Health Care Providers' Recommendations for Menstrual Suppression for Servicewomen Prior to Deploying to and Austere Field Environment

Problem: Servicewomen that are being deployed to austere field environments may need assistance in managing their menstrual hygiene. Often these servicewomen lack access to restrooms and adequate hand washing facilities. Managing a menstrual cycle in an austere field environment may be difficult, inconvenient, and lead to genitourinary tract infections. There are various contraceptive methods available that may be used for menstrual suppression if servicewomen desire to manage their menstrual cycle while deployed. These methods include use of long-acting reversible contraception (LARC), continuous use of a contraceptive by eliminating the withdrawal-bleeding week, or receiving injectable progesterone. Servicewomen have reported a desire for education on menstrual suppression options, yet most have not been provided this education from health care providers. Project Aim: The overall aim of this project was to identify the current practice of health care providers at a Midwestern U.S. Army Military Treatment Facility (MTF) in regards to their recommendations for menstrual suppression for servicewomen prior to deploying to an austere field environment. Project Method: A brief 11-question paper and pencil survey, concerning providers’ current recommendations regarding menstrual suppression techniques, was administered to health care providers during a routine staff meeting. The Project Director and the U.S. Army MTF Health Center Educator will ensure distribution of the surveys. The survey consisted of nine multiple-choice questions and two ranking style questions. Survey responses were analyzed and disseminated at the facility to encourage discussion on the topic of menstrual suppression for servicewomen deploying to an austere field environment. Results: Seven health care providers completed the survey and the majority did not routinely discuss menstrual suppression options with AD servicewomen. Most health care providers prescribed contraception for both birth control and menstrual suppression. Female health care providers were more likely to prefer a LARC for menstrual suppression. Conclusions: Servicewomen need counseling regarding menstrual suppression options from their health care provider prior to deploying to an austere field environment. LARC appears to be a viable option for menstrual suppression for these servicewomen. Future, large scale research with members from different branches of the military may help to better understand difficulties servicewomen face with menstrual suppression

Management of coronary artery fistulae Patient selection and results of transcatheter closure

AbstractObjectivesWe report short-term findings in 33 patients after transcatheter closure (TCC) of coronary artery fistulae (CAF) and compare our results with those reported in the recent transcatheter and surgical literature.BackgroundTranscatheter closure of CAF has been advocated as a minimally invasive alternative to surgery.MethodsWe reviewed all patients presenting with significant CAF between January 1988 and August 2000. Those with additional complex cardiac disease requiring surgical management were excluded.ResultsOf 39 patients considered for TCC, occlusion devices were placed in 33 patients (85%) at 35 procedures and included coils in 28, umbrella devices in 6 and a Grifka vascular occlusion device in 1. Post-deployment angiograms demonstrated complete occlusion in 19, trace in 11, or small residual flow in 5. Follow-up echocardiograms (median, 2.8 years) in 27 patients showed no flow in 22 or small residual flow in 5. Of the 6 patients without follow-up imaging, immediate post-deployment angiograms showed complete occlusion in 5 or small residual flow in 1. Thus, complete occlusion was accomplished in 27 patients (82%). Early complications included transient ST-T wave changes in 5, transient arrhythmias in 4 and single instances of distal coronary artery spasm, fistula dissection and unretrieved coil embolization. There were no deaths or long-term morbidity. Device placement was not attempted in 6 patients (15%), because of multiple fistula drainage sites in 4, extreme vessel tortuosity in 1 and an intracardiac hemangioma in 1.ConclusionsA comparison of our results with those in the recent transcatheter and surgical literature shows similar early effectiveness, morbidity and mortality. From data available, TCC of CAF is an acceptable alternative to surgery in most patients

The Moyjil site, south-west Victoria, Australia : Stratigraphic and geomorphic context

