Development and application of a systematic and quantitative weighting framework to evaluate the quality and relevance of relative potency estimates for dioxin-like compounds (DLCs) for human health risk assessment

The toxic equivalency factors (TEFs) approach for dioxin-like chemicals (DLCs) is currently based on a qualitative assessment of a heterogeneous data set of relative estimates of potency (REPs) spanning several orders of magnitude with highly variable study quality and relevance. An effort was undertaken to develop a weighting framework to systematically evaluate and quantitatively integrate the quality and relevance for development of more robust TEFs. Six main-study characteristics were identified as most important in characterizing the quality and relevance of an individual REP for human health risk assessment: study type, study model, pharmacokinetics, REP derivation method, REP derivation quality, and endpoint. Subsequently, a computational approach for quantitatively integrating the weighting framework parameters was developed and applied to the REP2004 database. This was accomplished using a machine learning approach which infers a weighted TEF distribution for each congener. The resulting database, weighted for quality and relevance, provides REP distributions from >600 data sets (including in vivo and in vitro studies, a range of endpoints, etc.). This weighted database provides a flexible platform for systematically and objectively characterizing TEFs for use in risk assessment, as well as providing information to characterize uncertainty and variability. Collectively, this information provides risk managers with information for decision making.

Multi-modal characterization of the left atrium by a fully automated integration of pre-procedural cardiac imaging and electro-anatomical mapping

Background

The combination of information obtained from pre-procedural cardiac imaging and electro-anatomical mapping (EAM) can potentially help to locate new ablation targets. In this study we developed and evaluated a fully automated technique to align left atrial (LA) anatomies obtained from CT- and MRI-scans with LA anatomies obtained from EAM.

Methods

Twenty-one patients scheduled for a pulmonary vein (PV) isolation with a pre-procedural MRI were enrolled. Additionally, a recent computed tomography (CT) scan was available in 12 patients. LA anatomies were segmented from MRI-scans using ADAS-AF (Galgo Medical, Barcelona) and from the CT-scans using Slicer3D. MRI and CT anatomies were aligned with the EAM anatomy using an iterative closest plane-to-plane algorithm. Initially, the algorithm included the PVs, LA appendage and mitral valve anulus as they are the most distinctive landmarks. Subsequently, the algorithm was applied again, excluding these structures, with only three iterative steps to refine the alignment of the true LA surface. The result of the alignments was quantified by the Euclidian distance between the aligned anatomies after excluding PVs, LA appendage and mitral anulus.

Results

Our algorithm successfully aligned 20/21 MRI anatomies and 11/12 CT anatomies with the corresponding EAM anatomies. The average median residual distances were 1.9 ± 0.6 mm and 2.5 ± 0.8 mm for MRI and CT anatomies respectively. The average LA surface with a residual distance less than 5.00 mm was 89 ± 9% and 89 ± 10% for MRI and CT anatomies respectively.

Conclusion

An iterative closest plane-to-plane algorithm is a reliable method to automatically align pre-procedural cardiac images with anatomies acquired during ablation procedures.

Metabolomic responses based on transcriptome of the hepatopancreas in Exopalaemon carinicauda under carbonate alkalinity stress

High carbonate alkalinity is one of the major stress factors for survival of aquatic animals in saline-alkaline water. Exopalaemon carinicauda is a good model for studying the saline-alkaline adaption mechanism in crustacean because of its great adaptive capacity to alkalinity stress. In this study, non-targeted liquid chromatography-mass spectrometry (LC-MS) metabolomics analyses based on high-throughput RNA sequencing (RNA-Seq) were used to study the metabolomic responses of hepatopancreas in E. carinicauda at 12 h and 36 h after acute carbonate alkalinity stress. The results revealed that most of the significantly differential metabolites were related to the lipid metabolism. In particular, the sphingolipid metabolism was observed at 12 h, the glycerophospholipid metabolism was detected at 36 h, and the linoleic acid metabolic pathway was significantly enriched at both 12 h and 36 h. The combined transcriptome and metabolome analysis showed that energy consumption increased at 12 h, resulting in significant enrichment of AMPK signaling pathways, which contributed to maintain energy homeostasis. Subsequently, the hepatopancreas provided sufficient energy supply through cAMP signaling pathway and glycerophosphate metabolism to maintain normal metabolic function at 36 h. These findings might help to understand the molecular mechanisms of the E. carinicauda under carbonate alkalinity stress, thereby promote the research and development of saline-alkaline resistant shrimp.

[Integration of natural sciences and basic medical subjects in the integrated dentistry program (iMED DENT) at the University of Hamburg]

In October 2019, an integrated dentistry program (iMED DENT) was implemented at the University of Hamburg and was the first of its kind in Germany. This model curriculum builds on didactic concepts that have been applied successfully for many years in curricula for human medicine, including interdisciplinary teaching, early clinical experience, and scientific education. The first year focuses on the healthy situation ("normal function") and aims to integrate the natural sciences (biology, chemistry, physics) and the basic medical subjects (anatomy, biochemistry, physiology, medical terminology) in the context of dental health. Further, basic practical and clinical tasks are assigned to the students during the first year.From the experience of the first four cohorts, initial conclusions can be drawn about this stage of study. Generally, its modular structure results in a condensation of learning content, which students judge as demanding. However, its interdisciplinary approach is well accepted. For instance, presenting the basics of the natural sciences in the context of their dental relevance is much better evaluated in the new compared to the previous curriculum, in which this content was taught without specific references to dental health. Teaching the basics of medicine within clinical context and the inclusion of early clinical practice are similarly appreciated. Presently, the interdisciplinary approach is limited by the focus on practical competencies of the dentistry curriculum, as some practical courses offer only few opportunities for other disciplines to interconnect their teaching. The continuous evaluation of the curriculum and exchange of experiences between the disciplines will further improve the integrative concept of the curriculum.

Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa

In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.

[Study section "From Symptom to Disease"-steps towards an integrated dentistry program]

Based on the integrated medicine program (iMED) at the University Medical Center Hamburg-Eppendorf, the dental education concept was fundamentally revised and an integrated dentistry program (iMED DENT) was developed. During this process, reform goals such as interdisciplinarity between dentistry and medicine, early patient contact, and psychosocial and communicative competencies as well as a scientific orientation were defined. The second study section "From Symptom to Disease" during the second and third years of study form a link between "Normal Function" in the first year and the final training section "Therapy". The modular structure of the integrated dentistry program allows topics to be taken up repetitively and deepened as well as strengthen dental skills during the preclinical practical training in preparation for patient treatment. Here, the implementation of dental prophylaxis, assisting in the clinic, and the assessment of patients' findings create an early link to the practice. Newly integrated are the science and communication tracks, which are also modular and closely interlinked with dentistry. So far, the results of the first three cohorts indicate a successful implementation of the new concept, but it should be continuously developed and improved.

HIV assisted partner services (aPS) to support integrated HIV and hypertension screening in Kenya: a pre-post intervention study

BACKGROUND

People living with HIV (PLWH) have a higher risk of developing hypertension compared to HIV uninfected individuals. HIV assisted partner services (aPS), where PLWH are assisted by a healthcare provider to disclose their status to sexual and / or drug injecting partner(s), offers an opportunity for integrated HIV and hypertension screening. We evaluated the feasibility of the aPS model in supporting integrated HIV and hypertension screening at the Kenyatta National Hospital, Kenya.

METHODS

Between August 2019 and December 2020, we conducted a pre-post intervention study. We enrolled women receiving HIV testing services (HTS) with confirmed hypertension (female index clients) and traced their male relatives for HIV and hypertension screening and reviewed management at 3-months. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg, diastolic blood pressure (DBP) ≥ 90 mmHg, and/or use of antihypertensive medication.

