Background

Almost 3 quarters of India's roughly 16 million annual abortions are done through medication abortion purchased from pharmacists outside of healthcare facilities. The quality of information provided by pharmacists about medication abortion is often poor.

Objective

To determine whether pharmacists selling medication abortion provide different information or ask different, potentially stigmatizing questions to clients by gender and marital status.

Study design

Mystery clients presenting as 4 profiles (unmarried woman, unmarried man, married woman, and married man) purchasing medication abortion interacted with 111 pharmacists in 3 districts around Lucknow, Uttar Pradesh in 2018. Data were collected immediately after the interaction. The differences in the information conveyed and the questions asked by the pharmacists by mystery client characteristics were analyzed using logistic regression in Stata 15 MP.

Results

Pharmacists very rarely asked intrusive, medically irrelevant questions and appeared willing to sell medication abortion to all the mystery clients regardless of gender, age, or marital status. However, the pharmacists were overall less likely to provide the female mystery clients with as comprehensive and correct information on medication abortion as they were to male mystery clients, particularly if female mystery clients presented as unmarried.

Conclusion

Pharmacists are observed to provide differential and poorer quality information about medication abortion to women, especially if they seem unmarried, potentially putting women at risk of having a lower-quality and less supported experience of using the medication. However, the pharmacists' willingness to sell the medication to all mystery clients and the lack of intrusive questions and comments reinforces out-of-facility medication abortion as a way for individuals to access an often-stigmatized service. Interventions must find a way to either address this bias among pharmacists, or more practically, to provide high-quality information directly to the individuals seeking medication abortion.

Soil disinfestation with steam was evaluated as an alternative to fumigation. Following soil disinfestation, plant health has traditionally been measured using plant size and yield. Plant health can be measured in a timely manner more efficiently, more easily and non-destructively using image analysis. We hypothesized that plant health could be quantified and treatments can be differentiated using an RGB (Red, Green, Blue) image analysis program, particularly by observing the greenness of plant leaves. However, plant size or the proportion of green area could be unreliable due to plant loss and camera's position and angle. To this end, we decided to evaluate plant health by analyzing the RGB codes associated with the green color only, which detects the chlorophyll reflectance and nutrient status, noting that the degree of greenness within the green-leaf-area was not affected by the plant size. We identified five RGB codes that are commonly observed in the plant leaves and ordered them from dark green to light green. Among the five RGB codes, the relative percentage covered by the darkest green to the lightest green was significantly different between the steam and chloropicrin treatments and the control, and it was not significantly different between the steam and chloropicrin treatments. Furthermore, the result was correlated with the total yield, and the trend observed in the first year was replicated in the second year of this experiment. In this study, we demonstrate that the RGB image analysis can be used as an early marker of the treatment effect on the plant health and productivity.

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

Background

The use of medication abortion is increasing rapidly in India, the majority of which is purchased through pharmacies. More information is needed about the quality of services provided by pharmacist about medication abortion, especially barriers to providing high quality information. The goal of this study was to explore the quality of pharmacist medication abortion provision using mixed methods to inform the developed of an intervention for this population.

Methods

Data was collected via convenience sampling using three methods: a quantitative survey of pharmacists (N = 283), mystery clients (N = 111), and in-depth qualitative interviews with pharmacist (N = 11). Quality indictors from the quantitative data from surveys and mystery clients were compared. Qualitative interviews were used to elucidate reasons behind findings from the quantitative survey.

Results

Quality of information provided to client purchasing medication abortion was low, especially related to timing and dosing of misoprostol (18% of pharmacists knew correct timing) and side effects (31% not telling any information on side effects). Mystery clients reported lower quality (less correct information) than pharmacists reported about their own behaviors. Qualitative interviews suggested that many barriers exist for pharmacists, including perceptions about what information clients can understand and desire, and also lack of comfort giving certain information to certain types of clients (young women).

Conclusions

It is essential to improve the quality of information given to client purchasing medication abortion from pharmacists. Our findings highlight specific gaps in knowledge and reasons for poor quality information. Differences in guidelines available at that time from the Indian Government, World Health Organization, and the medication abortion boxes may lead to confusion amongst pharmacists and potentially clients. Interventions need to improve both knowledge about medication abortion and also biases in the provision of care.

Introduction

Abortion is legal in India and medication abortion (MA) using a combined regimen of mifepristone and misoprostol is the preferred method. Users increasingly purchase MA kits directly from pharmacies, in some cases experiencing perceived complications and approaching a facility for care. We present findings of a qualitative research tracing the decision-making pathway(s) of MA users in Uttar Pradesh, India, to help understand knowledge and behaviour gaps, and recommend ways to improve the overall quality of care at these service delivery points.

Methods

Forty in-depth interviews were conducted with recent MA users (20 each of clinic and pharmacy clients) across three districts. Providers were purposively selected in collaboration with an international organization selling MA kits, using their list of pharmacies and clinics. MA users were identified from the clients of the selected providers, and additionally through the snow ball method. Interviews were conducted in Hindi with verbal informed consent in a private place convenient to the respondent. Transcripts were translated to English and analysed thematically.

