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ImportanceTall cell morphology (TCM) is a rare and aggressive variant of papillary thyroid carcinoma (PTC) that has been associated with poor outcomes; however, the risk factors for worse survival are not well characterized.ObjectiveTo identify prognostic factors associated with cancer recurrence and death in patients with PTC-TCM.Design, Setting, and ParticipantsAll patients treated for PTC-TCM at a single tertiary-level academic health care institution from January 1, 1997, through July 31, 2018, were included. Tall cell variant (TCV) was defined as PTC with TCM of 30% or more; and tall cell features (TCF) was defined as PTC with TCM of less than 30%. Patients with other coexisting histologic findings and/or nonsurgical management were excluded. Clinicopathologic features associated with worse outcomes were identified using Kaplan-Meier and Cox proportional-hazards model. Data were analyzed from March 1, 2018, to August 15, 2018.Main Outcomes and MeasuresLocoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and overall survival (OS) after surgery.ResultsA total of 365 patients (median [range] age, 51.8 [15.9-91.6] years; 242 [66.3%] female) with PTC-TCM (TCV, 32%; TCF, 68%) were evaluable. Total thyroidectomy was performed in 336 (92%) patients; 19 (5.2%) received radiotherapy; and 15 (4.1%) received radioactive iodine. Clinical features were pT3 or T4, 65%; node-positive, 53%; and positive surgical margins, 24%. LRRFS at 1-, 3-, 5-, and 10-year was 95%, 87%, 82%, and 73%, respectively. On multivariable analysis, male sex and age were not independent predictors of inferior 5-year LRRFS, whereas positive surgical margins (HR, 3.5; 95% CI, 2.0-6.3), positive lymph nodes (HR, 2.8; 95% CI, 1.4-5.8), and primary tumor size of 3 cm or more (HR, 3.3; 95% CI, 1.4-7.8) were strongly associated with worse LRRFS. Age 55 years or older (HR, 3.2; 95% CI, 1.5-7.0), male sex (HR 4.5; 95% CI, 2.1-10.0), positive surgical margins (HR, 2.7; 95% CI, 1.2-6.0), nodal positivity (HR, 3.1; 95% CI, 1.3-7.7), tumor diameter of 1.5 cm or more (HR, 20.6; 95% CI, 2.8-152.1), and TCV vs TCF (HR, 3.1; 95% CI, 1.5-6.7) were associated with worse DRFS. Male sex (HR, 3.1; 95% 1.4-6.8) and tumor diameter of 1.5 cm or more (HR, 2.8; 95% CI, 1.0-7.4) were associated with worse OS. A findings-based nomogram was constructed to predict 10-year LRRFS (C index, 0.8).Conclusions and RelevanceThis retrospective cohort study found that in patients with PTC-TCM, positive surgical margins, node positive disease, and tumor size of 3 cm or more were risk factors for worse LRRFS. Intensified locoregional therapy, including adjuvant radiation, may be considered for treating these patients.

The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology.This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons.Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively.This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

Context The Afirma® GSC aids in risk stratifying indeterminate thyroid nodule cytology (ITN). The 2018 GSC validation study (VS) reported a sensitivity (SN) of 91%, specificity (SP) of 68%, positive predictive value (PPV) of 47%, and negative predictive value (NPV) of 96%. Since then, 13 independent real-world (RW) postvalidation studies have been published. Objective This study's objective is to compare the RW GSC performance to the VS metrics. Methods Rules and assumptions applying to this analysis include: (1) At least 1 patient with molecular benign results must have surgery for that study to be included in SN, SP, and NPV analyses. (2) Molecular benign results without surgical histology are considered true negatives (TN) (as are molecular benign results with benign surgical histology). (3) Unoperated patients with suspicious results are either excluded from analysis (observed PPV [oPPV] and observed SP [oSP]) or assumed histology negatives (false positives; conservative PPV [cPPV] and conservative SP [cSP]) 4. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features is considered malignant. Results In RW studies, the GSC demonstrates a SN, oSP, oPPV, and NPV of 97%, 88%, 65%, 99% respectively, and conservative RW performance showed cSP of 80% and cPPV of 49%, all significantly higher than the VS except for SN and cPPV. There was also a higher benign call rate (BCR) of 67% in RW studies compared to 54% in the VS (P < 0.05). Conclusion RW data for the Afirma GSC demonstrates significantly better oSP and oPPV performance than the VS, indicating an increased yield of cancers for resected GSC suspicious nodules. The higher BCR likely increases the overall rate of clinical observation in lieu of surgery.

Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/mThis was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range).For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT.There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Patient-reported outcome measures for parathyroid and thyroid disease (PROMPT) is a 30-question, previously validated, survey assessing symptoms on a scale from 0 to 100. Using PROMPT, we aimed to assess symptom improvement for patients undergoing thyroidectomy and parathyroidectomy.Single-center prospective study in which PROMPT was used to assess symptom improvement in patients undergoing parathyroidectomy or thyroidectomy. A postoperative assessment was performed approximately 6 months after surgery and compared to its baseline preoperative assessment.A total of 144 patients completed both assessments (71 parathyroidectomy, 73 thyroidectomy). Parathyroidectomy patients demonstrated significant improvements in all hyperparathyroidism domains (38.2-28.3, p 0.001) regardless of preoperative calcium and parathyroid hormone levels. Thyroidectomy patients experienced improvement in their compressive symptoms (25.6-16.5, p 0.001).PROMPT objectively demonstrates the clinical effectiveness of parathyroidectomy and thyroidectomy in alleviating subjective patient symptoms. PROMPT offers promising use as a standardized metric to assess quality of life improvement within endocrine surgery.

Background Culex mosquitoes are the primary vectors of West Nile virus (WNV) across the USA. Understanding when these vectors are active indicates times when WNV transmission can occur. This study determined the proportion of female Culex mosquitoes that were in diapause during the fall and winter and when they terminated diapause and began blood feeding in the spring. Methods Mosquitoes were collected from parks using various traps and/or aspirated from culverts in Franklin County, Ohio, from October to mid-May from 2019 to 2022. Culex mosquitoes were morphologically identified to species, and the ovaries of females were dissected to determine their diapause and parity statuses. Results By early October 2021, roughly 95% of Culex pipiens collected in culverts were in diapause and 98% of Cx. erraticus were in diapause. Furthermore, gravid and blood-fed Culex salinarius, Cx. pipiens, and Cx. restuans were collected in late November in 2019 and 2021 in standard mosquito traps. In the winter of 2021, the proportions of non-diapausing Culex decreased within culverts. The last non-diapausing Cx. erraticus was collected in late December 2021 while the final non-diapausing Cx. pipiens was collected in mid-January 2022, both in culverts. Roughly 50% of Cx. pipiens terminated diapause by mid-March 2022, further supported by our collections of gravid females in late March in all 3 years of mosquito collection. In fact, male mosquitoes of Cx. pipiens, Cx. restuans, and Cx. territans were collected by the 1st week of May in 2022, indicating that multiple species of Culex produced a second generation that reached adulthood by this time. Conclusions We collected blood-fed and gravid Culex females into late November in 2 of the 3 years of our collections, indicating that it might be possible for WNV transmission to occur in late fall in temperate climates like Ohio. The persistence of non-diapausing Cx. pipiens and Cx. erraticus throughout December has important implications for the winter survival of WNV vectors and our overall understanding of diapause. Finally, determining when Culex terminate diapause in the spring may allow us to optimize mosquito management programs and reduce the spread of WNV before it is transmitted to humans. Graphical Abstract

Background Vascular penetration during aesthetic filler injections can cause serious side effects such as skin necrosis and blindness. Objectives To analyze the effect of cannula brand and gauge on the risk of vascular penetration. Methods The minimal force to penetrate the superficial temporal artery with 3 cannula brands and 1 needle brand in 4 sizes (22, 25, 27, and 30-gauge) was measured in 4 fresh frozen cadavers utilizing a force gauge that measures as low as 0.1 newtons. Tissue penetration force in the subdermal plane of the nasolabial fold was measured and compared to retrospective training data in live humans. A second site repeated the arterial penetration test on one fresh cadaver with 2 different force gauges. Results Significantly lower forces were needed with all size needles vs the same gauge cannulas in all brands to penetrate the cadaveric artery and advance in the subdermal plane of the nasolabial fold in both cadavers and live humans. To successfully enter the artery in a cadaver with any cannula, numerous attempts were necessary. The tissue penetration force in the subdermal plane of the nasolabial fold in a cadaver was not significantly different than a living person; however, it was significantly higher than the arterial penetration force in a dissected cadaver. Conclusions All gauge cannulas (including 27 and 30-gauge), require more force than the same size needle to penetrate an artery. However, it appears the friction coefficient and flexibility, not the arterial penetration force, is the most important factor in keeping the instrument outside the vessel.

Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma.In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χThere was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048).In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.

Understanding students’ perspectives on inclusive behavior is important for addressing the bullying, victimization, and exclusion that many middle school and high school students, particularly marginalized students, continue to face at school. This study explored how students give meaning to inclusive behavior at school and the conditions that support inclusive behavior. Using data from 30 focus groups conducted with students, the findings expand on three primary themes: students’ broad descriptions of inclusive behavior, their understanding of the qualities and characteristics of an inclusive person, and their beliefs about what makes a school inclusive. Findings from this study can inform organizational practices to facilitate inclusive behavior in schools in a manner consistent with how students themselves view inclusivity.

