Reproductive Planning: Long-Acting Reversible Contraceptives and Emergency Contraception.

Long-acting reversible contraceptives (LARCs) include progestin and copper intrauterine devices (IUDs) and progestin subdermal implants. LARCs may be the preferred for individuals who want a method that is highly effective and can last for several years, or for whom estrogen is contraindicated. LARCs should be offered using a shared decision-making approach, keeping in mind that historically these methods have been used coercively to control the reproductive choices of marginalized or disabled people. To ensure safe prescribing and reduce barriers to receiving LARCs, family physicians should be familiar with two evidence-based national contraceptive guidelines: the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) and the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). Information about insertion, removal, potential complications, and expected adverse effects should be included when counseling patients about LARC options. Both types of LARC IUDs can safely be used for emergency contraception if inserted within 5 days of unprotected intercourse. Several oral emergency contraception drug options also are available.

Reproductive Planning: Unintended Pregnancy.

Unintended pregnancy is seen commonly in the family medicine setting. It is defined as a pregnancy that is mistimed (occurring sooner than wanted) or unwanted (not desired at that time or any time in the future). Approximately 45% of all US pregnancies are unintended. Childbirth resulting from an undesired pregnancy has been associated with adverse maternal and child health outcomes. Clinicians should be prepared to manage unplanned pregnancies, including dating pregnancies and discussing pregnancy options. Pregnancy options counseling entails discussing the options to parent, make an adoption plan, or undergo an abortion. Because of the complexity around pregnancy intentions, a framework that places patients at the center of their reproductive decisions and engages them in collaborative decision-making during options counseling is paramount. Patients commonly seek abortion, which is considered essential health care. Because of the current legal climate surrounding abortion in many states, patients may opt to use abortion drugs without licensed clinician oversight, called self-managed medication abortion, which has been shown to be safe and effective. No states require clinicians to report known or suspected self-managed medication abortion.

Reproductive Planning: Contraceptive Counseling and Nonhormonal Methods.

More than 65% of US women ages 15 to 49 years use contraception every year, many of whom seek care with family medicine. Family physicians are well equipped to provide comprehensive contraceptive counseling to patients in the primary care setting. When discussing options and providing education to patients, clinicians should consider patient preferences, patient autonomy, and adverse effect concerns, and should use a patient-centered approach that upholds the principles of reproductive justice. Nonhormonal methods of contraception include barrier methods and spermicides, fertility awareness-based methods, and (in postpartum individuals) lactational amenorrhea. With barrier methods, spermicides, and fertility awareness-based methods, 13 to 29 out of 100 women may become pregnant. Permanent forms of contraception include female and male sterilization procedures, which are some of the most effective (more than 99% effective) and most commonly used methods in the United States.

Reproductive Planning: Short-Acting Reversible Contraceptives.

Short-acting reversible contraceptives (SARCs) are prescribed routinely by primary care clinicians. SARCs are among the most commonly prescribed contraceptive methods and include combined hormonal oral contraceptive pills, the combined hormonal transdermal patch, the combined hormonal vaginal ring, progestin-only pills, and the 3-month depot medroxyprogesterone acetate injection. To ensure safe prescribing and reduce barriers to receiving SARC methods, family physicians should be familiar with two evidence-based national contraceptive guidelines, the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) and the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). SARCs have benefits in addition to pregnancy prevention; as such, these methods may be chosen for reasons other than contraception.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care.

BACKGROUND: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy. METHODS: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither. RESULTS: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features. CONCLUSIONS: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

The Impact of Microbial Composition on Postprandial Glycaemia and Lipidaemia: A Systematic Review of Current Evidence.

