Ultrasound Elastography in Benign Gynecology: A Scoping Review.

OBJECTIVE: To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations. METHODS: A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations. RESULTS: The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer. CONCLUSION: Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions.

The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri.

OBJECTIVES: To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging. METHODS: 3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models. RESULTS: Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference. CONCLUSIONS: Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline.

OBJECTIVE: To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada. TARGET POPULATION: Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis. OPTIONS: The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging. OUTCOMES: There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment. BENEFITS, HARMS, AND COSTS: Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments. EVIDENCE: Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text. VALIDATION METHODS: The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE: This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them. TWEETABLE ABSTRACT: Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers.

Directive clinique no 449 : Directive canadienne sur le diagnostic et les impacts de l'endométriose.

OBJECTIF: Fournir une approche contemporaine pour comprendre les impacts de l'endométriose et les méthodes de diagnostic au Canada. POPULATION CIBLE: Les personnes, familles, communautés, prestataires de soins et administrateurs de services de santé qui sont concernés par l'endométriose, qui soignent des patientes atteintes d'endométriose ou qui gèrent la prestation de services relatifs à l'endométriose. OPTIONS: Le diagnostic de l'endométriose se fait par une anamnèse détaillée, un examen physique et des examens d'imagerie effectués par des prestataires expérimentés dans le traitement de l'endométriose. L'évaluation chirurgicale avec analyse anatomopathologique confirme le diagnostic d'endométriose; toutefois, elle n'est pas nécessaire pour les personnes ayant un diagnostic confirmé par imagerie. RéSULTATS: Il est nécessaire de détecter l'endométriose le plus tôt possible afin de favoriser l'accès rapide aux soins et au soutien. L'éducation du public, des personnes atteintes et de leur famille, des prestataires de soins et des administrateurs de services de santé est essentielle pour éviter de retarder le diagnostic et le traitement. BéNéFICES, RISQUES ET COûTS: La sensibilisation et l'éducation sur les impacts et l'approche du diagnostic peuvent améliorer la rapidité d'accès aux soins pour les personnes atteintes d'endométriose et leur famille. Des soins précoces et appropriés peuvent contribuer à réduire le fardeau pour le système de santé; toutefois, l'amélioration de l'évaluation clinique peut nécessiter des investissements initiaux. DONNéES PROBANTES: Chaque section a été examinée au moyen d'une stratégie de recherche unique représentant les données disponibles dans la littérature spécifique au domaine concerné. Les recherches pour chaque section de la directive sont énumérées à l'annexe A et comprennent l'information de revues systématiques publiées décrites dans le texte. MéTHODES DE VALIDATION: Les recommandations ont été élaborées à la suite de deux cycles analyse par un groupe d'experts nationaux dans le cadre d'un processus de consensus itératif de deux ans. Le processus est décrit plus en détail à l'annexe B. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe C (tableau C1 pour les définitions et tableau C2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Cette directive vise à aider les prestataires de soins et les décideurs politiques impliqués dans les soins aux personnes touchées par l'endométriose et dans les ressources nécessaires pour les soutenir. RéSUMé POUR TWITTER: Directive mise à jour sur le diagnostic et les impacts de l'endométriose à l'intention des prestataires de soins et décideurs politiques canadiens.

Guideline No. 445: Management of Chronic Pelvic Pain.

OBJECTIVE: To provide evidence-based recommendations for the management of chronic pelvic pain in females. TARGET POPULATION: This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. BENEFITS, HARMS, AND COSTS: The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. EVIDENCE: Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. TWEETABLE ABSTRACT: Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS: RECOMMENDATIONS.

Tobacco use in currently married pregnant & lactating women in India; key findings from the National Family Health Survey-5.