Background A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. Methods Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. Results The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). Conclusions Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

Interphase properties in composites, adhesives and protective coatings can be predicted on the basis of interfacial interactions between polymeric precursor molecules and the inorganic surface during network formation. The strength of molecular interactions is expected to determine local segmental mobility (polymer glass transition temperature, Tg) and cure degree.Conventional analysis techniques and atomic force microscopy coupled with infrared (AFM-IR) are applied to nanocomposite specimens to precisely characterise the epoxy-amine/iron oxide interphase, whilst molecular dynamics simulations are applied to identify the molecular interactions underpinning its formation.Attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy and high-resolution AFM-IR mapping confirm the presence of nanoscale under-cured interphase regions. Interfacial segregation of the molecular triethylenetetraamine (TETA) cross-linker results in an excess of epoxy functionality near synthetic hematite, (Fe

Although most clinicians agree that diffusion of botulinum neurotoxin (BoNT) occurs, its extent, timeline, and clinical importance have been debated. A literature search on PubMed (National Institutes of Health, Bethesda, MD) was done up to January 15, 2023, which included the following search terms: botulinum toxin A uptake; botulinum toxin A diffusion; and botulinum spread. A total of 421 publication titles were found and analyzed. Based on titles, the author selected 54 publications as potentially applicable and reviewed each 1 in depth, along with its supporting references. There are several publications that support a novel theory that small amounts of BoNT can remain in the area days after injection and spread to adjacent muscles. Although current thinking is that BoNT is completely taken up within hours, making its spread days after injection of BoNT not a plausible theory, the following literature review and case report support a novel theory. Level of Evidence: 5

Mosquitoes transmit a wide variety of devastating pathogens when they bite vertebrate hosts and feed on their blood. However, three entire mosquito genera and many individual species in other genera have evolved a nonbiting life history in which blood is not required to produce eggs. Our long-term goal is to develop novel interventions that reduce or eliminate the biting behavior in vector mosquitoes. A previous study used biting and nonbiting populations of a nonvector mosquito

Hyaluronic acid (HA) fillers have been studied extensively on the face; however, their safety and efficacy on the neck has not yet been evaluated in a prospective trial in the United States.Analyze the efficacy and safety of a HA filler for static horizontal neck rhytides using either a cannula or needle.Twenty-six subjects were randomized to receive up to 1 mL of the HA filler Restylane Refyne (HARR, n = 20) or saline (n = 6) using a cannula on one side and a needle on the other with optional repeat treatment. Subjects were graded using the Transverse Neck Line Scale, Canfield photography, and the Global Aesthetic Improvement Scale.A significant improvement 30 days after the last treatment was achieved on the Transverse Neck Line Scale when comparing HARR with saline according to the blind evaluator, subjects, and investigator without any significant side effects. In addition, the blind evaluator, subjects, and investigator rated the side of the neck injected with a needle as having significantly greater improvement than the cannula.The hyaluronic acid filler, Restylane Refyne, achieved significant improvement in static horizontal neck rhytides using either a cannula or needle without any serious side effects, although the needle was more effective.

Epoxy resins coatings are commonly found in corrosion protection coatings but the presence of water can affect their adhesion to the substrate, often weakening the adhesion of the coating to the solid, reducing its efficiency. Nevertheless, small amounts of water can enhance the epoxy/substrate interactions. In this work, the interphase region of an epoxy precursor and metal oxide substrates is investigated using molecular simulations and it is found that water accumulates between the epoxy layer and the solid substrate. At high water concentrations (9 wt %) the interaction between the epoxy precursor and the solid surface is weakened regardless of the nature of the solid, but at low water concentrations the nature of the solid surface becomes important. For hematite, the presence of water decreases the strength of adhesion but for goethite the presence of a small amount of water (3 wt %) enhances the adhesion to the surface resulting in a densification at the interface.

The separation of CO/N2 mixtures is a challenging problem in the petrochemical sector due to the very similar physical properties of these two molecules, such as size, molecular weight and boiling point. To solve this and other challenging gas separations, one requires a holistic approach. The complexity of a screening exercise for adsorption-based separations arises from the multitude of existing porous materials, including metal-organic frameworks. Besides, the multivariate nature of the performance criteria that needs to be considered when designing an optimal adsorbent and a separation process - i.e. an optimal material requires fulfillment of several criteria simultaneously - makes the screening challenging. To address this, we have developed a multi-scale approach combining high-throughput molecular simulation screening, data mining and advanced visualization, as well as process system modelling, backed up by experimental validation. We have applied our recent advances in the engineering of porous materials' morphology to develop advanced monolithic structures. These conformed, shaped monoliths can be used readily in industrial applications, bringing a valuable strategy for the development of advanced materials. This toolbox is flexible enough to be applied to multiple adsorption-based gas separation applications.

