Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review.

Musculoskeletal conditions of the upper and lower extremities are commonly treated with corticosteroid injections. Ketorolac, a parenteral nonsteroidal anti-inflammatory drug, represents an alternative injectant for common shoulder, hip, and knee conditions. A review of the current literature was conducted on the efficacy of ketorolac injection in musculoskeletal diseases. Several studies support the use and efficacy of ketorolac injection in subacromial bursitis, adhesive capsulitis, and hip and knee osteoarthritis. Given the systemic effects of glucocorticoid injections, ketorolac may be a safe and effective alternative in patients with musculoskeletal disease. However, more evidence is required to better understand the effects ketorolac has on the human body during inflammatory processes.

The Dysmorphic Concern Questionnaire: Is It Possible to Predict a Satisfactory Result After Cosmetic Eyelid Surgery?

PURPOSE: As oculofacial surgeons performing esthetic surgery, the most valuable result is a satisfied patient. It can be extremely frustrating to have an unhappy patient with, what we believe is, a satisfactory result. Therefore, the ability to predict satisfaction is of extreme importance. We studied our cosmetic eyelid surgery patients to try to find factors that can predict satisfaction. METHODS: We retrospectively studied 454 consecutive patients, who underwent any combination of 7 cosmetic surgical procedures. Patients answered the Dysmorphic Concern Questionnaire (DCQ) before surgery. We studied age, gender, type and number of procedures performed, DCQ score, presence of complications, and history of previous fillers. At the 3-month follow-up visit, patients were given an outcome report survey to graduate their surgical results on a scale from 1 to 5. Results were evaluated using a model of binary logistic regression in which the outcome variable was divided into 2 groups. RESULTS: Three hundred eighty-six patients (85%) were female and the median age was 54.8 years old. The median for the number of procedures was 2 (range, 1-5). Two hundred two of the 454 patients (44.5%) had a history of fillers. Twenty-five patients had complications. DCQ score was significantly lower in the satisfied group (median score, 3) versus the unsatisfied group (median, 6), p = 0.007. In the multiple binary logistical model, the variables age, male gender, DCQ, presence of complications, and upper eyelid blepharoplasty resulted as significant. CONCLUSIONS: We found a significant positive association with upper lid blepharoplasty and a negative association with increasing age, male gender, occurrence of complications, and DCQ score, as predictors of patient satisfaction. We routinely administer the DCQ to all cosmetic patients: It is a brief, sensitive, and specific screening instrument for body dysmorphic disorder.

Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries.

BACKGROUND: Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. METHODS: We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. RESULTS: We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. CONCLUSIONS: Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

Recruiting hard-to-reach populations via respondent driven sampling for mobile phone surveys in Colombia: a qualitative study.

BACKGROUND: Uptake of mobile phone surveys (MPS) is increasing in many low- and middle-income countries, particularly within the context of data collection on non-communicable diseases (NCDs) behavioural risk factors. One barrier to collecting representative data through MPS is capturing data from older participants.Respondent driven sampling (RDS) consists of chain-referral strategies where existing study subjects recruit follow-up participants purposively based on predefined eligibility criteria. Adapting RDS strategies to MPS efforts could, theoretically, yield higher rates of participation for that age group. OBJECTIVE: To investigate factors that influence the perceived acceptability of a RDS recruitment method for MPS involving people over 45 years of age living in Colombia. METHODS: An MPS recruitment strategy deploying RDS techniques was piloted to increase participation of older populations. We conducted a qualitative study that drew from surveys with open and closed-ended items, semi-structured interviews for feedback, and focus group discussions to explore perceptions of the strategy and barriers to its application amongst MPS participants. RESULTS: The strategy's success is affected by factors such as cultural adaptation, institutional credibility and public trust, data protection, and challenges with mobile phone technology. These factors are relevant to individuals' willingness to facilitate RDS efforts targeting hard-to-reach people. Recruitment strategies are valuable in part because hard-to-reach populations are often most accessible through their contacts within their social network who can serve as trust liaisons and drive engagement. CONCLUSIONS: These findings may inform future studies where similar interventions are being considered to improve access to mobile phone-based data collection amongst hard-to-reach groups.

Ankle Telemedicine Planning Considerations.