RESULTS

One hundred female index clients (median age: 55 years; interquartile range (IQR): 47-65) mentioned 165 male relatives (median: 49 years; IQR: 40-59) of whom 35% (n = 58/165) were enrolled. Of the male relatives, 29% had hypertension (n = 17/58), 34% had pre-hypertension (n = 20/58), and none were HIV-positive (n = 0/58). Among the female index clients, there was a statistically significant decline in SBP (pre: 156 mmHg, post: 133 mmHg, p-value: < 0.0001) and DBP (pre: 97 mmHg, post: 80 mmHg, p-value: < 0.0001), and increase in antihypertensive medication uptake (pre: 91%, n = 84/92; post: 98%, n = 90/92; X2: 4.3931, p-value: 0.036) relative to baseline. Among the male relatives, there was a statistically significant increase in antihypertensive medication uptake among those with hypertension (pre: 13%, n = 6/46; post: 17%, n = 8/46; X2: 32.7750, p-value: < 0.0001) relative to baseline.

CONCLUSION

HIV aPS holds promise for integrated HIV and hypertension screening among at-risk clients and their families. Twenty-nine percent of the male relatives had hypertension, higher than the national prevalence (24%), while one-third had pre-hypertension. We observed relatively high participant retention, reductions in blood pressure, and increase in antihypertensive medication uptake among those with confirmed hypertension. Future research expanding the aPS model to other non-communicable diseases through larger studies with longer follow-ups is required to better assess causal relationships and optimize integrated service delivery.

Family planning integration in Ethiopia's primary health care system: a qualitative study on opportunities, challenges and best practices

BACKGROUND

Family planning (FP) service integration into primary health care (PHC) is an effective approach to realize reproductive autonomy, increase the use of contraceptives, and improve maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care (PHC). However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration.

METHODS

A qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report.

RESULTS

Family planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers' capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness.

CONCLUSIONS

Integration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

Evaluating the internalisation of the intrinsic role of health advocacy of student pharmacists in a new integrated Bachelor of Pharmacy curriculum: a mixed-methods study

To keep up with the contemporary health landscape, there is an imperative need for healthcare professionals to practise health advocacy through health promotion on the individual, population, and systems levels. In the Academic Year of 2020/2021, the National University of Singapore (NUS) Department of Pharmacy implemented a new spiral curriculum integrating basic, clinical, and systems sciences with one of its aims to deepen students' health advocacy internalisation and prepare them as future health advocates. A mixed-methods approach was adopted. Questionnaires were disseminated across three time-points to elicit students' levels of internalisation of health advocacy, which were then categorised into levels, and a Mann-Whitney U test was conducted. In comparison with prematriculation, no significant difference was found after students underwent the first year of the curriculum, while a significant difference was found after students underwent two years of the curriculum. Semi-structured interviews were also conducted after each Academic Year to gain deeper insights into the questionnaire results. Thematic analysis of the interviews revealed that curricular integration in the first year was perceived to be lacking. However, with learnt knowledge constantly reinforced and more experiential learning opportunities incorporated throughout the second year, students found the integrated curriculum beneficial in instilling confidence to practise health advocacy. This study offers insights into the prospects of a spiral integrated curriculum in imparting health advocacy, and may even suggest its potential to be applied to other educational settings. Future follow-up studies can also be conducted on the same study population to evaluate long-term impacts and areas for improvement of the curriculum.

Sustainability of integrated hypertension and diabetes with HIV care for people living with HIV at primary health care in South Ethiopia: implication for integration

BACKGROUND

People living with human immunodeficiency virus (PLWH) have an increased risk of developing noncommunicable diseases (NCDs) compared with people without HIV. The multimorbidity of NCDs and HIV increases the need for integrated care. However, there is a paucity of evidence on the implementation of integrated sustained hypertension and diabetes with HIV care to address the multiple chronic care needs of PLWH in Ethiopia.

OBJECTIVE

This study aimed to determine the sustainability of integrated hypertension and diabetes within HIV care for PLWH in primary healthcare (PHC) in southern Ethiopia.

METHODS

The National Health Service Institute for Innovation and Improvement Sustainability Model (NHS- SM) self-assessment tool was used to assess sustainability. HIV care and NCD team members from five PHC facilities in South Ethiopia were included. Participants completed the self-administered NHS-SM assessment tool independently.

RESULT

The overall mean sustainability was 43.74 (95% CI: 42.15-45.33). All facilities had an overall sustainability score of less than 55. The perceived benefit beyond helping the patient, the likelihood of adaptability, and perceived alignment with the organizational goal were identified as potential factors promoting sustainability. The perceived lack of an effective system to monitor progress, staff behavior, inadequate staff involvement and training, inadequate senior leadership support and clinical leadership engagement, and infrastructure limitations could negatively affect sustainability.

CONCLUSIONS

Integrating hypertension and diabetes with HIV care sustainably at PHC requires staff involvement and training, staff behavior change communication, ensuring PHC management and clinical leadership (doctors and senior clinicians) engagement, and addressing infrastructure limitations.

The impact of integrating bioscience and nursing subjects in a first-year nursing curriculum: A retrospective study

AIM

The aim of this study is to explore the effects of integrating bioscience and nursing units on academic achievement and perception in the first-year nursing curriculum.

BACKGROUND

Nursing students have historically found biosciences difficult and struggle to relate it to nursing practice. In response, nursing and non-nursing academics have employed different teaching modes and integration strategies to enhance learning. Despite these efforts, substantial gaps still persist concerning the integration of biosciences within nursing curriculum and the effect of integration on student academic achievement and student perception.

DESIGN

Retrospective descriptive. The setting was a large University in Victoria Australia with two undergraduate nursing campuses (metropolitan and non-metropolitan).

METHOD

Student academic records and online evaluation surveys that were completed from 2014 to 2019 were examined. Students self-reported their experiences of the unit using a five-point Likert scale and two open-ended questions. Descriptive and inferential statistics were used to analyse the data. Content analysis was used to analyse the two open-response survey items.

RESULTS

First-year student records from 2014 to 2016 (pre-integration) and 2017-2019 (post-integration) were examined. Student mean age was 24.5 years (SD 7.2) and 20.9 years (SD 4.8) pre-integration and post-integration respectively. There was a statistically significant decrease in student attrition from pre-integration (n=536, 29.9%) to post-integration (n=358, 20.2%) (p <0.001), and a significant improvement in students' mean academic scores post-integration in the first semester 61.9 (SD 15.9) and 67.0 (SD 14.9) respectively, confidence interval 3.9-6.2 (p <0.001). Student satisfaction with the units improved post-integration, from 77.8% to 85.8% (χ2 = 10.1076) (p=0.001). However, there was no significant difference in students' perception of feeling overwhelmed, and their self-reported ability to link theory to practice.

CONCLUSION

Integrating bioscience and clinical nursing practice units in the first-year curriculum can help decrease student attrition rates, improve student academic results and increase student satisfaction which may lead to an overall improvement in student learning experiences.

The Integration of Foot and Ankle Instruments to Enhance Orthopedic Hand Surgery: Technical Note

Introduction

The scaphoid fracture is the most common type of carpal fracture, and disruption of the proximal row of carpal bones alters wrist mechanics altering the stabilization that permits the wrist to work efficiently. When the displacement is at least 2 mm, the majority of surgeons would preferentially operatively intervene in this fracture. Non-union of the fracture will occur when left untreated. The gold standard for treatment is open reduction and internal fixation using autologous bone graft. This case report is the first to describe the integration of the Hintermann™ Distractor, used as an integral part of the surgery in scaphoid waist fracture fixation to improve fracture stabilization, preparation, and compression.

