Childhood outcomes after maternal antenatal sildenafil treatment for severe early-onset fetal growth restriction: a randomized trial (STRIDER NZAus).

In this follow-up at 2.5 years of children from the STRIDER NZAus Trial (N = 112), in which women with singleton pregnancies affected by severe early fetal growth restriction were randomized to sildenafil citrate 75 mg daily or placebo until 32 weeks, there was no difference between groups in survival without neurosensory impairment, defined as any of cerebral palsy, deafness, blindness, cognitive delay (Bayley III cognition or language score >1 SD below mean) or motor delay: 30/56[54%] vs. 34/56[61%]; aOR = 0.74, 95%CI: 0.31, 1.77. However, children exposed to sildenafil appeared to be more likely to have cognitive delay (13/45[29%] vs. 4/40[10%]; aOR = 3.71, 95% CI: 1.01, 13.63) but less likely to have emotional-behavioural difficulties (2/43[5%] vs. 8/38[21%]; aOR = 0.19, 95%CI: 0.03, 1.00). Conclusion: maternal sildenafil treatment for severe early-onset FGR was not associated with altered survival free of neurosensory impairment at 2.5 years' corrected age.

Electronic health records and clinical documentation in medical residency programs: preparing residents to become master clinicians.

OBJECTIVE: The ubiquity of electronic health records (EHRs) has made incorporating EHRs into medical practice an essential component of resident's training. Patient encounters, an important element of practice, are impacted by EHRs through factors that include increasing documentation requirements. This research sheds light on the role of EHRs on resident clinical skills development with emphasis on their role in patient encounters. MATERIALS AND METHODS: We conducted qualitative semistructured interviews with 32 residents and 13 clinic personnel at an internal medicine residency program in a western US medical school focusing on the resident's clinic rotation. RESULTS: Residents were learning to use the EHR to support and enhance their patient encounters, but one factor making that more challenging for many was the need to address quality measures. Quality measures could shift attention away from the primary reason for the encounter and addressing them consumed time that could have been spent diagnosing and treating the patient's chief complaint. A willingness to learn on-the-job by asking questions was important for resident development in using the EHR to support their work and improve their clinical skills. DISCUSSION: Creating a culture where residents seek guidance on how to use the EHR and incorporate it into their work will support residents on their journey to become master clinicians. Shifting some documentation to the patient and other clinicians may also be necessary to keep from overburdening residents. CONCLUSION: Residency programs must support residents as they develop their clinical skills to practice in a world where EHRs are ubiquitous.

Could a culturally and age-appropriate song contribute towards malaria prevention in primary school learners?

BACKGROUND: Although it is a preventable disease, malaria continues to present one of the major global health challenges. The disease is especially deadly to children under the age of 5 years. This is partly due to the fact that they have yet to build up an immune system to help protect them against malaria. As a prevention strategy, music is one way of communicating knowledge to young children and could therefore potentially be used to change children's behaviour in order to avoid getting sick from malaria. This exploratory study aimed to compare intervention strategies designed to educate and improve knowledge growth about malaria and its prevention in Grade 3 learners in a high-risk malaria region in Vhembe District, Limpopo Province, South Africa. METHODS: Various intervention strategies were employed and evaluated to determine the most effective intervention method. The study was split into two Phases. Phase 1 used a culturally and age-appropriate song as an intervention, along with a drama piece, a song and drama piece combination, and a control group. The most effective intervention strategy determined during Phase 1 was then subjected to Phase 2, against a control group to validate its efficacy. Questionnaires were used during pre-intervention and post-intervention interviews to evaluate the knowledge growth, if any, of the learners of selected primary schools in two different areas in Vhembe District. Pre-intervention interviews were followed by a specific intervention, based on the respective study groups. After 6 weeks, the post-intervention interviews were done to determine how much learners managed to learn and retain from the intervention received. RESULTS: The study found that the group that had only the song as intervention was the most effective learning intervention method in both Phases 1 and 2. Both phases showed that there was statistical significance in almost all of the nine questions asked on the questionnaires. CONCLUSIONS: The study concluded that a culturally and age-appropriate song can play a significant role in developing behavioural changes and spreading awareness against disease in a high-risk malaria region.

