Repeated sprint training in hypoxia induces specific skeletal muscle adaptations through S100A protein signaling.

Athletes increasingly engage in repeated sprint training consisting in repeated short all-out efforts interspersed by short recoveries. When performed in hypoxia (RSH), it may lead to greater training effects than in normoxia (RSN); however, the underlying molecular mechanisms remain unclear. This study aimed at elucidating the effects of RSH on skeletal muscle metabolic adaptations as compared to RSN. Sixteen healthy young men performed nine repeated sprint training sessions in either normoxia (FIO2 = 0.209, RSN, n = 7) or normobaric hypoxia (FIO2 = 0.136, RSH, n = 9). Before and after the training period, exercise performance was assessed by using repeated sprint ability (RSA) and Wingate tests. Vastus lateralis muscle biopsies were performed to investigate muscle metabolic adaptations using proteomics combined with western blot analysis. Similar improvements were observed in RSA and Wingate tests in both RSN and RSH groups. At the muscle level, RSN and RSH reduced oxidative phosphorylation protein content but triggered an increase in mitochondrial biogenesis proteins. Proteomics showed an increase in several S100A family proteins in the RSH group, among which S100A13 most strongly. We confirmed a significant increase in S100A13 protein by western blot in RSH, which was associated with increased Akt phosphorylation and its downstream targets regulating protein synthesis. Altogether our data indicate that RSH may activate an S100A/Akt pathway to trigger specific adaptations as compared to RSN.

Electronic Health Record Data for Lyme Disease Surveillance, Massachusetts, USA, 2017-2018.

Lyme disease surveillance based on provider and laboratory reports underestimates incidence. We developed an algorithm for automating surveillance using electronic health record data. We identified potential Lyme disease markers in electronic health record data (laboratory tests, diagnosis codes, prescriptions) from January 2017-December 2018 in 2 large practice groups in Massachusetts, USA. We calculated their sensitivities and positive predictive values (PPV), alone and in combination, relative to medical record review. Sensitivities ranged from 57% (95% CI 47%-69%) for immunoassays to 87% (95% CI 70%-100%) for diagnosis codes. PPVs ranged from 53% (95% CI 43%-61%) for diagnosis codes to 58% (95% CI 50%-66%) for immunoassays. The combination of a diagnosis code and antibiotics within 14 days or a positive Western blot had a sensitivity of 100% (95% CI 86%-100%) and PPV of 82% (95% CI 75%-89%). This algorithm could make Lyme disease surveillance more efficient and consistent.

Towards addressing the awarding gap-Using critical race theory to contextualise the role of intersectionality in Black pharmacy student attainment.

INTRODUCTION: The awarding gap between White and Black students in UK health curricula is well established. Critical race theory (CRT) is a lens to deconstruct pedagogic practice and consider the intersectionality of Black student lived experience to provide a realist critique of the phenomenon of Whiteness in higher education and the impact this has on Black attainment. Using one UK pharmacy programme as a case study, this paper aims to explore Black lived experience as a means of problematising and disrupting structural oppressions. METHODS: Sixteen Black students from one UK pharmacy degree programme were purposively recruited to the study. Love and breakup letter methodology (LBM) was used to facilitate sharing experiences of intersectionality in relation to their undergraduate education, with data thematically analysed through the lens of CRT. RESULTS: Two meta-themes (identity and inclusion; and cultural capital) and four subthemes (social capital; access; family expectations; and help-seeking) were identified. The intersectionality of Black students was articulated as not possessing the social capital and the 'language' to succeed within the White structures of the curriculum. The conflict of capital and the absence of Black culture gave rise to confined help-seeking behaviours. Whilst Black students experienced equality of access to the curriculum, an absence of rights to legitimate involvement (inclusion) worked to diminish participation in the curriculum. DISCUSSION: This is the first study to consider the intersectionality of Black pharmacy students in relation to academic awarding gaps and has found that oppressive educational structures marginalise and other Black experience. Black students experience the curriculum as a place where their social and cultural capital is undervalued, and as a White space where they lack the artefacts to succeed, leading to peripheral participation and detachment. The approach used in this study can be adopted across medical and health education as a means to problematise racial inequality through the exemplar of White:Black awarding gaps.

The impact of regional disparities on the availability of meningococcal vaccines in the US.

