included over the data collection period. There was no statistically significant impact of the COVID-19 pandemic on AGST operative exposure to major, minor operations, endoscopies, or operative autonomy. CONCLUSIONS: The impact of COVID-19 on surgical trainees globally has been significant. Although this study does not assess all aspects of surgical training, this data demonstrates that there has not been a significant impact of the pandemic on operative exposure or autonomy of AGST.

Women's knowledge and attitudes to the menopause: a comparison of women over 40 who were in the perimenopause, post menopause and those not in the peri or post menopause.

OBJECTIVES: To evaluate women's knowledge and attitudes towards the menopause by comparing three groups of women: perimenopause, post menopause and those women not in either the peri or post menopause (other). METHODS: A 35 question online survey was advertised on social media to evaluate women's attitudes and knowledge of the menopause. Three groups of women were compared: perimenopause, post menopause and those women not in either the peri or post menopause (other). RESULTS: Most women were completely uninformed or only had some knowledge of the menopause before the age of 40. Most women thought that the menopause should be taught at school, but over 80% had received no menopause education at school themselves. The most popular sources of menopause information were independent websites and friends. Perimenopausal women were significantly more likely than postmenopausal women to use online resources for menopause information. The perimenopausal and postmenopausal groups had more positive attitudes towards the menopause than the other group. 57.5% of postmenopausal women found the menopause difficult or very difficult. Most women were happy about no longer menstruating, although some expressed sadness regarding fertility loss. CONCLUSIONS: Most women had limited knowledge and negative attitudes towards the menopause, leaving them unprepared to cope with the physical and psychological changes associated with this stage of life. Improved menopause education is required to improve quality of life during the menopausal transition and a most positive narrative of life postmenopause.

An online survey of postmenopausal women to determine their attitudes and knowledge of the menopause.

OBJECTIVE: To explore postmenopausal women's attitudes and knowledge of the menopause. STUDY DESIGN: An online survey to evaluate women's attitudes and knowledge of the menopause, promoted via social media. In this study, only the data from 829 women who identified as postmenopausal were analysed. MAIN OUTCOME MEASURES: Quantitative and qualitative data. RESULTS: Regarding women's attitudes towards the menopause before they went through it, 18.0% were accepting of it, 15.8% were dreading it and 5.1% were looking forward to it. 38.1% of women felt that the menopause was difficult, 24.6% felt it was very difficult and 20.7% felt it was fine. 94.1% of women had never been taught about the menopause at school, and 49.0% did not feel informed at all about the menopause. More than 60% started looking for information regarding menopause as their symptoms started. The qualitative thematic analysis of the participants' responses produced six themes: the need for education, knowledge and understanding of symptoms, why is getting treatment so difficult, feelings and attitudes towards the menopause, the impact of menopause on a woman's life, the importance of the media - are they getting it right. CONCLUSION: Women's lack of education and their healthcare professionals' lack of adequate training on the menopause means that women enter this critical life stage uneducated and unsupported. It is vital that everyone is taught about the menopause and that general practitioners receive proper training. The negative narrative of menopause needs to be re-addressed to normalise the menopause and give postmenopause women hope.

Pneumococcal vaccination-A literature review and practice guideline update.

Streptococcus pneumoniae (pneumococcus) remains a significant cause of both mild infections such as otitis media, sinusitis, and bronchitis and more severe manifestations such as bacteremia, pneumonia, and invasive pneumococcal disease. Several key serotypes have been targeted in vaccine development due to their association with increased infectivity. Pneumococcal vaccines are available in two formulations, the unconjugated purified polysaccharide (PPSV) and the conjugated formulation (PCV), which leads to a more robust and prolonged immune response. There have been dramatic reductions in mortality attributed to invasive pneumococcal disease over the past 2 decades due to improved vaccination rates and improved serotype coverage with the existing arsenal of vaccines (PCV13 and PPSV23). Utilizing both conjugate and purified polysaccharide modalities in series has produced greater and lasting immunity. The development of both the PCV15 and the PCV20 vaccines provides an opportunity to use conjugated vaccines against a wider spectrum of pneumococcal serotypes. National guidelines have been updated to incorporate the new pneumococcal vaccines into clinical practice.

An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause.