A Workflow Change in Anterior Approach Total Hip Arthroplasty Leads to Improved Accuracy of Biomechanical Reconstruction Without Increased Risk of Complications.

BACKGROUND: During anterior approach total hip arthroplasty (THA), the femur may be an impediment for acetabular access, pushing reamers proximally and consequently altering the hip center. In an effort to address this, the senior author changed the surgical workflow from acetabulum first (AF) to femur first (FF). The objective of this study was to compare the precision of biomechanical hip reconstruction and clinical outcomes between the FF and AF techniques. METHODS: This is a retrospective, case-control study of 267 anterior THAs (132 AF and 135 FF). A normal, contralateral hip was used to determine the native biomechanical parameters. Using a calibrated software program, radiographic measurements were performed to calculate the hip center position, femoral offset, global offset, and leg length of the operative and native hips using 2-week postoperative anteroposterior pelvis radiographs. Demographics, operative information, hemoglobin change, and complication data were obtained. Functional outcomes were assessed with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement survey at 1 year postoperatively. RESULTS: The groups exhibited similar demographic characteristics. The FF group demonstrated significantly more accurate and more precise reconstruction of horizontal and vertical hip centers, femoral offset, and leg length. There was no significant difference in operative time, hemoglobin change, complication rate, or Hip Disability and Osteoarthritis Outcome Score, Joint Replacement scores between groups. CONCLUSIONS: The FF technique allowed for more accurate and precise reconstruction of the hip center, leg length, and offset in THA than the AF workflow. Furthermore, the FF approach demonstrated no significant differences in complication rate or blood loss, nor in clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Study Level III.

Mortality and Cholinesterase Inhibition in Butterflies Following Aerial Naled Applications for Mosquito Control on the National Key Deer Refuge.

Natural resource managers are concerned about the impacts of aerial ultra-low volume spray (ULV) of insecticides for mosquito control (i.e., mosquito adulticides) and seek science-driven management recommendations that reduce risk but allow vector control for nearby human populations. Managers at the National Key Deer Refuge (Florida Keys, FL) are concerned for ULV effects upon conservation efforts for imperiled butterflies (Florida leafwing [Anaea troglodyta floridalis] and Bartram's hairstreak [Strymon acis bartrami] butterflies). No-spray zones were designated for protection of those butterflies, but their effectiveness for mitigation is unclear. To address this uncertainty, cholinesterase activity (ChE) and mortality were monitored for caged butterflies gulf fritillary [Agraulis vanilla] and great southern white [Ascia monuste]) deployed on the Refuge during three aerial ULV applications of the insecticide naled. Residue samplers also were deployed to estimate butterfly exposure. Spray efficacy against mosquitoes was assessed by deploying caged mosquitoes at the same locations as the butterflies. Average naled residue levels on filter paper samplers in the target area (1882-2898 µg/m2) was significantly greater than in the no-spray zone (9-1562 µg/m2). Differences between the no-spray zone and target area for butterfly mortality and ChE were inconsistent. Average mortality was significantly lower, and average ChE was significantly higher in the no-spray zone for larvae of one species but not for larvae of the other species. Mosquito mortality did not differ significantly between the two areas. Data from the present study reflect the inconsistent effectiveness of no-spray zones on the Refuge using standard methods employed at the time by the vector control agency in the Florida Keys and possibly by other vector control agencies in similar coastal environments. Furthermore, these findings helped to guide the design and to improve the conservation value of future no-spray zone delineations while allowing for treatment in areas where mosquito control is necessary for vector-borne disease reduction.

A randomized, controlled, two-month pilot trial of stannous fluoride dentifrice versus sodium fluoride dentifrice after oxalate treatment for dentinal hypersensitivity.

