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A recent outbreak of the mpox virus (MPXV) occurred in non-endemic regions of the world beginning in May 2022. Pathogen surveillance systems faced pressure to quickly establish response protocols, offering an opportunity to employ wastewater-based epidemiology (WBE) for population-level monitoring. The pilot study reported herein aimed to: (i) develop a reliable protocol for MPXV DNA detection in wastewater which would reduce false negative reporting, (ii) test this protocol on wastewater from various regions across the United States, and (iii) conduct a state of the science review of the current literature reporting on experimental methods for MPXV detection using WBE. Twenty-four-hour composite samples of untreated municipal wastewater were collected from the states of New Jersey, Georgia, Illinois, Texas, Arizona, and Washington beginning July 3rd, 2022 through October 16th, 2022 (n = 60). Samples underwent vacuum filtration, DNA extraction from captured solids, MPXV DNA pre-amplification, and qPCR analysis. Of the 60 samples analyzed, a total of eight (13%) tested positive for MPXV in the states of Washington, Texas, New Jersey, and Illinois. The presence of clade IIb MPXV DNA in these samples was confirmed via Sanger sequencing and integration of pre-amplification prior to qPCR decreased the rate of false negative detections by 87% as compared to qPCR analysis alone. Wastewater-derived detections of MPXV were compared to clinical datasets, with 50% of detections occurring as clinical cases were increasing/peaking and 50% occurring as clinical cases waned. Results from the literature review (n = 9 studies) revealed successful strategies for the detection of MPXV DNA in wastewater, however also emphasized a need for further method optimization and standardization. Overall, this work highlights the use of pre-amplification prior to qPCR detection as a means to capture the presence of MPXV DNA in community wastewater and offers guidance for monitoring low-titer pathogens via WBE., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rolf U. Halden reports financial support was provided by Virginia G Piper Charitable Trust. Rolf U. Halden reports financial support was provided by National Institutes of Health. Matthew Scotch reports financial support was provided by National Institutes of Health. Arvind Varsani reports financial support was provided by National Institutes of Health. Rolf U. Halden reports a relationship with AquaVitas, LLC that includes: board membership. Rolf U. Halden reports a relationship with OneWaterOneHealth Nonprofit Project that includes: board membership. Erin M. Driver reports a relationship with AquaVitas, LLC that includes: board membership., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Grade III ankle sprains that fail conservative treatment can require surgical management. Anatomic procedures have been shown to properly restore joint mechanics, and precise localization of insertion sites of the lateral ankle complex ligaments can be determined through radiographic techniques. Ideally, radiographic techniques that are easily reproducible intraoperatively will lead to a consistently well-placed CFL reconstruction in lateral ankle ligament surgery., Purpose: To determine the most accurate method to locate the calcaneofibular ligament (CFL) insertion radiographically., Methods: MRIs of 25 ankles were utilized to identify the "true" insertion of the CFL. Distances between the true insertion and three bony landmarks were measured. Three proposed methods (Best, Lopes, and Taser) for determining the CFL insertion were applied to lateral ankle radiographs. X and Y coordinate distances were measured from the insertion found on each proposed method to the three bony landmarks: the most superior point of the postero-superior surface of the calcaneus, the posterior most aspect of the sinus tarsi, and the distal tip of the fibula. X and Y distances were compared to the true insertion found on MRI. All measurements were made using a picture archiving and communication system. The average, standard deviation, minimum, and maximum were obtained. Statistical analysis was performed using repeated measures ANOVA, and a post hoc analysis was performed with the Bonferroni test., Results: The Best and Taser techniques were found to be closest to the true CFL insertion when combining X and Y distances. For distance in the X direction, there was no significant difference between techniques (P = 0.264). For distance in the Y direction, there was a significant difference between techniques (P = 0.015). For distance in the combined XY direction, there was a significant difference between techniques (P = 0.001). The CFL insertion as determined by the Best method was significantly closer to the true insertion compared to the Lopes method in the Y (P = 0.042) and XY (P = 0.004) directions. The CFL insertion as determined by the Taser method was significantly closer to the true insertion compared to the Lopes method in the XY direction (P = 0.017). There was no significant difference between the Best and Taser methods., Conclusion: If the Best and Taser techniques can be readily used in the operating room, they would likely prove the most reliable for finding the true CFL insertion., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Prior orthopedic literature has found patients with chronic obstructive pulmonary disease (COPD) to be at an increased risk for postoperative morbidity and mortality. Thus, the purpose of this study is to identify whether there are any differences in risk for 30-day morbidity or mortality following ORIF for ankle fractures between adult patients with COPD and without COPD. Patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database from 2006 to 2018. Patients were divided into 2 cohorts: non-COPD and COPD patients. In this analysis, demographics data, medical comorbidities, and thirty-day postoperative outcomes were analyzed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10,346 total patients who underwent operative treatment for ankle fracture, 9986 patients (96.5%) did not have a history of COPD whereas 360 (3.5%) had COPD. Following adjustment to control for demographic and comorbidity data, relative to patients without COPD, those with COPD had an increased risk of pneumonia (odds ratio [OR] 4.601; p = .001), unplanned intubation (OR 3.085; p = .043), and hospital readmission (OR 1.828; p = .020). Patients with COPD did not have a statistically significant difference with regards to mortality (OR 2.729; p = .080). Adult patients with COPD are at an increased risk for pneumonia, unplanned intubation, and hospital readmission within 30 days following ORIF of ankle fractures compared to patients without COPD. Despite these risks, this is a relatively safe procedure for these patients and the presence of COPD alone should not serve as a barrier to surgery., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The number of babies born extremely low birth weight surviving to be discharged home after experiencing the NICU continues to improve. Unfortunately, early sensory development for these babies occurs in an environment vastly different from the intended in-utero environment and places them at high risk of long-term neurodevelopmental and neurocognitive challenges. Our goal in the NICU must transition from simply discharge home to supporting the neurosensory development necessary for a thriving lifetime. To accomplish a goal of thriving families and thriving babies, it is clear the NICU interprofessional team must share an understanding of neurosensory development, the neuroprotective strategies safeguarding development, the neuropromotive strategies supporting intended maturational development, and the essential nature of family integration in these processes. We share the educational endeavors of 11 center collaboratives in establishing the foundational knowledge necessary to support preterm babies and their families., (© Copyright 2021 Springer Publishing Company, LLC.)

