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This qualitative descriptive study aimed to explore the daily experiences of caregivers of children with medical complexity with a tracheostomy at home. This study used photovoice, a participatory action research methodology. Adult English-speaking caregivers of children with a tracheostomy, living in Texas, with access to a smartphone were recruited. Photographs taken by participants and an interview guide were used to guide semi-structured interviews with caregivers. Eight participants were recruited. After analyzing photographs and caregiver interviews, four main themes were identified: role transition, daily challenges, finding support, and thriving in the new normal. Caregivers take on multiple roles, including providing medical care, advocating for their children, and educating others. While facing emotional challenges such as guilt, fear, and exhaustion, caregivers rely on external support systems, emphasizing the need for nurses and healthcare providers to provide comprehensive support and improve the accessibility of home nursing services. The findings of this study can inform nurse-led interventions and advocacy efforts aimed at supporting marginalized children with medical complexity with a tracheostomy and their families. These efforts may include enhancing communication and collaboration between families, healthcare workers, and the public, providing comprehensive, proactive support for caregivers, and improving access to home nursing services. • This study uses photovoice, an innovative participatory research methodology. • Caregivers are tired and stressed but find joy and gratitude in their "new normal". • Advocacy and awareness are needed to improve support for caregivers. [ABSTRACT FROM AUTHOR]

This study aimed to assess the effectiveness of a systems-based secondary injury prevention intervention aimed at early detection and management of hamstring strain injury (HSI) and time-loss groin injury in an Australian male professional football club. Prospective cohort study. Australian male professional football club. Data were collected from male professional football players (n = 73) from a single football club. Unilateral knee flexion and side-lying hip adduction maximum voluntary isometric contractions were monitored routinely in-season, two days post-match (≥40 h [h]) during a three-season intervention period. Strength reductions greater than the tests' minimal detectable change percentage prompted intervention. HSI and time-loss groin injury burdens were calculated per 1000 player hours and compared with those from an immediately preceding two-season control period, to assess the effectiveness of the intervention. Across the intervention period, there was a decrease in HSI (4.98 days absence/1000 h (19.8%) decrease) and time-loss groin injury burdens (0.57 days absence/1000 h (49.1%) decrease) when compared with the control period. A systems-based secondary injury prevention intervention shows preliminary positive findings in reducing HSI and time-loss groin injury burdens within a male professional football club, compared with usual care only. • Maximum voluntary isometric contractions may be safely monitored post-match play. • Indicated interventions may be individual- and position-specific. • Systems-based prevention may reduce hamstring and time-loss groin injury burden. [ABSTRACT FROM AUTHOR]

Limited information exists regarding the epidemiology, metastasis, and survival of dermatofibrosarcoma protuberans (DFSP). To measure DFSP incidence and assess metastasis and survival outcomes. Incidence rate, overall and DFSP-specific survival outcomes for primary DFSP tumors contained in the Surveillance, Epidemiology, and End Results (SEER) registry were analyzed via quasi-Poisson regression, Cox, and competing risk analyses. DFSP incidence rate was 6.25 (95% CI, 5.93-6.57) cases per million person-years with significantly higher incidence observed among Black individuals than White individuals (8.74 vs 4.53). DFSP with larger tumor size (≥3 cm, odds ratio [OR]: 2.24; 95% CI, 1.62-3.12; P <.001) and tumors located on the head and neck (OR: 4.88; 95% CI, 3.31-7.18; P <.001), and genitalia (OR: 3.16; 95% CI, 1.17-8.52; P =.023) were associated with significantly increased risk of metastasis whereas higher socioeconomic status was associated with significantly decreased risk of metastasis. Larger tumor size (≥3 cm), regardless of location, and age (≥60 years) were associated with significantly worse overall and cancer-specific survival. Retrospective design of SEER. DFSP incidence is 2-fold higher among Black than White individuals. The risk of DFSP metastasis is significantly increased with tumor size ≥3 cm and tumors located on head and neck, and genitalia. Larger tumor size (≥ 3 cm), regardless of location, and age (≥60 years) are the most important prognostic indicators of survival. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations. This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed. There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P =.6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P =.9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P =.2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P >.9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P =.2). With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed. [ABSTRACT FROM AUTHOR]

Assessing the relationship between vitamin K1 intakes, using region-specific food databases, with both all-cause, and cardiovascular disease (CVD) mortality warrants further investigation to inform future preventative strategies. Consequently, we examined the aforementioned associations in the Perth Longitudinal Study of Ageing Women (PLSAW). 1436 community-dwelling older Australian women (mean ± SD age 75.2 ± 2.7 years) completed a validated food frequency questionnaire at baseline (1998). Vitamin K1 intake was calculated based on an Australian vitamin K food database, supplemented with published data. All-cause and CVD mortality data was obtained from linked health records. Associations were examined using restricted cubic splines within Cox-proportional hazard models, adjusted for a range of cardiovascular and lifestyle related risk factors. Over 15 years of follow-up, 601 (41.9%) women died, with 236 deaths (16.4%) due to CVD. Compared to women with the lowest vitamin K1 intakes (Quartile 1, median 49.1 μg/day), those with the highest intakes (Quartile 4, median 119.3 μg/day) had lower relative hazards for all-cause mortality (HR 0.66 95%CI 0.51–0.86) and CVD mortality (HR 0.61 95%CI 0.41–0.92). A plateau in the inverse association was observed from vitamin K1 intakes of approximately ≥80 μg/day. Higher vitamin K1 intakes were associated with lower risk for both all-cause and CVD mortality in community-dwelling older women, independent of CVD related risk factors. A higher intake of vitamin K1 rich foods, such as leafy green vegetables, may support cardiovascular health. • Higher dietary vitamin K1 was inversely associated with mortality. • Specific benefits were observed for cardiovascular disease (CVD) mortality. • A nadir in benefit was observed from vitamin K1 intakes of ∼80 μg/day. • These relationships were independent of lifestyle and CVD-related risk factors. • Vitamin K1-rich foods (green leafy vegetables) should be promoted for CV health. [ABSTRACT FROM AUTHOR]