Shelly deposits at Moyjil (Point Ritchie, Warrnambool), Victoria, together with ages determined from a variety of techniques, have long excited interest in the possibility of a preserved early human influence in far south-eastern Australia. This paper presents a detailed analysis of the stratigraphy of the host Bridgewater Formation (Pleistocene) at Moyjil and provides the context to the shelly deposits, evidence of fire and geochronological sampling. We have identified five superposed calcarenite–palaeosol units in the Bridgewater Formation, together with two prominent erosional surfaces that may have hosted intensive human activity. Part of the sequence is overlain by the Tower Hill Tuff, previously dated as 35 ka. Coastal marine erosion during the Last Interglacial highstand created a horizontal surface on which deposits of stones and shells subsequently accumulated. Parts of the erosional surface and some of the stones are blackened, perhaps by fire. The main shell deposit was formed by probable mass flow, and additional shelly remains are dispersed in the calcareous sand that buried the surface

Long-term ocean and resource dynamics in a hotspot of climate change

Unidad de excelencia María de Maeztu CEX2019-000940-MThe abundance, distribution, and size of marine species are linked to temperature and nutrient regimes and are profoundly affected by humans through exploitation and climate change. Yet little is known about long-term historical links between ocean environmental changes and resource abundance to provide context for current and potential future trends and inform conservation and management. We synthesize >4000 years of climate and marine ecosystem dynamics in a Northwest Atlantic region currently undergoing rapid changes, the Gulf of Maine and Scotian Shelf. This period spans the late Holocene cooling and recent warming and includes both Indigenous and European influence. We compare environmental records from instrumental, sedimentary, coral, and mollusk archives with ecological records from fossils, archaeological, historical, and modern data, and integrate future model projections of environmental and ecosystem changes. This multidisciplinary synthesis provides insight into multiple reference points and shifting baselines of environmental and ecosystem conditions, and projects a near-future departure from natural climate variability in 2028 for the Scotian Shelf and 2034 for the Gulf of Maine. Our work helps advancing integrative end-to-end modeling to improve the predictive capacity of ecosystem forecasts with climate change. Our results can be used to adjust marine conservation strategies and network planning and adapt ecosystem-based management with climate change

Lifestyle modification for resistant hypertension: The TRIUMPH randomized clinical trial

Resistant hypertension (RH) is a growing health burden in this country affecting as many as one in five adults being treated for hypertension. RH is associated with increased risk of adverse cardiovascular disease (CVD) events and all-cause mortality. Strategies to reduce blood pressure in this high risk population are a national priority

Treatment of anxiety in patients with coronary heart disease: Rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial

Anxiety is highly prevalent among patients with coronary heart disease (CHD), and there is growing evidence that high levels of anxiety are associated with worse prognosis. However, few studies have evaluated the efficacy of treating anxiety in CHD patients for reducing symptoms and improving clinical outcomes. Exercise and selective serotonin reuptake inhibitors have been shown to be effective in treating patients with depression, but have not been studied in cardiac patients with high anxiety

Treatment of anxiety in patients with coronary heart disease: Rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial

Anxiety is highly prevalent among patients with coronary heart disease (CHD), and there is growing evidence that high levels of anxiety are associated with worse prognosis. However, few studies have evaluated the efficacy of treating anxiety in CHD patients for reducing symptoms and improving clinical outcomes. Exercise and selective serotonin reuptake inhibitors have been shown to be effective in treating patients with depression, but have not been studied in cardiac patients with high anxiety

Agreement between physicians and non-physician clinicians in starting antiretroviral therapy in rural Uganda

