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Background This study investigated the completeness, accuracy, quality and clinical outcomes of the British Orthopaedic Foot and Ankle Society (BOFAS) registry - Ankle Arthrodesis pathway. Methods An observational study using retrospective data derived from the BOFAS registry. Adults aged ≥18 years with a record of undergoing ankle arthrodesis in the UK from 2014 to 31/10/2019 were included. Accuracy of data capture and completeness were explored using means, SD, medians and IQR for continuous variables and frequencies for categorical variables. The pre and post treatment pathway was evaluated by analysing Patient Reported Outcome Measures (PROMs) including MOXF-FQ scores for pain/walking/standing/social interaction; NRS pain; EQ-5D-5L; and EQ-5D-5L-Health VAS at baseline, 6 months, and 12 months. Results Mean age of the study population (n = 186) was 62.3 (±12.9) years and 65% of the study cohort were male. Completeness of data collection was disappointing but variables such as BMI (62.4%) smoking status (82.3%) were reasonably well recorded. PROMs scores were well recorded at baseline but rapidly declined at 6 and 12-months intervals. Reductions in MOXFQ and NRS pain scores by 12 months following surgery were statistically significant (p = 0.001 and p = 0.008), illustrating that most patients demonstrated reductions in pain intensity, improved walking/standing ability, and social interaction. Conclusion These findings illustrate the potential effectiveness of surgery on all outcomes following ankle arthrodesis that merits evaluation in a clinical trial; but also demonstrated the difficulties in obtaining representative data sets. The analyses strongly suggest that with the improvements in data quality greater resources would bring, the BOFAS registry would become a valuable tool.

When patients are harmed by health care, concerns fan out in all directions. Patients and families confront a sea of uncertainty, contending with injuries that drain them physically, emotionally, and financially. Health care professionals experience a powerful mix of emotions, but are seldom afforded the time to process what happened or the resources to relieve suffering and prevent harm. Honesty, transparency, and empathy are indispensable to a comprehensive approach that prioritizes patient and family-centered response to unintended harm, clinical improvement, and redemptive peer review. Part 2 introduces the second of three pillars for advancing the clinical mission: communication and transparency.

At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.

BACKGROUND Observational studies have linked pesticide exposure to various diseases, whereas organic food consumption has been associated with positive health outcomes. Organic farming standards prohibit the use of most pesticides, and organic food consumption may therefore reduce pesticide exposure. OBJECTIVES To determine the effects of diet (Western compared with Mediterranean) and food type (conventional compared with organic) and sex on urinary pesticide residue excretion (UPRE), as well as associations between specific diet components and UPRE. METHODS In this 2-wk, randomized dietary intervention trial, healthy adults were randomly allocated to an intervention (n = 13) or conventional (n = 14) group. Whereas participants in the intervention group consumed a Mediterranean diet (MedDiet) made entirely from organic foods, the conventional group consumed a MedDiet made entirely from conventional foods. Both groups consumed habitual Western diets made from conventional foods before and after the 2-wk intervention period. The primary outcome was UPRE. In addition, we assessed diet composition and pesticide residue profiles in foods eaten. Participants were aware of group assignment, but the study assessors were not. RESULTS During the intervention period, total UPRE was 91% lower with organic (mean 17 μg/d; 95% CI: 15, 19) than with conventional (mean 180 μg/d; 95% CI: 153, 208) food consumption (P

The hidden epidemic of burnout exacts a staggering toll on professionals and patients, reflected in increased risk of medical errors, complications, and staff turnover. For surgeons, nurses, and other team members working at the sharp end of care, adverse events can amplify work exhaustion, interpersonal disengagement, and risk of moral adversity. Visionary leaders are not content to mitigate burnout and moral injury; they elevate the human experience throughout health care by modeling wellness, fostering moral courage, promoting safety of professionals, and restoring joy in work. Part 3, Health Professional Wellness and Resilience, introduces the final pillar for advancing the clinical mission.

