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Objective: This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients., Methods: The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO 2 gas pressure, and surgical complications., Results: BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO 2 pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon's work or the course of the operation., Conclusions: In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery., Trial Registration: ISRCTN38987, 10 December 2019.

I shall argue, first, that potential kidney donors may be subject to harmful pressure to donate. This pressure may take almost any form; people have diverse interests, and anything that could set them back may qualify as pressure. Given features of the context-the high stakes, the involvement of family, and the social meaning of donation-such pressure may be especially harmful. This problem is less tractable than the more familiar worry that pressure may compromise consent. Screening may ensure donors validly consent, but it provides no protection against harmful pressure. I shall argue, second, that the use of such pressure is the predictable consequence of the prohibition on kidney sales. Potential donors have something-a transplantable kidney-that is both valuable and scarce. Many of them, informed about donation, decide against it. Those in need of a transplant may seek to persuade the unwilling. Given the prohibition, the donation cannot be made more attractive in absolute terms by, say, the addition of money. However, it can be made more attractive in relative terms. If declining the option is made worse, then, by comparison, accepting it is made better. The application of harmful pressure has the desired effect. With so much at stake, and no good alternatives, its use is predictable. I conclude that potential donors' interests should figure more prominently in the discussion of transplant policy. Those who defend the prohibition have made virtually no attempt to account for its impact on that group., (© 2023 John Wiley & Sons Ltd.)

Eagle's syndrome is a condition characterized by elongation of the styloid process or calcification of the styloid ligament that can manifest as a constellation of symptoms including dysphagia, globus sensation, hoarseness, headache, and neck pain. Anatomically, this can impinge neurovascular structures, distort the hypopharynx, and stiffen the epiglottis and other pharyngeal structures, increasing the difficulty of airway management. The objective of this case study was to discuss the features of Eagle's syndrome and anesthetic considerations in the management of the condition. Intubation may be challenging and presents a scenario where a glidescope is the preferred tool over direct laryngoscopy. Smooth emergence and extubation strategies, including the novel use of lidocaine and dexmedetomidine, are followed to minimize the risk of surgical complications., Competing Interests: Name: Brian Supsic, RN, BSN, SRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Debra Minzola, PhD, MBA, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

The Devonian trilobite Walliserops carries a remarkable anterior cephalic trident posing a challenge to functional interpretation. A unique teratological specimen of Walliserops trifurcatus showing four, rather than three tines, is inconsistent with possible hypotheses connecting the trident to feeding techniques and suggests a sexually selected function. Malformations in a variety of living organisms support this conclusion. Morphometric comparisons to similar structures used for intraspecific combat in dynastine beetles show that the trident occupies a comparable shape space consistent with the hypothesis that it was a sexual combat weapon, the oldest reported example of its kind. This lends further credibility to the idea that some trilobites may have been strongly sexually dimorphic.

Many humans live in large, complex political centers, composed of multi-scalar communities including neighborhoods and districts. Both today and in the past, neighborhoods form a fundamental part of cities and are defined by their spatial, architectural, and material elements. Neighborhoods existed in ancient centers of various scales, and multiple methods have been employed to identify ancient neighborhoods in archaeological contexts. However, the use of different methods for neighborhood identification within the same spatiotemporal setting results in challenges for comparisons within and between ancient societies. Here, we focus on using a single method-combining Average Nearest Neighbor (ANN) and Kernel Density (KD) analyses of household groups-to identify potential neighborhoods based on clusters of households at 23 ancient centers across the Maya Lowlands. While a one-size-fits all model does not work for neighborhood identification everywhere, the ANN/KD method provides quantifiable data on the clustering of ancient households, which can be linked to environmental zones and urban scale. We found that centers in river valleys exhibited greater household clustering compared to centers in upland and escarpment environments. Settlement patterns on flat plains were more dispersed, with little discrete spatial clustering of households. Furthermore, we categorized the ancient Maya centers into discrete urban scales, finding that larger centers had greater variation in household spacing compared to medium-sized and smaller centers. Many larger political centers possess heterogeneity in household clustering between their civic-ceremonial cores, immediate hinterlands, and far peripheries. Smaller centers exhibit greater household clustering compared to larger ones. This paper quantitatively assesses household clustering among nearly two dozen centers across the Maya Lowlands, linking environment and urban scale to settlement patterns. The findings are applicable to ancient societies and modern cities alike; understanding how humans form multi-scalar social groupings, such as neighborhoods, is fundamental to human experience and social organization., Competing Interests: The authors have declared that no competing interests exist.

The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: (1) a significant increase in donation, and (2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits., (© 2022 The Authors. American Journal of Transplantation published by Wiley Periodicals LLC on behalf of The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: Mobile health technologies can be useful for providing disease self-management information and support to people with inflammatory bowel disease (IBD)., Objective: The aim of this study was to test a self-management SMS text messaging intervention for people with IBD. Our goal was to examine intervention feasibility, acceptability, and engagement and to preliminarily evaluate improvements in certain self-reported health outcomes among participants., Methods: We developed an SMS text messaging program called Text4IBD. The program sent daily support messages and resources about disease self-management over the course of a 2-week, single-group, pretest-posttest intervention to participants (N=114) diagnosed with IBD. We examined intervention feasibility, acceptability, and engagement through Text4IBD message topic recall and use of resources (ie, visiting supplemental websites recommended by the Text4IBD program). We also assessed pretest-posttest measures of IBD-related distress, self-efficacy, perceived support, use of coping strategies, and medication adherence. Analyses examined participants' evaluations of the intervention and compared pretest-posttest changes in secondary outcomes using paired-samples statistics., Results: Approximately all participants who completed the intervention (n=105) were receptive to Text4IBD and viewed the program as feasible and acceptable. In addition, most participants (103/105, 98.1%) recalled at least one of the message topics sent by the program, and 79% (83/105) of them self-reported engaging with at least one of the external self-management resources recommended by the Text4IBD program. Pretest-posttest results showed reduced IBD-related distress (mean 3.33, SD 0.68 vs mean 2.86, SD 0.73; P<.001) and improvements in most other secondary outcomes., Conclusions: Findings from this study highlight the value of SMS text messaging as a useful digital medium for providing support to people with IBD, particularly to those who may struggle with disease-related distress. Text4IBD was highly feasible and acceptable and may help people self-manage their IBD. Future studies should aim to evaluate this program in a randomized controlled trial in clinical settings., (©Jacob A Rohde, Edwin B Fisher, Marcella H Boynton, Deen Freelon, Dennis O Frohlich, Edward L Barnes, Seth M Noar. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.05.2022.)