Concern is often voiced over the ongoing loss of atmospheric O 2 . This loss, which is caused by fossil-fuel burning but also influenced by other processes, is likely to continue at least for the next few centuries. We argue that this loss is quite well understood, and the eventual decrease is bounded by the fossil-fuel resource base. Because the atmospheric O 2 reservoir is so large, the predicted relative drop in O 2 is very small even for extreme scenarios of future fossil-fuel usage which produce increases in atmospheric CO 2 sufficient to cause catastrophic climate changes. At sea level, the ultimate drop in oxygen partial pressure will be less than 2.5 mm Hg out of a baseline of 159 mmHg. The drop by year 2300 is likely to be between 0.5 and 1.3 mmHg. The implications for normal human health is negligible because respiratory O 2 consumption in healthy individuals is only weakly dependent on ambient partial pressure, especially at sea level. The impacts on top athlete performance, on disease, on reproduction, and on cognition, will also be very small. For people living at higher elevations, the implications of this loss will be even smaller, because of a counteracting increase in barometric pressure at higher elevations due to global warming., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Keeling, Powell, Shaffer, Robbins and Simonson.)

Background: We conducted a chart review of prospectively collected data in order to demonstrate the safety and efficacy of an innovative technique of pleural and mediastinal drain injections., Methods: Patients who had undergone cardiac surgery and who continued to have pain despite the use of a multimodal pain protocol received injections of 20 mL of 0.25% bupivacaine in pleural and/or mediastinal chest drainage tubes., Results: Patients were evaluated for the incidence mediastinitis, osteitis, and deep sternal wound infection as well as the speed and intensity of pain relief. The odds ratio of infection in the infused group was 0.955 (CI = 0.4705, 1.9384). The adjusted mean "decrease in pain" was 4.01 (SEM = 0.15 and 95% CI = 3.78, 4.38), using the 11-point Likert Numerical Rating Scale. The mean adjusted "time to maximum pain relief" was 8.33 minutes (SEM = 0.42 and 95% CI = 7.50, 9.15)., Conclusion: This technique is a powerful, safe, and efficient tool in the armamentarium of pain management and its growing use within our institution has provided a substantial benefit in the treatment of early post-operative pain., Competing Interests: The authors report no conflicts of interest for this work and declare that they have no conflict of interest with respect to this research related to this article., (© 2020 Cogan et al.)

