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The objective of this study was to evaluate the educational impact following the implementation of a robotic thoracic surgery program on cardiothoracic (CT) surgery trainees. We hypothesized that the introduction of a robotic thoracic surgery program would adversely affect the CT surgery resident experience, decreasing operative involvement and subsequent competency of surgical procedures. CT surgery residents and thoracic surgery attendings from a single academic institution were administered a recurring, electronic survey from September 2019 to September 2020 following each robotic thoracic surgery case. Surveys evaluated resident involvement and operative performance. This study was exempt from review by our Institutional Review Board. Attendings and residents completed surveys for 86 and 75 cases, respectively. Residents performed > 50% of the operation independently at the surgeon console in 66.2 and 73.3% of cases according to attending and resident responses, respectively. The proportion of trainees able to perform > 75% of the operation increased with each increasing year in training (p = 0.002). Based on the Global Evaluative Assessment of Robotic Skills grading tool, third-year residents averaged higher scores compared to first-year residents (22.9 versus 17.4 out of 30 possible points, p

Background The ongoing Appalachian opioid epidemic has led to increasing hepatitis C virus (HCV) infections among people who inject drugs (PWID), and Human Immunodeficiency Virus (HIV) outbreaks have been observed. The primary aim of this study was to assess the potential increase in screening for HIV and HCV in an academic central Appalachian emergency department (ED) through the use of Best Practice Alerts (BPAs) in the electronic medical record (EMR). A secondary aim was to assess for an increase in linkage to care using patient navigators. Methods EMR algorithms based on current Centers for Disease Control and Prevention HIV and HCV testing recommendations were created that triggered Best Practice Alerts (BPAs), giving providers a one-click acceptance option to order HIV and/or HCV testing. Placards were placed in care areas, informing patients of the availability of routine screening. Patient navigators facilitated linkage to care for seropositive patients. Results The BPA appeared 58,936 times on 21,098 patients eligible for HIV screening and 24,319 times on 11,989 patients eligible for HCV screening over a one-year period. Of those, 7106 (33.7%) patients were screened for HIV and 3496 (29.2%) patients were screened for HCV, for an overall testing increase of 2269% and 1065% for HIV and HCV, respectively. Linkage to care increased by 15% for HIV to 100, and 14% for HCV to 64%. Conclusion HIV and HCV screening and linkage to care were increased in an academic ED setting in central Appalachia using EMR alerts. This approach could be utilized in multiple ambulatory settings. Increased testing and earlier linkage to care may help combat the current injection drug use-related HCV epidemic and avoid additional HIV outbreaks.

Mycobacterium abscessus surgical site infections are rare, but notoriously difficult to treat. Eradication requires aggressive surgical resection, removal of foreign material, prolonged antibiotics, and consideration of delayed reconstruction.

In this article we present an all-fiber vector bend sensor by means of a self-fabricated micro-structured multicore optical fiber. The reported solution is based on differential intensity variations of the light transmitted along the cores whose changes are influenced by the bending angle and orientation. The unique asymmetric structure of the air-holes in the optical fiber provides each core with different confinement losses of the fundamental mode depending on the bending radius and orientation, making each of the cores bend-sensitive in a range of at least 80°. It has been experimentally demonstrated that the reported sensor enables the bending angle and orientation to be detected in a full range of 360° without any dead-zones, and the possibility of end point detection with millimeter precision. Additionally, a reconstruction of the bending vector has been carried out theoretically, and a good match can be observed between the experimental and theoretical data.

Background Body fluid cytology (BFC) is an important tool in the diagnosis and staging of malignancy and is aided by the judicious use of immunohistochemistry (IHC). The aim of this study was to determine the usage rates of IHC stains in BFC, their type and indications, and their diagnostic impact. We also attempted to estimate the optimal rate of IHC use in BFC by comparing the entire laboratory's and each individual cytopathologist's IHC use rates with their respective indeterminate and malignant diagnosis rates. Methods We conducted a retrospective study of IHC stain use in BFC during a 5.5-year interval (2013-2018) and determined the laboratory's and each individual cytopathologist's IHC usage patterns according to the final diagnosis, site, and indications for their use. Results A total of 477 out of 4144 (11.5%) BFC cases had 2128 individual immunostains performed, with an average of 4.5 immunostains per case. Individual cytopathologists used IHC stains on 6.7% to 22% of their BFC cases. Pathologists with higher rates of IHC stain use than the laboratory's mean were less experienced and had higher rates of indeterminate but not of malignant diagnoses. The most common indication for the use of IHC stains was differentiating mesothelial from malignant cells. MOC31, calretinin, Ber-EP4, CD68, and D2-40 were the most commonly used of the 67 different IHC stains used in BFC. Conclusions The laboratory's mean may represent the optimal IHC use rate, as higher IHC use rates did not lead to more diagnostic certainty or higher pickup rates of malignant cells.