Recent research has shown the power of large-scale regional traffic simulations—such as MATSim—to model the systemic impacts and costs of capacity-reducing incidents. At the same time, observational studies have illustrated the potential for traffic Incident Management Teams (IMTs) to reduce these impacts and costs on a local scale; mathematical optimization models have also attempted to scale or locate these programs. In this research, we connect these two separate lines of scholarly inquiry by simulating the dynamic response of an IMT fleet to incidents arising on a metropolitan highway network. We introduce a MATSim module that handles stochastically-generated incidents of varying severity, dispatches IMT to clear the incidents based on path distance and availability, and measures excess user costs based on the incidents. We apply this module in a scenario with data from the Salt Lake City, Utah metropolitan region. We demonstrate the potential use of the module through an illustrative experiment increasing the IMT fleet size with a collection of simulated incident days. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe the characteristics and outcomes of remote-dwelling pregnant women with threatened labor referred for air medical retrieval to a regional birthing center as well as factors associated with birth within 48 hours. This was a retrospective observational study of all pregnant women in the remote Central Australian region referred to the Medical Retrieval Consultation and Coordination Centre for labor > 23 weeks' gestation between February 12, 2018, and February 12, 2020. Univariate and multivariate statistical analyses were performed. There were 116 women referred for retrieval for labor. There were no births during transport, and less than half of the cases resulted in birth within 48 hours of retrieval. Tocolysis was frequently used. Predictors of birth within 48 hours were cervical dilatation ≥ 5 cm, preterm gestational age, and ruptured membranes in the univariate analysis. Nearly one third of this cohort required intervention or had complications during birth. Birth during transport for threatened labor did not occur in this cohort, and more than half of the retrievals did not result in birth within 48 hours; however, the high risk of birth complications may offset any benefit of avoiding air medical transport from remote regions. Retrieval clinicians should consider urgent transfer in cases of ruptured membranes, cervical dilatation of 5 cm or more, or gestational age less than 37 weeks. [ABSTRACT FROM AUTHOR]

Iodinated contrast medium (ICM) is available in single- and multiuse vials of varying sizes, but CT departments often preferentially stock only a single or a limited number of vial sizes. The aims of this study were to assess actual ICM waste at a large safety-net hospital and to compare with estimated waste if single-use vials in a variety of vial sizes or multiuse vials were used. ICM administrations were retrospectively reviewed for all CT examinations performed in 2021 in a department that stocked only 100-mL ICM vials. Administered ICM dose, opened ICM volume and number of vials, and wasted ICM were compared with hypothetical models using optimally sized single-use vials and multiuse vials. Contrast use was also compared by patient class. In total, 40,393 ICM administrations over 49,670 CT examinations among 26,028 patients were reviewed, totaling 4,168,335 mL of contrast media. The mean dose was 103 mL, with mode of 100 mL. Exclusive use of 100-mL vials resulted in 1,006,165 mL waste (mean waste, 26 mL/administration). Optimally sized single-use vials resulted in 436,515 mL waste (mean waste, 11 mL/administration). Multiuse vials resulted in 537,074 mL waste (mean waste, 13 mL/administration). The distribution of optimal single-use vial size differed significantly by patient class (P <.001), with inpatient examinations more amenable to the use of smaller single-use vials. Optimizing ICM inventory can reduce contrast waste by 50% to 59%. Regular monitoring of contrast use may help optimize inventory selection across care settings. This retrospective review supports scrutiny of ICM inventory management to reduce waste, save costs, and mitigate the impacts of supply-chain disruptions. [Display omitted] [ABSTRACT FROM AUTHOR]

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

The 3rd Anesthesia Patient Safety Conference of the American Association of Oral and Maxillofacial Surgeons was held at the Daniel M Laskin Institute for Oral and Maxillofacial Surgery Education and Innovation at American Association of Oral and Maxillofacial Surgeons headquarters in Rosemont, Illinois on June 6, 2022. The conference provided a platform to scrutinize collective errors, explore optimal practices, comprehend the concepts and principles of human complacency, assessing the system's capacity to handle deviations from the norm, and contemplate ideas and initiatives to enhance our practice model. These safety conferences are designed to foster collaborative, proactive conversations and understand best practices in safe delivery of anesthetic care to our patients. [ABSTRACT FROM AUTHOR]

A subset of HF patients can experience significant improvement of their cardiac structure and function while on LVAD support. We sought to investigate the impact of HF etiology on the durability of cardiac improvement and favorable outcomes after LVAD weaning. We studied 324 HF patients enrolled in the international multicenter VAD Wean Registry who received a durable continuous-flow LVAD and underwent device support weaning (Figure Panel A). Indications for VAD weaning included: structural/functional cardiac improvement meeting institutional criteria for "myocardial recovery" (responders) or LVAD-related complications accompanied by variable degrees of cardiac improvement (partial responders). Patients were divided into seven categories based on HF etiology: ischemic cardiomyopathy (CM) (n=30), post-myocarditis CM (n=65), peripartum CM (n=53), valvular CM (n=12), chemotherapy-induced CM (n=14) and idiopathic CM (n=150). The primary outcome was 2-year survival free of transplant or LVAD re-implantation. The secondary outcome was the LVEF, measured by echocardiography at 3, 6, 12 and 24 months post-LVAD weaning. Patients with idiopathic, peripartum and post-myocarditis CM had higher rate of 2-year survival free of transplant or LVAD re-implantation compared to patients with chemotherapy-induced CM (Figure-Panel B) (p-values: 0.009, 0.004, 0.001, respectively). Patients with post-myocarditis CM were also more likely to achieve the primary outcome compared to those with ischemic CM (ICM) (p-value, 0.009). The LVEF changes over time are depicted in the Figure-Panel C and detailed in the Table. In this multicenter analysis the etiology of HF appears to impact the durability of favorable response after LVAD weaning. The degree of reverse remodeling achieved before VAD weaning and its impact on the durability of response in different HF etiologies warrants further investigation in studies with larger patient population and power. [ABSTRACT FROM AUTHOR]