Results

Users first sought MA kits at pharmacies out of convenience, low cost and customer anonymity. Men often purchased kits for their partners and trusted the chemist for guidance on dosage, progression and side effects. For side effects or other concerns after using an MA kit, users first visited their neighbourhood doctor or traditional practitioner. These providers either attempted to treat the issue and failed, or directly advised her to consult a gynaecologist. The final point of care was gynaecologists, preferably female private practitioners with their own clinics. They diagnosed most abortion-related cases as incomplete abortions, emptying the uterus using the dilation and curettage method. Comparatively low cost and convenience made users inclined towards repeat use of MA.

Conclusion

There are information gaps at various stages in the MA pathway that need to be addressed. Large scale public information programmes are required on safe abortion care- when is it legal, where to obtain MA, dosage, side effects and signs of possible complications. Pharmacists could be trained or incentivized to improve their quality of care to facilitate adequate exchange of information on MA. Since, for most couples, the male partner purchases MA, information approaches or tools are needed that pharmacists can give men to share directly with the MA user.

The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724-1729, 2019.

We demonstrate that Magnetic Particle Imaging (MPI) enables monitoring of cellular grafts with high contrast, sensitivity, and quantitativeness. MPI directly detects the intense magnetization of iron-oxide tracers using low-frequency magnetic fields. MPI is safe, noninvasive and offers superb sensitivity, with great promise for clinical translation and quantitative single-cell tracking. Here we report the first MPI cell tracking study, showing 200-cell detection in vitro and in vivo monitoring of human neural graft clearance over 87 days in rat brain.

Purpose

To describe clinical use and potential benefits of cone-beam computed tomography (CT) navigation to perform image-guided percutaneous tumor ablation.

Materials and methods

All ablations performed between February 2011 and February 2013 using cone-beam CT navigation were included. There were 16 patients who underwent 20 ablations for 29 lesions. Cone-beam CT ablation planning capabilities include multimodality image fusion and tumor segmentation for visualization, depiction of the predicted ablation zones for intraprocedural planning, and segmentation of the ablated area for immediate verification after treatment. Number and purpose of cone-beam CT scans were examined. The initial ablation plan, defined as number of probes and duration of energy delivery, was recorded for the 20 of the 29 lesions ablated. Technical success and local recurrences were recorded. Primary and secondary effectiveness rates were calculated.

Results

Image fusion was used for 16 lesions, and intraprocedural ultrasound was used for 4 lesions. Of the 20 ablations, where the ablation plans were recorded, there was no deviation from the plan in 14 ablations. In the remaining 6 ablations, iterative planning was needed for complete tumor coverage. An average of 8.7 cone-beam CT scans ± 3.2 were performed per procedure, including 1.3 ± 0.5 for tumor segmentation and planning, 1.7 ± 0.7 for probe position confirmation, and 3.9 ± 2 to ensure complete coverage. Mean follow-up time was 18.6 months ± 6.5. Ablations for 28 of 29 lesions were technically successful (96.5%). Of ablations performed with curative intent, technical effectiveness at 1 month was 25 of 26 lesions (96.1%) and 22 of 26 lesions (84.6%) at last follow-up. Local tumor progression was observed in 11.5% (3 of 26 lesions).

Conclusions

Cone-beam CT navigation may add information to assist and improve ablation guidance and monitoring.

Our expression microarray studies showed messenger RNA (mRNA) for solute carrier family 39 (zinc transporter), member 12 (SLC39A12) was higher in dorsolateral prefrontal cortex from subjects with schizophrenia (Sz) in comparison with controls. To better understand the significance of these data we ascertained whether SLC39A12 mRNA was altered in a number of cortical regions (Brodmanns area (BA) 8, 9, 44) from subjects with Sz, in BA 9 from subjects with mood disorders and in rats treated with antipsychotic drugs. In addition, we determined whether inducing the expression of SLC39A12 resulted in an increased cellular zinc uptake. SLC39A12 variant 1 and 2 mRNA was measured using quantitative PCR. Zinc uptake was measured in CHO cells transfected with human SLC39A12 variant 1 and 2. In Sz, compared with controls, SLC39A12 variant 1 and 2 mRNA was higher in all cortical regions studied. The were no differences in levels of mRNA for either variant of SLC39A12 in BA 9 from subjects with mood disorders and levels of mRNA for Slc39a12 was not different in the cortex of rats treated with antipsychotic drugs. Finally, expressing both variants in CHO-K1 cells was associated with an increase in radioactive zinc uptake. As increased levels of murine Slc39a12 mRNA has been shown to correlate with increasing cellular zinc uptake, our data would be consistent with the possibility of a dysregulated zinc homeostasis in the cortex of subjects with schizophrenia due to altered expression of SLC39A12.