The European honey bee, Apis mellifera L., is the single most valuable managed pollinator in the world. Poor colony health or unusually high colony losses of managed honey bees result from a myriad of stressors, which are more harmful in combination. Climate change is expected to accentuate the effects of these stressors, but the physiological and behavioral responses of honey bees to elevated temperatures while under simultaneous influence of one or more stressors remain largely unknown. Here we test the hypothesis that exposure to acute, sublethal doses of neonicotinoid insecticides reduce thermal tolerance in honey bees. We administered to bees oral doses of imidacloprid and acetamiprid at 1/5, 1/20, and 1/100 of LD50 and measured their heat tolerance 4 h post-feeding, using both dynamic and static protocols. Contrary to our expectations, acute exposure to sublethal doses of both insecticides resulted in higher thermal tolerance and greater survival rates of bees. Bees that ingested the higher doses of insecticides displayed a critical thermal maximum from 2 ˚C to 5 ˚C greater than that of the control group, and 67%-87% reduction in mortality. Our study suggests a resilience of honey bees to high temperatures when other stressors are present, which is consistent with studies in other insects. We discuss the implications of these results and hypothesize that this compensatory effect is likely due to induction of heat shock proteins by the insecticides, which provides temporary protection from elevated temperatures., Competing Interests: The authors have declared that no competing interests exist.

Formaldehyde is a well-known industrial material regularly used in fishery, vegetable markets, and fruit shops for maintaining their freshness. But due to its carcinogenic nature and other toxic effects, it is very important to detect it in very low concentrations. In recent years, amine-containing fluorescent probes have gained significant attention for designing formaldehyde sensors. However, the major drawbacks of these small molecular probes are low sensitivity and long exposure time, which limits their real-life applications. In this regard, polymeric probes have gained significant attention to overcome the aforementioned problems. Several polymeric probes have been utilized as a coating material, nanoparticle, quartz crystal microbalance (QCM), etc., for the selective and sensitive detection of formaldehyde. The main objective of this review article is to comprehensively describe the recent advancements in formaldehyde sensors based on small molecules and polymers, and their successful applications in various fields, especially in situ formaldehyde sensing in biological systems., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by National Institute for Materials Science in partnership with Taylor & Francis Group.)

This article explores a novel methodology in the globalized classroom to face and tackle new challenges across cultures. The new online educational form of international discourse has the potential to make a difference in and outside Academia as it encompasses interpersonal communication across cultures and thus offers a novel framework for interpretation of different sociocultural perspectives to bring about social change. It transcends geographical and physical boundaries as it brings people together for discussion in the online joint event. Our study guides the reader through a collaborative educational framework and offers a methodology that transcends boundaries, exemplifying a tool for 21st century education. It offers techniques that bring on social change and enhances open-mindedness in tackling social problems with valuable methods from the fields of humanities and intercultural, collaborative communication., Competing Interests: Competing interestsThe authors declare no competing interests., (© The Author(s) 2022.)

Teaching is inherently connected with specific burdens that may imply stressful situations. The goal of this study was to explore the prevalence of type D (distressed) personality in teachers. This is known to cause depressive episodes and sleep disorders, which not only have direct physical health effects, but can also impact the wellbeing of individuals and hence adversely affect their job performance. The participants consisted of 412 high school teachers from the Silesian Province, located in the south of Poland. Using the following research tools: Type D Scale (DS14), Perceived Stress Scale, Athens Insomnia Scale, and Beck Depression Inventory, it was found that type D personality was observed in a large percentage of teachers (30.1%). It was reported that teachers with distressed personality suffered from insomnia and depression significantly more often. Findings from the current study indicate the need to implement preventive activities focused on reducing psychosocial risk factors in the work environment in order to reduce the frequency of depressive disorders among teachers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Domagalska, Rusin, Razzaghi and Nowak.)

Background Severe patient prosthesis mismatch (sPPM) after surgical aortic valve replacement is associated with worse outcomes. Limited data exists on the impact of sPPM on outcomes after transcatheter aortic valve replacement (TAVR), especially regarding the newer generation valves. The aim of this study was to evaluate the incidence, determinants, and outcomes of sPPM in patients undergoing TAVR with Edwards SAPIEN XT (ES XT) and Edwards SAPIEN 3 (ES3) valves (Edwards Lifesciences, Irvine, CA, USA). Methods We retrospectively reviewed 366 patients who underwent TAVR with ES XT (n = 114) or ES3 (n = 252) valves between July 2012 and June 2018. sPPM was defined as indexed effective orifice area (iEOA) <0.65 cm 2 /m 2 . Kaplan-Meier survival estimates were used to determine outcomes. Results Multivariate linear regression analysis was utilized to determine potential independent effects of PPM on outcomes. sPPM was present in 40 (11%) of the patients [8 (7%) ES XT and 32 (13%) ES3] and was associated with female sex, smaller left ventricular outflow tract (LVOT) diameter and aortic valve annular area, absence of prior coronary artery bypass graft (CABG) surgery, shorter height, higher body mass index, and smaller pre-TAVR valve area (all p < 0.05). Among those with ES3 valves, the incidence of sPPM was inversely proportional to the valve size (50%, 25%, 5% and 3% for 20-, 23-, 26- and 29-mm valve sizes, respectively; p < 0.001). At a mean follow-up period of 3.5 ± 1.5 years, there was no difference in all-cause mortality (22.5% vs. 25.6%, p = 0.89) or a composite endpoint of heart failure, arrhythmias, stroke, and myocardial infarction (30% vs. 34%, p = 0.24) in those with or without sPPM. Conclusion ES3 was associated with a higher incidence of sPPM, particularly with smaller valve sizes. However, the presence of sPPM as defined by iEOA was not an independent predictor of adverse outcomes in patients undergoing TAVR within an intermediate follow-up period., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Vallabhaneni et al.)