A virtual medical visit, also known as telemedicine or telehealth, is a valuable alternative method of providing health care to patients who do not have easy access to a hospital, or during times when limited social interaction is crucial such as our current COVID-19 pandemic. A virtual approach to evaluating musculoskeletal system ailments is particularly challenging, for diagnosis of these conditions generally rely greatly on physical examination, which may be challenging. However, a properly planned and executed telemedicine visit will yield successful results in most cases. Our aim is to produce a document with instructions and suggestions, including physical examination maneuvers, to help physicians carry out a proper virtual medical visit with patients complaining of ankle musculoskeletal problems. Virtual visits should not be thought of as a replacement for traditional face-to-face medical consultations, but rather a complementary method to provide health care when deemed appropriate. By following this guide, and tailoring it to the specific case at hand, medical providers should be able to effectively carry out a successful telemedicine consultation for musculoskeletal ailments relating to the ankle.Levels of Evidence: Level V.

Immune thrombotic thrombocytopenic purpura in older patients: Results from the Spanish TTP Registry (REPTT).

Immune thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare disease that seldom occurs in the elderly. Few reports have studied the clinical course of iTTP in older patients. In this study, we have analysed the clinical characteristics at presentation and response to therapy in a series of 44 patients with iTTP ≥60 years at diagnosis from the Spanish TTP Registry and compared them with 209 patients with <60 years at diagnosis from the same Registry. Similar symptoms and laboratory results were described in both groups, except for a higher incidence of renal dysfunction among older patients (23% vs. 43.1%; p = 0.008). Front-line treatment in patients ≥60 years was like that administered in younger patients. Also, no evidence of a difference in clinical response and overall survival was seen in both groups. Of note, 14 and 25 patients ≥60 years received treatment with caplacizumab and rituximab, respectively, showing a favourable safety and efficacy profile, like that observed in patients <60 years.

Co-Expression Networks in Sunflower: Harnessing the Power of Multi-Study Transcriptomic Public Data to Identify and Categorize Candidate Genes for Fungal Resistance.

Fungal plant diseases are a major threat to food security worldwide. Current efforts to identify and list loci involved in different biological processes are more complicated than originally thought, even when complete genome assemblies are available. Despite numerous experimental and computational efforts to characterize gene functions in plants, about ~40% of protein-coding genes in the model plant Arabidopsis thaliana L. are still not categorized in the Gene Ontology (GO) Biological Process (BP) annotation. In non-model organisms, such as sunflower (Helianthus annuus L.), the number of BP term annotations is far fewer, ~22%. In the current study, we performed gene co-expression network analysis using eight terabytes of public transcriptome datasets and expression-based functional prediction to categorize and identify loci involved in the response to fungal pathogens. We were able to construct a reference gene network of healthy green tissue (GreenGCN) and a gene network of healthy and stressed root tissues (RootGCN). Both networks achieved robust, high-quality scores on the metrics of guilt-by-association and selective constraints versus gene connectivity. We were able to identify eight modules enriched in defense functions, of which two out of the three modules in the RootGCN were also conserved in the GreenGCN, suggesting similar defense-related expression patterns. We identified 16 WRKY genes involved in defense related functions and 65 previously uncharacterized loci now linked to defense response. In addition, we identified and classified 122 loci previously identified within QTLs or near candidate loci reported in GWAS studies of disease resistance in sunflower linked to defense response. All in all, we have implemented a valuable strategy to better describe genes within specific biological processes.

Improving COVID-19 vaccine uptake: a message co-design process for a national mHealth intervention in Colombia.