BACKGROUND The Centers for Disease Control and Prevention recommends screening baby boomers and high-risk patients for hepatitis C virus (HCV); however, the incidence of HCV is rapidly increasing among younger populations, and screening is limited by access to care and risk factor assessment. The purpose of this study was to evaluate characteristics of HCV antibody-positive (Ab+) and ribonucleic acid (RNA)-confirmed-positive patients identified via two screening models in an Appalachian emergency department (ED). METHODS This was a retrospective cohort study of patients who screened HCV Ab+ in the ED from January 1 to October 31, 2018. Data were extracted, and comparative analyses were conducted between the risk-based and the universal screening models. RESULTS Overall, 444 patients screened HCV Ab+, with a median age of 39 years. From January to May 2018, the risk factor model identified 126 HCV Ab+ patients out of 3,014 screened (4%), whereas from June to October 2018, the universal model identified 318 HCV Ab+ patients out of 5,407 screened (6%; p

Introduction COVID19 has raised concerns for resource allocation across various sectors of healthcare. At the frontlines, emergency departments are required to triage a wide range of acuity and non-specific symptomology. Methods This retrospective study aimed to pave the way for more concrete detection and triage of patients by analyzing symptomology, physical findings, diagnostic testing and relevant hospital course of the 458 suspected cases that initially presented to an academic level one trauma center emergency department between March and August 2020. A total of 202 COVID positive cases were analyzed. Results The most common symptoms were cough (70.63%), fatigue (77%), and shortness of breath (59%). There was a significantly higher percentage of abnormal chest imaging in inpatient groups compared to the ED discharge group (42.86% vs 79%, p

STUDY OBJECTIVE Access to naloxone is a priority for reducing opioid deaths. Although community members who complete naloxone training are able to administer nasal naloxone successfully and rapidly, little is known about the ability of community members to administer naloxone without training. The objective of this study was to assess the ability of untrained individuals to administer naloxone successfully in a simulated opioid overdose setting. DESIGN Prospective single-site open-label randomized usability assessment. SETTING Scenario station at a large state fair during August and September 2017. PARTICIPANTS A total of 207 healthy adults who were randomly assigned to administer naloxone using a nasal spray (NS) device (69 participants), an intramuscular (IM) kit (68 participants), or an improvised nasal atomizer (AT) kit (70 participants). INTERVENTION Participants were instructed to administer the device to a high-fidelity mannequin in a public environment with distractions to mimic those that might be present in an actual overdose. No device instructions or administration materials were provided. MEASUREMENTS AND MAIN RESULTS Participants were assessed by trained study team members who directly observed all naloxone administrations using the predetermined end-point criteria. Individual participant perceptions were evaluated immediately following the naloxone administration using a standardized questionnaire form. The primary outcome was successful administration, defined as administration within 7 minutes and without critical errors. Secondary outcomes were time to successful naloxone administration and ease of use of the device. The NS (66.7%, p

Awareness about food allergy and food-induced anaphylaxis (FIA) has increased dramatically over the past decade. It remains unclear, however, whether concordance with guidelines for FIA management has improved over time.Our objective was to describe changes in emergency department (ED) concordance with guidelines for FIA management.We analyzed data from 2 multicenter retrospective studies of patients with food-related acute allergic reactions seen in 1 of 17 EDs during 2 time periods: 1999 to 2001 and 2013 to 2015. Visits were identified similarly across years-for example, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.60, 995.61-995.69, 995.0, and 995.3. Anaphylaxis was defined as an acute allergic reaction with involvement of 2+ organ systems or hypotension. We compared concordance between time periods for 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for an epinephrine autoinjector (EAI), (3) referral to an allergist/immunologist, and (4) instructions to avoid offending allergen.We compared 290 patients with FIA during 1999 to 2001 and 459 during 2013 to 2015. Any treatment with epinephrine (pre-ED or in the ED) for patients with FIA increased over time (38% vs 56%; P.001). Prescriptions for EAI at discharge (24% vs 54%; P.001) and documentation for referral to an allergist/immunologist (14% vs 24%; P = .001) approximately doubled, whereas instructions to avoid the offending allergen did not change significantly (37% vs 43%; P = .08). Receipt of 3+ guideline recommendations remained low but almost quadrupled over the study interval (6% vs 23%; P.001).Over the nearly 15-year study interval, we observed clinically and statistically significant increases in ED concordance with epinephrine-related guidelines for FIA. Management gaps remain and interventions to standardize care still appear warranted.

Background Urinary tract cytology (UTCy) is used for screening urothelial carcinoma (UC) and it must have a high negative predictive value (NPV) to be an effective test. To the authors' knowledge, the literature regarding the NPV of UTCy provides little information regarding the risk of malignancy, especially for patients with high-grade urothelial carcinoma (HGUC). Methods Patients with negative UTCy specimens were identified in the pathology files at the study institution for the years 2012 through 2013. Cases were deemed true-negative cases if there was at least 1 subsequent negative specimen or negative clinical follow-up within 6 months of the index case. False-negative cases were defined as HGUC or carcinoma in situ by surgical biopsy and/or any UTCy with suspicious for HGUC or HGUC follow-up. Results A total of 2614 UTCy specimens from 2089 patients were identified. There was a disease prevalence of 6.5%. There were 87 false-negative results for HGUC, which corresponded to an overall NPV of 96.7%. When categorized by clinical indication, hematuria resulted in the highest NPV of 99.5% followed by other indications (97.7%) and a history of UC (90.1%). When categorized by the specimen type, voided urine specimens were found to have the highest NPV of 98.7% followed by other indications (96.9%) and washing specimens (96.2%). Of the 717 patients with a history of UC, the NPV was lower for washing specimens (89.8%) than for voided urine specimens (96.2%). When including either low-grade urothelial carcinoma or HGUC as a positive follow-up, the NPV dropped to 93.3% from 96.7% (HGUC only). The sensitivity of the diagnostic category of atypical urothelial cells or higher was 93.0%. Conclusions Overall, UTCy appears to have a good NPV and a high sensitivity for HGUC. The clinical indication had a greater impact on NPV compared with the specimen type.