Complex health policy challenges such as antimicrobial resistance and other emerging infections are driven by activities in multiple sectors. Therefore, addressing these also requires joint efforts from multiple sectors as exemplified in the One Health approach. We undertake a critical review to examine the different ways in which multisector partnerships have been conceptualized across multiple disciplines and thematic areas. We started with a set of six articles from the disciplines of health, nutrition and public administration that reviewed conceptual frameworks within their respective fields. We conducted backward citation tracing using the bibliography of the six articles to identify other articles in the same and related fields that conceptualized multisector partnerships. We identified 58 articles published from 1967 to 2018 from the fields of global health, infectious diseases, management, nutrition and sustainability sciences indicating that multisector partnerships have been a topic of study across different fields for several decades. A thematic analysis of the 58 articles revealed that multisector partnerships assume a variety of forms and have been described in different ways. Partnerships can be categorized by scope, scale, formality and strength. Multisector partnerships emerge in conditions of dynamic uncertainty and sector failure when the information and resources required are beyond the capacities of any individual sector. Such partnerships are inherently political in nature and subsume multiple competing agendas of collaborating actors. Sustaining collaborations over a long period of time will require collaborative approaches like One Health to accommodate competing political perspectives and include flexibility to allow multisector partnerships to respond to changing external dynamics.

BackgroundMoral distress adversely affects the delivery of high-quality patient care and places health care professionals at risk for burnout, moral injury, and the loss of professional integrity.ObjectivesTo investigate whether pediatric critical care professionals are experiencing moral distress during the COVID-19 pandemic and, if so, for what reasons.MethodsAn exploratory survey of pediatric critical care professionals was conducted via the Pediatric Acute Lung Injury and Sepsis Investigators Network from April to May 2020. The survey was derived from a framework integrating contemporary literature on moral distress, moral resilience, and expert consensus. Integration of descriptive statistics for quantitative data and thematic analysis for qualitative data yielded mixed insights.ResultsOverall, 85.8% of survey respondents reported moral distress. Nurses reported higher degrees of moral distress than other professional groups. Inducers of moral distress were related to challenges to professional integrity and lack of organizational support. Five themes were identified: (1) psychological safety, (2) expectations of leadership, (3) connectedness through a moral community, (4) professional identity challenges, and (5) professional versus social responsibility. Most respondents were confident in their ability to reason through ethical dilemmas (76.0%) and think clearly when confronting an ethical challenge even when pressured (78.9%).ConclusionsDuring the COVID-19 pandemic, pediatric critical care professionals are experiencing moral distress due to various factors that challenge their professional integrity. Despite these challenges, they also exhibit attributes of moral resilience. Organizations have opportunities to cultivate a psychologically safe and healthy work environment to mitigate anticipatory, present, and lingering moral distress.

Contains fulltext : 249004.pdf (Publisher’s version ) (Closed access) PURPOSE: The objective of this study was to identify and evaluate the value of prognostic factors related to disability, pain and quality of life (QoL) for adult patients undergoing lumbar spine fusion surgery (LSFS). METHODS: Two reviewers independently searched the literature, assessed eligibility, extracted data and assessed risk of bias and certainty of evidence. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. LSFS] to 20/9/2020; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥ 12-month follow-up after LSFS were included. Narrative synthesis was based on recommendations by Cochrane Consumers and Communication Review Group. The GRADE tool enabled assessment of certainty of evidence. Prognostic factors and outcome were analysed and summarised when examined in ≥ 2 studies and when results pointed in the same direction in ≥ 75% of studies. RESULTS: Sixteen studies (n = 8388, 2 low and 14 high risk of bias) were included with 39 prognostic factors identified. There is low certainty evidence that higher pre-operative severity of leg pain predicts greater improvement of leg pain and that pre-operative working predicts less post-operative disability both at 1-2-year follow-up. Other found associations were of very low certainty evidence. CONCLUSION: No moderate to high certainty evidence exists. Use of leg pain and pre-operative working may be valuable predictors of outcome to inform clinical decision-making and advice regarding LSFS surgery. There is need for adequately powered low-risk-of-bias prospective observational studies to further investigate candidate prognostic factors.