Mineral dust aerosols cool Earth directly by scattering incoming solar radiation and indirectly by affecting clouds and biogeochemical cycles. Recent Earth history has featured quasi-100,000-y, glacial-interglacial climate cycles with lower/higher temperatures and greenhouse gas concentrations during glacials/interglacials. Global average, glacial maxima dust levels were more than 3 times higher than during interglacials, thereby contributing to glacial cooling. However, the timing, strength, and overall role of dust-climate feedbacks over these cycles remain unclear. Here we use dust deposition data and temperature reconstructions from ice sheet, ocean sediment, and land archives to construct dust-climate relationships. Although absolute dust deposition rates vary greatly among these archives, they all exhibit striking, nonlinear increases toward coldest glacial conditions. From these relationships and reconstructed temperature time series, we diagnose glacial-interglacial time series of dust radiative forcing and iron fertilization of ocean biota, and use these time series to force Earth system model simulations. The results of these simulations show that dust-climate feedbacks, perhaps set off by orbital forcing, push the system in and out of extreme cold conditions such as glacial maxima. Without these dust effects, glacial temperature and atmospheric CO 2 concentrations would have been much more stable at higher, intermediate glacial levels. The structure of residual anomalies over the glacial-interglacial climate cycles after subtraction of dust effects provides constraints for the strength and timing of other processes governing these cycles., Competing Interests: The authors declare no conflict of interest., (Copyright © 2018 the Author(s). Published by PNAS.)

The response of the Antarctic ice sheet (AIS) to changing climate forcings is an important driver of sea-level changes. Anthropogenic climate change may drive a sizeable AIS tipping point response with subsequent increases in coastal flooding risks. Many studies analyzing flood risks use simple models to project the future responses of AIS and its sea-level contributions. These analyses have provided important new insights, but they are often silent on the effects of potentially important processes such as Marine Ice Sheet Instability (MISI) or Marine Ice Cliff Instability (MICI). These approximations can be well justified and result in more parsimonious and transparent model structures. This raises the question of how this approximation impacts hindcasts and projections. Here, we calibrate a previously published and relatively simple AIS model, which neglects the effects of MICI and regional characteristics, using a combination of observational constraints and a Bayesian inversion method. Specifically, we approximate the effects of missing MICI by comparing our results to those from expert assessments with more realistic models and quantify the bias during the last interglacial when MICI may have been triggered. Our results suggest that the model can approximate the process of MISI and reproduce the projected median melt from some previous expert assessments in the year 2100. Yet, our mean hindcast is roughly 3/4 of the observed data during the last interglacial period and our mean projection is roughly 1/6 and 1/10 of the mean from a model accounting for MICI in the year 2100. These results suggest that missing MICI and/or regional characteristics can lead to a low-bias during warming period AIS melting and hence a potential low-bias in projected sea levels and flood risks., Competing Interests: The authors have declared that no competing interests exist.

Case: This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status., Conclusion: This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Research was conducted to assess the impact of oiling on fresh-marsh plant communities and to test the efficacy of techniques that may be used to enhance the bioremediation of crude oil spills in these environments while minimizing secondary anthropogenic impacts. To emulate field conditions, a mesocosm facility was used that houses 120 mesocosm vessels, each of 200-1 capacity. A five-way factorial treatment arrangement was used that included two substrates (inorganic, organic), two nutrient regimes (fertilized, not fertilized), two aeration levels (substrate aeration, no aeration), three oiling concentrations (0-, 5-, 10-1 m(-2) of South Louisiana Sweet Crude oil), and four vascular plant species (Alternanthera philoxeroides, Panicum hemitomon, Phragmites australis, Sagittaria lancifolia, and an unplanted control). Under the 5- and 10-1 m(-2) oiling concentrations, S. lancifolia displayed a short-term response of increased productivity, whereas P. hemitomon had the highest biomass production and photosynthetic rates at the end of the 18-month experiment. Overall plant growth and productivity, as well as oil degradation, were significantly higher in the inorganic substrate, indicating that biodegradation of oil spills in organic substrates may require a longer time period. Time-released fertilizer also stimulated plant productivity and resulted in higher soil respiratory quotients, suggestive of greater microbial activity, particularly in aerated mesocosms. The amount of oil remaining after 18 months was lowest in aerated and fertilized mesocosms containing either P. hemitomon or S. lancifolia and a substrate of low organic matter content.