There is a well-documented sex disparity in clinical research worldwide. Historically, most studies were conducted predominantly on male participants. This raises concerns about the generalisability and extrapolability of the findings to female patients, who exhibit different physiological and pharmacological responses. The present study aimed to investigate whether participation willingness in prospective clinical trials, having no sex-specific restrictions on inclusion, was disparate for both sexes. This observational retrospective study utilised prospectively collected screening logs of clinical trials conducted in the Department of Anaesthesiology, Amsterdam UMC, over a 5-year period from 1 January 2019 to 31 December 2023. The Institutional Review Board of the Amsterdam UMC, situated at AMC, verified on 15 March 2023 that this study did not fall within the scope of the Medical Research involving Human Subjects Act (W23_111#23.136). The study population included adult patients of both sexes who were approached for participation in prospective interventional and observational clinical trials. Importantly, only clinical trials were included where both sexes had equal opportunity to participate, with no other sex-specific restrictions. To ensure data integrity, any patients who were approached for multiple trials were included only once, to avoid double-counting of individuals in the final analysis. The preliminary data analysis included a total of 5 145 approached patients, of whom 3 995 (78%) were willing to participate in a study and 1 150 (22%) refused study participation. The study population had a median age of 62 years with a range from 18 to 96 years. Of the 5 145 patients approached, 2 509 (49%) were male, and 2 636 (51%) were female. However, when examining participation rates by sex, 2 018 (80%) of the males approached were willing to take part in a study, while only 1 977 (75%) of the females approached were inclined to do so. The difference in participation rates between males and females was statistically significant (p<.001). This study showed that when no sex-specific restrictions are placed on participation, the sexes were approached almost equally. However, when investigating effective participation rates by sex, a statistically significant difference is seen, where males participate more often, compared to females. It is important to understand the underlying factors that contribute to this observed sex disparity. Researchers should strive to ensure that the representation of males and females in clinical trials is proportional to the prevalence of the disease or condition being studied, in order to enhance the applicability of the research findings to the diverse patient population. [ABSTRACT FROM AUTHOR]

Primary graft dysfunction of the transplanted lung still is a serious problem and greatly impacts outcome. Despite medical and technological progress, primary graft dysfunction continues to be a leading cause of morbidity and mortality in recipients, necessitating early intervention. Assessment of lung function post-transplantation, particularly static compliance, emerges as a promising indicator of short-term outcomes. We, therefore, investigated whether static compliance determined immediately after lung transplantation for end-stage pulmonary failure is predictive of 30-day mortality. In this single-centre retrospective investigation we analysed data from 755 consecutive patients who underwent orthotopic lung-transplantation between the years 2014 and 2023. The primary endpoint was 30-day mortality. Patients older than 18 years of age undergoing lung transplantation were eligible for inclusion. Patients who underwent single lung transplantation, multi-organ transplantation, or re-transplantation were excluded from the analysis. Respiratory parameters for calculating static compliance were collected after chest closure and muscle relaxation at the end of surgery. Lung-protective ventilation strategies were applied whenever feasible. Univariate and multivariate analyses were conducted and Receiver Operating Characteristic curves constructed. Results Two hours after surgery, 695 of the 755 patients (65%), were classified as having primary graft dysfunction grade 0, 30 patients (4%) were classified as grade 1, 40 patients (5%) received a grade 2 classification, 91 patients (12%) a grade 3, and 85 patients (11%) were categorized as ungradable. In this huge cohort we observed a thirty-day mortality of 1.9%. Increased static compliance was predictive for 30-day survival with an acceptable area under the curve of 0.735 (95% CI: 0.5-0.9; p=0.003). Moreover, a static compliance below 25 mL/mbar had a statistically increased hazard ratio of 6.0 (95% CI: 1.3-27.0; P=0.005) for 30-day mortality. As determined in this study, static compliance measured immediately after lung transplantation could serve as a predictive marker for short-term outcome. Integrating this measure into clinical practice could potentially improve risk stratification and guide early interventions. Nevertheless, further prospective studies are needed for validation of this data and for a better understanding of the underlying pathophysiology. [ABSTRACT FROM AUTHOR]

To determine if outpatient robotic assisted hysterectomies performed at freestanding ambulatory surgery centers yield comparable safety and outcomes to those performed at hospitals. Retrospective cohort study. Academic community hospital and freestanding ambulatory surgery center. Biological females age >18 who underwent outpatient robotic hysterectomies for benign indications at CFH (Carle Foundation Hospital) (n = 316) and CSC (Carle Surgery Center) (n=152) between November 2021 and June 2023. Robotic assisted total laparoscopic hysterectomy. Preoperative health profiles between locations showed significant differences in ASA classifications, average BMI, hemoglobin levels, and uterine size (P =.05). However, no significant correlations were found between these conditions and complication rates. There were comparable rates of hypertension, diabetes, and smoking status (P>.05) between locations. Incidence and severity of complications between locations showed 22% (n=316) of CFH patients experienced complications versus 15% (n=152) at CSC without statistical significance (P=.13). Specific complication incidences varied; caution advised in interpretation due to non-significance. Complication grades by Clavien-Dindo classification system across CFH and CSC showed no significant difference (P=.60) and a uniform distribution, indicating similar patterns in complication severity. There was no significant difference between CFH (148.70 min) and CSC (139.95 min) procedure length (P=.11), indicating comparable operative times. There was however, significant difference in PACU times; CFH's average (205.29 min) is notably longer than CSC's (116.76 min) (P<.001). Cases with observation or admission complications were excluded from this analysis to avoid distortion by outliers. With comparable postoperative complication rates at CFH and CSC, the study confirms that select patients can safely undergo outpatient robotic-assisted hysterectomies at freestanding ambulatory surgery centers, supporting the model for patient care delivery. This retrospective chart review emphasizes the strategic role of ambulatory surgery centers in a resource optimized healthcare system, highlighting an innovative approach to expanding access to high quality care. [ABSTRACT FROM AUTHOR]

The human dura mater is known to impact vastly traumatic brain injury mechanopathology. In spite of this involvement, dura mater is typically neglected in computational and physical human head models. The lack of location-dependent microstructural and related mechanical data of dura mater may be considered a rationale behind this simplification. The anisotropic nature of dura mater under various loading conditions so far remains unelucidated. Furthermore, principal collagen fiber orientation is yet to be quantified for a morpho-mechanically-informed material model on the dura mater. This study aims to assess how location-dependent mechanical anisotropy is linked to principal collagen fiber orientation. Uniaxial extension tests were performed in a heated tissue bath for 60 samples from six individuals and correlated to the three-dimensional collagen structure in four individuals using second-harmonic generation (SHG) imaging. Failure stress and stretch at failure, elastic modulus, and a microstructurally motivated material model were integrated to examine local differences in dura mater morpho-mechanics. The quantitative observation of collagen fiber orientation and dispersion confirmed that collagen is highly aligned in the human dura mater and that both fiber orientation and dispersion differ depending on the location investigated. This observation provides a possible explanation for the previously observed isotropic mechanical behavior, as the main collagen fiber direction is not oriented along the anterior-posterior or medial-lateral direction at most of the mapped locations. Additionally, these site-dependent structural properties have implications for the mechanical load response and therefore potentially for the regional functions dura mater has to fulfill. The here chosen non-symmetrical fiber dispersion material model fits the data well and provides a comprehensive parameter base for further studies and future finite element models. The human dura mater greatly affects traumatic brain injury mechanisms, but it is often ignored in computational and physical head models. This is because there is a lack of detailed microstructural and mechanical data specific to the dura mater. Its anisotropic nature and collagen fiber orientation have not been fully understood, hindering the development of an accurate material model. Hence, this study combines morphological data on collagen fiber orientation and dispersion at multiple locations of human cranial dura mater, and links microstructure to location-specific load-displacement behavior. It provides microstructurally informed mechanical information towards realistic head models for predicting location-dependent tissue behavior and failure for assessing brain injury and graft material development. [Display omitted] [ABSTRACT FROM AUTHOR]