Background context Musculoskeletal (MSK) pain presents a global challenge. Individual and group pain management programmes (PMPs) are recommended approaches for patients with chronic MSK disorders. With advances in remote healthcare capability, telehealth, and the recent COVID-19 pandemic, the importance of telehealth PMPs has become even more evident. Nevertheless, it is not known how patients perceive PMPs for their MSK complaint when delivered via telehealth. Objective To synthesise the evidence of patients' experiences of group and individual telehealth PMPs for chronic MSK pain. Design A scoping review informed by the PRISMA extension for scoping reviews. Data sources Based on a planned search strategy, modified following initial searches, an electronic search was conducted of key databases: Cochrane Library, Medline, CINAHL, EMBASE, AMED, SportDiscus and APA PsychInfo from 2010 until 11 May 2021. Study selection Any qualitative or mixed methods study reporting patient experiences of telehealth PMPs for patients with MSK disorders. Data extraction and data synthesis Data were extracted and synthesised using thematic analysis. Results From 446 identified studies, 10 were included. Just two studies investigated group telehealth PMPs for patients with MSK disorders, with eight delivered individually. Four main themes emerged: (1) Usability of the technology, (2) Tailored care, (3) Therapeutic alliance and (4) Managing behaviour. The findings highlight patient acceptability of telehealth to support self-management for chronic MSK disorders, with appropriate clinical and technical support. Group telehealth has the potential to empower patients with peer support. Remote delivery of PMPs also impacts on how patients and providers interact, communicate and develop a therapeutic relationship. Conclusions and implications Barriers and enablers to engagement in telehealth PMPs for patients with chronic MSK disorders have been identified. Peer support and group cohesiveness can be achieved remotely to enhance the patient experience. There is a critical need for further research in this area.

Purpose To investigate whether upright magnetic resonance imaging (MRI) has a role in defining thoracolumbar spine pathology in elite gymnastics. Methods A prospective cross-sectional observational study of National Senior and Junior Artistic gymnasts in three MRI positions (standard supine, upright flexed and extended positions). Two specialist musculoskeletal radiologists independently analysed images with neutral as a baseline with the effects of flexion and extension reported in line with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Results Forty (18 males) gymnasts aged 13–24 years with a mean (SD) of 32 (5.3) training hours per week consented with 75% showing MRI abnormalities. Degenerative disc disease (DDD) was evident in 55% participants with vertebral end plate (VEP) changes in 42.5%. Spondylolysis was present in 40% with an additional 17% showing chronic bilateral complete L5 pars defects. 23% participants demonstrated different MRI findings in upright flexion compared to neutral. Conclusion Findings suggest a high levels of MRI abnormalities in elite gymnastics including altered disc morphology and posterior element abnormalities. High prevalence of T11/12 DDD and VEP changes reflects the thoracolumbar junction being a transition zone. Upright MRI and varying spine position offer promise for enhanced visualisation of posterior element abnormalities.

International audience; Everyday movements are guided by objects’ positions relative to other items in the scene (allocentric information) as well as by objects’ positions relative to oneself (egocentric information). Allocentric information can guide movements to the remembered positions of hidden objects, but is it also used when the object remains visible? To stimulate the use of allocentric information, the position of the participant’s finger controlled the velocity of a cursor that they used to intercept moving targets, so there was no one-to-one mapping between egocentric positions of the hand and cursor. We evaluated whether participants relied on allocentric information by shifting all task-relevant items simultaneously leaving their allocentric relationships unchanged. If participants rely on allocentric information they should not respond to this perturbation. However, they did. They responded in accordance with their responses to each item shifting independently, supporting the idea that fast guidance of ongoing movements primarily relies on egocentric information.

ObjectivesThis study provides an overview of the influence of occupational risk factors on the global burden of disease as estimated by the occupational component of the Global Burden of Disease (GBD) 2016 study.MethodsThe GBD 2016 study estimated the burden in terms of deaths and disability-adjusted life years (DALYs) arising from the effects of occupational risk factors (carcinogens; asthmagens; particulate matter, gases and fumes (PMGF); secondhand smoke (SHS); noise; ergonomic risk factors for low back pain; risk factors for injury). A population attributable fraction (PAF) approach was used for most risk factors.ResultsIn 2016, globally, an estimated 1.53 (95% uncertainty interval 1.39–1.68) million deaths and 76.1 (66.3–86.3) million DALYs were attributable to the included occupational risk factors, accounting for 2.8% of deaths and 3.2% of DALYs from all causes. Most deaths were attributable to PMGF, carcinogens (particularly asbestos), injury risk factors and SHS. Most DALYs were attributable to injury risk factors and ergonomic exposures. Men and persons 55 years or older were most affected. PAFs ranged from 26.8% for low back pain from ergonomic risk factors and 19.6% for hearing loss from noise to 3.4% for carcinogens. DALYs per capita were highest in Oceania, Southeast Asia and Central sub-Saharan Africa. On a per capita basis, between 1990 and 2016 there was an overall decrease of about 31% in deaths and 25% in DALYs.ConclusionsOccupational exposures continue to cause an important health burden worldwide, justifying the need for ongoing prevention and control initiatives.