BACKGROUND: COVID-19 vaccination is a global priority. Latin American countries have some of the highest COVID-19 death rates worldwide with vaccination hampered by a variety of reasons, including mis- and disinformation, vaccine hesitancy, and vaccine supply constraints. Addressing vaccine hesitancy through effective messages has been found to help increase vaccine uptake. Participatory processes could be used to co-design health messages for this purpose. OBJECTIVE: This article describes the methodology used to co-design evidence-based audio messages to be deployed in a cohort of individuals through an interactive voice response (IVR) mobile phone survey intervention, aimed towards increasing vaccination uptake in an adult population in Colombia. METHODS: Participants of the COVID-19 vaccination message co-design process included a sample of the general population of the country, representatives of the funder organisation, and research team members. The co-design process consisted of four phases: (1) formative quantitative and qualitative research, (2) message drafting based on the results of the formative research, (3) message content evaluation, and (4) evaluation of the voices to deliver the audio messages; and was informed by reflexive meetings. RESULTS: Three categories of evidence-based audio messages were co-designed, each corresponding to an arm of the mHealth intervention: (1) factual messages, (2) narrative messages, and (3) mixed messages. An additional fourth arm with no message was proposed for control. The iterative co-design process ended with a total of 14 audio messages recorded to be deployed via the intervention. CONCLUSIONS: Co-developing health messages in response to health emergencies is possible. Adopting more context-relevant, participatory, people-centred, and reflexive multidisciplinary approaches could help develop solutions that are more responsive to the needs of populations and public health priorities. Investing resources in message co-design is deemed to have a greater potential for influencing behaviours and improving health outcomes.

Examination of the demographic representativeness of a cross-sectional mobile phone survey in collecting health data in Colombia using random digit dialling.

OBJECTIVES: As mobile phone ownership becomes more widespread in low-income and middle-income countries, mobile phone surveys (MPSs) present an opportunity to collect data on health more cost-effectively. However, selectivity and coverage biases in MPS are concerns, and there is limited information about the population-level representativeness of these surveys compared with household surveys. This study aims at comparing the sociodemographic characteristics of the respondents of an MPS on non-communicable disease risk factors to a household survey in Colombia. DESIGN: Cross-sectional study. We used a random digit dialling method to select the samples for calling mobile phone numbers. The survey was conducted using two modalities: computer-assisted telephone interviews (CATIs) and interactive voice response (IVR). The participants were assigned randomly to one of the survey modalities based on a targeted sampling quota stratified by age and sex. The Quality-of-Life Survey (ECV), a nationally representative survey conducted in the same year of the MPS, was used as a reference to compare the sample distributions by sociodemographic characteristics of the MPS data. Univariate and bivariate analyses were performed to evaluate the population representativeness between the ECV and the MPSs. SETTING: The study was conducted in Colombia in 2021. PARTICIPANTS: Population at least 18 years old with a mobile phone. RESULTS: We completed 1926 and 2983 interviews for CATI and IVR, respectively. We found that the MPS data have a similar (within 10% points) age-sex data distribution compared with the ECV dataset for some subpopulations, mainly for young populations, people with none/primary and secondary education levels, and people who live in urban and rural areas. CONCLUSIONS: This study shows that MPS could collect similar data to household surveys in terms of age, sex, high school education level and geographical area for some population categories. Strategies are needed to improve representativeness of the under-represented groups.

MAPK11 (p38ß) is a major determinant of cellular radiosensitivity by controlling ionizing radiation-associated senescence: An in vitro study.

Background and purpose: MAPKs are among the most relevant signalling pathways involved in coordinating cell responses to different stimuli. This group includes p38MAPKs, constituted by 4 different proteins with a high sequence homology: MAPK14 (p38α), MAPK11 (p38ß), MAPK12 (p38γ) and MAPK13 (p38δ). Despite their high similarity, each member shows unique expression patterns and even exclusive functions. Thus, analysing protein-specific functions of MAPK members is necessary to unequivocally uncover the roles of this signalling pathway. Here, we investigate the possible role of MAPK11 in the cell response to ionizing radiation (IR). Materials and methods: We developed MAPK11/14 knockdown through shRNA and CRISPR interference gene perturbation approaches and analysed the downstream effects on cell responses to ionizing radiation in A549, HCT-116 and MCF-7 cancer cell lines. Specifically, we assessed IR toxicity by clonogenic assays; DNA damage response activity by immunocytochemistry; apoptosis and cell cycle by flow cytometry (Annexin V and propidium iodide, respectively); DNA repair by comet assay; and senescence induction by both X-Gal staining and gene expression of senescence-associated genes by RT-qPCR. Results: Our findings demonstrate a critical role of MAPK11 in the cellular response to IR by controlling the associated senescent phenotype, and without observable effects on DNA damage response, apoptosis, cell cycle or DNA damage repair. Conclusion: Our results highlight MAPK11 as a novel mediator of the cellular response to ionizing radiation through the control exerted onto IR-associated senescence.