Context: Preseason testing can be time intensive and cost prohibitive. Therefore, using normative data for postconcussion interpretation in lieu of preseason testing is desirable., Objective: To establish the recovery trajectory for clinical reaction time (RTclin) and assess the usefulness of changes from baseline (comparison of postconcussion scores with individual baseline scores) and norm-based cutoff scores (comparison of postconcussion scores with a normative mean) for identifying impairments postconcussion., Design: Case-control study., Setting: Multisite clinical setting., Patients or Other Participants: An overlapping sample of 99 participants (age = 19.0 ± 1.1 years) evaluated within 6 hours postconcussion, 176 participants (age = 18.9 ± 1.1 years) evaluated at 24 to 48 hours postconcussion, and 214 participants (age = 18.9 ± 1.1 years) evaluated once they were cleared to begin a return-to-play progression were included. Participants with concussion were compared with 942 control participants (age = 19.0 ± 1.0 years) who did not sustain a concussion during the study period but completed preseason baseline testing at 2 points separated by 1 year (years 1 and 2)., Main Outcome Measure(s): At each time point, follow-up RTclin (ie, postconcussion or year 2) was compared with the individual year 1 preseason baseline RTclin and normative baseline data (ie, sex and sport specific). Receiver operating characteristic curves were calculated to compare the sensitivity and specificity of RTclin change from baseline and norm-based cutoff scores., Results: Clinical reaction time performance declined within 6 hours (18 milliseconds, 9.2% slower than baseline). The decline persisted at 24 to 48 hours (15 milliseconds, 7.6% slower than baseline), but performance recovered by the time of return-to-play initiation. Within 6 hours, a change from baseline of 16 milliseconds maximized combined sensitivity (52%) and specificity (79%, area under the curve [AUC] = 0.702), whereas a norm-based cutoff score of 19 milliseconds maximized combined sensitivity (46%) and specificity (86%, AUC = 0.700). At 24 to 48 hours, a change from baseline of 2 milliseconds maximized combined sensitivity (64%) and specificity (61%, AUC = 0.666), whereas a norm-based cutoff score of 0 milliseconds maximized combined sensitivity (63%) and specificity (62%, AUC = 0.647)., Conclusions: Norm-based cutoff scores can be used for interpreting RTclin scores postconcussion in collegiate athletes when individual baseline data are not available, although low sensitivity and specificity limit the use of RTclin as a stand-alone test., (© by the National Athletic Trainers' Association, Inc.)

The purpose of this study was to examine the effect of test sequence on adults' ability to achieve maximal aerobic and anaerobic power during a single assessment visit. Forty-one adults (24 men, 17 women; 22.0 ± 1.8 years) completed two baseline visits in randomized order consisting of either a maximal oxygen consumption (V̇O 2max ) or Wingate anaerobic test (WAnT). The subsequent experimental visit consisted of both V̇O 2max and WAnT in randomized order separated by 20 minutes of rest. Mixed-model ANOVAs compared baseline and experimental performance between and within groups. Chi Squared Goodness of Fit tests determined if test sequence significantly affected V̇O 2max criteria achievement. Significant interaction effects were observed for relative V̇O 2max ( p = 0.005), RER ( p < 0.001), and exercise time ( p = 0.022). Within WAnT/V̇O 2max subjects, these values significantly decreased from baseline to experimental tests. No differences were found for WAnT values. During the experimental session, 50% of subjects who performed WAnt/V̇O 2max and 81% of subjects who performed V̇O 2max /WAnT achieved a valid V̇O 2max . Chi squared analysis found the change to be significant in WAnT/V̇O 2max subjects only. Therefore, performing the WAnT before V̇O 2max sequence significantly reduced the percent of subjects who achieved V̇O 2max criteria. These findings indicate that the sequence of V̇O 2max testing before a WAnT allowed maximal results similar to expected baseline values.

Chemical contamination of foods pose a significant risk to consumers. A source of this risk is due to the consumption of products contaminated with heavy metals such as cadmium (Cd) and lead (Pb). The aim of the study was to research the levels of Cd and Pb contamination of selected species of vegetables and fruits in the form of fresh, frozen, dried and processed products. The goal was to verify which of these food groups was more contaminated with heavy metals. The study covered 370 samples of fruits and vegetables including apples, pears, grapes, raspberries, strawberries, cranberries, as well as beetroots, celeries, carrots and tomatoes. The content of Cd and Pb was determined by atomic absorption spectrometry. Quantitative results were analyzed using statistical models: analysis of variance, outlier analysis, post-hoc multiple comparison Tukey test. The tests showed that the levels of Cd and Pb concentration in samples of fresh, processed, frozen and dried fruits and vegetables varied substantially. The highest concentrations were recorded in dried products. Several fruit and vegetable samples exceeded the maximum permissible concentrations of Cd and Pb. The contamination of these products could be a significant source of consumer exposure to heavy metals when these products are a part of the diet.