Background: Tobacco use among pregnant and lactating women carries dangerous repercussions for women and their children. Limited information is available at the national level on the prevalence and determinants of tobacco use in this vulnerable sub-population of women. This study aims to estimate the prevalence of tobacco use among currently married pregnant and lactating women and its association with demographic, behavioural and regional determinants in India. Methods: A cross-sectional study was conducted during which secondary data from the fifth National Family Health Survey, 2019-2020, was analysed. The prevalence and associated 95% confidence intervals (CI) for different forms of tobacco use were documented among currently married pregnant and lactating women. Adjusted Odds Ratio and 95% CI were calculated using multivariate logistic regression to identify the independent factors associated with different forms of tobacco use among respondents after applying sampling weights. Findings: In India, the prevalence of tobacco use among currently married pregnant and lactating women was 2.5% and 3.2%, respectively, with over 85% of tobacco-using currently married pregnant (85.6%) and lactating (85.6%) women using smokeless tobacco (SLT) only. Age group 30-34 years, working women and the richest wealth quintile were found to be independent predictors of smoked tobacco use among currently married pregnant women. In contrast, among the currently married lactating women, the middle wealth quintile and South Indian region were found to be independent predictors of smoked tobacco use. Interpretation: Smokeless tobacco was found to be the most prevalent type of tobacco consumed by pregnant and lactating women in India. There is an urgent need to curb tobacco use in this vulnerable sub-population of women in the country by sensitising them to the harmful consequences of tobacco use by integrating tobacco awareness and cessation services during routine ante-natal examinations. Funding: No funding was received for this study.

Integrating Nanotechnological Advancements of Disease-Modifying Anti-Rheumatic Drugs into Rheumatoid Arthritis Management.

Disease-modifying anti-rheumatic drugs (DMARDs) is a class of anti-rheumatic medicines that are frequently prescribed to patients suffering from rheumatoid arthritis (RA). Methotrexate, sulfasalazine, hydroxychloroquine, and azathioprine are examples of non-biologic DMARDs that are being used for alleviating pain and preventing disease progression. Biologic DMARDs (bDMARDs) like infliximab, rituximab, etanercept, adalimumab, tocilizumab, certolizumab pegol, and abatacept have greater effectiveness with fewer adverse effects in comparison to non-biologic DMARDs. This review article delineates the classification of DMARDs and their characteristic attributes. The poor aqueous solubility or permeability causes the limited oral bioavailability of synthetic DMARDs, while the high molecular weights along with the bulky structures of bDMARDs have posed few obstacles in their drug delivery and need to be addressed through the development of nanoformulations like cubosomes, nanospheres, nanoemulsions, solid lipid nanoparticles, nanomicelles, liposome, niosomes, and nanostructured lipid carrier. The main focus of this review article is to highlight the potential role of nanotechnology in the drug delivery of DMARDs for increasing solubility, dissolution, and bioavailability for the improved management of RA. This article also focusses on the different aspects of nanoparticles like their applications in biologics, biocompatibility, body clearance, scalability, drug loading, and stability issues.

The Availability of Essential Antimicrobials in Public and Private Sector Facilities: A Cross-Sectional Survey in a District of North India.

(1) Background: There is a need to assess the availability of essential antimicrobials, as the availability of an antimicrobial is a critical element of its rational use. We aimed to assess the availability of antimicrobials listed in the National List of Essential Medicines 2015, India (primary list), and a selected (secondary) list comprised of agents indicated for commonly encountered infectious illnesses in various healthcare settings and to identify the reasons for their non-availability. (2) Methods: A cross-sectional survey of 25 public, private, and other sector pharmacies was carried out in Rohtak, a district of the North Indian state of Haryana, from April to June 2022. (3) Results: Most of the antimicrobials surveyed were optimally available in various sector pharmacies with the exception of benzathine benzylpenicillin, benzylpenicillin, cloxacillin, cefazolin, cefuroxime, cefadroxil, amphotericin B, and antimalarials. The most frequent reasons for limited availability were low demand, no prescriptions, and the non-listing of drugs in the state's essential medicine list. (4) Conclusions: Enough evidence needs to be generated with respect to the status of availability of essential antimicrobials from different regions of India as well as other lower-middle-income countries to devise measures for ascertaining better availability of these agents, especially antibiotics at regional, national, and global scales.

A decade of improving nutritional quality of horticultural crops agronomically (2012-2022): A systematic literature review.