Data-driven approach for benchmarking DFTB-approximate excited state methods.

In this work we propose a chemically-informed data-driven approach to benchmark the approximate density-functional tight-binding (DFTB) excited state (ES) methods that are currently available within the DFTB+ suite. By taking advantage of the large volume of low-detail ES-data in the machine learning (ML) dataset, QM8, we were able to extract valuable insights regarding the limitations of the benchmarked methods in terms of the approximations made to the parent formalism, density-functional theory (DFT), while providing recommendations on how to overcome them. For this benchmark, we compared the first singlet-singlet vertical excitation energies (E1) predicted by the DFTB-approximate methods with predictions of less approximate methods from the reference ML-dataset. For the nearly 21800 organic molecules in the GDB-8 chemical space, we were able to identify clear trends in the E1 prediction error distributions, with respect to second-order approximate coupled cluster (CC2), showing a strong dependence on chemical identity.

An Equilibrium State Diagram for Storage Stability and Conservation of Active Ingredients in a Functional Food Based on Polysaccharides Blends.

A functional food as a matrix based on a blend of carbohydrate polymers (25% maltodextrin and 75% inulin) with quercetin and Bacillus claussi to supply antioxidant and probiotic properties was prepared by spray drying. The powders were characterized physiochemically, including by moisture adsorption isotherms, X-ray diffraction (XRD), scanning electron microscopy (SEM), and modulated differential scanning calorimetry (MDSC). The type III adsorption isotherm developed at 35 °C presented a monolayer content of 2.79 g of water for every 100 g of dry sample. The microstructure determined by XRD presented three regions identified as amorphous, semicrystalline, and crystalline-rubbery states. SEM micrographs showed variations in the morphology according to the microstructural regions as (i) spherical particles with smooth surfaces, (ii) a mixture of spherical particles and irregular particles with heterogeneous surfaces, and (iii) agglomerated irregular-shape particles. The blend's functional performance demonstrated antioxidant activities of approximately 50% of DPPH scavenging capacity and viability values of 6.5 Log10 CFU/g. These results demonstrated that the blend displayed functional food behavior over the complete interval of water activities. The equilibrium state diagram was significant for identifying the storage conditions that promote the preservation of functional food properties and those where the collapse of the microstructure occurs.

Sleep and the Young Athlete.

CONTEXT: Sleep plays a vital role in cognitive and physical performance. Teenage athletes (ages 13-19 years) are considered especially at risk for disordered sleep and associated negative cognitive, physical, and psychosomatic effects. However, there is a paucity of evidence-based recommendations to promote sleep quality and quantity in athletes who fall within this age range. We performed a review of the literature to reveal evidence-based findings and recommendations to help sports instructors, athletic trainers, physical therapists, physicians, and other team members caring for young athletes provide guidance on sleep optimization for peak sports performance and injury risk reduction. METHODS: PubMed, Scopus, and Cochrane CENTRAL were searched on May 11, 2016, and then again on September 1, 2020, for relevant articles published to date. STUDY DESIGN: Narrative review. LEVEL OF EVIDENCE: Level 4. RESULTS: Few studies exist on the effects disordered sleep may have on teenage athletes. By optimizing sleep patterns in young athletes during training and competitions, physical and mental performance, and overall well-being, may be optimized. Adequate sleep has been shown to improve the performance of athletes, although further studies are needed. CONCLUSION: Twenty-five percent of total sleep time should be deep sleep, with a recommended sleep time of 8 to 9 hours for most young athletes. Screen and television use during athletes' bedtime should be minimized to improve sleep quality and quantity. For young athletes who travel, jet lag can be minimized by allowing 1 day per time zone crossed for adjustment, limiting caffeine intake, planning meals and onboard sleeping to coincide with destination schedules, timing arrivals in the morning whenever possible, and using noise-canceling headphones and eyeshades. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): B.

Remote consent approaches for mobile phone surveys of non-communicable disease risk factors in Colombia and Uganda: A randomized study.