BACKGROUND: In the United States (US), three types of vaccines are available to prevent invasive meningococcal disease (IMD), a severe and potentially fatal infection: quadrivalent conjugate vaccines against serogroups A, C, W, Y (MenACWY), and monovalent vaccines against serogroup B (MenB) as well as a newly licensed pentavalent vaccine (MenABCWY) protecting against serogroup A, B, C, W, and Y. The CDC's Advisory Committee on Immunization Practices (ACIP) routinely recommends MenACWY vaccine for all 11- to 12-year-olds with a booster dose at 16 years. MenB vaccination is recommended based on shared clinical decision-making (SCDM) for 16- to 23-year-olds. Recently, the pentavalent meningococcal vaccine (MenABCWY) was recommended by the ACIP. Meningococcal vaccine uptake is suboptimal across the country, particularly among individuals with lower socioeconomic status (SES), despite these recommendations. The objective of the spatial analyses was to assess the relationship between stocking of MenACWY and MenB vaccines, area-level SES, and state-level policies. METHODS: The number of MenACWY and MenB doses stocked by vaccinators was obtained from IQVIA and the CDC's Vaccine for Children (VFC) program and compiled into a county-level dataset from 2016 to 2019. SES, as measured using the CDC's Social Vulnerability Index (SVI), state-level school recommendations, and universal purchasing programs were among the main county-level covariates included to control for factors likely influencing stocking. Data were stratified by public and private market. Bayesian spatial regression models were developed to quantify the variations in rates of stocking and the relative rates of stocking of both vaccines. RESULTS: After accounting for county-level characteristics, lower SES counties tended to have fewer doses of MenB relative to MenACWY on both public and private markets. Lower SES counties tended to have more supply of public vs. private doses. Universal purchasing programs had a strong effect on the markets for both vaccines shifting nearly all doses to the public market. School vaccination strategy was key for improving stocking rates. CONCLUSIONS: Overall, the results show that MenACWY has greater stock relative to MenB across the US. This difference is exacerbated in vulnerable areas without school entry requirements for vaccination and results in inequity of vaccine availability. Beyond state-level policy and SES differences, SCDM recommendations may be a contributing factor, although this was not directly assessed by our model.

Exploring factors influencing implementation of interprofessional education in undergraduate healthcare programmes: a multiple-case study.

Interprofessional education (IPE) can help prepare future graduates to work collaboratively in healthcare teams. Using a multiple-case study approach, we explored IPE across four United Kingdom (UK) Higher Education Institutions (HEIs) to identify factors affecting IPE implementation and outcomes. For each site, educators involved with IPE were surveyed and interviewed to explore IPE implementation. To examine outcomes, students took part in focus groups and accreditation reports published by professional regulators were explored. A total of five IPE courses were surveyed, six IPE leads were interviewed, three focus groups were conducted with students, and sixteen reports were reviewed. Regulators' standards mandating IPE and directives by the Deans were the main triggers for IPE initiation. In sites where the regulator's standards were perceived by educators as non-mandating IPE, some staff were less inclined to engage with IPE initiation, which adversely affected IPE planning and delivery. Students from such sites were less satisfied with their IPE experiences and uncertain about the purpose of IPE. Senior management (i.e. Dean) commitment and support is needed to establish IPE initiatives across the institution and cultivate a collaborative culture. The presence of a collaborative culture was associated with positive feedback from regulators and students regarding IPE.

Validation of Claims-Based Algorithm for Lyme Disease, Massachusetts, USA.

Compared with notifiable disease surveillance, claims-based algorithms estimate higher Lyme disease incidence, but their accuracy is unknown. We applied a previously developed Lyme disease algorithm (diagnosis code plus antimicrobial drug prescription dispensing within 30 days) to an administrative claims database in Massachusetts, USA, to identify a Lyme disease cohort during July 2000-June 2019. Clinicians reviewed and adjudicated medical charts from a cohort subset by using national surveillance case definitions. We calculated positive predictive values (PPVs). We identified 12,229 Lyme disease episodes in the claims database and reviewed and adjudicated 128 medical charts. The algorithm's PPV for confirmed, probable, or suspected cases was 93.8% (95% CI 88.1%-97.3%); the PPV was 66.4% (95% CI 57.5%-74.5%) for confirmed and probable cases only. In a high incidence setting, a claims-based algorithm identified cases with a high PPV, suggesting it can be used to assess Lyme disease burden and supplement traditional surveillance data.