California Healthy Cities and Communities is the longest running statewide program of its kind in the nation. After providing a brief history the authors give an overview of the supporting activities and resources the Program provides to Healthy Cities and Communities initiatives throughout California.

In the February 1996 issue of Occupational Medicine, we published a case study in which the Chief Medical Officer of Hempson Industries, Steve Saunders, had just returned from a European conference where he delivered a well-received keynote presentation on work-related stress disorders. He was delighted with this success and his more general success in establishing a professional and proactive occupational health service during his two years with Hempson Industries. His delight, however, was undermined by his receipt of an internal memorandum from the newly appointed Director of Finance and Administration, Richard Coleman. The letter cited Board colleagues' criticisms of the contribution of OHS to company results, the expense of some services like health screening and recruitment medicals and the seemingly slow and unresponsive behaviour of most OHS staff. It also proposed the out-sourcing of occupational health to Boone Occupational Health Care Inc., an American private occupational health service. We invited readers to reply to the case study, explaining what they would do in Steve's situation. Out of a number replies, four were selected for publication and follow. The author author of the case study, Greg Shaffer, then provides some final comments.

The Labeled Magnitude Scale (LMS) is a semantic scale of perceptual intensity characterized by a quasi-logarithmic spacing of its verbal labels. The LMS had previously been shown to yield psychophysical functions equivalent to magnitude estimation (ME) when gustatory, thermal and nociceptive stimuli were presented and rated together, and the upper bound of the LMS was defined as the 'strongest imaginable oral sensation'. The present study compared the LMS to ME within the more limited contexts of taste and smell. In Experiment 1, subjects used both methods to rate either taste intensity produced by sucrose and NaC1 or odor intensity produced by acetic acid and phenyl ethyl alcohol, with the upper bound of the LMS defined as either the 'strongest imaginable taste' or the 'strongest imaginable odor'. The LMS produced psychophysical functions equivalent to those produced by ME. In, Experiment 2 a new group of subjects used both methods to rate the intensity of three different taste qualities, with the upper bound of the LMS defined as the 'strongest imaginable [sweetness, saltiness, or bitterness]'. In all three cases the LMS produced steeper functions than did ME. Experiment 3 tested the hypothesis that the LMS yields data comparable to ME only when the perceptual domain under study includes painful sensations. This hypothesis was supported when the LMS again produced steeper functions that ME after subjects had been explicitly instructed to omit painful sensations (e.g. the 'burn' of hot peppers) from the concept of 'strongest imaginable taste'. We conclude that the LMS can be used to scale sensations of taste and smell when they are broadly defined, but that it should be modified for use in scaling specific taste (and probably odor) qualities. The implications of these results for theoretical issues related to ME, category-ratio scales and the size of the perceptual range in different sensory modalities are discussed.

Hempson Industries Inc. is a large (and fictitious), multi-national American owned corporation. Its wholly owned UK subsidiary, Hempson Industries UK Ltd., is a diversified organization with operations dispersed throughout the UK. The UK Chief Medical Officer, Dr. Stephen Saunders, has been with the company for nearly two years and has been proud of his achievements in establishing a professional and proactive in-house occupational health services department. His perceived success, however, has been questioned by some significant recent events.

Individual aspects of heparin or protamine dosing have been better controlled than previously as useful tests have become available. Although many variables including drug potency, drug source, and individual patient response have been separately identified, there has not been an attempt to integrate them into a single management strategy. This study was undertaken to learn whether more precise control of drug variables and patient response would affect blood loss and transfusion requirements. Adult patients having primary cardiac operations were prospectively randomized into two groups. A control group received heparin and protamine by conventional methods. The test group received heparin and protamine according to in vitro predictive tests integrating drugs, tests, and patient response. Supplemental protamine was given in this group only if heparin was specifically found by testing. Anticoagulation in all patients was maintained at an activated coagulation time greater than 400 seconds, and any other treatment for bleeding was at the discretion of the clinical team caring for the patients. Testing and treatment for both groups followed routine practice after patient arrival in the intensive care unit. Test patients received slightly more heparin and a markedly lower dose of protamine than the control patients. Testing identified patients with decreased heparin sensitivity (preoperative heparin therapy) and correctly predicted the effective heparin dose. Supplemental protamine was given twice as often to control patients and frequently when no heparin was detectable (retrospectively). Test patients exhibited less 24-hour chest tube drainage (671 ml versus 1298 ml) and fewer patients received transfusion (9/22 versus 18/24) with fewer donor exposures (22/22 versus 101/24). The management strategy used for heparin and protamine added accuracy and precision, which was associated with improved hemostasis. Although the observation is valid, the mechanism or mechanisms are not completely clear. Nevertheless, it is reasonable to apply basic pharmacologic principles and establishment of consistent, predictable protocols that are beneficial. It is against this background that the efficacy of additional drugs or equipment should be assessed. It is quite possible that only marginal if any improvement in hemostasis may be found in patients having primary, uncomplicated cardiac operation with the addition of more costly drugs or equipment.