Background Adult scoliosis represents a distinct subgroup of scoliosis patients for whom the diagnosis can have a large impact on their health-related quality of life (HR-QOL). Therefore, HR-QOL patient-reported outcome measures (PROMs) are essential to assess disease progression and the impact of interventions. The objective of this systematic review is to evaluate the measurement properties of HR-QOL PROMs in adult scoliosis patients. Methods We will conduct a literature search, from their inception onwards, of multiple electronic databases including AMED, CINAHL, EMBASE, Medline, PsychINFO and PubMed. The searches will be performed in two stages. For both stages of the search, participants will be aged 18 and over with a diagnosis of scoliosis. The primary outcome of interest in the stage one searches will be studies which use PROMs to investigate HR-QOL as defined by the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy, the secondary outcome will be to assess the frequency of use of the various PROMs. In stage two, the primary outcome of interest will be studies which assess the measurement properties of the HR-QOL PROMs identified in stage one. No specific measurement property will be given priority. No planned secondary outcomes have been identified but will be reported if discovered. In stage one, the only restriction on study design will be the exclusion of systematic reviews. In Stage two the only restriction on study design will be the exclusion of full-text articles not available in the English language. Two reviewers will independently screen all citations and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or risk of bias) will be appraised using the Consensus-based Standards for the selection of Health Measurement Instruments (COSMIN) checklist. The overall strength of the body of evidence will then be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A narrative synthesis will be provided with information presented in the main text and tables to summarise and explain the characteristics and findings of the included studies. The narrative synthesis will explore the evidence for currently used PROMs in adult scoliosis patients and any areas that require further study. Discussion The review will help clinicians and researchers identify a HR-QOL PROM for use in patients with adult scoliosis. Findings from the review will be published and disseminated through a peer-reviewed journal and conference presentations. Systematic review registration This systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), reference number: CRD42020219437

Investments in animal health and Veterinary Services can have a measurable impact on the health of people and the environment. These investments require a baseline metric that describes the burden of animal health and welfare in order to justify and prioritise resource allocation and from which to measure the impact of interventions. This paper is part of a process of scientific enquiry in which problems are identified and solutions sought in an inclusive way. It poses the broad question: what should a system to measure the animal disease burden on society look like and what value would it add? Moreover, it aims to do this in such a way as to be accessible by a wide audience, who are encouraged to engage in this debate. Given that farmed animals, including those raised by poor smallholders, are an economic entity, this system should be based on economic principles. These poor farmers are negatively impacted by disparities in animal health technology, which can be addressed through a mixture of supply-led and demand-driven interventions, reinforcing the relevance of targeted financial support from government and non-governmental organisations. The Global Burden of Animal Diseases (GBADs) Programme will glean existing data to measure animal health losses within carefully characterised production systems. Consistent and transparent attribution of animal health losses will enable meaningful comparisons of the animal disease burden to be made between diseases, production systems and countries, and will show how it is apportioned by people's socio-economic status and gender. The GBADs Programme will produce a cloud-based knowledge engine and data portal, through which users will access burden metrics and associated visualisations, support for decisionmaking in the form of future animal health scenarios, and the outputs of wider economic modelling. The vision of GBADs, strengthening the food system for the benefit of society and the environment, is an example of One Health thinking in action.