Hetero- and cisnormativity-UK pharmacy education as a queer opponent.

INTRODUCTION: Queer pedagogy is a lens through which the hegemonic discourses of curricula and the heterosexual assumptions within them can be made visible. Using this lens, sexuality and gender norms incorporated in undergraduate medical and health curricula can be located and the lived experience of a curriculum examined. This paper seeks to determine the extent of hetero/cisnormativity within UK pharmacy education with the aim of problematising the normalisation of heterosexuality; following this, strategies to disrupt structured hetero/cisnormativity are considered. METHODS: Online cross-sectional surveys were distributed to course leads (n = 29) and students enrolled on undergraduate pharmacy (MPharm) programmes. Surveys captured quantitative data on curriculum design and perceived barriers to implementation of inclusive curriculum design (the espoused LGBTQI+ curriculum), as well qualitative data on the lived experience of the hidden curriculum. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed thematically. RESULTS: Responses were received from 19 course leads and students from 25 MPharm programmes, representing varying completion rates. Findings suggest the shared values and goals of pharmacy education act to normalise and legitimise hetero and cis identities within curriculum design that othering as a consequence of heterosexual normativity is experienced and that pharmacy education is an LGBTQI+ opponent and does not adopt an ally attitude. Moreover, both educator and student data suggest that the enacted and experienced curriculum fails to prepare learners to care for LGBTQI+ people. DISCUSSION: Despite findings suggesting the espoused or enacted curriculum absents LGBTQI+ people, and the hidden curriculum is experienced as homonegative, learners are questioning, resisting and disrupting the hetero- and cisnormative benevolent heterosexism within UK pharmacy curricula. This method of curricula interrogation can be adopted across health professions education as a means for ongoing problematising and disruption of normativity in clinical education.

To be or not to be: The identity work of pharmacists as clinicians.

This study explores how pharmacists legitimise the expansion of their clinical work and considers its impact on pharmacists' professional identity work. In the context of pharmacy in the English NHS, there has been an ongoing policy shift towards pharmacists moving away from 'medicines supply' to patient-facing, clinical work since the 1950s. Pharmacists are continuously engaging in 'identity work' and 'boundary work' to reflect the expansion of their work, which has led to the argument that pharmacists lack a clear professional identity. Drawing insights from linguistics and specifically Van Leeuwen's 'grammar of legitimation', this study explains how the Pharmacy Integration Fund, a nationally funded learning programme, provides the discursive strategies for pharmacists to legitimise their identity work as clinicians.

Academic resilience in UK pharmacy education - a pilot study applying love and break up letters methodology.

INTRODUCTION: Academic resilience is seen as a positive attribute that supports academic attainment and protects against attrition and burnout. Studies have reported that UK pharmacy students have lower academic resilience and wellbeing than the general UK student population but the reasons for this have not been established. This study pilots the use of a novel methodology, love and break-up letter methodology (LBM), to explore these issues focusing on the lived experience of pharmacy students. METHOD: Final year undergraduate pharmacy study were purposely recruited to the study. Employing LBM, each participant was invited to write reflective love and break-up letters to their academic resilience in higher education during a focus group. Letters and transcripts of subsequent focus group discussion on the feelings and ideas expressed in the letters were thematically analysed. RESULTS: Three meta-themes were identified within the data; the curriculum as gas lighting; the curriculum as abusive; and the curriculum as controlling. Students described how the curriculum diminishes academic resilience by working against their sense of agency and self-esteem. A constant threat of failure emerged as defining the student lived experience; students felt controlled by a curriculum with negative impacts on wellbeing and perseverance. DISCUSSION: This is the first study to use LBM to explore academic resilience in UK pharmacy students. The results provide evidence that some students view the pharmacy curriculum as a source of relentless adversity that is responsible for promoting a hidden negative connection between students and their education. Further study is required to determine if the results can be generalised across the UK pharmacy student body to explain why UK pharmacy students have lower academic resilience than other UK university students and the steps needed to improve academic resilience in UK pharmacy students.

Pharmacy professionals' perceptions of educational supervision in primary care through the lens of Proctor's model.