Understanding how humans evaluate credibility is an important scientific question in the era of fake news. Message credibility is among crucial aspects of credibility evaluations. One of the most direct ways to understand message credibility is to use measurements of brain activity of humans performing credibility evaluations. Nevertheless, message credibility has never been investigated using such a method before. This article reports the results of an experiment during which we have measured brain activity during message credibility evaluation, using EEG. The experiment allowed for identification of brain areas that were active when participant made positive or negative message credibility evaluations. Based on experimental data, we modeled and predicted human message credibility evaluations using EEG brain activity measurements with F1 score exceeding 0.7.

Proportional electroluminescence (EL) in noble gases is used in two-phase detectors for dark matter searches to record (in the gas phase) the ionization signal induced by particle scattering in the liquid phase. The "standard" EL mechanism is considered to be due to noble gas excimer emission in the vacuum ultraviolet (VUV). In addition, there are two alternative mechanisms, producing light in the visible and near infrared (NIR) ranges. The first is due to bremsstrahlung of electrons scattered on neutral atoms ("neutral bremsstrahlung", NBrS). The second, responsible for electron avalanche scintillation in the NIR at higher electric fields, is due to transitions between excited atomic states. In this work, we have for the first time demonstrated two alternative techniques of the optical readout of two-phase argon detectors, in the visible and NIR range, using a silicon photomultiplier matrix and electroluminescence due to either neutral bremsstrahlung or avalanche scintillation. The amplitude yield and position resolution were measured for these readout techniques, which allowed to assess the detection threshold for electron and nuclear recoils in two-phase argon detectors for dark matter searches. To the best of our knowledge, this is the first practical application of the NBrS effect in detection science., Comment: 26 pages, 22 figures, 3 tables

Experiments searching for the neutrinoless double beta decay in $$^{76}$$ 76 Ge are currently achieving the lowest background level and, in connection with the excellent energy resolution of germanium detectors, they exhibit the best discovery potential for the decay. Expansion to a ton scale of the active target mass is presently considered – in this case on-site production of the detectors may be an option. In this paper we describe the fabrication and characterization procedures of a prototype detector with a small p+ contact, which enhances the abilities of the pulse shape discrimination – one of the most important tools for background reduction. Simulations of the shapes of pulses from the detector were carried out and tuned, taking the advantage of the fact that all the parameters of the Ge crystal, cryostat and of the spectroscopic chain were known. As a result, the pulse shape analyses performed on the simulated and measured data agree very well. The worked out method allows to optimize geometry and crystal parameters in terms of pulse shape analysis efficiency, before the actual production of the detectors.

Objective A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence. Design Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks. Setting Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. Participants Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation. Results 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p Conclusion Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

The electrical and optoelectronic properties of nanometer-sized ZnO structures are highly influenced by its native point defects. Understanding and controlling these defects are essential for the development of high-performance ZnO-based devices. Here, an electrical device consisting of a polycrystalline ZnO-coated silica nanospring was fabricated and used to characterize the electrical and photoconductive properties of the ZnO layer using near-UV (405 nm) and sub-bandgap (532 and 633 nm) excitation sources. We observe a photocurrent response with all three wavelengths and notably with 532 nm green illumination, which is the energy associated with deep oxygen vacancies. The polycrystalline ZnO-coated silica nanospring exhibits a high responsivity of 1740 A W−1 with the 405 nm excitation source. Physical models are presented to describe the photocurrent rise and decay behavior of each excitation source where we suggest that the rise and decay characteristics are highly dependent on the energy of the excitation source and the trapping of electrons and holes in intermediate defect levels in the bandgap. The energy levels of the trap depths were determined from the photoconductive decay data and are matched to the reported energy levels of singly and doubly ionized oxygen vacancies. A phenomenological model to describe the dependence of the saturation photocurrent on excitation intensity is presented in order to understand the characteristics of the observed breaks in the slopes of the saturation photocurrent versus excitation intensity profile.

Background: Fine needle aspiration (FNA) of renal masses can distinguish between benign and malignant neoplasms in 73–94% of cases. Previous studies suggested the correct subclassification of renal cell carcinomas (RCCs) by cytomorphology can be achieved in up to 80% of cases. However, as RCCs become increasingly subclassified by molecular signatures, correct subclassification based on cytology alone is increasingly difficult. Design: Two FNA passes (2 stained with Diff-Quik® and 2 with the Papanicolaou method) were performed on all fresh nephrectomy specimens for a 1-year period. There were 30 cases in this study, with 29 primary renal tumors and 1 case of metastatic lung adenocarcinoma. Each case was assigned a random number and came with 2 slides (1 from each staining method). Eight cytopathologists were asked to provide a diagnosis and the World Health Organization/International Society of Urological Pathology (WHO/ISUP) grading if applicable. Fleiss’ Kappa and Cohen’s Kappa equations were used to look at inter-rater variability. Results: When compared to the surgical pathology diagnosis, the average percent correct diagnosis for all cytopathologist was 35%. Chromophobe RCCs had the best average percent accuracy at 72% followed by clearcell RCC at 48%. Average accuracy for grading RCCs was 40%. Inter-rater variability among the cytopathologists for all RCC diagnoses was fair with a Fleiss’ Kappa coefficient of 0.28. For the WHO/ISUP grade, the weighted coefficient for each pathologist ranged from 0.11 to 0.45, ranging from fair to moderate, respectively. Conclusions: Renal tumors are difficult to classify on cytopathology alone. Core needle biopsy and ancillary studies are necessary if diagnosis will change management.