Background: Non-invasive determination of mitochondrial capacity via near infrared spectroscopy (NIRS) typically involves voluntary exercise of a single muscle group followed by as many as 26 brief ischemic cuff occlusions to determine a single recovery rate constant (k)., Purpose: To determine the within- and between-visit repeatability of a shortened bilateral NIRS protocol, and to establish the feasibility of hamstring k measurements., Methods: Sixteen young (eight women, eight men; 22 ± 3 years) active adults underwent a bilateral electrical stimulation protocol in which multiple (n = 4) measurements of k for the vastus lateralis (VL) and medial hamstring (MH) muscles were determined on two visits. Repeatability (CV% and intraclass correlations, ICC) and equivalency across visits were assessed for both muscles., Results: Mean k values in the VL were consistent with published values and within-visit ICCs were moderately high for both muscles in both sexes. In men, average k values on visit 2 were within 1% (VL muscle) and 5% (MH muscle) of the values on visit 1 (all p > 0.78). In women, average k values were 10%-15% lower on visit 2 (p = 0.01 and p = 0.15 for MH and VL) with the largest between-visit differences in a subset of participants with the most days between visits., Conclusions: This bilateral NIRS protocol is time efficient and provides valid estimates of k in both sexes and muscle groups with acceptable within-visit repeatability. Lower than expected between-visit repeatability in some participants reinforces the need for further investigation of this newly developed protocol to identify and control for experimental and behavioral sources of variation., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Collisions with buildings cause up to 1 billion bird fatalities annually in the United States and Canada. However, efforts to reduce collisions would benefit from studies conducted at large spatial scales across multiple study sites with standardized methods and consideration of species- and life-history-related variation and correlates of collisions. We addressed these research needs through coordinated collection of data on bird collisions with buildings at sites in the United States (35), Canada (3), and Mexico (2). We collected all carcasses and identified species. After removing records for unidentified carcasses, species lacking distribution-wide population estimates, and species with distributions overlapping fewer than 10 sites, we retained 269 carcasses of 64 species for analysis. We estimated collision vulnerability for 40 bird species with ≥2 fatalities based on their North American population abundance, distribution overlap in study sites, and sampling effort. Of 10 species we identified as most vulnerable to collisions, some have been identified previously (e.g., Black-throated Blue Warbler [Setophaga caerulescens]), whereas others emerged for the first time (e.g., White-breasted Nuthatch [Sitta carolinensis]), possibly because we used a more standardized sampling approach than past studies. Building size and glass area were positively associated with number of collisions for 5 of 8 species with enough observations to analyze independently. Vegetation around buildings influenced collisions for only 1 of those 8 species (Swainson's Thrush [Catharus ustulatus]). Life history predicted collisions; numbers of collisions were greatest for migratory, insectivorous, and woodland-inhabiting species. Our results provide new insight into the species most vulnerable to building collisions, making them potentially in greatest need of conservation attention to reduce collisions and into species- and life-history-related variation and correlates of building collisions, information that can help refine collision management., (© 2020 Society for Conservation Biology.)

Background: Just culture has been identified as a vital component of safety culture by national and international organisations. In a just culture, emphasis is not placed on blaming individuals for errors but rather on examining personal and system processes that can best support safety and prevent reoccurrence. Although those in the practice arena have worked to implement the concepts of just culture, the same is not true in nursing education, leaving nursing students lacking the pre-requisite knowledge, skills and attitudes to implement just culture in practice on graduation., Aims: Assessment of this phenomena is the essential first step to align nursing education with practice in promoting just culture as a mechanism for patient safety. The purpose of this paper is to further refine the Just Culture Assessment Tool-Nursing Education through exploratory factor analysis., Methods: The Just Culture Assessment Tool-Nursing Education was adapted from the Just Culture Assessment Tool, an instrument created for the practice setting. Validity and reliability were established for the Just Culture Assessment Tool-Nursing Education in a study of 800 nursing students to assess their perceptions and understanding of just culture with their nursing programmes. Using the previously conducted data, an exploratory factor analysis was conducted., Results: Factor analysis supports six subscales, similar to that of the Just Culture Assessment Tool. However, individual items were loaded into different subscales. All subscales demonstrated good reliability. Factor analysis supported further refinement of two items to improve the instrument's ability to capture data., Conclusions: Perceptions of just culture differ between experienced providers and nursing students; nursing students have less experience with reporting errors. Factor analysis of Just Culture Assessment Tool-Nursing Education items demonstrated these differences, supporting modification of items by the instrument developers. An 'if' statement for students to consider their possible actions rather than experience was added to two items to better capture data from nursing students when completing the assessment., Competing Interests: Declaration of conflicting interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article, (© The Author(s) 2020.)

Context: Pre-season testing is often used to establish baseline scores for post-concussion interpretation. However, pre-season testing can be time-intensive and cost-prohibitive, in which case normative data may be used for post-injury interpretation., Objective: To compare change from baseline and normative-based cutoff scores in interpreting clinical reaction time (RTclin) following concussion., Design: Prospective case-control study., Setting: Multi-site study with testing completed in university athletic training rooms., Patients or Other Participants: An overlapping sample of 99 participants (age=19.0±1.1 years) evaluated within 6 hours post injury, 176 participants (age 18.9±1.1 years) evaluated 24-48 hours post injury, and 214 participants (18.9±1.1 years) evaluated at the time they were cleared to begin a return-to-play progression. Concussion participants were compared to 942 control participants (age=19.0±1.0 years) who did not sustain a concussion during the study period but completed preseason baseline testing one year apart., Main Outcome Measures: At each time point, follow-up RTclin (i.e., post injury or year 2) was compared to individualized year 1 preseason baseline RTclin and to normative baseline data (i.e., sex- and sport-specific). Receiver operating characteristic curves were used to compare sensitivity and specificity of RTclin change from baseline and normative-based cutoff scores., Results: Within 6h, change from baseline of 16ms maximized combined sensitivity (52%) and specificity (78%, AUC=0.702), while normative-based cutoff scores of 19ms maximized combined sensitivity (45%) and specificity (86%, AUC=0.700). At 24-48h, change from baseline of 2ms maximized combined sensitivity (64%) and specificity (61%, AUC=0.666), while normative-based cutoff scores of 0ms maximized combined sensitivity (63%) and specificity (62%, AUC=0.647)., Conclusions: Normative-based cutoff scores can be used for interpreting RTclin scores following concussion when individualized baseline data is not available, although low sensitivity and specificity may limit clinical use as a stand-alone test., (© by the National Athletic Trainers' Association, Inc.)