BACKGROUND: Educational supervision plays a vital role in postgraduate medical education and more recently in pharmacy and advanced clinical practitioner training in England. Proctor's three-function model of clinical supervision (consisting of formative, restorative, and normative functions) is assumed to apply to educational supervision, but this has not been tested empirically. The aim of this study was to establish perceptions of the purpose of educational supervision from the perspective of primary care pharmacy professionals enrolled on a national training pathway in England. METHODS: Using a mixed methods design, data were collected using a validated 25-item online survey and respondents were invited to add comments explaining their responses. The survey was sent to all 902 learners enrolled on a postgraduate training pathway for pharmacy professionals working in primary care. Principal components analysis (PCA) was used to interpret patterns in the survey data, and framework analysis of qualitative free text comments was used to identify themes and aid interpretation of quantitative findings. RESULTS: One hundred eighty-seven pharmacy professionals responded (response rate 20.7%). PCA extracted three factors explaining 71.5% of the total variance. Factor 1 corresponded with survey items linked to the formative function of Proctor's model, while factor 2 corresponded with survey items linked to the restorative function. No items corresponded with the normative function. Framework analysis of qualitative free-text comments identified two themes: learning support, which corresponded with factor 1; and personal support, which corresponded with factor 2. CONCLUSIONS: This study identified that pharmacy professionals perceived educational supervision to perform two functions, formative (educational) and restorative (pastoral), but did not perceive it to perform a normative (surveillance) function. Educational supervision has the potential to support allied health professionals advancing their roles and we suggest the need for more research to develop models of effective educational supervision which can inform practice.

Congenital Syphilis Infection: A Case Study.

Congenital syphilis (CS) infection occurs by way of vertical transmission of the bacteria Treponema pallidum from mother to fetus. While nearly eliminated by the turn of the twenty-first century, CS has resurged in recent years and currently represents a worldwide public health calamity secondary to insufficient prenatal care and inadequate maternal treatment. Fetal and neonatal consequences include stillbirth, cutaneous and visceral symptoms, asymptomatic infection, and death. Given the rise in cases in both wealthy and resource-poor areas, neonatal clinicians are obligated to maintain acumen specific to risk factors, manifestations, and treatment regimens. However, limited data guide postnatal treatment regimens, particularly in preterm neonates. We present a case report of a preterm female with CS and integrated review of the literature. Our findings indicate that CS is preventable through efficient and judicious perinatal screening, early detection, and adequate treatment of maternal syphilis during pregnancy.

Hepatitis C coinfection and extrahepatic cancer incidence among people living with HIV.

OBJECTIVES: We assessed the incidence of extrahepatic cancer among people with HIV/HCV coinfection and the potential impact of direct-acting antivirals (DAAs) on extrahepatic cancer risk among people with HIV/HCV coinfection. DESIGN: Our study cohort included adults who initiated HIV care at a CNICS site in the US during 1995-2017, excluding those with previous cancer and without HCV testing. METHODS: We used Cox regression to estimate hazard ratios for extrahepatic cancer incidence among patients with HIV/HCV coinfection compared with those with HIV monoinfection. Standardized morbidity ratio (SMR) weights were used to create a 'pseudopopulation' in which all patients were treated with antiretroviral therapy (ART), and to compare extrahepatic cancer incidence among patients with untreated HIV/HCV coinfection with the incidence that would have been observed if they had been successfully treated for HCV. RESULTS: Of 18 422 adults, 1775 (10%) had HCV RNA and 10 899 (59%) were on ART at baseline. Incidence rates of any extrahepatic cancer among patients with HIV/HCV coinfection and HIV monoinfection were 1027 and 771 per 100 000 person-years, respectively. In SMR-weighted analyses, the risk of any extrahepatic cancer among patients with untreated HCV coinfection at baseline was similar to the risk if they had been successfully treated for HCV. Patients with untreated HCV coinfection at baseline had higher incidence of kidney, lung and inflammation-related cancers than if their HCV had been successfully treated, but these associations were not statistically significant. CONCLUSIONS: We did not find evidence that treating HCV coinfection with DAAs would reduce the incidence of extrahepatic cancers among people with HIV receiving ART.

Using communities of practice as a lens for exploring experiential pharmacy learning in general practice: Are communities of practice the way forward in changing the training culture in pharmacy?