Introduction The Paris System (TPS) for Reporting Urinary Cytology (UCyto) was published in 2016, but to date, no study addressing the unsatisfactory (UNSAT) category has been published. We aimed to identify the negative predictive value (NPV) for UNSAT UCyto after the implementation of TPS at our institution. Method For the period from January 1, 2017, to December 31, 2019, we identified all cases with UNSAT diagnosis on UCyto specimens and available cytologic and/or surgical pathology follow-up within 6 months from the UNSAT diagnosis. Cases were deemed true negative (TN) if the follow-up was “negative for high-grade urothelial carcinoma” (NHGUC). Information regarding previous medical history, clinical indications, and specimen type were tabulated and analyzed. Results From 6348 UCyto specimens, there were 230 (3.6%) UNSAT diagnoses made on 209 patients (112 [53.6%] men and 97 [46.4%] women) with a median age of 64 years. Of these, 116 UCyto specimens from 106 patients, which had cytologic and/or surgical pathology follow-up within 6 months, were further studied. Most UNSAT UCyto specimens were bladder washing/barbotage (BW/BB), and the most common indication for UCyto was cancer surveillance. The main cause of UNSAT UCyto was low cellularity. There were 5 false-negative (FN) results for high-grade urothelial carcinoma (HGUC), which corresponds to an overall NPV of 84.4%. NPV was highest for patients with UCyto for hematuria, and for patients with BW/BB as UCyto specimen type. Conclusions Our results show that UNSAT diagnoses have a lower NPV than that typical of NHGUC diagnoses, and should be managed accordingly.

Introduction The Paris System for Reporting Urinary Cytology (TPS) was developed for standardization purposes and it placed an emphasis on screening for high-grade urothelial carcinoma (HGUC). Since then, it has shown to reduce atypia rates and better correlate with surgical specimens. The aim of this study was to calculate the negative predictive value (NPV) of urinary cytology for detecting HGUC using TPS and compare these data to our recently published pre-TPS cohort. As a screening test, it is imperative that TPS has a high NPV. Material and methods A search of our institution's pathology database for the term “negative for HGUC” from January 1, 2016, to December 31, 2017, was conducted. A true negative was defined as a patient with at least 1 subsequent negative urine cytology/surgical biopsy specimen or the patient being clinically negative for 6 months. NPV rates were calculated based on the data obtained. Results The cohort consisted of 2960 urine cytology specimens from 1894 patients. A total of 99 false negatives were identified, generating a NPV of 96.7% (2861/2960). This NPV is identical to our previously published pre-TPS cohort (years 2012-2013; NPV: 96.7%). The clinical indication most effected NPV, with a history of urothelial carcinoma with a NPV of 93.9% followed by hematuria at 98.9%. The atypia rate in years 2012-2013 was 8.2% and in 2016-2017 it was 5.7% (P Conclusions We demonstrate that TPS did not alter the NPV for detecting HGUC compared to our pre-TPS cohort. We believe that TPS is an effective reporting system for screening HGUC in urinary cytology.

Objective Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years. Methods A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease. Results A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively. Conclusions Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.

This chapter focuses on using an algorithmic approach to reporting negative findings in serous fluids, rather than providing detailed morphologic descriptions of benign entities. Specimens may be negative for malignancy (NFM) and yet be pathologic, but most serous fluids are collected to screen for primary or metastatic neoplasia. This chapter provides report examples for pathologic entities that do not represent atypical or malignant processes.

The Borexino liquid scintillator neutrino observatory has a unique capability to perform high-precision solar neutrino observations thanks to its exceptional radiopurity and good energy resolution (5% at 1 MeV). A comprehensive study of the pp-chain neutrinos was presented that includes the direct measurements of 7Be, pp and pep neutrino fluxes with the highest precision ever achieved (down to 2.8% in the 7Be component), the 8B with the lowest energy threshold, the best limit on CNO neutrinos and the first Borexino limit on hep neutrinos. These results are important to validate the MSW-LMA oscillation paradigm across the full solar energy range and to exclude possible Non-Standard neutrino Interactions (NSIs). In particular the effects of neutrino-flavor-diagonal Neutral-Current (NC) interactions that modify the vee and vτe couplings while preserving their chiral and flavor structures, have been investigated. At detection, the shape of the electron-recoil spectrum is affected by changes in the vee and vτe couplings, quantified by the parameters ε e L / R and ε τ L / R . New bounds to all four parameters were obtained, quite stringent compared to the global ones. In particular, the best constraint to-date on ε e L was achieved. A comprehensive summary of all the recent results on solar neutrinos from Borexino is reported in the present paper.

In the Internet era, understanding why humans find messages from unknown receivers credible (such as fake news) is an important research topic. Message credibility is an important theoretical aspect of credibility evaluation that relies only on message contents and design. For the first time in the field, we study message credibility by directly measuring brain activity of humans who make credibility evaluations in an experiment that controls message design. Brain activity as measured using EEG is used to investigate areas of the brain involved in message credibility evaluation. We also model and predict human message credibility evaluations using EEG brain activity measurements.

Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs.The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (6 years, 6-13 years, 13-20 years,20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs.A large tertiary care teaching hospital.Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident.A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with6, 6-13, 13-20, and20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with20 years of experience compared to those with6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs.The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.