Postprandial hyperglycaemia is associated with increased risk of cardiovascular disease. Recent studies highlight the role of the gut microbiome in influencing postprandial glycaemic (PPG) and lipidaemic (PPL) responses. The authors of this review sought to address the question: "To what extent does individual gut microbiome diversity and composition contribute to PPG and PPL responses?". CINAHL Plus, PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from January 2010 to June 2020. Following screening, 22 studies were eligible to be included in the current review. All trials reported analysis of gut microbiome diversity and composition and PPG and/or PPL. Results were reported according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analysis' (PRISMA) statement. Individual microbiota structure was found to play a key role in determining postprandial metabolic responses in adults and is attributed to a complex interplay of diet, microbiota composition, and metagenomic activity, which may be predicted by metagenomic analysis. Alterations of gut microbiota, namely relative abundance of bacterial phylum Actinobacteria and Proteobacteria, along with Enterobacteriaceae, were associated with individual variation in postprandial glycaemic response in adults. The findings of the current review present new evidence to support a personalised approach to nutritional recommendations and guidance for optimal health, management, and treatment of common metabolic disorders. In conclusion, personalised nutrition approaches based on individual microbial composition may improve postprandial regulation of glucose and lipids, providing a potential strategy to ameliorate cardiometabolic health outcomes.

Single-day and multiday repeatability of stance analysis results for dogs with hind limb lameness.

OBJECTIVE: To assess single-day and multiday repeatability of weight distribution (stance) data obtained with a commercial analyzer for dogs with naturally occurring hind limb lameness. ANIMALS: 46 dogs (15 and 31 for single-day and multiday trials, respectively). PROCEDURES: For single-day trials, 5 to 10 measurements/trial were collected to determine body weight (BW), weight distribution on each limb, and forelimb and hind limb symmetry indices (SIs). The dog was removed from the room and returned immediately; 5 trials were performed. For multiday trials, measurements were performed in the same manner on 2 sequential days. Data were compared among trials (single-day measurements) and between days (multiday measurements). Repeatability (correlation coefficients and Lin concordance correlation coefficients [LCCCs]) and variability (coefficients of variation [CVs]) were assessed. RESULTS: In single-day trials, BW (r = 0.999), weight distribution on the lame hind limb (r = 0.915) and contralateral hind limb (r = 0.948), and hind limb SI (r = 0.964) were each significantly correlated among trials. In multiday trials, BW results were similar; weight distribution on the lame hind limb and contralateral hind limb and hind limb SI were each less closely but still significantly correlated between days. The LCCCs were highest for BW, weight distribution on the contralateral hind limb, and hind limb SI in single-day trials and for BW and weight bearing on the contralateral and lame hind limbs in multiday trials. The CVs were lowest for BW and highest for forelimb SI in both trial types. CONCLUSIONS AND CLINICAL RELEVANCE: The analyzer used allowed repeatable measurement of BW and weight distribution on the hind limbs of dogs with hind limb lameness. Measurement of forelimb stance variables was not repeatable in this group of dogs.

Comparison of the Effect of Dog, Surgeon and Surgical Procedure Variables on Improvement in Eight-Week Static Weight-Bearing following Tibial Plateau Levelling Osteotomy.

OBJECTIVE: The purpose of this article was to compare the effect of surgeon and tibial plateau levelling osteotomy (TPLO) procedure variations on the outcome of TPLO in naturally occurring cranial cruciate ligament disease. MATERIALS AND METHODS: Records from 142 dogs that had a TPLO procedure were reviewed for information regarding surgical procedure, status of meniscus at the time of surgery, surgeon identity, ACVS diplomate or resident, meniscal release, progression of healing at the progress evaluation based on radiographic interpretation and complications encountered. The primary outcome measure was static force on the affected limb at re-evaluation (42-84 days postoperatively) on a PetSafe Stance Analyzer. RESULTS: Re-evaluation tibial plateau angle (TPA) was negatively and significantly correlated with improvement (r = -0.2132, p = 0.013). Postoperative and re-evaluation TPA were all significantly correlated with one another. The amount of TPA change from initial to immediate postoperative values was significantly correlated with the preoperative TPA (r = 0.628, p < 0.001). Surgeon, surgical experience, arthrotomy, meniscal damage, meniscal intervention, complications, postoperative TPA and preoperative TPA had no significant effect on weight-bearing at recheck. CLINICAL SIGNIFICANCE: TPLO show improvement of 4.58% body weight on the affected limb at 6 to 12 weeks rechecks on a Stance Analyzer. Surgeon, surgical experience, arthrotomy, meniscal damage, meniscal intervention, complications, postoperative TPA and initial TPA have no effect on this measurement of surgical outcome.