BACKGROUND: Currently, there is little experiential learning in general practice (GP) during UK undergraduate and postgraduate pharmacy education and training. AIM: To apply educational theories to explore pharmacy stakeholders' perceptions of placements in general practice and contribute to the development of a model of experiential learning for pharmacy. METHODS: Qualitative, semi-structured interviews, conducted as part of two studies exploring experiential learning in general practice, with learners and their GP based supervisors. Interviews explored experiences of learning and practice, and what aided or hindered this. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation using Lave and Wenger's concept of "Communities of Practice". RESULTS: Forty-four interviews were conducted, with learners and placement supervisors. Participants valued placements for providing authentic patient-facing learning experiences in the workplace, facilitated through legitimate peripheral participation by supervisors and supported by the use of pre- and de-briefing. Learners benefitted from support from their supervisor(s) and other staff during their day-to-day learning (informal learning), whilst also having protected time with their supervisors to discuss learning needs or go through workplace-based assessments (formal learning). Lack of clarity regarding which and how competencies should be assessed / demonstrated in general practice challenged monitoring progress from peripheral to full participation. Findings suggest that GP placements provide opportunities for learning about the patient journey between care settings; to work effectively with multidisciplinary teams; and consolidation and application of consultation / communication skills learning. CONCLUSIONS: The learning culture of GP supports learners' development, providing time and opportunities for meaningful and authentic workplace learning, with healthcare professionals acting as supervisors and mentors. These findings can usefully inform implementation of meaningful learning opportunities in primary and secondary care for those involved in pharmacy education and training.

Can Machine Learning Help Identify Patients at Risk for Recurrent Sexually Transmitted Infections?

BACKGROUND: A substantial fraction of sexually transmitted infections (STIs) occur in patients who have previously been treated for an STI. We assessed whether routine electronic health record (EHR) data can predict which patients presenting with an incident STI are at greatest risk for additional STIs in the next 1 to 2 years. METHODS: We used structured EHR data on patients 15 years or older who acquired an incident STI diagnosis in 2008 to 2015 in eastern Massachusetts. We applied machine learning algorithms to model risk of acquiring ≥1 or ≥2 additional STIs diagnoses within 365 or 730 days after the initial diagnosis using more than 180 different EHR variables. We performed sensitivity analysis incorporating state health department surveillance data to assess whether improving the accuracy of identifying STI cases improved algorithm performance. RESULTS: We identified 8723 incident episodes of laboratory-confirmed gonorrhea, chlamydia, or syphilis. Bayesian Additive Regression Trees, the best-performing algorithm of any single method, had a cross-validated area under the receiver operating curve of 0.75. Receiver operating curves for this algorithm showed a poor balance between sensitivity and positive predictive value (PPV). A predictive probability threshold with a sensitivity of 91.5% had a corresponding PPV of 3.9%. A higher threshold with a PPV of 29.5% had a sensitivity of 11.7%. Attempting to improve the classification of patients with and without repeat STIs diagnoses by incorporating health department surveillance data had minimal impact on cross-validated area under the receiver operating curve. CONCLUSIONS: Machine algorithms using structured EHR data did not differentiate well between patients with and without repeat STIs diagnosis. Alternative strategies, able to account for sociobehavioral characteristics, could be explored.

High-fidelity simulation-based education in pre-registration healthcare programmes: a systematic review of reviews to inform collaborative and interprofessional best practice.

Simulation-based education (SBE) is recognized as an effective interprofessional teaching and learning method. Whilst there is a large volume of research evidence concerning elements of SBE there is a lack of clarity concerning foundational principles of best practice. This is important for educators wishing to utilize high-quality SBE to deliver interprofessional education. The aim of this review is to synthesize review evidence of SBE best practice in a broad range of pre-registration healthcare programs and contextualize findings in light of relevant educational theory. A systematic search of PubMed, Scopus, Medline/Ovid, British Nursing Index, and the Cochrane Library databases was undertaken in February 2020. Data extraction and quality evaluation were undertaken by two authors. Fifteen reviews were included. In addition to identifying barriers and enablers to implementation, three interdependent themes regarding SBE best practice were found: curriculum level integration and planning (curriculum level integration, the opportunity for deliberate repeated practice, distribution, and sequencing); simulation design and delivery (clearly defined learning outcomes and benchmarks, pre-brief, multiple learning strategies, interactivity and individualized learning, feedback, and debrief); and resources (facilitator competency, controlled environments). These themes broadly align with the social constructivist theory of experiential learning whereby structured opportunities to learn via concrete experience, reflective observation, abstract conceptualization, and active experimentation are provided through effective planning, design, and delivery of SBE. Interdependencies suggest that integration of SBE at curriculum-level enables planning and implementation of best practice principles which are associated with effective learning, which also inform and facilitate the availability of adequate simulation resources.