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data. [ABSTRACT FROM AUTHOR]

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis. [ABSTRACT FROM AUTHOR]

Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric procedural sedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings. [ABSTRACT FROM AUTHOR]

• Patients with elevated Lp(a) are at an increased risk of atherosclerotic cardiovascular disease partly due to pro-inflammatory effects of elevated Lp(a). • High dose ω-3FAs lowered arterial inflammation, as measured by SUVmax using 18F-FDG PET/CT, in patients with elevated Lp(a). • Reduction in arterial inflammation was inversely associated with on-treatment plasma levels of EPA, but not DHA or triglycerides, suggesting a favourable direct effect of EPA. Elevated lipoprotein(a) [Lp(a)] is a causal risk factor for atherosclerotic cardiovascular disease. However, there are no approved and effective treatments for lowering Lp(a) and the associated cardiovascular risks. Omega-3 fatty acids (ω-3FAs), primarily eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have both triglyceride-lowering and anti-inflammatory properties. This pilot study investigated the effect of high dose ω-3FAs (3.6 g/day) on arterial inflammation in 12 patients with elevated Lp(a) (> 0.5 g/L) and stable coronary artery disease (CAD) receiving cholesterol-lowering treatment. Arterial inflammation was determined using 18F-fluorodexoyglucose positron emission tomography/computed tomography before and after 12-weeks intervention. ω-3FAs significantly lowered plasma concentrations of triglycerides (–17%, p < 0.01), Lp(a) (-5%, p < 0.01) as well as aortic maximum standardized uptake value (SUVmax) (–4%, p < 0.05). The reduction in SUVmax was significantly inversely associated with average on-treatment EPA (r = -0.750, p < 0.01), but not DHA and triglyceride, concentrations. In conclusion, high dose ω-3FAs decrease arterial inflammation in patients with elevated Lp(a) and stable CAD, which may involve a direct arterial effect of EPA. [ABSTRACT FROM AUTHOR]

Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 – December 2019). Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22–59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62–144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval. Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts [ABSTRACT FROM AUTHOR]

• Common colds are primarily caused by rhinoviruses (RV). • Prevention of RV infections has enormous health and economic potential. • The major transmission route in many indoor settings is through the air. • Preventive measures should focus on reducing aerosol generation and concentration. • Hands may also contribute to the transmission of RV in some workplaces. Human rhinoviruses (RVs) are the most common cause of acute respiratory tract illness and upper respiratory tract infections, traditionally defined as 'common colds'. Experimental transmission of RV has been studied for more than 50 years. However, there are divergent results as to whether hands and fomites or aerosols constitute the dominant route of transmission in natural settings. We have systematically reviewed the literature according to the PRISMA 2020 statement. Searches were run in PubMed and Web of Science until August 2022. Inclusion criteria were original studies of relevance for revealing the route of transmission of rhinovirus in humans. The search yielded 663 results, and 25 studies met the inclusion criteria and were selected for this review. These articles addressing RV transmission routes were assigned to 1 of 3 groups: (1) indirect transmission by fomites and hands, (2) direct transmission via large aerosols (droplets) or small aerosols, or (3) transmission either direct via large aerosols (droplets) or small aerosols and fomite or hands. We found low evidence, that transmission via hands and fomite followed by self-inoculation is the dominant transmission route in real-life indoor settings. We found moderate evidence, that airborne transmission either via large aerosols or small aerosols is the major transmission route of rhinovirus transmission in real-life indoor settings. This suggests that the major transmission route of RVs in many indoor settings is through the air (airborne transmission). [ABSTRACT FROM AUTHOR]

• Oral and intra-arterial verapamil use has been described in at least 71 cases of RCVS. • Verapamil may be associated with reduced headache but requires further study. • The half-life of oral verapamil allows convenient once daily dosing. • Treatment with verapamil is very well tolerated with low rates of side effects. Extrapolating from efficacy in subarachnoid haemorrhage (SAH), nimodipine has been used as a treatment for reversible cerebral vasoconstriction syndrome (RCVS). However, 4-hourly dosing is a practical limitation and verapamil has been proposed as an alternative. The potential efficacy, adverse effects, preferred dosing and formulation of verapamil for RCVS have not been systematically reviewed previously. A systematic review was conducted of the databases PubMed, EMBASE, and the Cochrane Library from inception to July 2022 for peer-reviewed articles describing the use of verapamil for RCVS. This systematic review adheres to the PRISMA guidelines and was registered on PROSPERO. There were 58 articles included in the review, which included 56 patients with RCVS treated with oral verapamil and 15 patients treated with intra-arterial verapamil. The most common oral verapamil dosing regimen was controlled release 120 mg once daily. There were 54/56 patients described to have improvement in headache following oral verapamil and one patient who died from worsening RCVS. Only 2/56 patients noted possible adverse effects with oral verapamil, with none requiring discontinuation. There was one case of hypotension from combined oral and intra-arterial verapamil. Vascular complications including ischaemic and haemorrhagic stroke were recorded in 33/56 patients. RCVS recurrence was described in 9 patients, with 2 cases upon weaning oral verapamil. While no randomised studies exist to support the use of verapamil in RCVS, observational data support a possible clinical benefit. Verapamil appears well tolerated in this setting and represents a reasonable treatment option. Randomised controlled trials including comparison with nimodipine are warranted. [ABSTRACT FROM AUTHOR]