Fc γ receptor IIB (FcγRIIB) is an inhibitory molecule capable of reducing antibody immunotherapy efficacy. We hypothesized its expression could confer resistance in patients with diffuse large B-cell lymphoma (DLBCL) treated with anti-CD20 monoclonal antibody (mAb) chemoimmunotherapy, with outcomes varying depending on mAb (rituximab [R]/obinutuzumab [G]) because of different mechanisms of action. We evaluated correlates between FCGR2B messenger RNA and/or FcγRIIB protein expression and outcomes in 3 de novo DLBCL discovery cohorts treated with R plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) reported by Arthur, Schmitz, and Reddy, and R-CHOP/G-CHOP-treated patients in the GOYA trial (NCT01287741). In the discovery cohorts, higher FCGR2B expression was associated with significantly shorter progression-free survival (PFS; Arthur: hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.01-1.19; P = .0360; Schmitz: HR, 1.13; 95% CI, 1.02-1.26; P = .0243). Similar results were observed in GOYA with R-CHOP (HR, 1.26; 95% CI, 1.00-1.58; P = .0455), but not G-CHOP (HR, 0.91; 95% CI, 0.69-1.20; P = .50). A nonsignificant trend that high FCGR2B expression favored G-CHOP over R-CHOP was observed (HR, 0.67; 95% CI, 0.44-1.02; P = .0622); however, low FCGR2B expression favored R-CHOP (HR, 1.58; 95% CI, 1.00-2.50; P = .0503). In Arthur and GOYA, FCGR2B expression was associated with tumor FcγRIIB expression; correlating with shorter PFS for R-CHOP (HR, 2.17; 95% CI, 1.04-4.50; P = .0378), but not G-CHOP (HR, 1.37; 95% CI, 0.66-2.87; P = .3997). This effect was independent of established prognostic biomarkers. High FcγRIIB/FCGR2B expression has prognostic value in R-treated patients with DLBCL and may confer differential responsiveness to R-CHOP/G-CHOP.

Objective This study aims to describe the prevalence, anatomy and morphology of ERSA (exercise-related signal abnormality) lesions, a previously undescribed pattern of muscle signal changes on MRI in professional soccer players with suspected acute thigh muscle injury. Methods A multicenter retrospective review was performed of 287 MRIs of professional soccer players referred for suspected acute thigh injury from August 2017 to February 2020. MR images were reviewed for muscle signal abnormalities corresponding to a peritendinous ovoid region or a subfascial ring of faint increased signal on fluid-sensitive MR images. Imaging features including anatomical site, morphology, and craniocaudal length were recorded. Concomitant acute muscle injury was graded in accordance with the British Athletics Muscle Injury Classification (BAMIC). Results ERSA lesions comprising a peritendinous ovoid region, a subfascial ring, or both, were identified in 40 muscles across 31/287 studies (10.8%). These lesions had a mean length of 15.8 cm and were predominantly located in the proximal or mid-portions of muscles. Affected muscles were rectus femoris (n = 22), adductor longus (n = 11), semitendinosus (n = 6) and biceps femoris (n = 1). 21/31 studies (67.7%) had a BAMIC grade 1–4 injury in a separate muscle, which were largely (81%) in a separate anatomic compartment or contralateral. Conclusion ERSA lesions were evident on MRI in 10.8% of our cohort of professional soccer players referred for suspected acute thigh muscle injury. Characteristic morphology and the longitudinal length (mean 15.8 cm) distinguish ERSA lesions from recognized patterns of acute muscle injury.

The Hintegra total ankle replacement (TAR) has been widely used worldwide for ankle arthroplasty since its introduction in 2000. The implant survivorship, patient reported outcomes, rate of periprosthetic cyst formation and reoperation rates are variably reported. The purpose of this study is to determine the functional outcomes and survivorship of the Hintegra TAR, in consecutive cases by multiple surgeons in a single UK institution, with a minimum of five year follow-up. A retrospective review of prospectively collected data for 70 consecutive Hintegra TAR cases performed between 2010 and 2014. Data collected included patient demographics, complications, reoperations, revisions and patient reported outcome measures (PROMS: AOS, MOX-FQ, pain VAS and EQ-5D 3L). Seventy patients underwent Hintegra TAR (54 male/16 female) with an average age of 69 (range 48–84 years). Mean follow up was 76 months (range 60–104), 10 patients died during the follow-up. Implant survivorship was 81.7% at most recent follow-up. The commonest radiographic finding was periprosthetic cysts (n = 28, 40%): size range (7–40 mm). Nine patients required re-operation: six periprosthetic cyst debridement and grafting at a mean of 61 months (range 27–91), one lateral gutter debridement, one periprosthetic fracture and one debridement for deep infection. PROMS data was available for the majority of patients. Mean final follow-up scores were total AOS 35 (range: 0–97), MOX-FQ 36 (range: 2–93), pain VAS 34.6 (range: 0–100) and EQ-5D 3L Index 0.69 (range: 0.08–1.00). Our experience demonstrates implant survivorship similar to other TAR studies. We have identified a high incidence of periprosthetic cysts and would recommend ongoing surveillance of these patients.