The ultimate goal of world crop production is to produce more with less to meet the growing population demands. However, concentrating solely on increased quantity of production often impacts the quality of produce. Consumption of crops or foods that do not meet nutritional or dietary needs can lead to malnutrition. Malnutrition and undernutrition are prevalent in a significant portion of the population. Agronomic biofortification of minerals and vitamins in horticultural crops has emerged as a promising approach to address nutrient deficiencies and enhance the nutritional quality of food. Despite numerous research papers on plant nutrient biofortification, there remains a lack of systematic reviews that comprehensively summarize the latest knowledge on this topic. Herein we discuss different agronomic ways to biofortify several horticultural crops over the past decade. This systematic review aims to fill this gap by presenting various methodologies and comparing the outcomes of these methods in respect to nutrient content in plant parts. The review focuses on original research papers collected from various scientific databases including Scopus and Web of Knowledge, covering the most recent literature from the last ten years (2012-2022) for specific studies on the agronomic biofortification macronutrients, micronutrients, and vitamins in horticultural plants with exclusion of certain criteria such as 'genetic,' 'breeding,' and 'agronomic crops.' This review critically analyzes the current state of research and explores prospects for the future in this field. The biofortification of various minerals and vitamins, including calcium, selenium, iodine, B vitamins, vitamin A, and vitamin C, are examined, highlighting the achievements and limitations of existing studies. In conclusion, agronomic biofortification of minerals and vitamins in horticultural crops with further research offers a promising approach to address nutrient deficiencies and improve the nutritional quality of food.

Simultaneous biofortification of vitamin C and mineral nutrients in arugula microgreens.

Microgreens have shown promise in improving the overall nutritional value of diets due to their high nutrient density. Agronomic biofortification, is an efficient strategy for enhancing the nutritional value of crops, including microgreens. This study aimed to biofortify vitamin C and other essential nutrients in arugula microgreens using four treatments containing 0.25 % ascorbic acid, pH adjusted with different bases: KOH, Ca(OH)2, ZnCO3, or NaOH and a deionized water control. The results indicate that ascorbic acid-treated microgreens had more vitamin C, greater fresh weight and % dry matter than the control. The ascorbic acid + Zn treatment had an 135 % average increase in vitamin C compared to the control. Microgreens treated with ascorbic acid also showed increased levels of minerals that are present in the nutrient solution, such as potassium, sodium, calcium, and zinc. This research contributes to the growing interest in microgreens biofortification and their role in addressing multi-nutrient deficiencies.

Reactive oxygen species (ROS)-mediated oxidative stress in chronic liver diseases and its mitigation by medicinal plants.

Reactive oxygen species (ROS) play a crucial role in cell survival regulation, and its low levels may act as indicators to encourage cellular proliferation. In contrast, elevated levels of ROS may lead to apoptosis. Stability between generating and eliminating ROS allows the retention of effective functioning of redox-sensitive signaling proteins under physiologic conditions. Cells typically maintain redox homeostasis to guarantee appropriate responses to internal and external stimuli. However, oxidative stress occurs when the oxidation product level exceeds the number of standard antioxidant systems. ROS can cause harm to all types of hepatic cells, including endothelial cells, hepatocytes, Kupffer cells, and stellate cells. High levels of ROS may lead to tissue edema, ischemia, fibrosis, cell death, or malignant transformation and may eventually lead to complete tissue damage. Antioxidants in our body exist in a homeostatic balance with other enzymes involved in the repair of cellular functions in addition to the non-enzymatic molecules such as urate, bilirubin, several vitamins, and reduced glutathione to maintain the levels of ROS in the interest of cellular homeostasis. This balance may, however, get disturbed in case of acute or chronic liver injury due to the accumulation of ROS. In the current manuscript, we aim to review the relevance of oxidative stress and its indicator of liver injury in chronic liver diseases such as alcoholic and non-alcoholic fatty liver diseases and hepatitis. Since reactive oxidation species may also lead to lipid peroxidation and promote ferroptosis, we have also evaluated their impact on epigenetic modifications, such as oxidative damage to histone proteins and DNA methylation, and the differential expression of genes related to cellular injury. We also want to highlight the potential of traditional herbal medicines as redox regulators for managing chronic liver diseases.