BACKGROUND: Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice. METHODS: An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review. RESULTS: A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291–1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks. CONCLUSIONS: This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.

Background Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. Methods Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. Results Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. Conclusion Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.

The separation of CO/N2 mixtures is a challenging problem in the petrochemical sector due to the very similar physical properties of these two molecules, such as size, molecular weight and boiling point. To solve this and other challenging gas separations, one requires a holistic approach. The complexity of a screening exercise for adsorption-based separations arises from the multitude of existing porous materials, including metal–organic frameworks. Besides, the multivariate nature of the performance criteria that needs to be considered when designing an optimal adsorbent and a separation process – i.e. an optimal material requires fulfillment of several criteria simultaneously – makes the screening challenging. To address this, we have developed a multi-scale approach combining high-throughput molecular simulation screening, data mining and advanced visualization, as well as process system modelling, backed up by experimental validation. We have applied our recent advances in the engineering of porous materials' morphology to develop advanced monolithic structures. These conformed, shaped monoliths can be used readily in industrial applications, bringing a valuable strategy for the development of advanced materials. This toolbox is flexible enough to be applied to multiple adsorption-based gas separation applications.

Background Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. Methods Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. Results There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). Conclusion Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.

Background and objectives Senile purpura is a common condition characterized by recurrent ecchymoses in the elderly on the extensor surfaces of the forearms, hands, and legs. Our objective is to assess the efficacy and safety of a protocol using intense pulsed light (BBL; Sciton Inc., Palo Alto, CA) to improve the appearance of senile purpura on subjects' extensor forearms. Study design/materials and methods Five subjects over 65 years of age, with ecchymotic lesions measuring over 1 cm on each forearm and five younger subjects under 35 years of age, without any ecchymotic lesions, were included in the study. The subjects were treated on one randomized forearm with a new intense pulsed light protocol for four weekly sessions. Photographs and subject questionnaires were taken weekly before each treatment as well as 1 month after all treatments. Skin biopsies were taken 1 day after the last of four weekly treatments. Histological analysis, including hematoxylin and eosin, elastic van Gieson, and Masson's Trichrome staining, were carried out to assess both the epidermal thickness and dermal connective tissue structure. The protocol consists of multiple passes using an intense pulsed light (BBL; Sciton Inc.) device in which the wavelength, filter, and fluence are adjusted for each step. Step 1 uses infrared light (800-1,400 nm), high intensity, a smooth adapter, and a constant motion technique. Step 2 employs a 590-nm filter with two different fluences and step 3 utilizes a 560-nm filter. The fluence of steps 2-3 is increased by 1 J each treatment if no side effects are noted. Results Using a new intense pulsed light protocol in subjects with senile purpura, both the number and square area of ecchymoses on the treated arm were significantly reduced (P = 0.02 and P = 0.04, respectively, paired t test) as compared with the untreated arm at 1 month after four weekly treatments. Despite this pilot study including challenging cases of subjects on both inhaled and injected corticosteroids and blood thinners, all subjects with senile purpura had at least a 50% reduction in the total square area of their ecchymoses on their treated arm. There were no significant or long-lasting side effects, and all subjects reported satisfaction with the treatment with a desire to continue treatments on their control arm. Blinded evaluators were able to select 100% of the time in the subjects with senile purpura, which was the treated arm as compared with the control arm when reviewing photographs from 1 month after the last treatment. In addition, several subjects were noted to have a significant improvement in the appearance of hemosiderin deposition and photodamage. Histologically, intense pulsed light treatments significantly increased epidermal thickness in elderly subjects by 21.14% (P = 0.0153, two-tailed, paired t test), to levels comparable with young subjects. Such restoration is consistent with the other histological observations by blinded evaluators of more abundant and organized collagen fibers in the dermis and reduced aggregates of disorganized elastin fibers. Conclusion This new intense pulsed light protocol is safe and effective in improving the clinical appearance of senile purpura as well as preventing future lesions by improving the structure of the skin by increasing epidermal thickness and improving collagen and elastic fiber morphology. The treatment was well-tolerated, adverse effects were minimal, and there was high patient satisfaction. Lasers Surg. Med. 2020. © 2020 Wiley Periodicals LLC.