Case Report

A 20-year-old male presented with a volar flexed scaphoid non-union, 4 months after the initial injury. Open reduction internal fixation, with the use of the Hintermann™ Distractor, facilitated ease of reduction and placement of Russe graft.

Conclusion

Scaphoid waist non-unions with volar angulation and an associated DISI deformity can lead to a significant decrease in function. This case study is the first to describe the use of a foot and ankle instrument to assist with fracture preparation and distraction to place a corticocancellous strut graft in the scaphoid fracture efficiently. This case study demonstrates the efficiency of the technique.

A political economy analysis of strengthening health information system in Tanzania

BACKGROUND

Many countries' health systems are implementing reforms to improve the functioning and performance of the Health Management Information System (HMIS) to facilitate evidence-based decisions for delivery of accessible and quality health services. However, in some countries such efforts and initiatives have led to a complex HMIS ecosystem characterized by multiple and fragmented sub-systems. We undertook an in-depth analysis of the HMIS ecosystem in Tanzania to inform the ongoing initiatives, by understanding the relationship and power differences among stakeholders, as well as drivers and barriers to HMIS investment and strengthening.

METHODOLOGY

This was a qualitative research method incorporating data collection through document review and key informant interviews guided by political economy analytical framework. A total of 17 key informant interviews were conducted between April and May 2022. A thematic content analysis was used during data analysis.

RESULTS

Good relationship between the government and stakeholders dealing/supporting HMIS ecosystem was noted as there are technical working groups which brings stakeholders together to discuss and harmonize HMIS activities. The 'need for the data' has been the driving force toward investment in the HMIS ecosystem. The analysis showed that the government is the main stakeholder within the HMIS ecosystem and responsible for identifying the needs for improvement and has the power to approve or reject systems which are not in line with the government priority as stipulated with the HMIS investment roadmap/strategy. Moreover, partners with long relationship are powerful in influencing HMIS investment decision-making compared to those who are recently coming to support. It was further noted shortage of staff with technical competence, inadequate financial resources, and the development of fact that some of the existing systems have not been developed to their full capacity and have hindered the whole systems' integration and interoperability exercise of ensuring integration and interoperability of the systems.

CONCLUSION

A need-based assessment of staff capacity at the sub-national level is equally important to identify available capabilities and the knowledge gap to strengthen the HMIS ecosystem. Strong coordination of the ideas and resources intended to strengthen the HMIS ecosystem would help to reduce fragmentation. In addition, there is a need to mobilize resources within and outside the country to facilitate the integration and interoperability process smoothly.

Attitudes toward the integration of nutritional assessment and counseling in the framework of physical therapy: a cross-sectional survey

BACKGROUND

As the field of physical therapy increasingly acknowledges the integral role of nutritional assessment and counseling, revisiting this subject is essential due to limited updated information regarding this topic. Furthermore, it is crucial to investigate the factors that may influence physical therapists' attitudes toward integrating nutritional assessment and counseling into their physical therapy practice. The study's primary aim was to explore the attitudes of registered physical therapists in Israel toward incorporating nutritional assessment and counseling into their clinical practice. We also explored the relation between personal and professional characteristics of physical therapists and their attitudes.

METHODS

An anonymous nationwide online self-report survey was conducted. It included three sections: personal and professional background characteristics, self-reported level of nutritional knowledge and sources of nutritional knowledge, and attitudes toward incorporating nutritional assessment and counseling into practice. Descriptive statistics were calculated for all outcome measures. The total score of the attitude statements was compared between different groups of participants. Multiple linear regression analysis was used to predict positive attitudes.

RESULTS

The study included 409 physical therapists. The attitude score was 19.78 (2.53) of 25, indicating a positive attitude. A majority (67%) reported that they did not acquire knowledge regarding nutrition during their entry-level studies or in other formal settings (63%). The three primary sources of nutritional information for the participants reported were the Internet (87.0%), registered dietitian (70.0%), and professional, scientific journals (36.0%). Prior knowledge acquired during entry-level physical therapist studies and clinical experience of ≥ 13 years significantly predicted positive attitudes (β = 0.17, β = -0.13, respectively).

CONCLUSION

Registered physical therapists held a positive attitude toward incorporating nutritional assessment and counseling into their clinical practice. Two background professional characteristics were predictors of positive attitudes. Accordingly, there is need to appropriate formal education regarding nutritional issues. Further studies are required to explore the actual integration of nutrition into the physical therapy framework.

The Internet of Medical Things: Opportunities, Benefits, Challenges and Concerns

In this narrative review, we investigate the potential opportunities and benefits, as well as the challenges and concerns of integrating the Internet of Things in healthcare. The opportunities include enhanced patient monitoring and management, improved efficiency and resource utilization, personalized and precision medicine, empowering patients and promoting self-management, and data-driven decision-making, while the challenges include security and privacy risks, interoperability and integration, regulatory and compliance issues, ethical considerations and impact on healthcare professionals and patients. These challenges must be carefully weighed against the benefits before deployment of the IoMT-enabled services.

The coupling between the spatial and temporal scales of neural processes revealed by a joint time-vertex connectome spectral analysis

Brain oscillations are produced by the coordinated activity of large groups of neurons and different rhythms are thought to reflect different modes of information processing. These modes, in turn, are known to occur at different spatial scales. Nevertheless, how these rhythms support different spatial modes of information processing at the brain scale is not yet fully understood. Here we use "Joint Time-Vertex Spectral Analysis" to characterize the joint spectral content of brain activity both in time (temporal frequencies) and in space over the connectivity graph (spatial connectome harmonics). This method allows us to characterize the relationship between spatially localized or distributed neural processes on one side and their respective temporal frequency bands in source-reconstructed M/EEG signals. We explore this approach on two different datasets, an auditory steady-state response (ASSR) and a visual grating task. Our results suggest that different information processing mechanisms are carried out at different frequency bands: while spatially distributed activity (which may also be interpreted as integration) specifically occurs at low temporal frequencies (alpha and theta) and low graph spatial frequencies, localized electrical activity (i.e., segregation) is observed at high temporal frequencies (high and low gamma) over restricted high spatial graph frequencies. Crucially, the estimated contribution of the distributed and localized neural activity predicts performance in a behavioral task, demonstrating the neurophysiological relevance of the joint time-vertex spectral representation.

The neck as a keystone structure in avian macroevolution and mosaicism

BACKGROUND

The origin of birds from non-avian theropod dinosaur ancestors required a comprehensive restructuring of the body plan to enable the evolution of powered flight. One of the proposed key mechanisms that allowed birds to acquire flight and modify the associated anatomical structures into diverse forms is mosaic evolution, which describes the parcelization of phenotypic traits into separate modules that evolve with heterogeneous tempo and mode. Avian mosaicism has been investigated with a focus on the cranial and appendicular skeleton, and as such, we do not understand the role of the axial column in avian macroevolution. The long, flexible neck of extant birds lies between the cranial and pectoral modules and represents an opportunity to study the contribution of the axial skeleton to avian mosaicism.

RESULTS

Here, we use 3D geometric morphometrics in tandem with phylogenetic comparative methods to provide, to our knowledge, the first integrative analysis of avian neck evolution in context with the head and wing and to interrogate how the interactions between these anatomical systems have influenced macroevolutionary trends across a broad sample of extant birds. We find that the neck is integrated with both the head and the forelimb. These patterns of integration are variable across clades, and only specific ecological groups exhibit either head-neck or neck-forelimb integration. Finally, we find that ecological groups that display head-neck and neck-forelimb integration tend to display significant shifts in the rate of neck morphological evolution.