Objective To describe inpatient satisfaction with surgical resident care given the increasing importance of patient satisfaction as a quality metric. Design Surgical inpatients were invited to complete a survey that addressed their satisfaction with and attitudes regarding surgical resident care. The survey was based on the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Patients were required to positively identify photos of resident physicians prior to providing ratings. Adapted S-CAHPS items were scored using the “top-box” method. Setting Massachusetts General Hospital, a tertiary academic center. Participants General surgery inpatients recovering from elective, major abdominal surgery were recruited on postoperative days 2 to 4. Results Ninety-one percent of approached patients participated (102/112, mean age = 62.9, 51.6% male). Patients positively identified both seniors and interns 88% of the time. Thirteen seniors and 19 interns were rated, with 1 to 14 evaluations per trainee. Overall quality of care ratings for seniors and interns were 9.35 and 9.09, respectively (0-10 scale, 10 = “best possible care”). Sixty-three percent of senior resident evaluations and 60% of intern evaluations received a score of 10. The proportion of residents receiving top-box scores ranged from 59.5% to 97.7% depending on the item. Forty percent of senior resident and 38% of intern evaluations received top-box scores for all 8 items. Over 96% of patients reported strong or moderate agreement with the statements “I feel it is important to help in the education of future surgeons.” Conclusions Surgical inpatients willingly completed ratings about their surgery residents, typically can recognize their resident physicians, and rate quality of care highly. Despite many high ratings, there is room for improvement in some S-CAHPS domains. These results indicate patients are a valuable source of feedback regarding a resident's progress in several core competencies such as interpersonal skills, communication, professionalism, and patient care.

Author(s): Burrell, Carmen N.; Sharon, Melinda J.; Davis, Stephen M.; Wojcik, Elena M.; Martin, Ian B.K. | Abstract: Introduction: With the current hepatitis C (HCV) epidemic in the Appalachian region and the risk of human immunodeficiency virus (HIV) co-infection, there is a need for increased secondary prevention efforts. The purpose of this study was to implement routine HIV and HCV screenings in the urgent care setting through the use of an electronic medical record (EMR) to increase a provider’s likelihood of testing eligible patients. Methods: From June 2017 through May 2018, EMR-based HIV and HCV screenings were implemented in three emergency department-affiliated urgent care settings: a local urgent care walk-in clinic; a university-based student health services center; and an urgent care setting located within a multi-specialty clinic. EMR best practice alerts (BPA) were developed based on Centers for Disease Control and Prevention (CDC) guidelines and populated on registered patients who qualified to receive HIV and/or HCV testing. Patients were excluded from the study if they chose to opt out from testing or the provider deemed it clinically inappropriate. Upon notification of a positive HIV and/or HCV test result through the EMR, patient navigators (PNs) were responsible for linking patients to their first medical appointment. Results: From June 2017 through May 2018, 48,531 patients presented to the three urgent care clinics. Out of 27,230 eligible patients, 1,972 patients (7.2%) agreed to be screened for HIV; for HCV, out of 6,509 eligible patients, 1,895 (29.1%) agreed to be screened. Thirty-one patients (1.6%) screened antibody-positive for HCV, with three being ribonucleic acid confirmed positives. No patients in either setting were confirmed positive for HIV; however, two initially screened HIV-positive. PNs were able to link 17 HCV antibody-positive patients (55%) to their first appointment, with the remainder having a scheduled future appointment. Conclusion: Introducing an EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in Appalachian urgent care settings where universal screenings are not routinely implemented.

BACKGROUND AND AIMS Expanded access to naloxone has been identified as a key intervention for reducing opioid-related morbidity and mortality. It is not known which naloxone device will result in rapid, successful administration when administered by community members. The aims of this study were to estimate and compare (1) the rate of successful administration and (2) time to successful administration for single-step nasal spray, multi-step atomized nasal spray and intramuscular simulated naloxone by community members. DESIGN A prospective, single-site, open-label, randomized usability assessment of simulated naloxone administration in a convenience sample of community members. Participants were randomized to single-step nasal spray (SP), multi-step atomized nasal spray (AT) or intramuscular simulated (IM) naloxone and asked to administer the simulated medication to a mannequin after completing a 2-minute training video. SETTING New York, USA at a state fair that attracts between 60 000 and 120 000 individuals daily. PARTICIPANTS A total of 138 participants completed the study over a 2-day period in September 2016. All participants were at least 18 years of age and had no prior naloxone training. MEASUREMENTS The rate of successful administration and time to successful administration were recorded for each device. FINDINGS The SP device (100%; P

Background Readmission after abdominal aortic aneurysm (AAA) repair to a different (nonindex) hospital has been shown to be associated with high mortality rates. Factors influencing this association remain unknown. The objective of this study was to determine the impact of hospital teaching status on nonindex hospital readmission and mortality. Methods An observational analysis of the longitudinally linked California Office of Statewide Health Planning and Development database was conducted from 1995 to 2009. Patients who were readmitted within 30 days after open AAA repair were included. The primary outcome measured was mortality on readmission. Results Over the 15-year study period, 3,475 readmissions after AAA were analyzed, of which 1,020 (29.4%) were to a nonindex hospital. After adjusting for age, race, gender, insurance, comorbidities, perioperative factors, and reason for readmission, nonindex readmission for patients undergoing their initial operation at a teaching hospital did not impact mortality (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.28–2.17, P = 0.63). Nonindex readmission for patients undergoing their initial operation at a nonteaching hospital, however, significantly increased mortality (OR 1.63, 95% CI 1.04–2.54, P = 0.03). Conclusions Readmission to a different hospital is associated with a higher mortality rate for patients undergoing AAA repair at nonteaching hospitals. This effect is not seen in patients having their initial operation performed at teaching hospitals, possibly due to infrastructure at these hospitals allowing for decreased impact from fragmentation of care. In cases where triage to an index hospital for readmission is not possible, communication at a high level between the index hospital and readmission hospital is paramount.