OBJECTIVES: To compare the effects of a stannous fluoride dentifrice and a sodium fluoride dentifrice on dentinal hypersensitivity when used with an oxalate-based regimen combining in-office and at-home treatment. MATERIALS AND METHODS: In this single-center, randomized, controlled, double-blind, pilot clinical trial, 30 subjects were professionally treated at baseline with a 3% oxalate/potassium salt solution on up to two target teeth, then randomized 1:1 to either 0.454% stannous fluoride or 0.243% sodium fluoride overlabeled dentifrice. Both groups were given 6 sensitivity strips (3.14% potassium oxalate gel) and a soft, manual toothbrush. Subjects were permitted to apply strips on up to two teeth, up to three times per tooth, at home as desired throughout the study. Dentinal sensitivity (cold air blast challenge) was assessed at baseline, immediately after post-professional treatment, and at day 60 using the Schiff scale and a Visual Analog Scale (VAS). RESULTS: Immediately after professional oxalate treatment, the overall mean Schiff and VAS score decreased 25.6% and 22.4% from baseline, respectively (p ≤ 0.001 for both). At day 60, further reductions in both mean scores were seen in both groups. There were no significant differences between the groups at day 60. All treatments were well tolerated. CONCLUSIONS: In subjects treated with oxalates for dentinal hypersensitivity, both stannous fluoride and sodium fluoride dentifrices are well tolerated, are feasible for routine use, and do not detract from the desensitizing effects of an in-office and at-home oxalate combination treatment regimen. CLINICAL RELEVANCE: Either stannous fluoride or sodium fluoride dentifrices can be recommended to dentinal hypersensitivity patients who undergo professional oxalate treatment.

Using participatory risk analysis to develop a song about malaria for young children in Limpopo Province, South Africa.

BACKGROUND: In 2015, malaria infected over 212 million people and killed over 429,000 individuals, mostly children under 5 years of age, with 90% of malaria cases occurring in sub-Saharan Africa. The aim was to develop an age and culturally appropriate song for Tshivenda-speaking children under 5 years of age to decrease the risk of malaria in Limpopo Province, South Africa. METHODS: Document review was used to identify appropriate disease determinants to decrease risk in children < 5 years old in the study area. These were used to develop lyrics and music for a song about malaria in line with the principles of participatory risk analysis. The age and cultural appropriateness of the song as well as disease determinants chosen were reviewed using a modified Delphi technique, by 10 purposively selected experts in malaria (4), Vhavenda music (3) and early childhood education (3). Thereafter, the song was translated into Tshivenda and reviewed by two focus groups living in the study area, one including female caregivers and pre-school teachers (n = 7) and a second comprising of male community based malaria control personnel (n = 5). RESULTS: The experts surveyed and both focus groups strongly supported the inclusion of knowledge about the link between mosquitoes and malaria and that children should know the signs of malaria to facilitate early diagnosis. Although the expert group felt that bed nets should not be mentioned, both focus groups suggested the inclusion of bed nets and it was observed that community members were purchasing their own nets. Focus group members also felt that young children should not be involved in internal residual spraying initiatives. CONCLUSIONS: It was concluded that although risk communication on malaria prevention and treatment in young children should be aimed at caregivers, an age and culture appropriate song about malaria could be developed to help young children protect themselves. This song focused on understanding the link between mosquitoes and malaria, preventing exposure and recognising signs of disease.

A randomized, controlled comparison of two professional dentin desensitizing agents immediately post-treatment and 2 months post-treatment.