Objective: To examine the effects of a community education and law enforcement intervention on illegal tobacco sales to minors., Design: A 2-year, before and after trial with retail stores as the unit of analysis., Setting: Implementation occurred in four suburban California communities with populations of 25,000 to 100,000., Participants: All the retail stores in one intervention community and half the retail stores, randomly selected, in the other three intervention communities (n = 169) were visited by minors aged 14 to 16 years with the intent to purchase tobacco., Intervention: Ongoing community and merchant education and four law enforcement operations were conducted., Main Outcome Measures: Over-the-counter and vending machine sales of tobacco to minors were the primary outcomes., Results: Among a cohort of stores visited by minors at the pretest (n = 104) in June 1988, 71% sold tobacco over the counter and 92% sold tobacco through vending machines. At posttest 2 in May 1990, 24% sold tobacco over the counter and 93% sold tobacco through vending machines. Of the 31 stores issued citations, 16 were followed into the courts where the fines were dismissed or reduced., Conclusions: Education alone had a limited effect on reducing illegal tobacco sales to minors. It did promote community support for more aggressive enforcement strategies. Education plus enforcement decreased significantly over-the-counter sales; vending machine sales were unaffected by these interventions. The lack of support at the judicial level may temper the effectiveness of enforcement. Legislative remedies addressing judicial obstacles and vending machine sales are needed.

Cotton leaf, bract, fibre from opened bolls, and soil samples were collected weekly during two growing seasons (1984, 1985). Total and Gram negative bacterial populations were determined for each sample. Representative bacterial isolates were identified and endotoxin concentrations determined. For both years total and Gram negative bacterial populations on all sample types remained relatively stable until plant senescence. Afterwards, until plant death by frost, counts for all samples increased dramatically. Enterobacter agglomerans was the predominant species on leaf and bract, whereas the "all other" Gram negative bacterial species classification was the most common on fibre, with E agglomerans a close second. Senescence affected the occurrence of the species isolated. Statistical analysis partitioned by sample type showed strong correlations between endotoxin concentrations and certain bacteriological and environmental variables. The data suggest that in hot, humid environments the concentration of endotoxin on cotton leaf, bract, and fibre may be predicted by total and Gram negative bacterial counts, daily high temperature, and week after plant germination.

To determine how factors involved in infant carbohydrate metabolism could be effectively assayed in vitro, fecal materials from healthy infants were obtained and tested with fermentation mixtures incorporating glucose, fructose, and lactose incubated under aerobic and anaerobic conditions. The amounts of organic acids, hydrogen, carbon dioxide, and methane produced were determined. Principal component analysis indicated that products of the three sugar systems produced very similar factor patterns and, therefore, all three sugars may not be required to adequately characterize intestinal microbial fermentation processes. Moreover, the fermentation processes under aerobic and anaerobic conditions produced essentially identical cluster patterns of the factors from the three sugar systems. Collectively, the results indicated that two sugar systems, glucose and lactose, measured under aerobic fermentation conditions sufficed in accounting for most of the variation among babies.

A method which circumvents the lengthy procedural steps for sample preparation in the analysis of free amino acids (FAA) in the peanut is described. Sample preparation consists of extracting a full fat meal with a lithium citrate sample buffer for 15 min. The sample is centrifuged and filtered with two Millipore filters in series. The resulting extract is analyzed "as is" for FAA via a physiological amino acid procedure. The method significantly reduces sample preparation time and eliminates the use of hazardous chemicals. It is well adapted to the analysis of large numbers of samples or samples of limited quantity. It should be applicable to the analysis of FAA in other oilseeds.