Hyaluronic acid fillers have been studied extensively for facial wrinkles; however, their efficacy for atrophic facial scars has yet to be analyzed in a prospective placebo-controlled study.To analyze the efficacy and safety of a hyaluronic acid filler for atrophic facial scars.Fifteen subjects were randomized to receive up to 1 ml of VYC-17.5 L on one cheek and up to 1 ml of saline on the other side, with an optional touch-up treatment. Subjects were graded by a live blind evaluator using the Quantitative Global Scarring Grading System (QGSGS) (J Cosmet Dermatol. 2006;5:48), the Global Aesthetic Improvement Scale (GAIS), and Canfield photo-analysis.According to the blind evaluator, there was a significant reduction 90 days after the last treatment on the QGSGS for VYC-17.5L compared with saline (-6.6 VYC-17.5L vs -1.7 saline [t(28) = -4.3196, p = 0.008]). There was a smaller, but still significant reduction on the QGSGS for saline alone (10.4 to 8.6 [t(14) = -3.453, p = 0.004]). In addition, 93% (13/14) of subjects chose VYC-17.5L over saline treatment and reported an improvement on the GAIS. There were no serious side effects and all minor side effects resolved by Day 30.VYC-17.5L achieved significant improvements in rolling atrophic scars as compared to saline, though saline also had modest improvements.

Background Infraorbital hollows can give a fatigued or aged appearance, which can be treated by volumizing the segmented transition from the tear trough to the cheek with hyaluronic acid filler. Due to thin skin and the complex anatomy of the infraorbital area, both short- and long-term side effects (SEs) from this treatment are very common. While some patients are clear surgical candidates vs filler candidates, in real-world practice, many, if not most, patients are on a continuum where either procedure is appropriate, and the treatment decision is individualized based on each person’s risk vs benefit profile. Objectives Common aesthetic SEs from hyaluronic acid filler treatment in the infraorbital area will be reviewed, including their etiology, prevention, detection, and treatment. Methods The author’s experience from injecting the infraorbital areas of more than 800 patients in private clinical practice and observations from both short- and long-term follow-ups over 8 years is leveraged to provide detailed guidance. Results Recommendations on injection techniques, patient selection, and patient education are presented along with algorithms for the prevention and management of bruising, short- and long-term swelling, bumps, and blue discoloration (which is usually secondary to swelling from the filler rather than just the filler alone placed or migrating too superficially). Conclusions For nearly all patients, complete dissolution of filler with hyaluronidase is not required to address the issue, and the guidelines provided here will assist clinicians in the management of SEs to increase patient satisfaction with their treatment and aesthetic outcome. Level of Evidence: 5

Objective The aim of this study was to analyze the incidence of and risk factors for adrenocortical carcinoma (ACC) in adrenal incidentaloma (AI). Summary of background data AI guidelines are based on data obtained with old-generation imaging and predominantly use tumor size to stratify risk for ACC. There is a need to analyze the incidence and risk factors from a contemporary series. Methods This is a retrospective review of 2219 AIs that were either surgically removed or nonoperatively monitored for ≥12 months between 2000 and 2017. Multivariate logistic regression was performed to define risk factors. ROC curves constructed to determine optimal size and attenuation cut-offs for ACC. Results 16.8% of AIs underwent upfront surgery and rest initial nonoperative management. Of conservatively managed patients, an additional 7.7% subsequently required adrenalectomy. Overall, ACC incidence in AI was 1.7%. ACC rates by size were 0.1%, 2.4%, and 19.5% for AIs of 6 cm, respectively. The optimal size cut-off for ACC in AI was 4.6 cm. ACC risks by Hounsfield density were 0%, 0.5%, and 6.3% for lesions of 20 HU, with an optimal cut-off of 20 HU to diagnose ACC. 15.5% of all AIs and 19.2% of ACCs were hormonally active. Male sex, large tumor size, high Hounsfield density, and >0.6 cm/year growth were independent risk factors for ACC. Conclusion This contemporary analysis demonstrates that ACC risk per size in AI is less than previously reported. Given these findings, modern management of AIs should not be based just on size, but a combination of thorough hormonal evaluation and imaging characteristics.

The present study examined how a multicomponent intervention embedded in a high school's extracurricular framework impacts students' acceptance of peers with intellectual disability (ID). Data were collected from eight high schools, three of which implemented the Special Olympics Unified Champion Schools (UCS) program involving inclusive sports, clubs, and schoolwide events, and five of which did not. A pretest-posttest survey design was used to measure students' attitudes, perceptions, and interactions (n = 1,230). Lagged dependent variable modeling revealed that UCS participation significantly predicted improved attitudes toward peers with ID and perceptions of school social inclusion, as well as increased social interactions with peers with ID. Unified extracurricular activities may be the next step forward in promoting an inclusive school culture.