Objectives In concert with the 2015 publication of The Paris System for Urinary Cytopathology (TPS), a Web-based interobserver study, co-sponsored by the American Society of Cytopathology (ASC) and International Academy of Cytology (IAC), was performed to determine diagnostic agreement among volunteer participants and with the TPS author consensus. Material and Methods Participants at various levels of training and certification were recruited through national and international cytopathology professional societies. Although the survey was open to all comers, potential participants were screened by two basic cytopathology questions. Information was collected on the level of training, practice patterns, and experience. Study participants evaluated 85 images (previously unpublished) chosen from the TPS atlas. These images spanned all diagnostic categories. Results Of the 1993 attempts to access the survey, 1313 participants correctly answered the qualifying questions and were included in the survey. Respondents were concentrated in the United States, although many participants came from other countries. The majority of respondents were board-certified in anatomic pathology with cytopathology certification. A smaller number were cytotechnologists. Board-certified cytopathologists and specialist cytotechnologists outperformed other certifications. Practice type (academics versus non-academic), and country (US versus international) were not major factors in concordance. Diagnostic categories with the best agreement were Negative for High-Grade Urothelial Carcinoma (NHGUC; 71%), Low-Grade Urothelial Neoplasm (LGUN; 62%), and High-Grade Urothelial Carcinoma (HGUC; 57%). Indeterminate categories showed low concordance. Conclusions The NHGUC, LGUN, and HGUC were most correlated with diagnostic agreement among observers. This study can serve as a baseline for future comparisons.

Professional society membership enhances career development and productivity by offering opportunities for networking and learning about recent advances in the field. The quality and contribution of such societies can be measured in part through the academic productivity, career status, and funding success rates of their members. Here, using Scopus, NIH RePORTER, and departmental websites, we compare characteristics of the Shock Society membership to those of the top 55 NIH-funded American university and hospital-based departments of surgery. Shock Society members' mean number of publications, citations and H-indices were all significantly higher than those of non-members in surgery departments (P < 0.001). A higher percentage of members also have received funding from the NIH (42.5% vs. 18.5%, P < 0.001). Regression analysis indicated that members were more likely to have NIH funding compared with non-members (OR 1.46, 95% CI 1.12-1.916). Trauma surgeons belonging to the Shock Society had a higher number of publications and greater NIH funding than those who did not (130.4 vs. 42.7, P < 0.001; 40.4% vs. 8.5%, P < 0.001). Aggregate academic metrics from the Shock Society were superior to those of the Association for Academic Surgery and generally for the Society of University Surgeons as well. These data indicate that the Shock Society represents a highly academic and productive group of investigators. For surgery faculty, membership is associated with greater academic productivity and career advancement. While it is difficult to ascribe causation, certainly the Shock Society might positively influence careers for its members.

Background Changes in emergency department (ED) concordance with guidelines for the management of stinging insect-induced anaphylaxis (SIIA) are not known. Objective To describe temporal changes in ED concordance with guidelines for the management of SIIAs. Methods We analyzed data from 2 multicenter retrospective studies of patients with stinging insect-related acute allergic reactions seen in 1 of 14 North American EDs during 2 periods: 1999 through 2001 and 2013 through 2015. Visits were identified similarly across studies (eg, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 989.5, 995.0, and 995.3). Anaphylaxis was defined as an acute allergic reaction with involvement of at least 2 organ systems or hypotension. We compared concordance between periods with 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for epinephrine auto-injector, (3) referral to an allergist/immunologist, and (4) instructions to avoid the offending allergen. Results We compared 182 patients with SIIA during 1999 to 2001 with 204 during 2013 to 2015. Any treatment with epinephrine (before arrival to the ED or in the ED) increased over time (30% vs 49%; P P P = .002), and instructions to avoid the offending allergen did not change (23% vs 24%; P = .94). Receipt of at least 3 guideline recommendations increased over time; however, the comparison was not statistically significant (10% vs 16%; P = .15). Conclusion During the nearly 15-year study interval, we observed increased ED concordance with epinephrine-related guideline recommendations for the management of SIIA. Reasons for the decrease in allergy/immunology referrals merit further study.

Introduction: Limitations of urine drug-screening (UDS) by immunoassay include false-positive results. Pantoprazole, a proton-pump inhibitor (PPI), is reported to cause false-positive results for T...

Introduction Opioid withdrawal due to opioid use disorder (OUD) is an increasing health emergency and complaint in emergency departments (EDs) across the United States. As a response to the increased need for OUD treatment, a low threshold buprenorphine program, or Bridge Clinic, was established within our hospital system. Patients are primarily connected to the Bridge Clinic through the ED, and are able to complete their consultation appointment reliably within 1–3 days of referral. This program also serves to connect patients to community resources for continued treatment of OUD. Methods A retrospective chart review was performed to identify ED-based referrals to the Bridge Clinic in the period from January 1, 2017 – December 31, 2018. Outcomes of interest included: (1) ED utilization in the six months before and after consultation at the Bridge Clinic and (2) adherence to buprenorphine therapy at 2-year follow-up. Results A total of 269 patients were included in the study, with 167 males (62%) and a mean age of 37.8 years. There were 654 total visits to the ED six months before referral to the Bridge Clinic and 381 visits in the six-month period after the initial appointment. There was a high adherence to buprenorphine treatment at 2 year follow up (56%). Conclusions These early results suggest that prompt referral to a buprenorphine treatment program significantly reduces ED utilization and connects patients to community resources for continued buprenorphine treatment for OUD.