Vasa previa is a rare but serious medical condition characterized by a velamentous insertion of fetal blood vessels onto the placenta, which places those vessels at high risk of rupturing with rupturing of the membranes. Often vasa previa goes undetected until fetal compromise ensues following rupture of membranes. A recent case report of a 25-year-old pre-eclamptic female demonstrates the emergent and fatal nature of undiagnosed vasa previa., Competing Interests: The authors have declared no financial relationship with any commercial entity to the context of this article. The authors did not discuss off-label use within the article., (Copyright © by the American Association of Nurse Anesthetists.)

Methylenetetrahydrofolate reductase (MTHFR) deficiency is an autosomal recessive disorder that results in hyperhomocysteinemia. Elevated homocysteine levels in the blood can cause arterial and venous thrombosis, atherosclerosis, recurrent pregnancy loss, and neurologic symptoms. Emerging research suggests links to other chronic illnesses as well. Anesthetic management of patients with MTHFR deficiency should focus on decreasing the risk of arterial or venous thrombosis and minimizing elevations in homocysteine levels. Thrombosis prevention includes the use of antiembolism compression stockings, intermittent pneumatic compression sleeves, subcutaneous heparin or low-molecular-weight heparin, early ambulation, and adequate hydration. Nitrous oxide is known to inhibit methionine synthase, a vitamin B12-dependent enzyme responsible for the breakdown of homocysteine, resulting in homocysteine elevation, and should be avoided in these patients. Intravenous vitamin B12 infusion before surgery may help decrease homocysteine levels; however, it is not readily available in most operating rooms. Propofol and sevoflurane do not increase homocysteine levels and are considered safe for patients with MTHFR deficiency. This case study describes a 58-year-old man with known MTHFR deficiency and his subsequent uneventful anesthetic care during a total knee replacement., Competing Interests: The authors have declared no financial relationship with any commercial entity to the context of this article. The authors did not discuss off-label use within the article., (Copyright © by the American Association of Nurse Anesthetists.)

Context: In the absence of baseline testing, normative data may be used to interpret postconcussion scores on the clinical reaction-time test (RTclin). However, to provide normative data, we must understand the performance factors associated with baseline testing., Objective: To explore performance factors associated with baseline RTclin from among candidate variables representing demographics, medical and concussion history, self-reported symptoms, sleep, and sport-related features., Design: Cross-sectional study., Setting: Clinical setting (eg, athletic training room)., Patients or Other Participants: A total of 2584 National Collegiate Athletic Association student-athletes (n = 1206 females [47%], 1377 males [53%], and 1 unreported (<0.1%); mass = 76.7 ± 18.7 kg; height = 176.7 ± 11.3 cm; age = 19.0 ± 1.3 years) from 3 institutions participated in this study as part of the Concussion Assessment, Research and Education Consortium., Main Outcome Measure(s): Potential performance factors were sex; race; ethnicity; dominant hand; sport type; number of prior concussions; presence of anxiety, learning disability, attention-deficit disorder or attention-deficit/hyperactivity disorder, depression, or migraine headache; self-reported sleep the night before the test; mass; height; age; total number of symptoms; and total symptom burden at baseline. The primary study outcome measure was mean baseline RTclin., Results: The overall RTclin was 202.0 ± 25.0 milliseconds. Female sex (parameter estimate [B] = 8.6 milliseconds, P < .001, Cohen d = 0.54 relative to male sex), black or African American race (B = 5.3 milliseconds, P = .001, Cohen d = 0.08 relative to white race), and limited-contact (B = 4.2 milliseconds, P < .001, Cohen d = 0.30 relative to contact) or noncontact (B = 5.9 milliseconds, P < .001, Cohen d = 0.38 relative to contact) sport participation were associated with slower RTclin. Being taller was associated with a faster RTclin, although this association was weak (B = -0.7 milliseconds, P < .001). No other predictors were significant. When adjustments are made for sex and sport type, the following normative data may be considered (mean ± standard deviation): female, noncontact (211.5 ± 25.8 milliseconds), limited contact (212.1 ± 24.3 milliseconds), contact (203.7 ± 21.5 milliseconds); male, noncontact (199.4 ± 26.7 milliseconds), limited contact (196.3 ± 23.9 milliseconds), contact (195.0 ± 23.8 milliseconds)., Conclusions: Potentially clinically relevant differences existed in RTclin for sex and sport type. These results provide normative data adjusting for these performance factors., (© by the National Athletic Trainers' Association, Inc.)

The aim of this study was to determine the heavy metal contents of dietary supplements manufactured from medicinal plants and assess the potential daily burden on their consumers. The study consisted of 41 dietary supplements produced from terrestrial plants or microalgae. The analysis of cadmium, lead, and mercury content was performed using analytical methods. The content of Cd and Pb was determined by flame atomic absorption spectrometry (FAAS). The mercury content was determined using atomic absorption spectrometry with the generation of cold mercury vapor (CVAAS). The presence of at least one of the three analyzed heavy metals was found in 79.2% samples of supplements produced from terrestrial plants and in 88.2% supplement samples produced from microalgae. Hazard quotient was used to calculate noncarcinogenic risk for humans by ingestion of dietary supplements containing heavy metals. From among all supplements, 68.3% of samples were contaminated with Cd and Pb (this does not always apply to the same samples) and 29.3% of samples were contaminated with Hg. The health risk assessment of consumers of dietary supplements showed, in an extreme case, that taking this supplement for only one week poses a health risk associated with exposure to Pb. The health risk associated with the intake of dietary supplements primarily depends on the duration of consumption., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2020 The Authors. Food Science & Nutrition published by Wiley Periodicals LLC.)