Assessing the Impact of Training on Healthcare Providers' Adherence to Infection Control Measures in Hemodialysis Services.

Background and objective Developing and implementing nursing interventions to educate nurses on infection control procedures in hemodialysis units is of utmost importance and offers significant benefits in enhancing the quality of care. This study aimed to assess the impact of training on nursing professionals' practices of hospital infection control measures in hemodialysis services. The research also intended to explore the potential association between these practices and various sociodemographic variables. Materials and methods This was a single-group, pre- and post-interventional study carried out in Haryana State, India. A pretested questionnaire consisting of 29 statements, the responses of which were measured on a 5-point Likert scale, was used as the study tool. Descriptive and statistical tests like paired-t-test were used to analyze the data. Results The practices section of the questionnaire comprised 29 statements, the responses to which were measured on a five-point Likert scale. The scoring ranged from 5 ("strongly agree", i.e., positive practice) to 1 ("strongly disagree", i.e., negative practice). The maximum achievable score was 145 and the minimum achievable score was 9. The pre-test group (i.e., before training intervention) had a mean practice score of 115.0945 [standard deviation (SD)=9.34, standard error of the mean (SE)=0.66]. However, the post-test group (i.e. after training intervention) had a mean score of 135.26 (SD=8.34, SE=0.59). The study found that structured training significantly increased the mean practice score (t=-33.70, p=0.001). In addition, the study also highlighted the significant association of mean practice scores with various demographic variables among the pre-test and post-test groups. The improvement in mean practice scores among the post-test group after the structured training program reveals that such interventions will ultimately lead to a decrease in central line-associated bloodstream infections (CLABSIs) among hemodialysis patients. Conclusions Our findings showed that the educational intervention led to significant improvements in the practices of the participants.

Understanding the mechanistic pathways and clinical aspects associated with protein and gene based biomarkers in breast cancer.

Cancer is one of the most widespread and severe diseases with a huge mortality rate. In recent years, the second-leading mortality rate of any cancer globally has been breast cancer, which is one of the most common and deadly cancers found in women. Detecting breast cancer in its initial stages simplifies treatment, decreases death risk, and recovers survival rates for patients. The death rate for breast cancer has risen to 0.024 % in some regions. Sensitive and accurate technologies are required for the preclinical detection of BC at an initial stage. Biomarkers play a very crucial role in the early identification as well as diagnosis of women with breast cancer. Currently, a wide variety of cancer biomarkers have been discovered for the diagnosis of cancer. For the identification of these biomarkers from serum or other body fluids at physiological amounts, many detection methods have been developed. In the case of breast cancer, biomarkers are especially helpful in discovering those who are more likely to develop the disease, determining prognosis at the time of initial diagnosis and choosing the best systemic therapy. In this study we have compiled various clinical aspects and signaling pathways associated with protein-based biomarkers and gene-based biomarkers.

Impact of structured training program about Hospital Infection Control practices on Knowledge and Perception of nursing students at public and private nursing teaching institute of Northern India- An interventional study.

BACKGROUND: Hospital-acquired infections (HAIs) are a primary cause of illness and death and increased expenditure due to prolonged hospitalization and poor prognosis. HAI is a global safety concern, according to World Health Organization (WHO). This study assesses the current level of knowledge and perception regarding hospital infection control practices among nursing students and evaluates the impact of structured training interventions on their baseline knowledge and perception level. METHODS AND MATERIALS: It was a single group, a pre-post interventional study done on nursing students of one government and one private nursing college in the year 2021. A pretested questionnaire consisting of was used as a study tool. Various statistical tests like one repeated-measure ANOVA, Mauchly's Test of Sphericity, and Greenhouse-Geisser correction were used. RESULTS: The mean knowledge was minimum in the pretest group (Mean = 79.4430, SD = 17.49746) and maximum immediately after the training group (Mean = 96.5443, SD = 25.42322). But after one month, knowledge decreased; however, it was more than pre-training Knowledge (Mean = 84.4937, SD = 22.40313). CONCLUSIONS: Annual educational/training modules help retain knowledge in hospital infection control practices and HAI prevention. All healthcare workers need regular training.