BACKGROUND The aim of this study was to evaluate the potential use of the UroVysion® fluorescent in situ hybridization test (U-FISH) to stratify the risk of urothelial carcinoma (UC) in patients with a diagnosis of "atypical urothelial cells" (AUC) in urinary tract cytology (UTCy). METHODS Using a histologic diagnosis of UC and respectively of high grade UC (HGUC) within 12 months of the index UTCy as a reference standard, we determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of U-FISH for patients with AUC diagnosed 2008 to 2014. RESULTS Of the 377 patients with AUC, 62 (16.45%) were diagnosed with UC (29 low grade UC and 33 HGUC) within 12 months. U-FISH were uninformative in 45 (11.94%), positive in 63 (16.71%) and negative in 269 (71.35%). UC was diagnosed more frequently in patients with positive than in those with negative U- FISH results (31/63, 49.21% vs. 25/269, 9.29%, P

A user-friendly fibre-coupled single-photon source operating at telecom wavelengths is a key component of photonic quantum networks providing long-haul ultra-secure data exchange. To take full advantage of quantum-mechanical data protection and to maximize the transmission rate and distance, a true quantum source providing single-photons on demand is highly desirable. We tackle this great challenge by developing a ready to use semiconductor quantum dot (QD)-based device that launches single photons at a wavelength of 1.3 um directly into a single-mode optical fibre. In our approach the QD is deterministically integrated into a nanophotonic structure to ensure efficient on-chip coupling into a fibre. The whole arrangement is integrated into a 19" compatible housing to enable stand-alone operation by cooling via a compact Stirling cryocooler. The realized source delivers single photons with multiphoton events probability as low as 0.15 and single-photon emission rate up to 73 kHz into a standard telecom single-mode fibre., Comment: 20 pages, 3 figures

Short abstractBrain world representation emerges not by philosophy but from integrating simple followed by more complex actions (due to drives, instincts) with sensory feedback and inputs such as rewards. Our simulation provides this world representation holistically by identical information encoded as holographic wave patterns for all associative cortex regions. Observed circular activation in cell culture experiments provides building blocks from which such an integrative circuit can evolve just by excitation and inhibition transfer to neighbouring neurons. Large-scale grid-computing of the simulation brought no new emergent phenomena but rather linear gains and losses regarding performance. The circuit integrates perceptions and actions. The resulting simulation compares well with data from electrophysiology, visual perception tasks, and oscillations in cortical areas. Non-local, wave-like information processing in the cortex agrees well with EEG observations such as cortical alpha, beta, and gamma oscillations. Non-local information processing has powerful emergent properties, including key features of conscious information processing.

We present an effective method for direct fiber coupling of a quantum dot (QD) that is deterministically incorporated into a cylindrical mesa. For precise positioning of the fiber with respect to the QD-mesa, we use a scanning procedure relying on interference of light reflected back from the fiber end-face and the top surface of the mesa, applicable for both single-mode and multi-mode fibers. The central part of the fiber end-face is etched to control the required distance between the top surface of the mesa and the fiber core. Emission around 1260 nm from a fiber-coupled InGaAs/GaAs QD is demonstrated and its stability is proven over multiple cooling cycles. Moreover, a single photon character of emission from such system for a line emitting above 1200 nm is proven experimentally by photon autocorrelation measurements with an obtained value of the second order correlation function at zero time-delay well below 0.5.

The electroencephalographic activity of particular brain areas during the decision making process is still little known. This paper presents results of experiments on the group of 30 patients with a wide range of psychiatric disorders and 41 members of the control group. All subjects were performing the Iowa Gambling Task that is often used for decision process investigations. The electroencephalographical activity of participants was recorded using the dense array amplifier. The most frequently active Brodmann Areas were estimated by means of the photogrammetry techniques and source localization algorithms. The analysis was conducted in the full frequency as well as in alpha, beta, gamma, delta, and theta bands. Next the mean electric charge flowing through each of the most frequently active areas and for each frequency band was calculated. The comparison of the results obtained for the subjects and the control groups is presented. The difference in activity of the selected Brodmann Areas can be observed in all variants of the task. The hyperactivity of amygdala is found in both the patients and the control group. It is noted that the somatosensory association cortex, dorsolateral prefrontal cortex, and primary visual cortex play an important role in the decision-making process as well. Some of our results confirm the previous findings in the fMRI experiments. In addition, the results of the electroencephalographic analysis in the broadband as well as in specific frequency bands were used as inputs to several machine learning classifiers built in Azure Machine Learning environment. Comparison of classifiers' efficiency is presented to some extent and finding the most effective classifier may be important for planning research strategy toward finding decision-making biomarkers in cortical activity for both healthy people and those suffering from psychiatric disorders.