Relationship between cardiorespiratory phase coherence during hypoxia and genetic polymorphism in humans.

KEY POINTS: High altitude-induced hypoxia in humans evokes a pattern of breathing known as periodic breathing (PB), in which the regular oscillations corresponding to rhythmic expiration and inspiration are modulated by slow periodic oscillations. The phase coherence between instantaneous heart rate and respiration is shown to increase significantly at the frequency of periodic breathing during acute and sustained normobaric and hypobaric hypoxia. It is also shown that polymorphism in specific genes, NOTCH4 and CAT, is significantly correlated with this coherence, and thus with the incidence of PB. Differences in phase shifts between blood flow signals and respiratory and PB oscillations clearly demonstrate contrasting origins of the mechanisms underlying normal respiration and PB. These novel findings provide a better understanding of both the genetic and the physiological mechanisms responsible for respiratory control during hypoxia at altitude, by linking genetic factors with cardiovascular dynamics, as evaluated by phase coherence. ABSTRACT: Periodic breathing (PB) occurs in most humans at high altitudes and is characterised by low-frequency periodic alternation between hyperventilation and apnoea. In hypoxia-induced PB the dynamics and coherence between heart rate and respiration and their relationship to underlying genetic factors is still poorly understood. The aim of this study was to investigate, through novel usage of time-frequency analysis methods, the dynamics of hypoxia-induced PB in healthy individuals genotyped for a selection of antioxidative and neurodevelopmental genes. Breathing, ECG and microvascular blood flow were simultaneously monitored for 30 min in 22 healthy males. The same measurements were repeated under normoxic and hypoxic (normobaric (NH) and hypobaric (HH)) conditions, at real and simulated altitudes of up to 3800 m. Wavelet phase coherence and phase difference around the frequency of breathing (approximately 0.3 Hz) and around the frequency of PB (approximately 0.06 Hz) were evaluated. Subjects were genotyped for common functional polymorphisms in antioxidative and neurodevelopmental genes. During hypoxia, PB resulted in increased cardiorespiratory coherence at the PB frequency. This coherence was significantly higher in subjects with NOTCH4 polymorphism, and significantly lower in those with CAT polymorphism (HH only). Study of the phase shifts clearly indicates that the physiological mechanism of PB is different from that of the normal respiratory cycle. The results illustrate the power of time-evolving oscillatory analysis content in obtaining important insight into high altitude physiology. In particular, it provides further evidence for a genetic predisposition to PB and may partly explain the heterogeneity in the hypoxic response.

More Screening or More Disease? Gonorrhea Testing and Positivity Patterns Among Men in 3 Large Clinical Practices in Massachusetts, 2010-2017.

BACKGROUND: Gonorrhea diagnosis rates in the United States increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts. METHODS: The analysis included men (aged ≥15 years) who received care during 2010-2017 in 3 clinical practice groups. We calculated annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence the predilection to test and probability of gonorrhea disease. RESULTS: On average, 306 348 men had clinical encounters each year. There was a significant increase in men with ≥1 gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual risk ratio, 1.12; 95% confidence interval, 1.12-1.13). There was a significant, albeit lesser, increase in the percentage of tested men with ≥1 positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual risk ratio, 1.07; 95% confidence interval, 1.04-1.09). CONCLUSIONS: We estimated significant increases in the annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive gonorrhea test result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.

Implementing, embedding and sustaining simulation-based education: What helps, what hinders.