CONCLUSIONS

Combined, these results suggest that the interaction between trophic ecology and head-neck-forelimb mosaicism influences the evolutionary variance of the avian neck. By linking together the biomechanical functions of these distinct anatomical systems, the cervical vertebral column serves as a keystone structure in avian mosaicism and macroevolution.

The impact of funding models on the integration of Ontario midwives: a qualitative study

BACKGROUND

Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers.

METHODS

Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis.

RESULTS

We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs.

CONCLUSIONS

Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Integration of exome-seq and mRNA-seq using DawnRank, identified genes involved in innate immunity as drivers of breast cancer in the Indian cohort

Genetic heterogeneity influences the prognosis and therapy of breast cancer. The cause of disease progression varies and can be addressed individually. To identify the mutations and their impact on disease progression at an individual level, we sequenced exome and transcriptome from matched normal-tumor samples. We utilised DawnRank to prioritise driver genes and identify specific mutations in Indian patients. Mutations in the C3 and HLA genes were identified as drivers of disease progression, indicating the involvement of the innate immune system. We performed immune profiling on 16 matched normal/tumor samples using CIBERSORTx. We identified CD8+ve T cells, M2 macrophages, and neutrophils to be enriched in luminal A and T cells CD4+naïve, natural killer (NK) cells activated, T follicular helper (Tfh) cells, dendritic cells activated, and neutrophils in triple-negative breast cancer (TNBC) subtypes. Weighted gene co-expression network analysis (WGCNA) revealed activation of T cell-mediated response in ER positive samples and Interleukin and Interferons in ER negative samples. WGCNA analysis also identified unique pathways for each individual, suggesting that rare mutations/expression signatures can be used to design personalised treatment.

A New, Comprehensive Approach to Integration Using Measurement to Demonstrate Value

The comprehensive health care integration (CHI) framework promotes the delivery of integrated physical and behavioral health care to adults and children in community settings by providing a flexible integration approach for both physical and behavioral health settings, including ongoing measurement of outcomes linked to payment methodologies. The CHI framework demonstrates value, strengthening alignment between provider organizations and payers to support service integration at implementation and on an ongoing basis.

Moving beyond a figurative psychedelic literacy: Metaphors of psychiatric symptoms in ayahuasca narratives

Metaphors, analogies, and similes commonly appear in narratives of drinking the potent psychedelic "ayahuasca", presenting an intriguing transcultural pattern. Based upon survey and field research at an ayahuasca healing center in Pucallpa, Peru, the article investigates conceptual metaphors in narratives of ayahuasca experiences made by the visiting international guests. Bodily metaphors and visionary analogies frequently appear in narrative plots where they can express the reappraisal, overcoming, and sometimes emboldening of symptoms diagnosed by psychiatry. Moving beyond the literal-figurative divide, the article explores the intrinsic "metaphoricity" of psychedelic experiences and advocates for a literacy of conceptual metaphors regarding both clinical and non-clinical psychedelic narratives. Developing this literacy can broaden approaches in psychedelic psychiatry that analyze and treat syndromes and disorders, while also being applicable to social science and humanities research that examine psychoactive drug use beyond medical frameworks.

Predictions transform memories: How expected versus unexpected events are integrated or separated in memory

Our brains constantly generate predictions about the environment based on prior knowledge. Many of the events we experience are consistent with these predictions, while others might be inconsistent with prior knowledge and thus violate our predictions. To guide future behavior, the memory system must be able to strengthen, transform, or add to existing knowledge based on the accuracy of our predictions. We synthesize recent evidence suggesting that when an event is consistent with our predictions, it leads to neural integration between related memories, which is associated with enhanced associative memory, as well as memory biases. Prediction errors, in turn, can promote both neural integration and separation, and lead to multiple mnemonic outcomes. We review these findings and how they interact with factors such as memory reactivation, prediction error strength, and task goals, to offer insight into what determines memory for events that violate our predictions. In doing so, this review brings together recent neural and behavioral research to advance our understanding of how predictions shape memory, and why.

Using neurons to maintain autonomy: Learning from C. elegans

Understanding how biological organisms are autonomous-maintain themselves far from equilibrium through their own activities-requires understanding how they regulate those activities. In multicellular animals, such control can be exercised either via endocrine signaling through the vasculature or via neurons. In C. elegans this control is exercised by a well-delineated relatively small but distributed nervous system that relies on both chemical and electric transmission of signals. This system provides resources to integrate information from multiple sources as needed to maintain the organism. Especially important for the exercise of neural control are neuromodulators, which we present as setting agendas for control through more traditional electrical signaling. To illustrate how the C. elegans nervous system integrates multiple sources of information in controlling activities important for autonomy, we focus on feeding behavior and responses to adverse conditions. We conclude by considering how a distributed nervous system without a centralized controller is nonetheless adequate for autonomy.

Innovations for the integration of palliative care for hematologic malignancies

Specialist palliative care provides additional support to facilitate living well with a serious illness, like cancer, even while pursuing disease-directed therapy. For patients with hematologic malignancies, integrated specialist palliative care improves symptom burden, mood, and quality of life, with benefits even extending to caregivers. Despite this, patients with hematologic malignancies continue to have significant unmet palliative care needs and typically access palliative care late in their disease trajectories, if at all. In this paper, we will define specialist palliative care and review its benefits for patients with hematologic malignancies. We will discuss the unmet palliative care needs of this patient population and the barriers to integrating palliative care and oncologic care. Finally, we will explore innovations and areas of future research to enhance and optimize palliative care integration into usual cancer care treatment for patients with hematologic malignancies. We will explore the importance of ongoing clinical trials that are examining the correct "dose" of palliative care; the use of technology and telehealth; and the use of novel treatments for this patient population. Together, we will consider innovative avenues to provide palliative care to patients with hematologic malignancies and their caregivers.

The Tecan SiLA2 SDK: A royalty-free, open-source framework to develop SiLA2 servers and clients

Many devices in a laboratory only have proprietary interfaces. Integrating them into an automation platform such as a Robotic Liquid Handler (RLH) thus usually requires upfront technical configuration and often dedicated software development. In this paper, we present the Tecan SiLA2 SDK, a BSD-3 licensed, royalty-free open-source framework on the.NET platform that makes it very easy for developers to implement the open SiLA2 standard: A developer only has to specify a dedicated automation interface, annotate it with informational constraints such as units or MIME-constraints and then the code required to expose implementations of this interface through SiLA2 can be generated. To validate the applicability and the savings in terms of integration efforts, we conducted multiple case studies. First, we analyze the integration of the Tecan SPARK™ microplate reader into a lab execution system (LES), allowing us admittedly rough comparisons of device integrations using SiLA2 vs. the previous proprietary interface. Next, we analyze the integration of a RLH into the voice control software LabVoice, demonstrating the flexibility of integrations made possible through SiLA2. Lastly, we review the integration potential of liquid handling hardware into custom control softwares using a semi-automated exposure of the Tecan MAPlinx™ software platform through SiLA2.

Nurse leaders' experiences of how culturally and linguistically diverse registered nurses integrate into healthcare settings: An interview study

AIM

To describe nurse leaders' experiences of how culturally and linguistically diverse registered nurses integrate into healthcare settings.

DESIGN

A qualitative descriptive study design.

PARTICIPANTS

A total of 13 nurse leaders were recruited from four primary and specialized healthcare organizations in Finland.

METHODS

Data were collected through individual semi-structured interviews and analyzed using inductive content analysis.

RESULTS

Nurse leaders' experiences were categorized into seven main categories as follows: leadership, which concerns a leader's roles, style, and experience; organizational strategy and culture, which includes structure, policies, and intra-organizational culture; support strategies, including workplace and outside-of-work integration strategies; relationships and interactions, which considers interpersonal relationships and interactions; nurse competence requirements and development, which concerns both organizational and ward level competence demands, and support for competence development; language competence, which concerns challenges relating to language proficiency and development of language competence; and cultural diversity, which considers the importance of competence development brought about through experiences of being in a multicultural workplace.