INTRODUCTION: Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda. METHODS: Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed. RESULTS: Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p<0.001). In Uganda, 1890 completed surveys were collected. Though there were differences in contact, refusal, and cooperation rates by study arm, response rates were similar across arms. About 37% of respondents identified the survey purpose correctly, with no difference by arm. Those with higher levels of education and who completed the survey in English were able to more accurately identify the survey purpose. Again, participants were more likely to accurately identify the purpose of the survey after completing several NCD modules, compared to immediately following the consent module (42.0% vs 32.2% correct, p = 0.013). CONCLUSION: This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding.

Suspensión alta al ligamento uterosacro con suturas permanentes en el prolapso apical: seguimiento a 24 meses / High suspension to the uterosacral ligament with permanent sutures in the apical prolapse: 24-month follow-up

Introducción: El prolapso de órganos pélvico (POP) es una patología frecuente que afecta hasta el 60% de las mujeres. La fijación alta al ligamento uterosacro (FAUS) transvaginal es una alternativa para el tratamiento del prolapso apical con buenos resultados, tiempos operatorios y de recuperación acotados, además de bajas tasas de complicaciones. Objetivo: Evaluar la tasa de éxito anatómico y subjetivo en pacientes portadoras de un prolapso apical sometidas a FAUS en el Hospital de Quilpué a 24 meses de seguimiento. Materiales y método: Se realizó un estudio retrospectivo observacional descriptivo, seleccionando a todas las pacientes sintomáticas con un prolapso apical ≥ 2 de la clasificación de POP-Q, sometidas a una FAUS entre septiembre de 2014 y octubre de 2019. Los datos fueron obtenidos desde la base de datos de la unidad de uroginecología del Hospital de Quilpué, previa aprobación del comité de ética. El éxito objetivo se definió como un punto C a 1 centímetro sobre el himen y el éxito subjetivo con una escala de impresión de mejora global del paciente (PGI-I) mejor o mucho mejor y/o una escala visual analógica (EVA) mayor al 80%, a 24 meses de seguimiento. Resultados: Se incluyeron 46 pacientes. La tasa de éxito objetivo fue del 84% y de éxito subjetivo del 70%. Conclusiones: La FAUS transvaginal con suturas permanentes es una excelente alternativa para el tratamiento del prolapso apical con una tasa de éxito similar al gold standard a 24 meses de seguimiento.

Introduction: Pelvic organ prolapse (POP) is a frequent pathology that affects up to 60% of women. Transvaginal uterosacral ligament high fixation (USLs: utero-sacral ligaments) is an alternative for the treatment of apical prolapse with good results, limited operative and recovery times, as well as low rates of complications. Objective: To evaluate the anatomical and subjective success rate in patients with an apical prolapse undergoing STALUS at the Quilpué Hospital at 24 months of follow-up. Materials and method: A descriptive observational retrospective study was carried out, selecting all symptomatic patients with an apical prolapse ≥ 2 of the POP Q classification, submitted to a FAUS between September 2014 and October 2019. The data were obtained from the database of the Urogynecology Unit of the Quilpué Hospital, prior approval of the ethics committee. Objective success was defined as a C-point 1 centimeter above the hymen and subjective success with better or much better Patient Global Impression-Improvement (PGI-I) scale and/or a greater than 80% Visual Analogue Scale (VAS), at 24 months of follow-up. Results: 46 patients were included. The objective success rate was 84% and the subjective success rate was 70%. Conclusions: The transvaginal FAUS with permanent sutures is an excellent alternative for the treatment of apical prolapse with a success rate similar to the gold standard at 24 months of follow-up.

Saving lives through road safety risk factor interventions: global and national estimates.