INTRODUCTION: Women are not usually taught about the menopause formally, and many general practitioners have relatively little training. The aim of this study was to explore perimenopausal women's attitudes and knowledge of the menopause. METHOD: An online survey was designed to evaluate attitudes and knowledge of the menopause in women older than 40 years. The survey was generated with Qualtrics XM® and promoted via social media. In all, 3150 women started the survey. In this study, data from 947 perimenopausal women were analysed. RESULTS: Regarding women's attitudes to the menopause, 38.8% were accepting of it but more than 30% were dreading it. The women had experienced a number of menopause symptoms including mood swings (68.9%), brain fog (68.3%), and fatigue (66.8%). More than 90% of women had never been taught about the menopause at school, and more than 60% did not feel informed at all about the menopause. School was thought to be the best place for menopause education to start (83.6%). In all, 68.2% of women had only looked for information about the menopause as their symptoms started and they had talked to friends and used a variety of websites to look for information. When asked for their free-text views on the menopause, thematic analysis produced four themes: the overarching knowledge gap, the onset and impact of symptoms, perimenopause: the hidden phenomenon, and managing symptoms: differing schools of thought. CONCLUSION: Lack of education for women and their general practitioners is causing perimenopausal women to go through this important stage in their lives with a lack of knowledge and appropriate medical care. It is essential that women are taught about the menopause, from school onwards and that we offer health professionals appropriate training starting from the medical school curriculum.

Adaptation of clinical pharmacy services to meet patient care needs during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 has challenged health systems to find innovative ways of delivering patient care while protecting staff from infection with the virus. As the COVID-19 pandemic has continued to evolve establishing "hot spots" in various areas of the country, clinicians have learned more about caring for these patients. This has required the Department of Pharmacy at Thomas Jefferson University Hospital to constantly update the approach it has taken during this time, and the guidance which is provided for the pharmaceutical care of these patients. Because Philadelphia was in the initial stages of the pandemic within the United States, operations within the Department of Pharmacy at Thomas Jefferson University Hospital needed to be redesigned. This brief report provides an example of the swift changes that were made in the pharmacy practice model at a large academic medical center. Herein we describe the impact of the pandemic on the Department of Pharmacy at Thomas Jefferson University Hospital with a focus on clinical and operations aspects. The areas that will be highlighted in this report represent areas that required rapid and transformational change to the operations and/or clinical care in order to protect the health of pharmacists and allow them to continue to provide the necessary level of patient care.

Efficacy of osimertinib against EGFRvIII+ glioblastoma.

Epidermal Growth Factor Receptor variant III (EGFRvIII) is an active mutant form of EGFR that drives tumor growth in a subset of glioblastoma (GBM). It occurs in over 20% of GBMs, making it a promising receptor for small molecule targeted therapy. We hypothesize that poor penetration of the blood-brain barrier by previously tested EGFR-tyrosine kinase inhibitors (EGFR-TKIs) such as afateninb, erlotinib, gefitinib, and lapatinib played a role in their limited efficacy. The present study examined the effects of osimertinib (previously known as AZD9291) on EGFRvIII+ GBM models, both in vitro and in vivo. Therefore, a panel of six GBM stem cells (GSCs) expressing EGFRvIII+ was evaluated. The EGFRvIII+ GSC differed in the expression of EGFRvIII and other key genes. The GSC line D317, which expresses high levels of EGFRvIII and has robust tyrosine kinase activity, was selected for assessing osimertinib's efficacy. Herein, we report that osimertinib inhibits the constitutive activity of EGFRvIII tyrosine kinase with high potency (<100 nM) while also inhibiting its downstream signaling. Further, osimertinib inhibited D317's growth in vitro and in both heterotopic and orthotopic xenograft models. Additional preclinical studies are warranted to identify EGFRvIII+ GBM's molecular signature most responsive to osimertinib.

Long-term clinically relevant rodent model of methotrexate-induced cognitive impairment.