CONCLUSIONS

Culturally and linguistically diverse nurses are important within healthcare systems. These nurses constitute additional human resources, bring diverse experiences and expertise, and add to organizational cultural capital. Nurse leaders require competencies that are suitable for leading a diverse workforce, utilizing its competencies, establishing staff members' needs, and ensuring their continuous development. Resourcing, planning, and structuring the integration process affects nurses' experiences of the organizational socialization process.

IMPACT

The findings of our study can offer guidance to healthcare organizations with regard to structural integration strategies at an institutional level. Leadership and management educators can benefit from the findings towards developing a curriculum that supports leaders' diversity, equity and inclusion, knowledge management and formal leadership competencies. Finally, nurse leaders may benefit from this study through being more aware towards supporting a multicultural, cohesive, and competent workforce through strong social capital.

Dataset of motivational factors for using mobile health applications and systems

We created and carried out a cross-sectional anonymous structured questionnaire on what motivates users of mobile health applications and wearables to share their collected health related data. The questionnaire was distributed online in English, French, and Norwegian. In addition, a flyer with information of where to locate the online questionnaire was distributed during a Swiss health conference. We used snowball sampling and encouraged participants to forward the questionnaires to friends, family, and others. Data were collected between October 2018 and March 2020. 58.1 % (n = 473) responded to the English survey, 34.3 % (n = 279) responded to the French survey, and 7.6 % (n = 62) responded to the Norwegian survey. The questionnaire contained 38 questions divided into seven themes: Background and health goals, Wearables and sensors, Mobile applications, Logging of health data, Data sharing- and integration, Social media and entertainment, and Demographics (age, gender, country of origin, chronic disease status, and chronic disease caretaker status). Answer options were single answer, multiple-choice, open-ended, or on a 4-point Likert scale. Questions were defined based on 16 in-person interviews with people without any chronic disorder, people with diabetes, and people with sickle cell disease. All questions were optional. Data were collected from 814 participants. All answers to the open-ended questions have been translated into English. This dataset is especially interesting for researchers interesting in what motivates people with and without chronic disease across countries to use mHealth tools and share their collected health data. Only a subset of variables has been analyzed so far and new research questions on motivation can potentially be answered using this dataset.

Health of migrants and other vulnerable populations across Asian countries: Build Forward Better beyond the COVID-19 pandemic

Global migration has been increasing since before the COVID-19 pandemic. The pandemic has clearly shown a lack of preparedness for the next public health emergency when it comes to vulnerable populations including migrants. To include the issues of migration and health in the current global health agenda, it is important to establish/strengthen a network for collaboration among various stakeholders from both the migrant-sending and host countries of migrants especially in the Asian-Pacific region. As the initial step for networking in Asia, in March 2023, a hybrid style international symposium was held in Japan and agreed on a goal and five pillars: surveillance and monitoring, risk communications, community engagement, access to health and social protection services, and supportive environments. Considering the transition of context from the COVID-19 crisis to 'Build Forward Better', through the Asian network, we will envisage the better world, where vulnerable populations including migrants will not be left behind from health security.

The HIV-2 OGH double reporter virus shows that HIV-2 is less cytotoxic and less sensitive to reactivation from latency than HIV-1 in cell culture

A better understanding of HIV-1 latency is a research priority in HIV cure research. Conversely, little is known about the latency characteristics of HIV-2, the closely related human lentivirus. Though both viruses cause AIDS, HIV-2 infection progresses more slowly with significantly lower viral loads, even when corrected for CD4+ T cell counts. Hence a direct comparison of latency characteristics between HIV-1 and HIV-2 could provide important clues towards a functional cure. Transduction of SupT1 cells with single-round HIV-1 and HIV-2 viruses with an enhanced green fluorescent protein (eGFP) reporter showed higher levels of eGFP expression for HIV-2 than HIV-1, while HIV-1 expression appeared more cytotoxic. To compare HIV-1 and HIV-2 gene expression, latency and reactivation in more detail, we have generated HIV-2 OGH, a replication deficient, near full- length, double reporter virus that discriminates latently and productively infected cells in cell culture. This construct is based on HIV-1 OGH, and to our knowledge, first of its kind for HIV-2. Using this construct we have observed a higher eGFP expression for HIV-2, but higher losses of HIV-1 transduced cells in SupT1 and Jurkat cells and a reduced sensitivity of HIV-2 for reactivation with TNF-α. In addition, we have analysed HIV-2 integration sites and their epigenetic environment. HIV-1 and HIV-2 share a preference for actively transcribed genes in gene-dense regions and favor active chromatin marks while disfavoring methylation markers associated with heterochromatin. In conclusion the HIV-2 OGH construct provides an interesting tool for studying HIV-2 expression, latency and reactivation. As simian immunodeficiency virus (SIV) and HIV-2 have been proposed to model a functional HIV cure, a better understanding of the mechanisms governing HIV-2 and SIV latency will be important to move forward. Further research is needed to investigate if HIV-2 uses similar mechanisms as HIV-1 to achieve its integration site selectivity.

Primary care services in the English NHS: are they a thorn in the side of integrated care systems? A qualitative analysis

BACKGROUND

As integrated care systems are embedded across England there are regions where the integration process has been evaluated and continues to evolve. Evaluation of these integrated systems contributes to our understanding of the challenges and facilitators to this ongoing process. This can support integrated care systems nationwide as they continue to develop. We describe how two integrated care partnerships in different localities, at differing stages of integration with contrasting approaches experienced challenges specifically when integrating with primary care services. The aim of this analysis was to focus on primary care services and how their existing structures impacted on the development of integrated care systems.

METHODS

We carried out an exploratory approach to re-analysing our previously conducted 51 interviews as part of our prior evaluations of integrated health and care services which included primary care services. The interview data were thematically analysed, focussing on the role and engagement of primary care services with the integrated care systems in these two localities.

RESULTS

Four key themes from the data are discussed: (i) Workforce engagement (engagement with integration), (ii) Organisational communication (information sharing), (iii) Financial issues, (iv) Managerial information systems (data sharing, IT systems and quality improvement data). We report on the challenges of ensuring the workforce feel engaged and informed. Communication is a factor in workforce relationships and trust which impacts on the success of integrated working. Financial issues highlight the conflict between budget decisions made by the integrated care systems when primary care services are set up as individual businesses. The incompatibility of information technology systems hinders integration of care systems with primary care.

CONCLUSIONS

Integrated care systems are national policy. Their alignment with primary care services, long considered to be the cornerstone of the NHS, is more crucial than ever. The two localities we evaluated as integration developed both described different challenges and facilitators between primary care and integrated care systems. Differences between the two localities allow us to explore where progress has been made and why.

An interactive and integrated framework for collaborative product development in cloud manufacturing using STEP standard-based ontology model

Due to the growing competition of firms in manufacturing industries, the enhancement of the design of new products for quick and collaborative interaction of stakeholders is inevitable. A customer-oriented approach during the enhancing of product design requires the support of various stakeholders' collaboration from their functionality perspectives. Accordingly, manufacturing firms try to increase the product quality through the continuous collaboration and speeding up of the design process. Moreover, new manufacturing paradigms like cloud manufacturing require global and distributed collaboration of stakeholders. One competitive key necessity for firms is the integration of stakeholders in the design and production stages. This article has proposed an interactive and integrated framework for a cloud collaborative manufacturing system. The proposed framework uses the international STEP standard which ensures data integrity in the whole product development processes. The framework enables stakeholders to work collaboratively and interactively in their disciplines, while it also ensures coherency of modifications to avoid conflicts. The proposed model is introduced using an improvisational design method based on the STEP standard to create an interactive platform with a service-oriented approach and supports stakeholders for their own semantics. In addition to examining the needs of an interactive system, the article provides an architecture for implementation of this perspective. A comprehensive case study is designed to show the capabilities of the proposed framework.