Epoxy-based coatings are widely used in a range of industries as protective coatings. The performance of the final solid-polymer system is dependent on the physicochemical properties of the interface and the interaction between the polymer and the solid substrate. In this study, we perform atomistic molecular dynamics simulations to investigate the binding of a common component in epoxy resins, diglycidyl ether of bisphenol A (DGEBA), on two iron oxide surfaces, hematite (0001) and magnetite (100), and investigate the effect of surface hydroxylation on the binding energy. We show that adsorption of DGEBA on hematite is more favorable than on magnetite and that the adsorbed molecules are highly localized on the pristine hematite surface but mobile on highly hydroxylated hematite surfaces and magnetite surfaces irregardless of surface hydroxylation fraction. A high degree of hydroxylation significantly reduces the binding energy of DGEBA on hematite but not on magnetite. The free-energy calculations confirm the trends observed upon hydroxylation, but the magnitude of the potential of mean force is lower than the binding energy due to the entropic contributions. Therefore, it can be suggested that DGEBA will adsorb more strongly on a surface containing a higher content of hematite than magnetite and that the presence of hydroxyl groups will weaken this adsorption. The presence of hydroxyl groups increases mobility of the chains, which can affect the coating rigidity.

Graphene oxide (GO) membranes are highly touted as materials for contemporary separation challenges including desalination, yet understanding of the interplay between their structure and salt rejection is limited. K+ ion permeation through hydrated GO membranes was investigated by combining structurally realistic molecular models and high-throughput molecular dynamics simulations. We show that it is essential to consider the complex GO microstructure to quantitatively reproduce experimentally-derived free energy barriers to K+ permeation for membranes with various interlayer distances less than 1.3 nm. This finding confirms the non-uniformity of GO nanopores and the necessity of the high-throughput approach for this class of material. The large barriers arise due to significant dehydration of K+ inside the membrane, which can have as few as 3 coordinated water molecules, compared to 7 in bulk solution. Thus, even if the membranes have an average pore size larger than the ion's hydrated diameter, the significant presence of pores whose size is smaller than the hydrated diameter creates bottlenecks for the permeation process.

The Afirma Genomic Sequencing Classifier uses whole transcriptome RNA sequencing to identify thyroid nodules as benign or suspicious. The Afirma Xpression Atlas became available in 2018 and reports findings across 593 genes, including 905 variants and 235 fusions. When an alteration is identified, its risk of malignancy and associated neoplasm type is listed. We report the results of Afirma Xpression Atlas testing at our institution during its first 2 years of clinical use.All patient charts with indeterminate thyroid nodules and Afirma Xpression Atlas results at our institution were reviewed. Thyroid nodule characteristics, cytology, Afirma Genomic Sequencing Classifier results, Afirma Xpression Atlas results, and final histopathology were reported.Afirma Xpression Atlas was performed on 136 indeterminate nodules since May 2018, and 103 met inclusion criteria. Forty-three nodules had positive Afirma Xpression Atlas results, and of these, 83.7% were follicular cell-derived thyroid cancer on surgical histopathology. This is similar to the overall 82.5% positive predictive value among Afirma Genomic Sequencing Classifier-suspicious indeterminate nodules during the same time period. Of the 60 nodules with negative Afirma Xpression Atlas, 73.3% were follicular cell-derived thyroid cancer on surgical histopathology.Afirma Xpression Atlas positivity is predictive of follicular cell-derived thyroid cancer, but its positive predictive value is similar to that of Genomic Sequencing Classifier-suspicious results alone at our institution, which is higher than previously published. Specific mutations likely predict follicular cell-derived thyroid cancer with higher accuracy, but our current sample size of any given mutation is too small to evaluate this further. Larger studies are needed to determine whether Afirma Xpression Atlas results predictably inform the risk of malignancy and tumor characteristics in thyroid nodules.

OBJECTIVE Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.

Background Care pathways facilitate standardized, evidence-based treatment to improve outcomes and value of care. Care pathways consist of multiple nodes representing decision points. Few studies investigate care pathway compliance. We demonstrate nodal care pathway analysis by reviewing compliance with our institutional multidisciplinary, evidence-based care pathways on the treatment of thyroid nodule to generate strategies to increase care pathway adherence and value of care. Methods Patients undergoing workup and treatment of structural thyroid disease between January 2018 and June 2018 were included in a retrospective analysis of enterprise-wide compliance with the following 3 care pathway nodes: (1) laboratory testing: only patients with abnormal results from thyroid-stimulating hormone testing should have T3/T4 measured. (2) imaging: neck computed tomography, magnetic resonance imaging, and positron emission tomography ordered for the workup of nodules were reviewed to determine clinical appropriateness. (3) operative treatment: the first 200 thyroid resections conducted in 2018 were reviewed to determine whether the indication and extent of the operation complied with the care pathway. Medicare fee schedules were used for financial calculations. Results Care pathway nonadherence occurred in 48% of the thyroid-stimulating hormone studies and 38% of the imaging studies obtained, with annual costs exceeding $120,000. Substantial care pathway nonadherence occurred in 3% of nodule-related operations. Conclusion Care pathway nodal analysis can identify areas of care pathway nonadherence. Nodal analysis should be considered for care pathway maintenance and generation of strategies of quality improvement.