Determine the efficacy of intraoperative traction (IOT) on curve correction in AIS. A prospective, multicenter, longitudinal database identified patients with major thoracic AIS (Lenke 1–4) treated with surgery using IOT and follow-up of 2 years. These cases were matched to comparable cases treated without traction (non-IOT). All patients were treated with single-stage posterior only surgery with pedicle screw constructs. Perioperative, radiographic and clinical outcome data at 2 years post-op were compared between the groups. 104 cases treated with IOT were matched to 104 treated without IOT. Operating room time was significantly greater in the IOT group (339 vs. 306 min, p = 70° (IOT 72% vs. non-IOT 64%, p = 0.04). IOT was associated with a significant reduction in 2D T5–T12 kyphosis measurements (IOT − 6.5° vs non-IOT + 0.48°, p

Pattern hair loss (PHL) is a chronic regressive condition of the scalp, where follicular miniaturisation and decreased scalp hair coverage occurs in affected areas. In all PHL cases, there is a measurable progressive shortening of the terminal hair growth duration, along with reduced linear growth rates. In both genders, PHL initially shows an increase in short telogen hairs ≤30 mm in length, reflecting a cycle completion of under 6 months in affected terminal hair follicles. To understand the miniaturisation process, we re-examine the dynamics of miniaturisation and ask the question, "why do miniaturised hair follicles resist treatment?" In the light of recent developments in relation to hair regeneration, we looked back in the older literature for helpful clues "lost to time" and reprise a 1978 Hermann Pinkus observation of an array of elastin deposits beneath the dermal papilla following subsequent anagen/telogen transitions in male balding, originally described by Arao and Perkins who concluded that these changes provide a "morphologic marker of the entire biologic process in the balding scalp." Thus, we have reviewed the role of the elastin-like bodies in hair pathology and we propose that alterations in elastin architecture may contribute to the failure of vellus-like hair reverting back to their terminal status and may indicate a new area for therapeutic intervention.

Background Using frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process. Method In phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria. Results The COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels. Conclusion Frameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting.

Over the past quarter of a century, there have been calls in pediatrics to develop partnerships with home visitors to achieve synergy in the promotion of optimal child health and development. Yet, there is scant evidence-base upon which to move forward with such relationships. Efficacy data that exists is often of narrow focus and insufficient breadth. A working group met in South Carolina in early 2020 composed of pediatric clinicians and their staffs in offices with in-house home visitation programs to define postulated benefits of home-visiting medical home partnerships as a basis for further research. They suggested that benefits might include more opportunity for screening and assessment, an opportunity to address socio-environmental and mental health issues more fully, stronger supportive and therapeutic relationships among families and service providers, more appropriate health care utilization, and better child and family outcomes. Potential barriers to these partnerships included inadequate evidence-base, complicated funding issues, a lack of appreciation of home visitor, and pediatrician value as each profession works within their silos, inertia and resistance to change, family acceptance of services, and workforce issues. It is hoped that there will be more investigation and research focused on these parameters as we develop a robust evidence base for pediatric and home-visiting partnerships.

Background Echocardiographic parameters have been poorly investigated for estimating cardiovascular risk in patients with sepsis and new-onset atrial fibrillation. We aim to assess the prevalence of transesophageal echocardiographic abnormalities and their relationship with cardiovascular events in mechanically ventilated patients with sepsis and new-onset atrial fibrillation. Methods In this prospective multicenter pilot study, left atrial/left atrial appendage (LA/LAA) dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were assessed using an initial transesophageal echocardiographic study, which was repeated after 48–72 h to detect LA/LAA thrombus formation. The study outcome was a composite of cardiovascular events at day 28, including arterial thromboembolic events (ischemic stroke, non-cerebrovascular arterial thromboembolism, LA/LAA thrombus), major bleeding, and all-cause death. Results The study population comprised 94 patients (septic shock 63%; 35% women; median age 69 years). LA/LAA dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were detected in 17 (19%), 22 (24%), and 27 (29%) patients, respectively. At day 28, the incidence of cardiovascular events was 46% (95% confidence interval [CI]: 35 to 56). Arterial thromboembolic events and major bleeding occurred in 7 (7%) patients (5 ischemic strokes, 1 non-cerebrovascular arterial thromboembolism, 2 left atrial appendage thrombi) and 18 (19%) patients, respectively. At day 28, 27 patients (29%) died. Septic shock (hazard ratio [HR]: 2.36; 95% CI 1.06 to 5.29) and left ventricular systolic dysfunction (HR: 2.06; 95% CI 1.05 to 4.05) were independently associated with cardiovascular events. Conclusions Transesophageal echocardiographic abnormalities are common in mechanically ventilated patients with sepsis and new-onset atrial fibrillation, but only left ventricular systolic dysfunction was associated with cardiovascular events at day 28.