The purpose of this study was to assess the maturity-related differences in the aerobic and anaerobic adaptations to sprint interval training (SIT) among youth male athletes. Twenty-seven youth male athletes were assessed for years from peak height velocity (PHV) and classified into prepubescent (PRE, n = 7, years from PHV = -2.21 ± 0.47 years), peripubescent (PERI, n = 10, years from PHV = 0.25 ± 0.88 years), and postpubescent (POST, n = 10, years from PHV = 2.81 ± 0.50 years) groups based on their years from estimated peak height velocity. Participants completed a ramp exercise protocol on a cycle ergometer to determine maximal aerobic power, maximal oxygen consumption (VO 2peak ), and fatigue thresholds. Following baseline, all participants completed a 4-week SIT program that consisted of eight total training sessions. During each session, participants completed repeated 20-s sprints on a cycle ergometer against a resistance of 7.5% of body mass. The number of sprints per sessions increased from four in session 1 to seven in session 7, with four sprints in session 8. Peak and mean power from sessions 1 and 8 were recorded. All participants completed a post-testing ramp exercise protocol that mirrored baseline. Maximal aerobic power increased (p < .001) across all groups from baseline (212.61 ± 57.45 W) to post-testing (223.24 ± 58.90 W); however, VO 2peak only increased in POST (3.31 ± 0.43 to 3.54 ± 0.43 L min -1 , p = .003). Similarly, GET, VT, and RCP increased in POST, with no changes in PRE or PERI. In terms of anaerobic performance, PERI and POST had significant increases in peak and mean power. POST improved aerobic and anaerobic performance following SIT, while PERI only experienced improvements in anaerobic performance. Conversely, PRE had no changes in aerobic or anaerobic performance. The adaptations to SIT appear to be influenced by the somatic maturity status., (© 2020 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

This article delineates the theory and framework for an innovative child abuse training program for mandated reporters called ' iLookOut '. iLookOut is an online learning delivery system that utilizes mastery learning and self-determination theory in the Core Training program, along with spaced retrieval and retrieval practice in a follow-up micro-learning program that reinforces learning from the Core Training. A cognitive mapping model provides the structure for documenting and organizing the learning content in both the Core training and the follow-up micro-learning program. The article provides a conceptual framework for designing and implementing effective and efficient online learning programs.

Teachers commonly categorize students as visual or auditory learners. Despite a lack of empirical evidence, teaching to a student's perceived learning style remains common practice in education (Pashler et al., 2009). Having conducted an extensive review of the literature, Pashler et al. (2009) noted, "...very few studies have even used an experimental methodology capable of testing the validity of learning styles applied to education" (p. 105). Rogowsky et al. (2015) published the first study following the experimental design prescribed by Pashler et al. Focusing specifically on the visual/auditory dichotomy, Rogowsky et al. (2015) examined the extent to which learning style predicts comprehension and retention based on mode of instruction. Their study has been noted as "The only study located through the systematic literature search across six different databases and the screening of more than 1000 records that was totally aligned with Pashler's criteria" (Aslaksen and Loras, 2018, p. 3). The caveat to the 2015 study is that it was conducted with adult learners. The current study uses the same design and methodology as its predecessor, but on a school-aged population, making it the first of its kind. Consistent with earlier findings with adults, results failed to find a significant relationship between auditory or visual learning style preference and comprehension. Fifth graders with a visual learning style scored higher than those with an auditory learning style on listening and reading comprehension measures. As such, and counter to current educational beliefs and practices, teachers may actually be doing a disservice to students by using resources to determine their learning style and then tailoring the curriculum to match that learning style., (Copyright © 2020 Rogowsky, Calhoun and Tallal.)

Traumatic aortic rupture (TAR) is a highly fatal injury mechanism resulting from blunt deceleration forces against the descending aorta. The mechanism of TAR is directly attributed to the aorta suffering damage by indirect shearing forces. The descending aorta remains fixed to the posterior chest wall, while the heart and ascending aorta are exerted forward, thus causing the intimal tear. A characteristic triad presents as increased blood pressure in the upper extremities, decreased blood pressure in the lower extremities, and a widened mediastinum on radiography. Early recognition of signs and symptoms of the mechanism of injury is key to initiating early damage control surgery and ultimately decreasing morbidity and mortality. This case report describes the intraoperative management of an elderly female patient with TAR following a motor vehicle collision in a remote location in rural Pennsylvania., Competing Interests: The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright© by the American Association of Nurse Anesthetists.)

Background: Qualitatively atypical language development characterized by non-sequential skill acquisition within a developmental domain, which has been called developmental deviance or difference, is a common characteristic of autism spectrum disorder (ASD). We developed the Response Dispersion Index (RDI), a measure of this phenomenon based on intra-subtest scatter of item responses on standardized psychometric assessments, to assess the within-task variability among individuals with language impairment (LI) and/or ASD., Methods: Standard clinical assessments of language were administered to 502 individuals from the New Jersey Language and Autism Genetics Study (NJLAGS) cohort. Participants were divided into four diagnostic groups: unaffected, ASD-only, LI-only, and ASD + LI. For each language measure, RDI was defined as the product of the total number of test items and the sum of the weight (based on item difficulty) of test items missed. Group differences in RDI were assessed, and the relationship between RDI and ASD diagnosis among individuals with LI was investigated for each language assessment., Results: Although standard scores were unable to distinguish the LI-only and ASD/ASD + LI groups, the ASD/ASD + LI groups had higher RDI scores compared to LI-only group across all measures of expressive, pragmatic, and metalinguistic language. RDI was positively correlated with quantitative ASD traits across all subgroups and was an effective predictor of ASD diagnosis among individuals with LI., Conclusions: The RDI is an effective quantitative metric of developmental deviance/difference that correlates with ASD traits, supporting previous associations between ASD and non-sequential skill acquisition. The RDI can be adapted to other clinical measures to investigate the degree of difference that is not captured by standard performance summary scores.