• Patients with Guillain-Barré syndrome may be admitted to the Intensive Care Unit and require intubation and ventilation due to respiratory failure. • Spirometry parameters are commonly used to predict which patients require intubation and ventilation. • There is an association between a lower vital capacity and the need for intubation and ventilation. Patients with Guillain-Barré syndrome (GBS) may require intensive care unit (ICU) admission for intubation and ventilation (I + V). The means to predict which patients will require I + V include spirometry measures. The aims of this study were to determine, for adult patients with GBS, how effectively different spirometry parameter thresholds predict the need for ICU admission and the requirement for I + V; and what effects these different parameter thresholds have on GBS patient outcomes. A systematic review was conducted of the databases PubMed, EMBASE, and Cochrane library in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review was registered prospectively on PROSPERO. Initial searches returned 1011 results, of which 8 fulfilled inclusion criteria. All included studies were observational in nature. Multiple studies suggest that a vital capacity below 60% of predicted value on admission is associated with the need for eventual I + V. No included studies evaluated peak expiratory flow rate, or interventions with different thresholds for ICU or I + V. There is a relationship between vital capacity and the need for I + V. However, there is limited evidence supporting specific thresholds for I + V. In addition to evaluating these factors, future research may evaluate the effect of different patient characteristics, including clinical presentation, weight, age, and respiratory comorbidities, on the effectiveness of spirometry parameters in the prediction of the need for I + V. [ABSTRACT FROM AUTHOR]

The purpose of this study was to understand the experiences of parents and caregivers of children with special healthcare needs during the COVID-19 pandemic. In this descriptive phenomenological study, the researchers used purposive and snowball sampling to recruit nineteen participants, ranging in age from 21 to 55 years of age until saturation was established. Colaizzi's method guided data analysis. Iterative examination of the interview transcripts, an audit trail, bracketing, and validation of findings with a subset of participants established trustworthiness. Navigating the COVID-19 Pandemic was the overarching theme. Four major themes emerged under Navigating the COVID-19 Pandemic as follows: Disruptions in Daily Life, Shifts in Daily Life, Innovations in Daily Life, and Surprising Silver Linings. This study elucidated an in-depth understanding of the positive and negative impacts of the pandemic on the lives of families living with a child with special needs. The COVID-19 pandemic profoundly affected families and parenting approaches. Parents of children with special healthcare needs in this study found day-to-day living especially difficult in similar and unique ways. For virtually all parents the pandemic added new challenges in meeting their child's physical, mental, social, and educational needs. Parents and caregivers revealed innovative ways of maintaining a sense of normalcy during the height of the pandemic. These findings demonstrate the importance of developing interventions and creating public health policies as we move beyond the current pandemic and plan for potential outbreaks in the future. • People have been experiencing the effects of the public health crises differently leading to varying degrees of stress. • The COVID-19 affected families differently based on their existing health conditions, and socio-economic status. • CSHCN require higher levels of health and related services, and these essential needs intensified during the COVID-19. • Understanding the parents' experiences is foundational to implementing supportive measures to ensure uninterrupted care. [ABSTRACT FROM AUTHOR]

COVID-19 symptom presentation among adults is mostly understood. However, understanding COVID-19 symptom presentation in children lags. A literature search was conducted in three electronic databases. Twenty-three initial publications addressing COVID-19 symptom presentation among hospitalized children in the United States met the criteria for review and meta-analysis. Fever, the most common symptom, was present in nearly all cases. Gastrointestinal, respiratory, oral symptoms, and rash occurred in over half of the cases. Disease severity assessment showed that comorbidities were present in one-third of patients; intensive care was needed for half of the patients, and supplemental oxygen and mechanical ventilation were needed by 13.3% and 7.1%, respectively. The magnitude and significance of COVID-19 symptoms in children compared with those in adults and three common childhood viral illnesses: influenza, respiratory syncytial virus, and gastroenteritis, are discussed. Important clinical differences were found that may help clinicians distinguish COVID-19 from other illnesses. [ABSTRACT FROM AUTHOR]

• New protocol as a novel option for the treatment of proximal interphalangeal joint flexion contracture. • First orthosis 24 hour per day application in treatment of proximal interphalangeal joint flexion contracture. • New orthosis design, more comfortable for the patient, allows prolonged clinical use. This case report details the application of a treatment regimen using a serial elastic tension digital neoprene orthosis (ETDNO) protocol for a patient with an eight-month-old finger crush injury who experienced recurrence of a 45º proximal interphalangeal joint (PIPJ) flexion contracture two months after arthrolysis. To illustrate how the application strategy of ETDNO can increase the daily total end range time (TERT) and modify finger stiffness. The patient reached full extension following 15 weeks of ETDNO treatment. The six-month follow-up evaluation revealed that the PIPJ was stable with full flexion and extension. The joint did not require continued orthosis use. The literature describes orthosis application as the treatment of choice for PIPJ flexion contracture, but no study has described an ideal program for use nor the full and stable resolution of the flexion contracture. The current literature describes a maximum daily total end range time (TERT) of 12 hours a per day. The serial ETDNO protocol that this study described increased the daily TERT to nearly 24 hour per day and demonstrated an excellent result in the treatment of PIPJ flexion contracture This outcome suggests that clinicians will want to consider this new orthosis design and management protocol as a novel option for the treatment of PIPJ flexion contracture. We need future research to better define the optimum number of hours of daily TERT for the effective treatment of PIPJ flexion contracture. In addition, we will also benefit from the exploration of the optimum orthosis design to enable the highest amount of TERT [ABSTRACT FROM AUTHOR]

• The single breath count test (SBCT) may be a useful adjunct in the evaluation of respiratory function in MG. • SCBT has a moderate correlation with FVC and may aid in the identification of MG exacerbation. • The included studies describe a threshold count of ≥ 25 as representative of normal respiratory muscle function. • SCBT is described as a quick, inexpensive bedside test, which is well tolerated, including via assessment over the phone. Myasthenia gravis (MG) can have a variety of respiratory presentations, ranging from mild symptoms through to respiratory failure. The evaluation of respiratory function in MG can be limited by accessibility to testing facilities, availability of medical equipment, and facial weakness. The single count breath test (SCBT) may be a useful adjunct in the evaluation of respiratory function in MG. A systematic review of the databases PubMed, EMBASE, and the Cochrane Library was conducted from inception to October 2022 in accordance with PRISMA guidelines and was registered on PROSPERO. There were 6 studies that fulfilled the inclusion criteria. The described method of evaluating SCBT involves inhaling deeply, then counting at two counts per second, in English or Spanish, sitting upright, with normal vocal register, until another breath needs to be taken. The identified studies support that the SCBT has a moderate correlation with forced vital capacity. These results also support that SCBT can assist the identification of MG exacerbation, including via assessment over the telephone. The included studies support a threshold count of ≥ 25 as consistent with normal respiratory muscle function. Although further analysis is needed, the included studies describe the SCBT as a quick bedside tool that is inexpensive and well tolerated. The results of this review support the clinical utility of the SCBT in assessing respiratory function in MG and describe the most current and effective methods of administration. [ABSTRACT FROM AUTHOR]