Developing a combined framework for priority setting in integrated health and social care systems

BACKGROUND

There is an international move towards greater integration of health and social care to cope with the increasing demand on services.. In Scotland, legislation was passed in 2014 to integrate adult health and social care services resulting in the formation of 31 Health and Social Care Partnerships (HSCPs). Greater integration does not eliminate resource scarcity and the requirement to make (resource) allocation decisions to meet the needs of local populations. There are different perspectives on how to facilitate and improve priority setting in health and social care organisations with limited resources, but structured processes at the local level are still not widely implemented. This paper reports on work with new HSCPs in Scotland to develop a combined multi-disciplinary priority setting and resource allocation framework.

METHODS

To develop the combined framework, a scoping review of the literature was conducted to determine the key principles and approaches to priority setting from economics, decision-analysis, ethics and law, and attempts to combine such approaches. Co-production of the combined framework involved a multi-disciplinary workshop including local, and national-level stakeholders and academics to discuss and gather their views.

RESULTS

The key findings from the literature review and the stakeholder workshop were taken to produce a final combined framework for priority setting and resource allocation. This is underpinned by principles from economics (opportunity cost), decision science (good decisions), ethics (justice) and law (fair procedures). It outlines key stages in the priority setting process, including: framing the question, looking at current use of resources, defining options and criteria, evaluating options and criteria, and reviewing each stage. Each of these has further sub-stages and includes a focus on how the combined framework interacts with the consultation and involvement of patients, public and the wider staff.

CONCLUSIONS

The integration agenda for health and social care is an opportunity to develop and implement a combined framework for setting priorities and allocating resources fairly to meet the needs of the population. A key aim of both integration and the combined framework is to facilitate the shifting of resources from acute services to the community.

Flexible integration and segregation of large-scale networks during adaptive control

Adaptive control characterizes the dynamic adjustment of cognitive control to changing environmental demand, and has obtained growing interests in its neural mechanism for the past two decades. Recent years, interpreting network reconfiguration in terms of integration and segregation has been proved to shed light on neural structure underlying various cognitive tasks. However, the relationship between network architecture and adaptive control remains unclear. Here, we quantified the network integration (global efficiency, participation coefficient, inter-subnetwork efficiency) and segregation (local efficiency, modularity) in the whole-brain and analyzed how these graph theory metrics were modulated by adaptive control. The results showed that the integration of the cognitive control network (the fronto-parietal network, FPN), the visual network (VIN) and the sensori-motor network (SMN) was significantly improved when conflict was rare, so as to cope with the incongruent trials of high cognitive control demands. Additionally, as the conflict proportion increased, the segregation of the cingulo-opercular network (CON) and the default mode network (DMN) significantly enhanced, which may contribute to specialized functioning or automatic processing, and help to solve conflict in a less resource-intensive mode. Finally, using graph metrics as features, the multivariate classifier reliably predicted the context condition. These results demonstrate how large-scale brain networks support adaptive control through flexible integration and segregation.

Integrated transcriptome, proteome and metabolome analyses revealed secondary metabolites and auxiliary carbohydrate metabolism augmenting drought tolerance in rice

Drought is one of the major consequences of climate change and a serious threat to rice production. Drought stress activates interactions among genes, proteins and metabolites at the molecular level. A comparative multi-omics analysis of drought-tolerant and drought-sensitive rice cultivars can decipher the molecular mechanisms involved in drought tolerance/response. Here, we characterized the global-level transcriptome, proteome, and metabolome profiles, and performed integrated analyses thereof in a drought-sensitive (IR64) and a drought-tolerant (Nagina 22) rice cultivar under control and drought-stress conditions. The transcriptional dynamics and its integration with proteome analysis revealed the role of transporters in regulation of drought stress. The proteome response illustrated the contribution of translational machinery to drought tolerance in N22. The metabolite profiling revealed that aromatic amino acids and soluble sugars contribute majorly to drought tolerance in rice. The integrated transcriptome, proteome and metabolome analysis performed using statistical and knowledge-based methods revealed the preference for auxiliary carbohydrate metabolism through glycolysis and pentose phosphate pathway contributed to drought tolerance in N22. In addition, L-phenylalanine and the genes/proteins responsible for its biosynthesis were also found to contribute to drought tolerance in N22. In conclusion, our study provided mechanistic insights into the drought response/adaptation mechanism and is expected to facilitate engineering of drought tolerance in rice.

How do human newborns come to understand the multimodal environment?

For a long time, newborns were considered as human beings devoid of perceptual abilities who had to learn with effort everything about their physical and social environment. Extensive empirical evidence gathered in the last decades has systematically invalidated this notion. Despite the relatively immature state of their sensory modalities, newborns have perceptions that are acquired, and are triggered by, their contact with the environment. More recently, the study of the fetal origins of the sensory modes has revealed that in utero all the senses prepare to operate, except for the vision mode, which is only functional starting from the first minutes after birth. This discrepancy between the maturation of the different senses leads to the question of how human newborns come to understand our multimodal and complex environment. More precisely, how the visual mode interacts with the tactile and auditory modes from birth. After having defined the tools that newborns use to interact with other sensory modalities, we review studies across different fields of research such as the intermodal transfer between touch and vision, auditory-visual speech perception, and the existence of links between the dimensions of space, time, and number. Overall, evidence from these studies supports the idea that human newborns are spontaneously driven, and cognitively equipped, to link information collected by the different sensory modes in order to create a representation of a stable world.

Evaluation of a community-based aetiological approach for sexually transmitted infections management for youth in Zimbabwe: intervention findings from the STICH cluster randomised trial

Background

Young people are at high risk of sexually transmitted infections (STIs). We report STI testing uptake, prevalence and incidence within a community-based integrated HIV and sexual and reproductive health service for youth, being evaluated in a cluster randomised trial in Zimbabwe.

Methods

This paper reports the intervention findings of the cluster randomised trial whereby STI testing was offered to all service attendees (16-24 years) in 12 intervention clusters over 12 months between October 5, 2020, and December 17, 2021, in Zimbabwe. Testing for Chlamydia trachomatis [CT] and Neisseria gonorrhoeae [NG] was offered to males and females with results available in one week and follow-up of test-positive clients by telephone. Trichomonas vaginalis [TV] testing was offered to females only with same day results and treatment. Youth testing positive for any STI were offered partner notification slips and free treatment for partners. This trial was registered with ISRCTN Registry, ISRCTN15013425.

Findings

Overall, 8549/9891 (86.1%) eligible youth accepted CT/NG testing. Prevalence of CT and NG was 14.7% (95% CI 13.6-15.8) and 2.8% (95% CI 2.2-3.6) respectively. Combined prevalence of CT, NG or TV in women was 23.2% (95% CI 21.5-25.0). After adjusting for cluster, age and sex, the odds of NG were increased in those living with HIV (aOR 3.14, 95% CI 2.21-4.47). The incidence rate among those who initially tested negative for CT or NG was 25.6/100PY (95% CI 20.6-31.8). CT/NG treatment uptake was 924/1526 (60.6%). TV treatment uptake was 483/489 (98.8%). A partner returned for treatment for 103/1807 clients (5.7%).

Interpretation

Our findings show high acceptability of STI testing among youth. STI prevalence was high particularly among females and youth with HIV, underscoring the need for integration of HIV and STI services.