BACKGROUND: With the enhanced use of chemotherapy and the advent of increased patient survival rates, there are an increasing number of cancer survivors living with chemotherapy-induced cognitive impairment. A growing number of clinical studies have brought to light the association of agents like methotrexate in generating these neurological sequelae, although mechanisms remain unclear. METHODS: Here, we use a clinically relevant regimen of several cycles of methotrexate and leucovorin rescue to develop a model of chemotherapy-induced cognitive impairment, and investigate the in vivo long-term (16 mo) impact of high-dose systemic methotrexate on white matter cellular dynamics as assessed by stereology, animal behavior, and diffusion tensor imaging. RESULTS: Our results indicate that at 6 and 16 months post-chemotherapy, methotrexate-treated rats exhibit a significant and permanent decrease in the number of oligodendrocytes and their progenitors in the white matter, in corpus callosum volumes, and myelin basic protein. These findings are associated with mostly delayed deficits in performance on Morris Water Maze and Novel Object Recognition tasks. Diffusion tensor imaging demonstrates significantly decreased fractional anisotropy values in the callosum genu, body, and splenium, as well as previously unassessed areas like the fimbria. Interestingly, these white matter changes are preceded by an earlier, transient decrement in white matter microglia at 3 months, and hippocampal neural progenitors at 3 and 6 months. CONCLUSION: These results demonstrate a significant negative impact of methotrexate on the oligodendrocyte compartment and white matter, associated with cognitive impairment. The data also support the use of diffusion tensor imaging in monitoring white matter integrity in this context.

Lymphoma Study Titles on ClinicalTrials.gov Lack Details Necessary for Study Identification.

BACKGROUND: ClinicalTrials.gov is used by clinicians and patients to identify clinical trials. We assessed the ease with which users could identify relevant trials related to lymphoma using the short and official titles. We hypothesized that lymphoma titles frequently lack important information. MATERIALS AND METHODS: We performed 2 searches on ClinicalTrials.gov. The first search was performed before June 2017, when ClinicalTrials.gov underwent updates to improve usability. The second was performed after 2017. We assessed whether the short and official titles of each trial provided information on the study phase, eligible disease status, lymphoma histologic subtype, study intervention, primary objective, and the presence of randomization and placebo control. RESULTS: Of the pre-overhaul lymphoma trials, the official versus short titles included information regarding study intervention (99% vs. 96%), study phase (82% vs. 14%), lymphoma histologic subtype (78% vs. 72%), disease status (46% vs. 35%), randomization (13% vs. 2%), presence of placebo (6% vs. 2%), and primary objective (38% vs. 26%). Of the post-overhaul trials, the official versus short titles included information regarding study intervention (97% vs. 96%), lymphoma histologic subtype (83% vs. 78%), study phase (78% vs. 8%), disease status (64% vs. 50%), primary objective (38% vs. 23%), presence of placebo (11% vs. 0%), and randomization (18% vs. 0%). CONCLUSION: The official titles were more informative than were the short titles on ClinicalTrials.gov. However, the short and official titles both often lacked the basic information needed to understand a clinical trial. This has persisted despite updates to the platform. These results highlight the need for standardization of the format and content included in study titles.

Sex and Relationships Education for Individuals with Cystic Fibrosis: A Service-Based Approach.

Increasing life expectancy within cystic fibrosis (CF) raises challenges around previously neglected topics such as sexual and reproductive health (SRH). The study aimed to gather retrospective experiences of service provision around SRH to consider the role of the CF service, age of information provision and unmet needs highlighting possible improvements to provision. A mixed-methods retrospective survey-based design was employed. An Adult CF team participated in a consultation session generating survey questions around SRH. A 20-item online survey was constructed and disseminated to adult CF patients. Unmet needs were found in SRH provision in pediatric and adult CF services, with further information required by patients on topics including parenthood and fertility. Results support previous research findings highlighting the need for standardized provision around SRH. Age of SRH provision suggested individual differences in need within the pediatric service. Further research could explore format and specific age of SRH information provision.

Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter 2 Inhibitor Use in Two Patients Undergoing Pancreatectomy.

Background: Euglycemic diabetic ketoacidosis (euDKA) is a potential side effect associated with inhibitors of the sodium-glucose cotransporter 2 (SGLT-2). This effect is most often recognized during physiologic stress (i.e., sepsis) or in patients who undergo surgery. Case presentations: Case 1: A 66-year-old woman underwent distal pancreatectomy with en bloc splenectomy after presenting with a biopsy-proven pancreatic adenocarcinoma in the body of the pancreas noted incidentally on a screening magnetic resonance imaging for an ovarian mass. The patient had a history of type 2 diabetes mellitus (T2DM) and used canagliflozin, which she was instructed to hold 24 h before surgery. Case 2: A 75-year-old man underwent a pylorus-preserving pancreaticoduodenectomy after presenting with obstructive jaundice. This patient also had a history of T2DM and was on dapagliflozin, which he was also instructed to hold 24 h before surgery. Postoperatively, both patients were diagnosed with euDKA, which was suspected primarily because of intraoperative and postoperative polyuria. Conclusions: SGLT-2 inhibitors are associated with euDKA that can be potentiated in patients who undergo surgery. This medication side effect can be easily unrecognized and potentially lead to significant morbidity.