Remote Australian women in labour often rely on retrieval services to allow birthing in specialist obstetric centres. However, there is currently debate over when not to transfer a woman in labour, for risk of an in-transit birth, associated with worse neonatal outcomes. A scoping review methodology was undertaken, to define the scope of published literature on the topic and identify gaps in the current knowledge. A total of seven full texts were deemed suitable for synthesis, which were all retrospective observational studies. Four themes from the studies' findings were identified: population features, predicting time-to-birth, use of tocolysis and birth during medical evacuation. The evidence identified in this review was of low methodological quality and heterogenous. The key findings were that births in-flight are rare, despite geographical distances and long transport times, with a knowledge gap on predictors of time-to-birth. [ABSTRACT FROM AUTHOR]

Carbon circulation on Earth. Anthropogenic and natural carbon emissions and carbon sequestration routes. [Display omitted] • Carbon is often negatively associated with the anthropogenic emissions of greenhouse gases and, consequently, with environmental issues such as global warming. However, carbon is an element of paramount importance for life and ecological processes. • The knowledge of carbon fixation cycles, in addition to the ecological and evolutionary studies on the emergence of the first beings that inhabited Earth and metabolized carbon, provides a detailed understanding of the enzymes and important intermediaries involved in these cycles. • The central carbon metabolizing enzymes can be used for a variety of purposes; artificial CO 2 fixation pathways can be designed and implemented in suitable host organisms; new solutions are possible for manipulating carbon fixation pathways and increasing their final yields. • The multidisciplinary integration of omics, synthetic biology, molecular biology, and biochemistry can enable the scientific community to describe new carbon fixation pathways and predict important routes and enzymes involved in these processes. This integration may further provide guidance for overcoming the limitations of natural carbon fixation pathways and allow the development of biotechnological applications. • Investigating thermophilic microorganisms is crucial for understanding many evolutionary events. These microorganisms are investigated extensively for developing biotechnological applications because of their metabolic diversity. • In addition to the six well-known natural carbon fixation pathways, the development of omics and systems biology has spearheaded the discovery of new natural and synthetic pathways for carbon metabolism. Autotrophic carbon fixation is the primary route through which organic carbon enters the biosphere, and it is a key step in the biogeochemical carbon cycle. The Calvin–Benson–Bassham pathway, which is predominantly found in plants, algae, and some bacteria (mainly cyanobacteria), was previously considered to be the sole carbon-fixation pathway. However, the discovery of a new carbon-fixation pathway in sulfurous green bacteria almost two decades ago encouraged further research on previously overlooked ancient carbon-fixation pathways in taxonomically and phylogenetically distinct microorganisms. In this review, we summarize the six known natural carbon-fixation pathways and outline the newly proposed additions to this list. We also discuss the recent achievements in synthetic carbon fixation and the importance of the metabolism of thermophilic microorganisms in this field. Currently, at least six carbon-fixation routes have been confirmed in Bacteria and Archaea. Other possible candidate routes have also been suggested on the basis of emerging "omics" data analyses, expanding our knowledge and stimulating discussions on the importance of these pathways in the way organisms acquire carbon. Notably, the currently known natural fixation routes cannot balance the excessive anthropogenic carbon emissions in a highly unbalanced global carbon cycle. Therefore, significant efforts have also been made to improve the existing carbon-fixation pathways and/or design new efficient in vitro and in vivo synthetic pathways. [ABSTRACT FROM AUTHOR]

Undergraduate nursing students will play a pivotal role in caring for the rising numbers of older adults and people living with dementia (PLWD). However, many do not receive training in geriatrics or dementia and do not enter this field post-graduation, contributing to the workforce shortage. We aimed to capture students' interest and intention to work with PLWD, their suggestions about training, and to evaluate interest in a new elective long-term care (LTC) externship. We developed and administered a survey to Bachelor of Science in Nursing students consisting of questions modified from the Dementia Attitude Scale and related to respondents' health care experience, attitudes about caring for older adults, comfort working with PLWD, and willingness to develop geriatric and dementia care skills. We then conducted focus groups about desired curricular and clinical content. Seventy-six students completed the survey. The majority reported low interest in working with and low knowledge of caring for older adults and PLWD. Six focus group participants expressed interest in participating in hands-on learning opportunities. Participants identified specific training components to attract students to geriatrics education. Our findings informed the development, piloting, and evaluation of a new LTC externship at the University of Washington Schoool of Nursing. • Nursing students had low desire to work with older adults and PLWD post-graduation. • Nursing students wanted hands-on experience in working with older adults and PLWD. • Nursing students sought instructors who are experts in caring for PLWD. [ABSTRACT FROM AUTHOR]

The various plaque components have been associated with ischemia and outcomes in patients with coronary artery disease (CAD). The main goal of this analysis was to test the hypothesis that, at patient level, the fraction of non-calcified plaque volume (PV) of total PV is associated with ischemia and outcomes in patients with CAD. This ratio could be a simple and clinically useful parameter, if predicting outcomes. Consecutive patients with suspected CAD undergoing coronary computed tomography angiography with selective positron emission tomography perfusion imaging were selected. Plaque components were quantitatively analyzed at patient level. The fraction of various plaque components were expressed as percentage of total PV and examined among patients with non-obstructive CAD, suspected stenosis with normal perfusion, and those with reduced myocardial perfusion. Clinical outcomes included all-cause mortality and myocardial infarction. In total, 494 patients (age 63 ​± ​9 years, 55% male) were included. Total PV and all plaque components were significantly larger in patients with reduced myocardial perfusion compared to patients with normal perfusion and those with non-obstructive CAD. During follow-up 35 events occurred. Patients with any plaque component ​≥ ​median showed worse outcomes (log-rank p ​< ​0.001 for all). In addition, low-attenuation plaque ​≥ ​median was associated with worse outcomes independent of total PV (adjusted HR: 2.754, 95% CI: 1.022–7.0419, p ​= ​0.045). The fractions of the various plaque components were not associated with outcomes. Larger total PV or any plaque component at patient level are associated with abnormal myocardial perfusion and adverse events. The various plaque components as fraction of total PV lack additional prognostic value. Total PV and low-attenuation PV are associated with outcomes. Multiplanar reconstructions of CCTA scans showing a large burden of calcified- and mixed plaques (left panel), as well as low-attenuation non-calcified plaques (right panel). Increased total PV and low-attenuation PV are associated with adverse events. The various plaque components as fraction of total PV are not associated with outcomes (lower panel). CCTA ​= ​coronary computed tomography angiography, PV ​= ​plaque volume. [Display omitted] It has been suggested that the relative fractions of various plaque components are important for ischemia and outcomes in patients with coronary artery disease. This study evaluated the association of plaque volume (PV), composition, and the various plaque components as fraction of total PV with ischemia and outcomes in 494 patients who underwent clinically indicated coronary computed tomography angiography. Larger total PV or PV of any plaque component are associated with ischemia and an increased risk of future myocardial infarction or all-cause mortality. However, the various plaque components as fraction of total PV lack additional prognostic value. [ABSTRACT FROM AUTHOR]