Funding

MRC/ESRC/DFID/NIHR (MR/T040327/1) and Wellcome Trust (206316/Z/17/Z).

Integrating Foundational and Clinical Science Remotely by Combining Team-Based Learning and Simulation

Integrating foundational and clinical science in medical and other professional healthcare degree programs has been well established as a means to enhance learning. However, implementation remains challenging, and a significant gap exists in guidance for non-professional degree programs to effectively accomplish both types of integration. Additionally, many modalities described in the literature are resource-intensive, scale poorly to larger groups, and are widely inaccessible. We present an online modality combining team-based learning and a simulation-based learning experience that fosters vertical and horizontal integration of physiology, pharmacology, and clinical science. The tools utilized include a vital sign simulator, video conferencing software, and a document-sharing platform. The activity demonstrated improved knowledge comparing pre- and posttests and evidence that the activity helped students integrate physiology, pharmacology, and clinical medicine. The novel structure is effective and accessible, uses open-source software and standard equipment available to most undergraduate and graduate faculty, and is adaptable to in-person, hybrid-remote, and fully remote delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01817-9.

Form and Function: Learning Anatomy Using Ultrasound

Ultrasound (US) is increasingly used across medical specialities as a diagnostic tool and medical faculties are therefore further incorporating imaging into their programmes. Using US within undergraduate instruction has several benefits. US, as a learning instrument, may strengthen existing anatomical knowledge and improve visual understanding of anatomy. The cost-effectiveness, as well as portability of the US, makes it a valuable means to add to traditional anatomy teaching modalities. Furthermore, students have an opportunity to develop skills in interpreting US images and this may add a different element to the learning of anatomy. This study aimed to explore undergraduate clinical anatomy students' perceptions of the use of US as an add-on to cadaveric dissection. Students were invited to participate in virtual focus group discussions. Three virtual focus group discussions were conducted, and 11 participants volunteered to take part. Thematic analysis of the data generated six themes. These are described as the study of living anatomy, learning cross-sectional anatomy, enhanced relevance of anatomy learning, increased interest in anatomy, instructional design, and the affective and technical experience of using US. The results suggest that it is feasible and advantageous to implement US sessions as an add-on to the teaching of anatomy during practical dissection sessions of clinical anatomy students. The use of innovative technologies such as US enhances the interest of students and allows them to develop dexterity and competencies in their learning process.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01806-y.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Doing primary care integration: a qualitative study of meso-level collaborative practices

BACKGROUND

The integration of Primary Care (PC) into broader health systems has been a goal in jurisdictions around the world. Efforts to achieve integration at the meso-level have drawn particular attention, but there are few actionable recommendations for how to enact a 'pro-integration culture' amongst government and PC governance bodies. This paper describes pragmatic integration activity undertaken by meso-level participants in Alberta, Canada, and suggests ways this activity may be generalizable to other health systems.

METHODS

11 semi-structured interviews with nine key informants from meso-level organizations were selected from a larger qualitative study examining healthcare policy development and implementation during the COVID-19 pandemic. Selected interviews focused on participants' experiences and efforts to 'do' integration as they responded to Alberta's first wave of the Omicron variant in September 2021. An interpretive descriptive approach was used to identify repeating cycles in the integration context, and pragmatic integration activities.

RESULTS

As Omicron arrived in Alberta, integration and relations between meso-level PC and central health system participants were tense, but efforts to improve the situation were successfully made. In this context of cycling relationships, staffing changes made in reaction to exogenous shocks and political pressures were clear influences on integration. However, participants also engaged in specific behaviours that advanced a pro-integration culture. They did so by: signaling value through staffing and resource choices; speaking and enacting personal and group commitments to collaboration; persevering; and practicing bi-directional communication through formal and informal channels.

CONCLUSIONS

Achieving PC integration involves not just the reactive work of responding to exogenous factors, but also the proactive work of enacting cultural, relationship, and communication behaviors. These behaviors may support integration regardless of the shocks, staff turnover, and relational freeze-thaw cycles experienced by any health system.

Enrichment strategies to enhance genome editing

Genome editing technologies hold great promise for numerous applications including the understanding of cellular and disease mechanisms and the development of gene and cellular therapies. Achieving high editing frequencies is critical to these research areas and to achieve the overall goal of being able to manipulate any target with any desired genetic outcome. However, gene editing technologies sometimes suffer from low editing efficiencies due to several challenges. This is often the case for emerging gene editing technologies, which require assistance for translation into broader applications. Enrichment strategies can support this goal by selecting gene edited cells from non-edited cells. In this review, we elucidate the different enrichment strategies, their many applications in non-clinical and clinical settings, and the remaining need for novel strategies to further improve genome research and gene and cellular therapy studies.

Pharmacy students' perceptions of clinical reasoning development through a foundational thinking application framework

BACKGROUND AND PURPOSE

Pharmacy students must learn to integrate the foundational and clinical sciences to make therapeutic decisions. There is a need for a developmental framework and scaffolding tools to bridge foundational knowledge with clinical reasoning among novice learners in pharmacy education. Our purpose is to describe the development and student perceptions of a framework designed to integrate foundational knowledge and clinical reasoning in second-year pharmacy students.

EDUCATIONAL ACTIVITY AND SETTING

Using script theory as a conceptual model, a Foundational Thinking Application Framework (FTAF) was designed around a four-credit Pharmacotherapy of Nervous Systems Disorders course at the beginning of the second year of the doctor of pharmacy curriculum. The framework was implemented as two structured learning guides known as a unit plan and a pharmacologically based therapeutic evaluation. A total of 71 students in the course were asked to complete a 15-question online survey assessing perceptions towards specific components of the FTAF.

FINDINGS

Of 39 survey respondents, 37 (95%) described the unit plan as a useful organizer for the course. Thirty-five (80%) students agreed or strongly agreed that the unit plan helped organize instructional material for a given topic. Students (n = 32, 82%) preferred the pharmacologically based therapeutic evaluation format, with text comments highlighting that it provided good practice for clinical experiences and helped to organize critical thinking.

SUMMARY

Our study found that students had positive perceptions of FTAF's implementation within a pharmacotherapy course. Pharmacy education can benefit by adapting script-based strategies that have been successful in other health professions.

The cost of implementing measles campaign in Nigeria: comparing the stand-alone and the integrated strategy

BACKGROUND

Effective integration, one of the seven strategic priorities of the Immunization Agenda 2030, can contribute to increasing vaccination coverage and efficiency. The objective of the study is to measure and compare input costs of "non-selective" measles vaccination campaign as a stand-alone strategy and when integrated with another vaccination campaign.

METHODS

We conducted a cost-minimization study using a matched design and data from five states of Nigeria. We carried-out our analysis in 3 states that integrated measles vaccination with Meningitis A and the 2 states that implemented a stand-alone measles campaign. The operational costs (e.g., costs of personnel, training, supervision etc.) were extracted from the budgeted costs, the financial and technical reports. We further used the results of the coverage surveys to demonstrate that the strategies have similar health outputs.

RESULTS

The analysis of the impact on campaign budget (currency year: 2019) estimated that savings were up to 420,000 United States Dollar (USD) with the integrated strategies; Over 200 USD per 1,000 children in the target population for measles vaccination (0.2 USD per children) was saved in the studied states. The savings on the coverage survey components were accrued by lower costs in the integration of trainings, and through reduced field work and quality assurance measures costs.

CONCLUSIONS

Integration translated to greater value in improving access and efficiency, as through sharing of costs, more life-saving interventions are made accessible to the communities. Important considerations for integration are resource needs, micro-planning adjustments, and health systems delivery platforms.