PURPOSE: To compare the desensitizing effects of two different marketed professional dentin hypersensitivity treatments, a 5% sodium fluoride varnish and an oxalic acid/potassium salt solution, in a single-center, randomized, controlled, subject-blind pilot study. METHODS: A total of 22 subjects with dentin hypersensitivity on at least two teeth were recruited from a general dentistry practice and randomized 1:1 to treatment with a 5% sodium fluoride varnish (Acclean Fluoride Varnish) group or a 3% oxalic acid/potassium salt solution (Super Seal Desensitizer). The study population was predominantly female (91%) and Caucasian (77%). The mean age was 46.4 years, with ages ranging from 18-73 years. Dentin hypersensitivity was assessed after an air blast challenge by the examiner (Schiff Index Sensitivity Scale) and by the subject [Visual Analog Scale (VAS)] for each tooth tested. Hypersensitivity was assessed immediately post-treatment and at 2 months post-treatment. RESULTS: For the sodium fluoride varnish group, the mean Schiff score decreased 61% from baseline immediately post-treatment (P= 0.0006) and 41% at Month 2 (P= 0.0069). For the oxalic acid/potassium salt solution group, the mean Schiff score decreased 33% from baseline immediately post-treatment (P= 0.0305) and 29% at Month 2. Similarly, the mean VAS scores in the sodium fluoride varnish group decreased 41% from baseline immediately post-treatment (P= 0.0030) and 34% at Month 2 (P= 0.0275). The mean VAS scores in the oxalic acid/potassium salt solution group decreased 35% from baseline immediately post-treatment (P= 0.0168) and 33% at Month 2 (P= 0.0283). An analysis of covariance found no statistically significant between-group differences in mean Schiff scores or VAS scores immediately post-treatment or at Month 2. Both treatments were well tolerated. There were no reported adverse events in either treatment group. CLINICAL SIGNIFICANCE: Both 5% sodium fluoride varnish and an oxalic acid/potassium salt solution are safe and effective options to treat dentin sensitivity in otherwise healthy adults. The examiner-rated Schiff scores and the patient-rated VAS scores consistently demonstrated a reduction in sensitivity with either treatment, both immediately after professional application and at 2 months post-treatment.

Use of Oxalate Strips in Dentistry: Overall Response and Case Studies With Recent and Longstanding Sensitivity.

Practice-based research was conducted to assess professional in-office treatment of dentin hypersensitivity with a strip-based device as part of a recall visit. The study population came from two sources within the dental practice. The majority were recall patients with evident sensitivity that was observed during routine care, while others were patients with history of dentin hypersensitivity in dental records. Treatment consisted of a 1.5% oxalate gel on a polyethylene strip (Crest® Sensi-Stop™ Strips, Procter and Gamble) that was professionally applied directly to sensitivity sites. Sensitivity was measured clinically and perceptually prior to and immediately after treatment, and again 30 days later. A total of 27 adults received oxalate gel strip treatment, and analysis focused on tooth location (arch and position) to ascertain the feasibility of introducing professional strip treatment as part of routine care. Results demonstrated that patients with cervical dentin hypersensitivity were easy to identify, professional strip application was feasible at different tooth sites across both arches, and treatment resulted in both immediate and durable sensitivity effects over a 1-month period.

Exposure to the lampricide 3-trifluoromethyl-4-nitrophenol results in increased expression of carbohydrate transporters in Saccharomyces cerevisiae.

The lampricide 3-trifluoromethyl-4-nitrophenol (TFM) is used to control sea lamprey (Petromyzon marinus) populations in freshwater lakes. Although TFM can have sublethal and lethal effects, little is known about gene expression changes with TFM exposure. Microarray analysis was used to determine differential gene expression over 4 h of exposure in Saccharomyces cerevisiae. Among the most significantly up-regulated genes were regulators of carbohydrate transport, including HXT1, HXT3, HXT4, IMA5, MIG2, and YKR075C. Environ Toxicol Chem 2016;35:1727-1732. © 2015 SETAC.

Tablet computers in support of rural and frontier clinical practice.