The multitude of artificial intelligence (AI)–based solutions, vendors, and platforms poses a challenging proposition to an already complex clinical radiology practice. Apart from assessing and ensuring acceptable local performance and workflow fit to improve imaging services, AI tools require multiple stakeholders, including clinical, technical, and financial, who collaborate to move potential deployable applications to full clinical deployment in a structured and efficient manner. Postdeployment monitoring and surveillance of such tools require an infrastructure that ensures proper and safe use. Herein, the authors describe their experience and framework for implementing and supporting the use of AI applications in radiology workflow. [ABSTRACT FROM AUTHOR]

To demonstrate how students, alums and faculty view the effectiveness of the integration of university mission statements into curriculum and their significance for preparing for professional practice. This study builds on previous research exploring the influence of mission, vision and values statements in informing DNP program curricula and contributing to the development of students' professional identity by analyzing how the themes found were integrated into curricula and their perceived relevancy for practice. A mixed-methods approach was used called Group Concept Mapping, which built on the previous qualitative data found using quantitative analysis. A DNP program in the U.S. American Midwest participated in this research. Participants included thirty-one students, alumni and faculty from this DNP program. 32 statements were generated from the previous study, where participants completed a sorting and rating activity in the Group Wisdom software system. Next, the participants sorted these same statements into groups based on their perceived similarity and the results were analyzed using two bivariate statistical methods that created concept maps. Lastly, participants further identified how each statement was clearly articulated in their DNP educational experiences and how relevant these themes were for professional practice. The results suggest that the participants found most themes to be clearly articulated in the curriculum and found them relevant to practice. This study provides evidence that educational experiences that allow nurses to develop a professional identity are well-integrated into the DNP curriculum and that these themes have relevance to professional practice. • Group Concept Mapping is suitable for mixed-methods research in Nursing. • Themes central to the development of a professional identity of APNs were found. • APN program curricula cultivate a professional identity for nurses. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy in the world. Atrial fibrillation (AF) is a common arrhythmia in HCM, present in 20-30% of individuals. The high incidence of AF in HCM has been postulated to be due to left atrial (LA) enlargement from diastolic dysfunction, ventricular remodeling, and left ventricular outflow tract obstruction. We hypothesized that LA volumes are enlarged in this population and that there is an interval increase in LA volumes between diagnosis of HCM and AF, particularly in those whose AF develops later in the HCM clinical course. A retrospective review of HCM patients was performed in the Medical College of Wisconsin Affiliated Hospital system from 2019-2023. Baseline demographics were obtained as well as cardiac imaging studies (TTE and cMRI) within 6 months of the respective diagnosis of both HCM and AF. There were 103 individuals with a concurrent diagnosis of AF and HCM included in this study. Mean age was 69.3 (± 13.3) years, 41.7% were female, and 44.7% had obstructive physiology. LA volume data was available at the time of HCM diagnosis in 72% (n= 74), AF diagnosis in 58% (n= 60), and both in 53% (n=55) of individuals. For individuals with both diagnoses, there was not a significant difference between average LA volumes at the time of HCM vs AF diagnosis (88.2 ± 46.1 vs 91.1 ± 42.6 ml, p= 0.57). In patients who developed AF after an established diagnosis of HCM (n = 49), the average time from HCM to AF diagnosis was 4.98 (± 5.75) years. There was also no statistical difference in LA volumes (79.7 ± 42.6 vs 87.8 ± 43.0 ml, p= 0.55) in this cohort. While LA volumes in those with HCM and AF were found to be on average enlarged, there was no statistically significant difference between the LA volumes at the time of HCM and AF diagnosis respectively. When accounting for individuals who developed AF after HCM diagnosis, presumably later in their HCM disease course, there was again no significant evidence of interval enlargement in LA volume. This lack of interval growth may indicate that LA stretch occurs earlier in the HCM disease process and, in many cases, prior to clinical recognition of HCM. Overall, the number of available imaging studies was limited, and further investigation needs to be done to assess for temporal progression in LA size during the HCM clinical course. [ABSTRACT FROM AUTHOR]

There is renewed interest in anterior cruciate ligament (ACL) preservation techniques. Prior studies have shown good outcomes and low failure rates with ACL preservation in patients with good tissue quality and more proximal tears. We describe a technique intended to assist surgeons in obtaining maximal length of the ACL stump during ACL preservation surgery. We find this to be effective in reapproximating the ACL remnant to its origin on the femoral wall in many cases, even those with a relatively short-appearing stump on preoperative imaging. This technique may allow for surgeons to feel more comfortable offering ACL repair or restoration to patients with a smaller distal ACL remnant. [Display omitted] [ABSTRACT FROM AUTHOR]