Deficiency of Shank2 causes mania-like behavior that responds to mood stabilizers.

Genetic defects in the synaptic scaffolding protein gene, SHANK2, are linked to a variety of neuropsychiatric disorders, including autism spectrum disorders, schizophrenia, intellectual disability, and bipolar disorder, but the molecular mechanisms underlying the pleotropic effects of SHANK2 mutations are poorly understood. We generated and characterized a line of Shank2 mutant mice by deleting exon 24 (Δe24). Shank2Δe24-/- mice engage in significantly increased locomotor activity, display abnormal reward-seeking behavior, are anhedonic, have perturbations in circadian rhythms, and show deficits in social and cognitive behaviors. While these phenotypes recapitulate the pleotropic behaviors associated with human SHANK2-related disorders, major behavioral features in these mice are reminiscent of bipolar disorder. For instance, their hyperactivity was augmented with amphetamine but was normalized with the mood stabilizers lithium and valproate. Shank2 deficiency limited to the forebrain recapitulated the bipolar mania phenotype. The composition and functions of NMDA and AMPA receptors were altered at Shank2-deficient synapses, hinting toward the mechanism underlying these behavioral abnormalities. Human genetic findings support construct validity, and the behavioral features in Shank2 Δe24 mice support face and predictive validities of this model for bipolar mania. Further genetic studies to understand the contribution of SHANK2 deficiencies in bipolar disorder are warranted.

Prospective Relations among Low-Income African American Adolescents' Maternal Attachment Security, Self-Worth, and Risk Behaviors.

This study examined prospective mediating relations among mother-adolescent attachment security, self-worth, and risk behaviors, including substance use and violence, across ages 13-17 in a sample of 901 low-income African American adolescents. Path analyses revealed that self-worth was a significant mediator between attachment security and risk behaviors, such that earlier attachment security predicted self-worth 1 year later, which in turn, predicted substance use, weapon carrying, and fighting in the 3rd year. Implications for the role of the secure base concept within the context of urban poverty are discussed.

A Qualitative Analysis of the Information Needs of Parents of Children with Cystic Fibrosis prior to First Admission.

PURPOSE: Hospitalization can be stressful for patients and their families. Pre-hospitalization information is crucial in establishing a good basis for patient satisfaction. In order to develop better preparatory material for parents, this qualitative study explored whether parents of children with cystic fibrosis, admitted to a UK Children's Hospital, felt adequately prepared for their child's admission. DESIGN AND METHODS: Data were collected from twelve parents whose children had been admitted within the last two years for routine intravenous antibiotics. Semi-structured interviews were analyzed using thematic analysis. RESULTS: Four themes emerged from the analysis: (1) preparing for admission, (2) the ward as a challenging environment, (3) changes in the parent-professional relationship and (4) the parental role in medical care. CONCLUSION: Provision of adequate preparatory information is essential in reducing parental stress, influencing how future experiences are appraised and managed. Effective parent-professional communication and opportunities to participate in care are likely to improve parental satisfaction. PRACTICE IMPLICATIONS: Preparatory information prior to hospital admission greatly assists parents in making informed decisions and working as joint advocates in their child's inpatient care.

Use of emergency department transcranial Doppler assessment of reperfusion after intravenous tPA for ischemic stroke.

BACKGROUND: Thrombolysis with intravenous recombinant tissue plasminogen activator (IV-tPA) has been associated with significant improvements in clinical outcomes when initiated within 3 h of symptom onset. Although adjunctive therapies for acute stroke have been developed, challenges remain in identifying appropriate patients and therapeutic end-point measurements. OBJECTIVE: To describe the use of transcranial Doppler (TCD) monitoring in the Emergency Department (ED) to guide the decision for advanced reperfusion strategies after failure of IV-tPA. CASE REPORT: A 75-year-old man presented to the ED within 50 min after the acute onset of right-sided hemiparesis and aphasia. After administration of IV-tPA, there was no immediate improvement in neurological symptoms. TCD performed in the ED demonstrated persistent left middle cerebral artery (MCA) occlusion. Based on this information, the patient received intra-arterial tPA followed by mechanical thrombectomy of the MCA occlusion, resulting in clinical improvement of the patient's right hemiparesis and aphasia. CONCLUSION: TCD is a feasible assessment tool for use in the ED to aid in diagnosis and to guide treatment decisions in patients with acute ischemic stroke, including those not responding to IV-tPA therapy.