Borexino is running at the INFN Gran Sasso National Laboraries, Italy since 2007. Its technical distinctive feature is the unprecedented ultralow background of the inner scintillating core, which is the foundation for the outstanding achievements accumulated by this experiment. In this contribution, after recalling the main features of the detector, the impressive solar data gathered so far by Borexino will be summarized. Special emphasis will be given to the illustration of the recent release of the fluxes as stemming from the simultaneous real time spectroscopy of the neutrinos from the entire $pp$ nuclear fusion chain in the Sun, opening with the remarkable 2.7% accuracy of the ⁷Be flux the era of precision measurements also in the realm of the sub-MeV solar neutrinos. Such results put Borexino in the unique situation of being the only detector able to perform solar neutrino spectroscopy over the entire solar spectrum; the counterpart of this peculiar status, in the flavor conversion interpretation of the solar neutrino data, is the capability of Borexino alone to perform the full validation across the solar energy range of the MSW-LMA paradigm. This contribution will be concluded with an account of the Borexino accomplishments in the geo-neutrino field, marked by the detection of the geo-neutrino signal with a significance as high as $5.9\sigma$.

Introduction Flat urothelial lesions fall into one of four diagnostic categories including urothelial carcinoma in-situ (CIS). There is morphologic overlap between the categories leading to immunohistochemistry (IHC) utilization in difficult cases. The purpose of this study was to examine the frequency, variation and utility of IHC use in bladder biopsy specimens over a 17 year period. Methods A search of “CD44”, “p53”, and “CK20” keywords was conducted from the pathology files (1/1/2003 to 12/31/2017) on bladder biopsy specimens at our institution. Atypical (AUS), dysplastic (UD) and CIS rates were calculated. Results A total of 4597 cases were identified. IHC was performed on 345 specimens (7.5%, 345/4597). For cases without IHC (H&E only), the AUS rate was 4.8% (206/4252), UD rate was 9.4% (399/4252), and the CIS rate was 8.4% (359/4252). For IHC cases, the AUS rate was 5.2% (18/345), the UD rate was 8.1% (28/345), and the CIS rate was 11.3% (39/345). There was no statistical difference between the H&E only or IHC rates ( p > 0.05). The absolute number IHC orders per year increased until 2011 (60 cases) but drastically declined over the last five years (5 total cases in 2017). The CIS rates have remained relatively constant. Conclusion We found the AUS, UD and CIS rates were similar regardless of IHC use. Our institution was an early adopter of IHC and it quickly fell out of favor. We agree with the ISUP in that IHC has limited clinical utility for flat urothelial lesions and morphology remains the gold standard.

The main purpose of urine cytology is to detect high-grade urothelial carcinoma (HGUC). With this principle in mind, The Paris System (TPS) Working Group, composed of cytopathologists, surgical pathologists, and urologists, has proposed and published a standardized reporting system that includes specific diagnostic categories and cytomorphologic criteria for the reliable diagnosis of HGUC. This paper outlines the essential elements of TPS and the process that led to the formation and rationale of the reporting system. The Paris System Working Group, organized at the 2013 International Congress of Cytology, conceived a standardized platform on which to base cytologic interpretation of urine samples. The widespread dissemination of this approach to cytologic examination and reporting of urologic samples and the scheme's universal acceptance by pathologists and urologists is critical for its success. For urologists, understanding the diagnostic criteria, their clinical implications, and the limitations of TPS is essential if they are to utilize urine cytology and noninvasive ancillary tests in a thoughtful and practical manner. This is the first international/inclusive attempt at standardizing urinary cytology. The success of TPS will depend on the pathology and urology communities working collectively to improve this seminal paradigm shift, and optimize the impact on patient care.

The study aimed to analyse the intake of Na with cereal products by the population of Poland. In addition, based on available literature, changes in the content of Na in bread sold in the Polish market from 2009 to 2018 were analysed with regard to Na intake reduction campaigns held in Poland since 2009 popularising information about the adverse effect of sodium on the human cardiovascular system. The results led to the conclusion that the analysed products contained 3.042 ± 3.4 g of Na per 1 kg of fresh product. The content of Na in the analysed products was bread > bread rolls > grains > pasta > rice. Cereal products provide 48.3 % of an adult’s intake of Na, where as much as 48.2 % is covered by bread, with only 0.04 % by grains, 0.04 % by pasta, and 0.01 % by rice. According to information available in reference literature from 2009–2017 the content of Na in baked goods has not been subject to significant modifications. In Poland, with regard to an excessive consumption of Na, efficient strategies must be developed to increase the awareness of consumers and to reduce the use of table salt in the most popular products, and in particular in baked goods. One of the ways to reduce the intake of Na would be consumers’ selection of an adequate range of foodstuffs naturally poor in this element or having its content reduced by means of a suitable technology. This can be a significant component of practices preventing the development of hypertension. However, the fact that information about the content of Na in cereal products is often missing from product labels makes consumer choice difficult.

The color of urine, once considered by uroscopists to give the most important clues to the diagnosis, still can provide some diagnostic clues in modern medicine. Pigmented cells are an uncommon and surprising find in urine cytology and can at the same time provide important diagnostic clues or represent a dangerous pitfall. We present a review of the significance of pigmented cells in urine cytology. The presence of intracellular pigment granules; their color, size, shape, and variation in size and shape; as well as their staining reactions with special stains can provide useful diagnostic insight, especially when interpreted in the cytologic context (type of pigmented cell and its degree of atypicality) and patient's clinical context. The main differential diagnosis of cytoplasmic pigmented granules includes hemosiderin, lipofuscin, and melanin, each having a different pathogenesis and significance. The goal of this paper is to describe the morphological, histochemical, and ultrastructural characteristics of the pigments seen in urinary cytology, and to review the benign and malignant conditions associated with them.