• Retrospective analysis of electronic health records and brain MRIs of MS patients. • Insurance type is associated with longitudinal MS lesion and tissue volumes. • Baseline lesion burden and tissue volumes worse in public insurance group. • Lesion volume increase and tissue atrophy rates greater in private insurance group. • MS patients with public insurance may present with more advanced disease. Health insurance in the United States varies in coverage of essential diagnostic tests, therapies, and specialists. Health disparities between privately and publicly insured patients with MS have not been comprehensively assessed. The objective of this study is to evaluate the impact of public versus private insurance on longitudinal brain outcomes in MS. Lesional, thalamic, and gray and white matter volumes were extracted from longitudinal MRI of 710 MS patients. Baseline volumes and atrophy rates of lesional, thalamic, and gray and white matter volumes were compared across insurance groups. After image quality assessment, 376 (284 private / 92 public), 638 (499 / 139), and 331 (250 / 81), patients were in MS lesion, thalamic, gray and white matter analyses respectively. Baseline lesion volume was higher for publicly insured patients but increased at a slightly higher rate in those privately insured (p = 0.01). Baseline gray matter measurements were lower for patients with public insurance, but thalamic (p < 0.01) and gray matter (p < 0.01) atrophy rates were slightly higher in the private insurance group. Insurance type was associated with lesion, thalamic, and gray matter volumes. The results suggest that patients with public insurance may present with more advanced disease. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) causes significant morbidity and mortality, especially in young children. Why RSV infection in children is more severe compared to healthy adults is not fully understood. We used ex-vivo human nasal organoid platforms from infants and adults to investigate the underlying mechanism of this disease disparity at the initial site of RSV replication, the nasal epithelium. Infant-derived human nasal organoid-air liquid interface (HNO-ALIs) lines were more susceptible to early RSV replication. Moreover, infant-derived HNO-ALIs elicited a statistically significant greater overall cytokine response, enhanced mucous production, and greater cellular damage compared to their adult counterparts. Furthermore, the adult cytokine response was associated with a superior regulatory cytokine response, which could explain less cellular damage than in infant lines. Our data highlights substantial differences in how infant and adult upper respiratory tract epithelium responds to RSV infection at the cellular level. These differences in epithelial cellular response can lead to impaired mucociliary clearance, a more dysregulated innate immune response predisposing infants to more severe RSV infection compared to adults. • Infant-derived compared to adult-derived HNOs have more mucus production at baseline. • During RSV infection, infants produce higher amounts of infectious virus over adults. • Infant HNOs have a more robust cytokine response. • RSV infection causes increased cellular damage in infants compared to adult HNOs. [ABSTRACT FROM AUTHOR]

The Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients. Patients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared. Forty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement. Valve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed. [Display omitted] [ABSTRACT FROM AUTHOR]

A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (−11.50 per 1,000 patients [95% CI, −1.47 to −0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97–2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by −23.57 per 1,000 patients (95% CI, −37.72 to −9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives. [ABSTRACT FROM AUTHOR]

Double-crested cormorants (Nannopterum auritum) have been implicated as causes of fish population declines in many locations across their breeding range. Two challenges facing managers are identifying fisheries population metrics indicative of cormorant impacts and determining when this evidence becomes actionable. Building upon existing studies, we conducted a meta -analysis of eight data-rich systems across the Laurentian Great Lakes region of the United States for common fish population responses to changes in cormorant abundance. Specifically, we examined trends in mean total female length at age-3 (TL 3), female mean length and age at 50 % maturity, and mean age evenness as indicated by Shannon's Equitability Index. Annual observations for these metrics were independently regressed linearly against cormorant density by system for walleye (Sander vitreus), yellow perch (Perca flavescens), smallmouth bass (Micropterus dolomieu), and northern pike (Esox lucius) populations. TL 3 was the most sensitive with 9 of the 14 datasets statistically significant (r2 range 0.29 to 0.86). Maturity metrics were moderately sensitive to trends in cormorant predation with mean total length at 50 % maturity significant in 4 out of 11 datasets (r2 range 0.27–0.41) and mean age at 50 % maturity significant in 3 out of 11 datasets (r2 range 0.12 – 0.51). Least sensitive was age evenness with the Shannon Index significant in 3 out of 12 datasets (r2 typically < 0.25). Of metrics tested, TL 3 was the most reliable indicator of changes in cormorant effects despite varying system changes and management responses among locations. [ABSTRACT FROM AUTHOR]

Objective: To determine whether a musculoskeletal curriculum involving gamification via Kahoot! (an online classroom response system) was acceptable and more effective at teaching pediatric residents musculoskeletal knowledge and skills than a nongamified curriculum. Methods: A prospective, randomized controlled trial was conducted at an urban, academic pediatric clinic. All participants received a curriculum that included brief didactics and knowledge questions. The knowledge questions were delivered via Kahoot! to the intervention group and administered via paper to the control group. The primary outcome was knowledge and skill acquisition following curriculum participation. Results: A total of 73 of 85 (86%) residents completed the study (intervention group: 46; control group: 27). Following participation in the curriculum, intervention and control residents demonstrated an improvement in musculoskeletal knowledge (P < .05) measured via questionnaire, as well as an improvement in physical exam skills during a standardized patient encounter (P < .05). There was no difference in knowledge or skill improvement between groups. Intervention participants indicated positive attitudes toward Kahoot!. Conclusions: Our musculoskeletal curriculum demonstrated improvements in knowledge and skills among residents, though inclusion of Kahoot! did not enhance the experimental effect. Further research is needed to identify strategies to optimize gamification for learning. [ABSTRACT FROM AUTHOR]

Introduction: Placental alterations caused by severe acute respiratory coronavirus-2 (SARS-CoV-2) infection have already been described, but most studies used small sample groups and the difference according to the severity of the disease has not been verified. Our objective was to describe placental alterations in patients with coronavirus disease 2019 (COVID-19) and analyze the association of pathological placental findings with the clinical parameters of COVID-19 and perinatal results.Methods: This was a nested study within a prospective cohort study involving 109 symptomatic pregnant women with COVID-19. The prevalence of observed placental alterations was described, and the associations of pathological findings with the clinical parameters of COVID-19 severity and with perinatal outcomes were assessed.Results: The frequency of types of placental features was poor maternal vascular perfusion in 45% of cases, poor fetal vascular perfusion in 33.9%, hematogenous origin infection in 32.1%, and morphological changes corresponding to ascending infection in 21.1%. Hematogenous infection differed significantly according to COVID-19 severity (p = 0.008), with a prevalence ratio (PR) of 1.74 (95% confidence interval, 1.02-2.98) in the moderate COVID-19 group compared to the mild COVID-19 group. Among the perinatal outcomes, there was an unexpected inverse association between prematurity and placental infection of hematogenous origin, with lower rates of prematurity among cases with inflammation of hematogenous origin (p = 0.029).Discussion: Moderate SARS-Cov-2 infection presented a higher prevalence of placental pathological findings. There was no association of placental findings with adverse perinatal outcomes. [ABSTRACT FROM AUTHOR]

Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases. [ABSTRACT FROM AUTHOR]