Comparison of surgical time and complication rate of subcutaneous and skin closure using barbed suture or traditional knotted suture in dogs.

This prospective study evaluated the handling, intraoperative and postoperative complication rates of a barbed knotless suture for closure of subcutaneous tissue and skin in 17 client-owned dogs (group A) following a tibial plateau leveling osteotomy procedure. Clinical characteristics, surgical time, and complication rates were compared to a control group of 17 client-owned dogs (group B) with subcutaneous tissue and skin closure using traditional suture material. Signalment was not significantly different between groups and did not have an effect on complication rates. Surgical times were not significantly different for subcutaneous tissue or skin closure between the 2 groups. There were significantly more intraoperative complications in the barbed suture group (A: 4/17; B: 0/17; P = 0.033) but no difference in minor or major postoperative complication rates (minor A: 2/16; B: 1/14; P = 0.626, major A: 2/16; B: 0/14; P = 0.171).

Comparaison du temps opératoire et du taux de complication de la fermeture sous-cutanée et de la peau en utilisant des points de suture barbelés ou des points de suture noués traditionnels chez les chiens. Cette étude prospective a évalué les taux de complication liés à la manipulation, peropératoire et postopératoire des points de suture barbelés sans noeuds pour la fermeture du tissu sous-cutané et de la peau chez 17 chiens appartenant à des clients (groupe A) après une intervention d'ostéotomie de nivellement du plateau tibial. Les caractéristiques cliniques, le temps opératoire et les taux de complication ont été comparés à un groupe témoin de 17 chiens appartenant à des clients (groupe B) avec du matériel de suture traditionnel pour la fermeture du tissus sous-cutanés et de la peau. Le signalement n'était pas significativement différent entre les groupes et n'a pas eu d'effet sur les taux de complication. Le temps opératoire n'était pas significativement différent pour la fermeture du tissu sous-cutané ou de la peau entre les deux groupes. Il y avait significativement plus de complications peropératoires dans le groupe à points de suture barbelés (A : 4/17; B : 0/17; P = 0,033) mais aucune différence pour les taux de complications postopératoires mineures ou majeures (mineure A : 2/16; B : 1/14; P = 0,626, majeure A : 2/16; B : 0/14; P = 0,171).(Traduit par Isabelle Vallières).

Rates of reinforcement and measures of compliance in free and protected contact elephant management systems.

Protected contact is an alternative to traditional captive elephant training techniques that emerged as a result of concerns for animal welfare and personnel safety. The present study documented the behavior of elephants and their animal care professionals to determine rates of reinforcement and measures of compliance under two handling systems. Behavioral data were collected from animal care professionals and elephants during the elephants' baths in both free contact (FC) and protected contact (PC). Positive reinforcement, in the form of food, was delivered, on average, nearly eight times more frequently in the PC condition. Further, the mean rate at which the animal care professionals used the ankus in the FC condition as negative reinforcement was similar to the mean rate at which they provided positive reinforcement to the elephants in the FC condition. Latencies between verbal commands and the elephants' behaviors demonstrated an inconsistent pattern, but were generally longer in the PC condition. The mean percent of "refusals" by the elephants was higher for most behaviors across elephants in the PC condition. The findings suggest that animal care professionals did not heavily rely on positive reinforcement in the FC condition to elicit desired behaviors from the elephants, but this was the case in the PC condition. We propose that longer latencies and higher mean percent of refusals by the elephants may indicate that they were exercising choice or control over their environment, which has been associated with improved well-being. Additional studies of this kind are needed to enable other institutions to make informed decisions about elephant management and welfare.