Global road mortality is a leading cause of death in many low-income and middle-income countries. Data to support priority setting under current resource constraints are urgently needed to achieve Sustainable Development Goal (SDG) 3.6. This Series paper estimates the potential number of lives saved if each country implemented interventions to address risk factors for road injuries. We did a systematic review of all available evidence-based, preventive interventions for mortality reduction that targeted the four main risk factors for road injuries (ie, speeding, drink driving, helmet use, and use of seatbelt or child restraint). We used literature review variables and considered three key country-level variables (gross domestic product per capita, population density, and government effectiveness) to generate country-specific estimates on the potential annual attributable number of lives that would be saved by interventions focusing on these four risk factors in 185 countries. Our results suggest that the implementation of evidence-based road safety interventions that target the four main road safety risk factors could prevent between 25% and 40% of all fatal road injuries worldwide. Interventions addressing speed could save about 347 258 lives globally per year, and at least 16 304 lives would be saved through drink driving interventions. The implementation of seatbelt interventions could save about 121 083 lives, and 51 698 lives could be saved by helmet interventions. We identify country-specific estimates of the potential number of lives saved that would be attributable to these interventions. Our results show the potential effectiveness of the implementation and scaling of these interventions. This paper presents key evidence for priority setting on road safety interventions and shows a path for reaching SDG 3.6.

Foot evaluation via telephone and video virtual medical visits.

BACKGROUND: Telemedicine plays a very important role in our society by allowing providers to treat patients who do not have easy access to a healthcare facility, especially in the setting of the COVID-19 pandemic. OBJECTIVE: We aimed to create an extensive, yet concise guide for medical providers to virtually evaluate patients with foot concerns. METHODS: This article outlines how to conduct a well-planned virtual consultation with specific questions, instructions, and examination manoeuvres to navigate musculoskeletal foot problems. CONCLUSION: With this narrative review, we have provided a guide with suggestions, questions and interpretations of answers to help physicians new to the practice of telemedicine have successful virtual encounters with patients suffering from foot musculoskeletal ailments.

Shoulder Evaluation by Telephone and Video Visit: A Narrative Review.

Telemedicine has a very important role in today's healthcare system, which has been accentuated during the SARS-CoV-2 pandemic. Virtual medical evaluations offer a myriad of benefits for both patients and providers. Evaluations of the musculoskeletal system, however, present unique challenges because diagnosis significantly relies on a physical examination, something not easily accomplished by virtual means. The shoulder, a complex region with four separate articulations, is no exception. Nevertheless, a properly planned and executed telemedicine visit may yield successful results even with challenging shoulder pathologies. This narrative review aims to offer clinicians who are novices in the practice of telemedicine a basic framework with instructions, questions, and some examples of interpretation of patient answers to guide them through encounters for the evaluation of shoulder complaints via telephone and video consultation.

10 city analysis of child passenger helmet use.

INTRODUCTION: Road traffic injuries are the leading cause of death in children over age five. Most of these deaths occur in low- and middle-income countries. Vulnerable road users, such as motorcyclists and their passengers, are at higher risk. Helmets have significantly decreased morbidity and mortality for motorcyclists; however, they are often unused. The second phase of the Bloomberg Philanthropies Initiative for Global Road Safety was launched in 2015 to improve road safety in 10 cities. This study focuses on child passenger helmet use data from that study to understand the prevalence of helmet use and factors that are associated with helmet use. METHODS: The 10 cities selected were Accra, Addis Ababa, Bandung, Bangkok, Bogota, Fortaleza, Ho Chi Minh City, Mumbai, Sao Paulo, and Shanghai. Eight rounds of roadside observational data were collected from February 2015 to April 2019. Observers noted correct child motorcycle passenger helmet use and other site observations including weather patterns, traffic volume, and road surface conditions. A multivariable Poisson regression model was used to examine correct helmet use trends over time. A multivariable logistic regression model was fitted for correct child passenger helmet use in all cities controlling for weather, observation time, number of passengers, and driver's correct helmet use. RESULTS: This dataset contained 99,846 motorcycle child passenger observations across the 10 cities. The highest prevalence of correct child passenger helmet use was in Sao Paulo at 97.33%. Six cities had under 25% correct helmet use for child passengers. Examining helmet use over time, only five cities had a significant increase, four cities had no change, and Ho Chi Minh City demonstrated a decrease. In the multivariable regression model, child passengers had higher odds of wearing helmets in adverse weather conditions, early mornings, if the driver wore a helmet, and if there were fewer passengers. CONCLUSIONS: The prevalence of correct child passenger helmet utilization shows large variation globally and is concerningly low overall. Enhanced enforcement in combination with media campaigns may have contributed to increasing helmet use prevalence over time. Further research is needed to understand reasons for low child passenger helmet use in most cities.