Discriminative capacity of biomarkers for acute stroke in the emergency department.

BACKGROUND: Acute ischemic stroke remains largely a clinical diagnosis. OBJECTIVE: To assess the potential of several biomarkers to distinguish acute ischemic stroke from mimics in the emergency department (ED). METHODS: In this prospective study, 63 patients with suspected acute stroke were enrolled. Blood samples were collected at ED presentation and assayed for B-type natriuretic peptide, C-reactive protein (CRP), matrix metalloproteinase 9 (MMP-9), D-dimer, and protein S100B. Final diagnosis of stroke was rendered by blinded independent stroke experts after review of all clinical, imaging, and conventional laboratory data during admission. Logistic regression and bootstrapping models were used to evaluate the association between biomarker values and acute stroke. RESULTS: Thirty-four patients had a final diagnosis of stroke and 29 with mimics. The initial ED values of CRP, MMP-9, and S100B (C-indices of 0.808, 0.811, and 0.719, respectively) and the National Institutes of Health Stroke Scale (NIHSS) (C-index 0.887) predicted acute cerebral ischemia. CRP levels added discriminative value over clinical variables alone in the diagnosis of stroke. When the levels of CRP were added to the NIHSS, the combination was highly predictive of stroke (bootstrap mean C-index 0.951, 90% Confidence Interval 0.903-0.991, likelihood test p = 0.004). CONCLUSIONS: Biomarker testing with CRP and potentially MMP-9 and S100B, may add valuable and time-sensitive diagnostic information in the early evaluation of patients with suspected stroke in the ED. Future prospective evaluations are necessary to validate the diagnostic capability of these biomarkers for acute ischemic stroke in the ED before they should be considered for use in clinical practice.

Risk factors for work-related stress and health in head teachers.

BACKGROUND: Work-related stress (WRS) is known to cause ill-health and decreased productivity. Work in the education sector is thought to be particularly stressful. Few studies have considered risk factors for WRS and health in head teachers. AIMS: To investigate health in head teachers in West Sussex. To determine personal risk factors most likely to predict cases of WRS and of poor health in head teachers. METHODS: A cross-sectional study, in a population of 290 head teachers and principals of colleges of further education, using a validated questionnaire, 'a short stress evaluation tool' (ASSET) and additional questions derived from earlier studies. Results were compared with the ASSET database 'norm' groups: a general population of workers (GPN) group and a group of managers and professionals (MPN). 'Caseness' was defined as respondents who felt work was 'very or extremely stressful'. RESULTS: Head teachers had poor physical and mental health compared to the GPN group. Psychological well-being, particularly of females and primary head teachers was worse than a comparative group of managers and professionals. Teaching<5 h/week was a significant predictor of caseness and being female was the main risk factor for poor psychological well-being. CONCLUSIONS: Prevalence of self-reported stress in head teachers in West Sussex is high. Female head teachers had worse health outcomes. Our study identified possible personal risk factors predicting WRS and/or poor health in head teachers.

Prevalence and causes of self-reported work-related stress in head teachers.

BACKGROUND: Work-related stress (WRS) is the leading cause of occupational ill-health in the education sector in the UK. Headship is believed to be a stressful role although there is little current research into stress in head teachers. Changes in the education sector since the late 1980s have meant that the findings of many existing studies are outdated. AIM: To investigate prevalence and causes of self-reported, WRS in head teachers in West Sussex, UK. METHODS: A cross-sectional study using postal questionnaire in a population of 290 head teachers and principals. The measuring instrument was a short stress evaluation tool (ASSET) plus additional questions derived from previous studies. Stress cases were defined as respondents who felt their work was 'very or extremely stressful'. RESULTS: Prevalence of self-reported, WRS was 43%. Using ASSET scoring, work overload and work-life imbalance were the key stressors. Females were significantly more stressed than males for a number of stressors including overload and control. Although there was some evidence that primary head teachers fared worse than their secondary counterparts, once the confounding effects of gender were included, there were few significant differences. CONCLUSIONS: The prevalence of self-reported stress in head teachers in West Sussex is significantly increased compared to recent studies of workers in the UK. The recurring theme in existing studies of workload as a main stressor is confirmed in the findings of this study. Gender and type of school does affect outcome and female head teachers have more reported stressors than their male colleagues.