Impact of Structured Training Program about Cadaver Organ Donation and Transplantation on Knowledge and Perception of Nursing Students at Public and Private Nursing Teaching Institute of Northern India - An Interventional Study.

Background: "Donation gap" refers to the shortage of organ donors worldwide. The medical/nursing students and various healthcare workers have poor awareness and attitude toward organ donation. Objective: We conducted this study to assess the current level of knowledge and perception regarding cadaver organ donation and transplantation among nursing students and to evaluate the impact of structured training interventions on their baseline knowledge and perception level. Methods: It was a single-group pre-post interventional study done by nursing students of one government and one private nursing college.A pre-tested questionnaire was used as a study tool. Statistical Analysis: Various statistical tests like one-way repeated measure ANOVA, Mauchly's test of sphericity, and Greenhouse-Geisser correction were used. Pairwise comparisons used Bonferroni corrections. Results: The pre-test group had the lowest mean knowledge (50.2346, SD = 15.35188), and immediately after training group had the highest (57.3900, SD = 14.34626). After one month, knowledge decreased but was still higher than pretraining (mean = 52.3607, SD = 13.28141). Conclusions: The positive attitude of nursing students may augment cadaver organ donation and transplantation in the future. The study has also highlighted the further training needs of the participants.

Placenta Accreta Spectrum Disorders: A National Survey.

OBJECTIVES: Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS: We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS: We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS: This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.

Current trends in epigenetic, cellular and molecular pathways in management of rheumatoid arthritis.

Rheumatoid arthritis is a systemic chronic polyarticular autoimmune disorder of joints and joint membrane mainly affecting feet and hands. The pathological manifestation of the disease includes infiltration of immune cells, hyperplasia of the lining of synovium, formation of pannus and bone and cartilage destruction. If left untreated, the appearance of small focal necrosis, adhesion of granulation, and formation of fibrous tissue on the surface of articular cartilage is noted. The disease primarily affects nearly 1% of the population globally, women being more affected than men with a ratio 2:1 and can initiate regardless of any age. The synovial fibroblast in rheumatoid arthritis individuals exhibits an aggressive phenotype which upregulates the manifestation of protooncogenes, adhesive compounds, inflammatory cytokines and matrix-deteriorating enzymes. Apart from the inflammatory effects of cytokines, chemokines are also noted to induce swelling and pain in arthritic individuals by residing in synovial membrane and forming pannus. The current treatment of rheumatoid arthritis includes treatment with non-steroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, treatment with biologics such as inhibitors of TNF-α, interleukins, platelet activating factor, etc. which provides significant relief from symptoms and aids in management of the disease. The current review highlights the pathogenesis involved in the onset of rheumatoid arthritis and also covers epigenetic, cellular and molecular parameters associated with it to aid better and advanced therapeutic approaches for management of the debilitating disease.

The HOPE study: evaluating the impact of an online educational resource for heavy menstrual bleeding on the patient-physician dynamic.

The Heavy menstrual bleeding: Evidence-based Learning for best Practice (HELP) Group developed an educational website about heavy menstrual bleeding (HMB). The "HMB improving Outcomes with Patient counseling and Education" (HOPE) project examined the website's impact on women's knowledge, confidence, and consultations with healthcare providers (HCPs). HOPE was a quantitative online survey of gynecologists and women with HMB in Brazil. After an initial consultation, patients had unlimited access to the website and completed a survey. HCPs also completed a survey about the sconsultation. After a second consultation, HCPs and patients completed another survey. HCP surveys assessed their perception of patients' awareness, understanding, and willingness to discuss HMB. Patient surveys assessed their knowledge, experience, and confidence in discussing HMB. Forty HCPs recruited 400 women with HMB. Based on HCP perceptions at the first consultation, 18 percent of patients had "good knowledge" or "very good knowledge" of HMB, increasing to 69 percent after patients had visited the website. Before and after visiting the website, 34 percent and 69 percent of patients, respectively, regarded their HMB knowledge as "goo.d" Additionally, 17 percent of women reported their anxiety as "highest" during the first consultation; this decreased to 7 percent during the second consultation. After visiting the HELP website, patients' knowledge of HMB improved and they were less anxious.