PURPOSE: Healthcare organizations are increasingly faced with an environment in which they must implement health information systems to achieve higher standards for efficiency and quality of care while at the same time being asked to provide needed services with fewer resources. This is particularly challenging for rural health systems where access to resources is often more limited. This study investigates the potential value of iPad tablets for enhancing health services delivery by primary care physicians in rural Nevada. METHODS: Five physicians from rural Nevada were selected to receive iPads and funding for apps that would enhance their medical practices. Following a year of use, data was gathered on each physician's actual use and perceived value of the iPads. A case study approach was taken using both an online survey and semi-structured phone interviews to collect case data. RESULTS: Use and perceived usefulness of the iPad was mixed but generally positive with some physicians utilizing it much more than others. The iPads were primarily used by the physicians to access medical information through online resources (e.g. Epocrates and UpToDate) for reference and diagnostic purposes, although they were also used for some interaction with patients. All felt that resources available through the iPad were limited and that better applications would improve the usefulness of the iPad, particularly in regard to graphical and video content suitable to sharing with patients. CONCLUSIONS: Physicians in this study felt that the iPad could fill a need between smartphones and desktops, which were their primary technology tools prior to receiving the iPad, but that useful medical applications and resources are currently limited for the iPad. In particular, better graphical and video content would improve the usefulness of the iPad as a tool for patient interactions. Apps that store content locally would serve to mitigate inconsistent internet access that is still common in rural settings, increasing the usefulness of the iPad in that context. Tablets like the iPad also have potential for use in accessing the electronic medical record systems that are increasingly being implemented in rural hospitals and healthcare facilities.

Development of a high-volume, multiple-operator program for percutaneous chronic total coronary occlusion revascularization: procedural, clinical, and cost-utilization outcomes.

BACKGROUND: Development of a specialized chronic total coronary occlusion (CTO) revascularization program attentive to procedural guidelines, quality oversight, and cost/resource utilization has not been described. METHODS: A single-center CTO interventional program was initiated with requirements including: extensive didactic training, on-site proctorship, routine determination of case appropriateness, adherence to procedural safety guidelines, and a 2-operator/case approach. Clinical and angiographic characteristics, procedural outcomes, in-hospital clinical events, and cost/resource utilization were examined. RESULTS: Among 145 patients, 160 consecutive CTO revascularization procedures were attempted between October 2009 and December 2010. Selected procedural and technical characteristics included: bilateral femoral access, 90.0%; planned retrograde guidewire placement, 37.5%; re-entry catheter, 10.0%; reattempt, 10.6%; fluoroscopic time, 67.4 ± 45.5 min; contrast volume, 403 ± 215 mL. Average stent number and total stent length per CTO vessel were 2.6 ± 1.1 and 64.7 ± 30.7 mm, respectively. Overall CTO success rate was 85.6% (137/160). In-hospital adverse outcomes included: death 0.6%; emergency bypass surgery, 0.6%; tamponade, 0.6%; myocardial infarction, 1.9%; transient nephropathy, 1.2%. Compared with patients undergoing non-CTO PCI, procedural and total cost per patient were significantly higher among the CTO cohort despite overall similar contribution margins ($5,173 ± 12,052 versus $5,730 ± 8,958, P = 0.58). CONCLUSIONS: Following initiation of a dedicated program with implementation of quality and performance guidelines, complex CTO revascularization may be safely performed with outcomes comparable with reports from established centers. Despite higher resource utilization, CTO revascularization is associated with a positive contribution margin. Requirement of educational and performance standards, mentorship from experts, consensus review for appropriateness and provision of catheterization laboratory policies may represent a model for program development.

Ocular pulse amplitude and associated glaucomatous risk factors in a healthy Hispanic population.

BACKGROUND: With increasing evidence that vascular risk factors play a role in the development of glaucoma, it is critical to be familiar with factors related to intraocular blood flow, such as the ocular pulse amplitude (OPA). This study evaluates OPA and factors related to it in a healthy, Hispanic population. METHODS: Refractive error, corneal curvature, Goldmann applanation tonometry (GAT), dynamic contour tonometry (DCT), OPA, axial length, and central corneal thickness (CCT) measurements were obtained on 104 Hispanic subjects recruited from the community. RESULTS: OPA ranged from 0.7 to 4.7 mmHg (mean, 2.1 +/- 0.8 mmHg) and showed a significant correlation with refractive error, axial length, GAT, and DCT (r=0.250, -0.358, 0.460, 0.378; P=0.011, <0.001, <0.001, and <0.001, respectively). Mean intraocular pressure with GAT was 15.6 mmHg. Mean CCT was 541.2 microm. The average refractive error was 0.75 diopters (D) of myopia, with 25% having >1.00 D myopia. CONCLUSION: Normal OPA values have not been studied in Hispanic populations. OPA is thought to provide information regarding ocular blood flow; however, more studies are needed to determine its significance in glaucoma treatment.