The bovine lactoferricin L6 (RRWQWR) has been previously identified as a novel cell-penetrating peptide (CPP) that is able to efficiently internalize into human cells. L6 interacts with quantum dots (QDs) noncovalently to generate stable L6/QD complexes that enter cells by endocytosis. In this study, we demonstrate a modified L6 (HL6; CHHHHHRRWQWRHHHHHC), in which short polyhistidine peptides are introduced into both flanks of L6, has enhanced cell-penetrating ability in human bronchoalveolar carcinoma A549 cells. The mechanism of cellular uptake of HL6/QD complexes is primarily direct membrane translocation rather than endocytosis. Dimethyl sulfoxide (DMSO), but not pyrenebutyrate (PB), ethanol, oleic acid, or 1,2-benzisothiazol-3(2 H)-one (BIT), slightly enhances HL6-mediated protein transduction efficiency. Neither HL6 nor HL6/QD complexes are cytotoxic to A549 or HeLa cells. These results indicate that HL6 could be a more efficient drug carrier than L6 for biomedical as well as biotechnological applications, and that the function of polyhistidine peptides is critical to CPP-mediated protein transduction.

Subtelomeric transcription and chromatin can have a significant impact on telomere repeat maintenance and chromosome stability. We have previously found that tumor suppressor protein p53 (TP53) can bind to retrotransposon-like elements in a majority of human subtelomeres to regulate TERRA transcription and telomeric histone acetylation in response to DNA damage. TP53 also prevents the accumulation of γH2AX DNA-damage signaling at telomeres. We now show that the inherited TP53 polymorphism Pro47Ser (hereafter S47), which is enriched in populations of African descent, is associated with elevated marks of telomere dysfunction. We found that human and mouse cells carrying the S47 variant show increased γH2AX DNA-damage signals at telomeres, as well as reduced TERRA transcription and subtelomeric histone acetylation in response to DNA damage stress. Cell-lines containing inducible genes for P47 or S47 versions of p53, as well mouse embryo fibroblasts (MEFs) reconstituted with human p53, showed elevated telomere-induced DNA damage foci and metaphase telomere signal loss in cells with S47. Human lymphoblastoid cell lines (LCLs) derived from individuals homozygous for S47, show increased accumulation of subtelomeric γH2AX and unstable telomere repeats in response to DNA damage relative to age matched LCLs homozygous for P47. Furthermore, LCLs with S47 had reduced replicative lifespan. These studies indicate that the naturally occurring S47 variant of p53 can affect telomeric chromatin, telomere repeat stability, and replicative capacity. We discuss the potential evolutionary significance of the S47 variant to African populations with respect to telomere regulation and the implications for inherited health disparities., Competing Interests: CONFLICTS OF INTEREST PML is a founder of Vironika, LLC and has a financial relationship with Cullinan-Apollo, Inc.

A series of trivalent f-block tungstates, MW 2 O 7 (OH)(H 2 O) (M = La, Ce, Pr, Nd, and Pu) and AmWO 4 (OH), have been prepared in crystalline form using hydrothermal methods. Both structure types take the form of 3D networks where MW 2 O 7 (OH)(H 2 O) is assembled from infinite chains of distorted tungstate octahedra linked by isolated MO 8 bicapped trigonal prisms; whereas AmWO 4 (OH) is constructed from edge-sharing AmO 8 square antiprisms connected by distorted tungstate trigonal bipyramids. PuW 2 O 7 (OH)(H 2 O) crystallizes as red plates; an atypical color for a Pu(iii) compound. Optical absorption spectra acquired from single crystals show strong, broadband absorption in the visible region. A similar feature is observed for CeW 2 O 7 (OH)(H 2 O), but not for AmWO 4 (OH). Here we demonstrate that these significantly different optical properties do not stem directly from the 5f electrons, as in both systems the valence band has mostly O-2p character and the conduction band has mostly W-5d character. Furthermore, the quasi-particle gap is essentially unaffected by the 5f degrees of freedom. Despite this, our analysis demonstrates that the f-electron covalency effects are quite important and substantially different energetically in PuW 2 O 7 (OH)(H 2 O) and AmWO 4 (OH), indicating that the optical gap alone cannot be used to infer conclusions concerning the f electron contribution to the chemical bond in these systems.

Dioxins (PCDDs), furans (PCDFs) and polychlorinated biphenyls (PCBs) emitted into the environment can accumulate in foods and become a significant source of dietary exposure for consumers of these compounds. This study aims to assess the dietary exposure of the residents in a rural area of the Silesia region in southern Poland to PCDDs, PCDFs and PCBs. The goal is to estimate cancer and non-cancer health risks due to the consumption of foods of animal origin. The area has relatively higher concentration of PCDDs, PCDFs and PCBs in the air in comparison to large industrialized cities of the Silesia province. Three popular foods of animal origin, namely free-range chicken meat, free-range chicken eggs, and cow milk produced in the farms were used. The control samples were the same foods from the local grocery stores. Two exposure scenarios were considered: Firstly that residents consumed free-range foods and secondly that the food items were purchased from stores in the study area. In the first scenario, exposure to concentrations of PCDDs, PCDFs, and dioxin-like PCBs (dl-PCBs) yielded evidence of elevated cancer and non-cancer risks. The hazard quotient (HQ) was 71.3 for non-cancer risk and 7.5 × 10 -3 for cancer risk. The health risk from exposure to PCDDs, PCDFs and dl-PCBs in the second scenario was 6.9 × 10 -4 and HQ = 0.8, respectively. Implementation of educational activities in the study area is needed to increase the resident's awareness of the risks associated with the emissions of chlorinated persistent organic pollutants to the environment, including aspects such as the main sources of the emission and how to avoid exposure to these compounds., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to compare body composition measurements estimated by multi-frequency bioelectrical impedance analysis (MF-BIA) with air displacement plethysmography (ADP) in individuals with obesity., Methods: Bariatric patients were recruited from Geisinger's Center for Nutrition and Weight Management Clinic in Danville, Pennsylvania. Sixty-two participants (age = 52.4 ± 9.3 years; body mass index = 38.9 ± 8.0 kg m -2 ) reported for a same-day testing visit. Body composition was measured using a common MF-BIA analyzer (InBody 720, Biospace Co., Beverly Hills, CA) and ADP., Results: Strong relationships were observed between MF-BIA and ADP methods ( r  = 0.88-0.96, P  < 0.001). There were no differences between MF-BIA and ADP measures of per cent body fat, fat mass or fat-free mass for the total sample or when examined by gender., Conclusions: The InBody 720 MF-BIA analyzer produced body composition measurements that were similar to ADP supporting the use of this technology in the obese population., Competing Interests: No conflict of interest was declared.