Attitudes of Refugees Towards Integration: The Experience of South Sudanese Refugees in Adjumani District in Uganda

The question of how socioeconomic situations in and around refugees' settlement in Uganda affect their motivation and attitudes towards integration has not been clearly addressed in the literature. To address this gap, this study explores the integration framework, and uses thematic and content analysis to analyse data collected via in-depth interviews and focus group discussions. The study finds that access to socioeconomic factors such as livelihood opportunities and social services, especially education and health, can either motivate and positively affect refugees' attitudes, or demotivate and negatively affect refugees' attitudes towards integration in the host community. Other motivating factors were family history and success stories of refugees who were successfully integrated in the host community. Suggestions for improving refugee integration included empowerment in vocational skills, access to grants and loans, access to land for agriculture, and access to labour market. These require greater cooperation among different stakeholders, including policy makers, nongovernmental organisations, international organisations, and governments, to coalesce resources and buttress integration of refugees in the host society.

Cultivating Integration via Placemaking: an ArcGIS StoryMap and Inventory of Refugee-Centered Farming Organizations in the USA

This paper inventories the number, type, location, and characteristics of refugee resettlement agencies and refugee third sector organizations (RTSOs) in creating opportunities for placemaking and longer-term integration via refugee-centered farming programs in the USA. Using an ArcGIS StoryMap and accompanying database, we map how resettlement organizations engage in farming programs and provide insight into the various actors implementing refugee resettlement and integration policy in the USA, while also highlighting the role of place and placemaking in that process. Findings indicate that there are 40 total organizations involved in 30 states, with 100 farm sites scattered across 48 cities, primarily found in nontraditional sites of resettlement. Using Ager and Strang's (Journal of Refugee Studies, 21(2):166-191, 2008) integration model as a theoretical starting point, we use a two-cycle content analysis to illustrate that organizations have diverse goals focusing on employment, social connections, health, safety and security, and placemaking. Sponsored activities and community projects concentrate on workforce training and community-supported agriculture. This interactive visualization and analysis of existing programs nationwide allow the organizations involved, policymakers, scholars, and members of the public to explore the locations of programs with pertinent information about each organization. The research also illustrates that refugee-centered farming organizations should continue to emphasize their efforts on placemaking as a beneficial strategy for the longer-term integration of resettled refugees. Additionally, this research contributes to larger debates and theoretical understandings of longer-term integration by extending Ager and Strang's (Journal of Refugee Studies, 21(2):166-191, 2008) integration model and embedding place and placemaking as underpinning elements in the process.

A review on hybrid membrane-adsorption systems for intensified water and wastewater treatment: Process configurations, separation targets, and materials applied

In the era of rapid and conspicuous progress of water treatment technologies, combined adsorption and membrane filtration systems have gained great attention as a novel and efficient method for contaminant removal from aqueous phase. Further development of these techniques for water/wastewater treatment applications will be promising for the recovery of water resources as well as reducing the water tension throughout the world. This review introduces the state-of-the-art on the capabilities of the combined adsorption-membrane filtration systems for water and wastewater treatment applications. Technical information including employed materials, superiorities, operational limitations, process sustainability and upgradeing strategies for two general configurations i.e. hybrid (pre-adsorption and post-adsorption) and integrated (film adsorbents, low pressure membrane-adsorption coupling and membrane-adsorption bioreactors) systems has been surveyed and presented. Having a systematic look at the fundamentals of hybridization/integration of the two well-established and efficient separation methods as well as spotlighting the current status and prospectives of the combination strategies, this work will be valuable to all the interested researchers working on design and development of cutting-edge wastewater/water treatment techniques. This review also draws a clear roadmap for either decision making and choosing the best alternative for a specific target in water treatment or making a plan for further enhancement and scale-up of an available strategy.

Contribution of Medical Education through Role Playing in Community Health Promotion: A Review

Background

Didactic lecture is most commonly used method to teach medical students in Family and Community Medicine. However, considering its demerits and the need to integrate theoretical knowledge into practice, the objective of this paper is to review the contribution of role play in medical education and to propose it's applications to deliver healthcare services in community more effectively.

Methods

Research studies on role play were searched in PubMed, Google scholar, Google using terms role play, medical education, community medicine, family medicine, health promotion, awareness during the period between January 2000 up to December 2021 to evaluate the potential and contribution of role play in medical education and health promotion.

Results

Review of role play and related researches were included to analyze the outcome. The outcomes of different studies analyzed were showing several teaching methodologies used in medical field. Several studies have tested role play in other medical specialities and have found it to be a powerful educational tool. However, not many studies have tested its effectiveness to educate students in Family and Community Medicine although it could have immense practical applications like demonstrating and creating awareness in the community about the importance of cancer screening, breast feeding, immunisation, food fortification, genetic screening, premarital counselling, ante natal checkups, danger signs in pregnancy.

Conclusion

Role play simulates real scenarios enabling students to apply their skills and knowledge into practice in real time. It can integrate theory concepts into practice. Hence, it must be introduced in medical curriculum to achieve the objectives of teaching and learning more effectively.

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers

BACKGROUND

The incidence of anal cancer, largely associated with anal human papillomavirus (HPV) infection, is increasing among men who have sex with men (MSM), and transgender women living with or without HIV. Screening for anal cancer to detect anal precancerous lesions in high-risk groups is an important opportunity for prevention but still lacking in many low-and-middle-income countries. The aim of this study was to explore the readiness of Pakistan's healthcare system to integrate anal cancer and HPV screening into a national HIV program, as perceived by policymakers, health managers, and healthcare providers.

DESIGN

This qualitative study using key-informant interviews with participants influence in policy making, implementation and advocacy from public and private sector were conducted between March 2021 to August 2021 in Karachi Pakistan.

METHODS

Key informants were purposely selected from different domains of the healthcare system responsible for the target group of interest, MSM and transgender-women in general and people living with HIV in particular. A total of 18 key informants, at different levels of seniority were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives. Qualitative content analysis was used to identify the manifest and latent themes, based on socioecological framework.

RESULTS

The results were grouped into five major themes; (1) The policy context and priorities, (2) Health systems factors, (3) Community environment, (4) Healthcare setting & providers and (5) Individual-level obstacles. The policy actors expressed their concerns about their limited voice in country's health and health related priority setting. Informants reported a lack of political will and suggested that government should bring a change in the paradigm of healthcare service delivery from reactive to proactive approach. Although, participants unanimously favored integration of HPV preventive services into existing HIV program, they also identified several service delivery barriers including trained workforce shortage, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet key-populations needs. Participants also predicted other implementation challenges such as stigma, social victimization, and systemic discrimination against at-risk groups at healthcare facilities.

CONCLUSION

Although policy makers and health providers in Pakistan saw a clear need to scale-up and integrate anal cancer screening for key populations, the feasibility of this is dependent on political will, financing, anti-stigma and discrimination interventions and health system efficiency.

The Economic Performance of Reunited Families in Switzerland, 2013-2018

Family migration has gained prominence as one of the main reasons for international mobility in both Switzerland and the rest of western European countries. However, research aimed at evaluating the economic performance of reunited families has been constrained by the unavailability of individual income and/or household composition data. The joint use of population registers and information about individuals' social security contributions has allowed us to overcome this limitation. Using transition matrices and logistic models, we assess the economic performance of reunited families at the household level and evaluate differences based on the region of birth of the person initiating the process, as well as the financial situation of these families 5 years after the reunion. The results show a process of economic convergence between the three groups under analysis despite the initial differences in the income level of families, and that most reunited families achieve satisfactory living conditions. They also highlight the hybrid nature of Swiss-headed reunited families, which initially resemble those headed by a non-EU/EFTA person, in terms of the contributions their members make to the household income, but after 5 years they contribute similarly to EU/EFTA headed reunited families.