Carbon monoxide (CO)/nitrogen (N2) separation is a particularly challenging separation, yet it is the one with great industrial relevance for its use in petrochemical synthesis. Although an expensive cryogenic step can be used to perform such separation, it remains ineffective in purifying CO from syngas streams with a significant N2 content. Taking advantage of the lower energy requirement of adsorption processes, we have explored the use of metal–organic frameworks (MOFs) as adsorbents for this difficult separation. We have screened a range of MOF candidates for CO/N2 separation covering a range of chemical and textural features, using the flux response technology to evaluate their dynamic performance for throughput testing alongside equilibrium uptake measurements. We have identified Ni-MOF-74 and Co-MOF-74 as the most promising candidates because of their high metal density and strong metal–CO interactions. We have investigated further the effect of N2 impurity concentrations upon CO/N2 separation using breakthrough adsorption testing and cyclic testing (up to 20 cycles). Overall, using multiple adsorption measurement techniques, this study demonstrates the CO/N2 dynamic separation performance of M-MOF-74 and its ability to be applied for an industrially relevant separation.

Objective: Preservation of parathyroid function is one of the primary tenets of endocrine surgery. For patients with thyroid disease, an inadvertently compromised parathyroid gland is routinely autotransplanted into the neck at the time of surgery. By contrast, for patients with parathyroid disease secondary to hyperplasia, the timing of auto-transplantation needs to be further considered in order to balance the risks between persistent disease and permanent hypocalcemia. Cryopreservation preserves cellular function and permits the storage of parathyroid tissue for potential re-implantation at a later date in patients who develop hypoparathyroidism. Methods: In this paper, we review the process of cryopreservation, with particular emphasis on the regulatory issues involved in establishing a local service, tissue processing, billing and reimbursements, outcome (functionality), and complications. Results: A detailed description of the technique as performed at our institution is described and illustrated. Conclusion: Cryopreservation affords surgical insurance against the disastrous sequelae of permanent hypoparathyroidism. Our techniques are easy to adopt with only a modest initial investment of time and money, particularly for institutions that already cryopreserve other tissue types. Abbreviations: PTH = parathyroid hormone; RMPI = Roswell Park Memorial Institute; RPMI-SSS = RPMI-serum substitute supplement

Amino-functionalized mesoporous MCM-41 materials were synthesised by co-condensation of amino-organosiloxane precursors, namely 3-aminopropyltrimethoxysiloxane (APS), 3-(methylamino)propyltrimethoxysiloxane (MAPS) and 3-(phenylamino)propyltrimethoxysiloxane (PAPS) with tetraethyl orthosilicate (TEOS) in water solution containing ammonia and in the presence of surfactant as templating agent. The ratio of amino-organosiloxanes to TEOS in the synthesis mixture was 3, 5, 10, 20 and 30 wt%. The prepared samples were characterized by Small Angle X-ray Scattering (SAXS), High-Resolution Transmission Electron Microscopy (HRTEM), Thermogravimetric Analysis (TGA) and N2 adsorption/desorption. It followed from the measurements that the ordered porous materials of hexagonal symmetry were obtained at small ratios of APS and MAPS to TEOS (3, 5, 10 wt%). At larger ratios (20 and 30 wt%), disordered or non-porous amorphous amino-functionalized silica particles were obtained. For the PAPS precursor, hexagonally-packed structures were observed up to a PAPS to TEOS ratio of 30 wt%, when a transition to a lamellar phase occurs. The reasons of the structural changes are discussed in terms of modifications in the effective shapes of the cylindrical micelle aggregates, caused by different hydrophilicity/hydrophobicity of the used amine precursors and their interactions with surfactant micelles. To better understand the origin of this behavior, lattice Monte Carlo simulations of simple coarse-grained surfactant solutions were performed. All prepared samples were used to study CO2 adsorption. It was found that CO2 adsorption capacity in the samples increased with the increasing concentration of amino-organosiloxane precursor, independently of the surface area. These results imply that CO2 adsorption primarily takes place on amine active centers and physical adsorption, which is dependent on the high surface area, plays a less important role in CO2 adsorption on these materials.