Comparison of dynamic contour tonometry and Goldmann applanation tonometry and their relationship to corneal properties, refractive error, and ocular pulse amplitude.

BACKGROUND: Accurate intraocular pressure (IOP) measurement is essential in diagnosing and managing glaucoma. Dynamic contour tonometry (DCT) is less dependent on corneal properties, such as thickness, elasticity, and rigidity, than Goldmann applanation tonometry (GAT). This study examined the relationship between GAT and DCT as well as their relationship with corneal properties and ocular pulse amplitude (OPA). METHODS: GAT, DCT, OPA, pachymetry, refractive error, and corneal curvature measurements were obtained on 115 healthy volunteers. RESULTS: Participants with thicker corneas (>or=580 microm) had higher IOP measurements with GAT than DCT (P = 0.005). Those with thinner corneas (

Probability-based prediction of activity in multiple arm muscles: implications for functional electrical stimulation.

Functional electrical stimulation (FES) involves artificial activation of muscles with implanted electrodes to restore motor function in paralyzed individuals. The range of motor behaviors that can be generated by FES, however, is limited to a small set of preprogrammed movements such as hand grasp and release. A broader range of movements has not been implemented because of the substantial difficulty associated with identifying the patterns of muscle stimulation needed to elicit specified movements. To overcome this limitation in controlling FES systems, we used probabilistic methods to estimate the levels of muscle activity in the human arm during a wide range of free movements based on kinematic information of the upper limb. Conditional probability distributions were generated based on hand kinematics and associated surface electromyographic (EMG) signals from 12 arm muscles recorded during a training task involving random movements of the arm in one subject. These distributions were then used to predict in four other subjects the patterns of muscle activity associated with eight different movement tasks. On average, about 40% of the variance in the actual EMG signals could be accounted for in the predicted EMG signals. These results suggest that probabilistic methods ultimately might be used to predict the patterns of muscle stimulation needed to produce a wide array of desired movements in paralyzed individuals with FES.

Clinical evaluation of chemical and light-activated tooth whitening systems.

Tooth whitening has become one of the most popular dental treatments available. This article compares the efficacy of 2 in-office whitening systems using a split-arch, randomized, parallel, blinded clinical evaluation study. Both in-office tooth whitening systems were effective and there was no significant statistical difference over the 2-week period of observation. The use of light did not demonstrate any benefit over the chemically activated tooth whitening system after a 2-week recall.

Maintenance of whitening with a power toothbrush after bleaching treatment.

A randomized, parallel, examiner-blind clinical study was conducted to examine the ability of 2 toothbrushes to maintain teeth whitening after at-home bleaching. Forty subjects used a 15% carbamide peroxide tray bleaching system at home for 2 weeks per the manufacturer's instructions and then were randomly assigned to use either the Sonicare Advance power toothbrush or a manual toothbrush as part of their home oral hygiene routine for 6 months. The color of the labial surfaces of the subjects' maxillary anterior dentition was assessed before bleaching and immediately, 2 months, 3 months, and 6 months after bleaching. Color was assessed by comparison with Vita Classical shade tabs and by digital image analysis in the CIE L*a*b* color space. Both groups demonstrated a rebound effect at the 2-month visit and beyond, with mean Vita shade scores significantly higher than immediately after bleaching. At the 6-month evaluation, a significant difference in the amount of rebound in each group was observed. Specifically, the rebound of the Sonicare brush group was on average 1.12 Vita shades less than that of the manual brush group. The 6-month difference was confirmed through digital image analysis, with the Sonicare brush group 4.8 L* units lighter, corresponding to 2 Vita shades, and 2.1 b* units less yellow than the manual brush group. This clinical trial demonstrates that the Sonicare Advance toothbrush better maintains whitening after bleaching treatment than a manual toothbrush.