Purpose: To examine the impact of polyphenol supplementation on the recruitment, mobilization, and activation of monocyte subsets after resistance exercise., Methods: Thirty-eight recreationally active males (22.1 ± 3.1 yr; 173.9 ± 7.9 cm; 77.8 ± 14.5 kg) were assigned to 28 d of polyphenol blend (PPB) supplementation, placebo (PL), or control (CON). Blood samples were obtained before (PRE) postresistance exercise, immediately (IP) postresistance exercise, 1 h (1H) postresistance exercise, 5 h (5H) postresistance exercise, 24 h (24H) postresistance exercise, and 48 h (48H) postresistance exercise (PPB/PL) or rest (CON). Fine-needle biopsies were obtained from the vastus lateralis at PRE, 1H, 5H, and 48H. Circulating concentrations of macrophage chemoattractant protein-1 (MCP-1) and fractalkine, as well as intramuscular MCP-1 were analyzed via multiplex assay. Changes in the proportions and expression of CD11b on monocyte subsets were assessed via flow cytometry., Results: Circulating MCP-1 increased in PPB and PL at IP with further increases at 5H. Intramuscular MCP-1 was increased at 1H, 5H, and 48H in all groups. Classical monocyte proportions were reduced in PPB and PL at IP, and increased at 1H. Nonclassical monocytes were increased in PPB and PL at IP, whereas intermediate monocytes were increased at IP, and reduced at 1H. Intermediate monocytes were increased in PPB at 24H and 48H. CD11b expression was reduced on PPB compared with PL and CON at PRE on intermediate and nonclassical monocytes., Conclusions: Resistance exercise may elicit selective mobilization of intermediate monocytes at 24H and 48H, which may be mediated by tissue damage. Additionally, polyphenol supplementation may suppress CD11b expression on monocyte subsets at rest.

This systematic review and meta-analysis is to provide comprehensive evidence-based exercise recommendations targeting walking function for adults with Parkinson's disease., Methods: Fixed- or random-effect meta-analyses estimated standardized effect sizes (Hedge's g), comparing treatment effects from exercise with nonexercise and another form of exercise (non-EXE control and EXE control). Cuing and exercise duration were used as moderators for subanalyses., Results: The 40 included randomized controlled trials comprised 1656 patients. The exercise group showed significantly superior performance in timed up-and-go ( g = -0.458; g = -0.390) compared with non-EXE control and EXE control; significantly greater improvement in comfortable walking speed ( g = 0.449), fast walking speed ( g = 0.430), and stride or step length ( g = 0.379) compared with non-EXE control; and significantly greater cadence ( g = 0.282) compared with EXE controls. No significant differences between intervention and control groups were observed for double-leg support time (DLST), dynamic gait index (DGI), 6-minute walk test, or freezing of gait questionnaire (FOG-Q). Notably, treatment effect from the exercise of interest compared with a standard exercise was greater than for nonexercise for cadence and FOG-Q. Moreover, EXE control was favored for DLST and DGI. Cuing had a significantly positive effect on stride length alone. Exercise duration significantly, but negatively, influenced the treatment effect on comfortable walking speed., Conclusion: Gait-specific training, rather than a general exercise program, should be emphasized if gait is the outcome of interest. Further investigation is needed on exercise dosage and its selective effect on more challenging walking tasks, endurance, and freezing of gait.

Systemic health effects from exposure to a complex natural dust containing heavy metals from the Nellis Dunes Recreation Area (NDRA) near Las Vegas, NV, were evaluated. Several toxicological parameters were examined following lung exposure to emissive dust from three geologic sediment types heavily used for recreational off-road activities: yellow sand very rich in arsenic (termed CBN 5); a shallow cover of loose dune sand overlying a gravelly subsoil bordering dune fields (termed CBN 6); and brown claystone and siltstone (termed CBN 7). Adult female B6C3F1 mice were exposed by oropharyngeal administration to these three types of geogenic dusts at 0.01-100 mg of dust/kg of body weight, once per week for four weeks. The median grain sizes were 4.6, 3.1, and 4.4 μm, for CBN 5, 6, and 7, respectively. Each type of dust contained quantifiable amounts of aluminum, vanadium, chromium, manganese, iron, cobalt, copper, zinc, arsenic, strontium, cesium, lead, uranium, and others. Descriptive markers of immunotoxicity, neurotoxicity, hematology, and clinical chemistry parameters were assessed. Notable among all three CBN units was a systemic, dose-responsive decrease in antigen-specific IgM antibody responses. Geogenic dust from CBN 5 produced more than a 70% suppression in IgM responses, establishing a lowest adverse effect level (LOAEL) of 0.01 mg/kg. A suppression in IgM responses and a corresponding increase in serum creatinine determined a LOAEL of 0.01 mg/kg for CBN 6. The LOAEL for CBN 7 was 0.1 mg/kg and also was identified from suppression in IgM responses. These results are of concern given the frequent off-road vehicle traffic and high visitor rates at the NDRA, estimated at 300,000 each year.

Interscalene brachial plexus blockade is regularly used for postoperative pain management following shoulder surgery. A known but generally benign side effect of this technique is Horner syndrome. Another syndrome known as harlequin syndrome exists but does not appear to be as common. This syndrome consists of contralateral facial flushing and sweating secondary to ipsilateral sympathetic chain inhibition. Despite the alarming presentation in the perioperative setting, this syndrome appears to be benign and self-limiting when precipitated by regional anesthetic technique. This article describes an occurrence of harlequin syndrome without observed ptosis or miosis following a postoperative interscalene nerve block., Competing Interests: The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article., (Copyright© by the American Association of Nurse Anesthetists.)