OBJECTIVES: Although there is much evidence to support the use of simulation-based education (SBE) in undergraduate education of health care professionals, less attention has been paid to how SBE, viewed as a complex intervention, is implemented and becomes embedded and sustained. This paper aims to explore factors that inhibited or promoted SBE becoming normal practice in undergraduate health care professional programmes. METHODS: Participants involved in the organisation, design and delivery of SBE in the north of England were recruited purposefully from higher education institutions (HEI) and National Health Service (NHS) Trusts through local networks for qualitative telephone interviews. Transcripts were analysed inductively using a hybrid approach involving simultaneous inductive open coding and deductive coding using normalisation process theory (NPT) as a theoretical lens. FINDINGS: A total of 12 NHS staff from 11 trusts and seven individuals from four HEIs were interviewed. There was considerable variation in the approach taken to implementation across organisations, which resulted in varying degrees of embeddedness. Implementation was challenged or enabled by organisational leadership, professional buy-in and the development and maturity of the strategic approach. Variation in understanding of the scope and pedagogical aims of SBE led to inequity between professions and organisations in investment and participation, as well as design and delivery of SBE. CONCLUSIONS: Given the complexity of SBE, best practice in implementation should be considered fundamental to the successful delivery of SBE. The findings provide an explanation of how contextual factors can support or hinder implementation to maximise potential benefits and learning outcomes; this understanding can be used to better inform development of SBE strategies and highlight potential factors needed to navigate contextual barriers so that learning outcomes can be maximised.

Cardio-respiratory, oxidative stress and acute mountain sickness responses to normobaric and hypobaric hypoxia in prematurely born adults.

PURPOSE: We compared the effects of hypobaric and normobaric hypoxia on select cardio-respiratory responses, oxidative stress and acute mountain sickness (AMS) severity in prematurely born individuals, known to exhibit blunted hypoxic ventilatory response. METHODS: Sixteen prematurely born but otherwise healthy males underwent two 8-h hypoxic exposures under: (1) hypobaric hypoxic [HH; terrestrial altitude 3840 m; PiO2:90.2 (0.5) mmHg; BP: 478 (2) mmHg] and (2) normobaric hypoxic [NH; PiO2:90.6 (0.9) mmHg; FiO2:0.142 (0.001)] condition. Resting values of capillary oxyhemoglobin saturation (SpO2), heart rate (HR) and blood pressure were measured before and every 2 h during the exposures. Ventilatory responses and middle cerebral artery blood flow velocity (MCAv) were assessed at rest and during submaximal cycling before and at 4 and 8 h. Plasmatic levels of selected oxidative stress and antioxidant markers and AMS symptoms were also determined at these time points. RESULTS: HH resulted in significantly lower resting (P = 0.010) and exercise (P = 0.004) SpO2 as compared to NH with no significant differences in the ventilatory parameters, HR or blood pressure. No significant differences between conditions were found in resting or exercising MCAv and measured oxidative stress markers. Significantly lower values of ferric-reducing antioxidant power (P = 0.037) were observed during HH as opposed to NH. AMS severity was higher at 8 h compared to baseline (P = 0.002) with no significant differences between conditions. CONCLUSION: These data suggest that, in prematurely born adults, 8-h exposure to hypobaric, as opposed to normobaric hypoxia, provokes greater reductions in systemic oxygenation and antioxidant capacity. Further studies investigating prolonged hypobaric exposures in this population are warranted. REGISTRATION: NCT02780908 (ClinicalTrials.gov).

Characteristics of Out-of-Care Patients Who Required a Referral for Re-engagement Services by Public Health Bridge Counselors Following a Brief Clinic-Based Retention Intervention.

The NC-LINK Project initiated both clinic-based retention services and state public health bridge counselor-based (SBCs) re-engagement services to retain and re-engage people living with HIV infection (PLWH) in care. The goal of this project is to compare efforts between clinic-based retention and SBC re-engagement services to determine whether patients are more or less likely to remain in HIV care services. Clinic appointment data were used to identify patients who were last seen more than 6-9 months prior. Patients either received clinic-based retention services only or were subsequently referred to the SBC re-engagement intervention if the retention services were unsuccessful. The frequency of re-engagement in care (180 days) and HIV suppression (VLS, within 1 year) was examined for patients in these two groups. The SBC group was less likely to have VLS at the visit prior to referral (adjusted OR 2.04, 95% CI 1.53, 2.72). Patients who were referred to the SBC were less likely to re-engage in care within 180 days as compared to those who received clinic-based retention services only (adjusted OR 0.29, 95% CI 0.21, 0.41).