The Afirma Genomic Sequencing Classifier (GSC) is a rule‐out test for malignancy/noninvasive follicular thyroid neoplasms with papillary‐like nuclear features among patients with Bethesda category III/IV nodules, whereas the complimentary Xpression Atlas provides genomic insights from a curated panel of 511 genes among GSC suspicious and Bethesda category V/VI nodules. Together, they facilitate personalized treatment decisions based on genomic insights derived from the transcriptome of the biopsied target and extend the diagnostic and therapeutic reach of cytopathologists and fine‐needle aspiration biopsy sample collection.

Metal Organic Frameworks (MOFs) have the potential to be used as adsorbents in industrial separations. Different ligand lengths can generate MOFs with similar topology but differing pore sizes. Molecular simulations were used in this work to assess the adsorption isotherms, heats of adsorption and selectivity of H2S and CH4 in MOF UiO-66, UiO-67, and UiO-68. Detailed analysis of the distribution of molecules in the cages and the radial distribution functions suggest that the effect of the linker on the macroscopic properties is negligible at low pressures, but it becomes evident at high pressures, where adsorption far from the linker is observed in large pore materials. Based on the adsorption selection parameter, UiO-67 shows better performance in a wider range of conditions than the other materials.

With increasing recognition of more subtle presentations of primary hyperparathyroidism (pHPT), laboratory values are frequently seen in a range that would be expected for patients who have familial hypercalcemic hypocalciuria (FHH). Calcium creatinine clearance ratio (CCCR) has been advocated as a diagnostic tool to differentiate between these two disorders. However, it is limited by an indeterminate range (0.01-0.02). The aim of this study is to assess the relevance of CCCR in a modern series of patients with surgically managed pHPT.We performed a retrospective cohort study of 1000 patients who underwent parathyroid surgery for pHPT over eleven years. CCCR was evaluated by degree of biochemical derangement, single versus multiple gland disease and interfering medications.Patient demographics and resected histopathology were typical for a current series of patients with pHPT. In retrospect, none of the patients were suspected to have FHH post operatively. CCCR was less than 0.01 for 19.0%, between 0.01-0.02 for 43.7% and greater than 0.02 in 37.3%. Distribution of CCCR for patients free from interfering medications and different histological subtypes were the same. One third of the cohort had mild calcium elevations, more typical for FHH. Of these, almost two thirds had a CCCR in a range suspect for FHH (0.02).To our knowledge this is the largest series to evaluate the validity of CCCR for patients with surgically confirmed pPHT. The utility of CCCR in screening for FHH is limited, as 63% of modern patients with confirmed pHPT have low values.

The separation of CO/N2 mixtures is a challenging problem in the petrochemical sector due to the very similar physical properties of these two molecules, such as size, molecular weight and boiling point. To solve this and other challenging gas separations, one requires a holistic approach. The complexity of a screening exercise for adsorption-based separations arises from the multitude of existing porous materials, including metal–organic frameworks. Besides, the multivariate nature of the performance criteria that needs to be considered when designing an optimal adsorbent and a separation process – i.e. an optimal material requires fulfillment of several criteria simultaneously – makes the screening challenging. To address this, we have developed a multi-scale approach combining high-throughput molecular simulation screening, data mining and advanced visualization, as well as process system modelling, backed up by experimental validation. We have applied our recent advances in the engineering of porous materials' morphology to develop advanced monolithic structures. These conformed, shaped monoliths can be used readily in industrial applications, bringing a valuable strategy for the development of advanced materials. This toolbox is flexible enough to be applied to multiple adsorption-based gas separation applications., The separation of challenging mixtures through adsorption is a multidimensional problem that requires a holistic approach. Our toolbox combines experiments, molecular and process simulations with data visualization to find optimal, porous materials.

The isosteric heat of adsorption is an important thermodynamic property used to characterise and optimise adsorption processes. In this work, analytic expressions for isosteric heats of adsorption are derived for a collection of commonly used isotherm models and a two-dimensional molecular equation of state based on the SAFT-VR approach. The use of these expressions is presented with an example of adsorption of nitrous oxide, N₂O, on biochar, which is a waste biomass charcoal that exhibits high adsorption potential. The results show that accurate fitting of the adsorption isotherms leads to consistent results obtained with different approaches, however, the predicted isosteric heat of adsorption exhibits strong variations in the regions where experimental data is insufficient such in the region of low pressure/low coverage. Convergence on the prediction of the isosteric heat of adsorption by the different models is only observed in the region where no extrapolation of experimental data is needed.