<p>Abstract</p> <p>Background</p> <p>The scarcity of physicians in sub-Saharan Africa – particularly in rural clinics staffed only by non-physician health workers – is constraining access to HIV treatment, as only they are legally allowed to start antiretroviral therapy in the HIV-positive patient. Here we present a pilot study from Uganda assessing agreement between non-physician clinicians (nurses and clinical officers) and physicians in their decisions as to whether to start therapy.</p> <p>Methods</p> <p>We conducted the study at 12 government antiretroviral therapy sites in three regions of Uganda, all of which had staff trained in delivery of antiretroviral therapy using the WHO Integrated Management of Adult and Adolescent Illness guidelines for chronic HIV care. We collected seven key variables to measure patient assessment and the decision as to whether to start antiretroviral therapy, the primary variable of interest being the Final Antiretroviral Therapy Recommendation. Patients saw either a clinical officer or nurse first, and then were screened identically by a blinded physician during the same clinic visit. We measured inter-rater agreement between the decisions of the non-physician health workers and physicians in the antiretroviral therapy assessment variables using simple and weighted Kappa analysis.</p> <p>Results</p> <p>Two hundred fifty-four patients were seen by a nurse and physician, while 267 were seen by a clinical officer and physician. The majority (> 50%) in each arm of the study were in World Health Organization Clinical Stages I and II and therefore not currently eligible for antiretroviral therapy according to national antiretroviral therapy guidelines. Nurses and clinical officers both showed moderate to almost perfect agreement with physicians in their Final Antiretroviral Therapy Recommendation (unweighted κ = 0.59 and κ = 0.91, respectively). Agreement was also substantial for nurses versus physicians for assigning World Health Organization Clinical Stage (weighted κ = 0.65), but moderate for clinical officers versus physicians (κ = 0.44).</p> <p>Conclusion</p> <p>Both nurses and clinical officers demonstrated strong agreement with physicians in deciding whether to initiate antiretroviral therapy in the HIV patient. This could lead to immediate benefits with respect to antiretroviral therapy scale-up and decentralization to rural areas in Uganda, as non-physician clinicians – particularly clinical officers – demonstrated the capacity to make correct clinical decisions to start antiretroviral therapy. These preliminary data warrant more detailed and multicountry investigation into decision-making of non-physician clinicians in the management of HIV disease with antiretroviral therapy, and should lead policy-makers to more carefully explore task-shifting as a shorter-term response to addressing the human resource crisis in HIV care and treatment.</p

Cytoplasmic CUG RNA Foci Are Insufficient to Elicit Key DM1 Features

The genetic basis of myotonic dystrophy type I (DM1) is the expansion of a CTG tract located in the 3′ untranslated region of DMPK. Expression of mutant RNAs encoding expanded CUG repeats plays a central role in the development of cardiac disease in DM1. Expanded CUG tracts form both nuclear and cytoplasmic aggregates, yet the relative significance of such aggregates in eliciting DM1 pathology is unclear. To test the pathophysiology of CUG repeat encoding RNAs, we developed and analyzed mice with cardiac-specific expression of a beta-galactosidase cassette in which a (CTG)400 repeat tract was positioned 3′ of the termination codon and 5′ of the bovine growth hormone polyadenylation signal. In these animals CUG aggregates form exclusively in the cytoplasm of cardiac cells. A key pathological consequence of expanded CUG repeat RNA expression in DM1 is aberrant RNA splicing. Abnormal splicing results from the functional inactivation of MBNL1, which is hypothesized to occur due to MBNL1 sequestration in CUG foci or from elevated levels of CUG-BP1. We therefore tested the ability of cytoplasmic CUG foci to elicit these changes. Aggregation of CUG RNAs within the cytoplasm results both in Mbnl1 sequestration and in approximately a two fold increase in both nuclear and cytoplasmic Cug-bp1 levels. Significantly, despite these changes RNA splice defects were not observed and functional analysis revealed only subtle cardiac dysfunction, characterized by conduction defects that primarily manifest under anesthesia. Using a human myoblast culture system we show that this transgene, when expressed at similar levels to a second transgene, which encodes expanded CTG tracts and facilitates both nuclear focus formation and aberrant splicing, does not elicit aberrant splicing. Thus the lack of toxicity of cytoplasmic CUG foci does not appear to be a consequence of low expression levels. Our results therefore demonstrate that the cellular location of CUG RNA aggregates is an important variable that influences toxicity and support the hypothesis that small molecules that increase the rate of transport of the mutant DMPK RNA from the nucleus into the cytoplasm may significantly improve DM1 pathology