21st Century Standards and the Deeper Learning movement emphasize the ability to think critically and solve complex problems, to work well in teams, and to communicate effectively. While traditional classroom activities can meet these objectives, digital games and simulations provide unique affordances. When designed to incorporate formative assessment functions, games and simulations can capture detailed data on learners’ performances and provide learners with immediate feedback. In spite of their strengths, barriers exist to practitioners’ adoption of game-based and simulation-based formative assessments. Adoption can be slowed where product designs do not account for unique local requirements of classrooms and schools. The current work investigates reduction and removal of barriers to adoption of games and simulations among classroom instructors through use of the Integrated BEAR Design System (IBDS). The IBDS provides a design process that accounts for local requirements by engaging practitioners in principled design and development of game-based formative assessments. The paper summarizes the IBDS and a single case in which the IBDS was applied to design a game-based formative assessment for collaborative-problem solving, Little Fish Lagoon. The game is accompanied by a stand-alone chat system, Libra Text, that allows collaborating players to send text messages to each other while they use the game. Study participants were six instructors from six U.S. schools. The participating instructors planned for broad adoption of the multiplayer collaboration game in their local classroom settings. The authors illustrate their use of the IBDS with the participating instructors in order to co-develop formative assessments that fit their local needs using data collected from the Little Fish Lagoon educational game and the Libra Text chat tool. The benefits of the IBDS, its implications for learning designers, potential improvements, and needed future research are discussed. The paper is expected to be of interest to learning and assessment designers working with educational games and simulations, and others interested in barriers to adoption of new technologies in general.

To describe a distinct constellation of MRI demonstrated soft tissue abnormalities centred around the tibialis anterior tendon in a subset of patients presenting as suspected tibial stress injury. A retrospective review was performed of the clinical and MRI imaging findings from 5 selected patients referred for MRI with suspected tibial stress injury. MRI studies at presentation of each case were systematically reviewed for peritendinous fluid, tibialis anterior tendon change, tibialis anterior muscle and myotendinous junction oedema, periosteal oedema over the tibia and tibial marrow oedema. All 5 cases were athletes (3 soccer players, 2 runners) of between 20 and 40 years of age. On MRI, all 5 cases demonstrated peritendinous fluid around an intact tibialis anterior tendon. This fluid was maximal at the junction of mid and distal thirds of the lower leg, and extended down to the superior extensor retinaculum, with a mean cranio-caudal length of 13 cm (range 8–17 cm). Associated oedema was present in the surrounding subcutaneous tissue, tibial periosteum and distal tibialis anterior musculotendinous junction. Peritendinous fluid around an intact tibialis anterior tendon over the mid-to-distal third tibia, with surrounding subcutaneous, periosteal and tibialis anterior myotendinous junction oedema is demonstrable on MRI in a subset of patients presenting as suspected tibial stress injury. A friction syndrome of tibialis anterior between the superior extensor retinaculum and the anterior tibia is proposed as the aetiology of this entity.

Background The term temporomandibular disorder (TMD) includes disorders of the temporomandibular joints (TMJ), masticatory muscles and adjacent tissues. Several studies have examined the effectiveness of manual therapy (MT) for TMDs by evaluating changes in pain and maximum mouth opening (MMO). Nevertheless, the effectiveness of MT exclusively applied to the craniomandibular structures (craniomandibular manual therapy (CMMT)) on pain and TMJ range of motion remains unclear. This review aims to evaluate the effectiveness of CMMT on pain and TMJ range of motion in people with TMDs. Methods This protocol is reported in line with the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P). Databases including MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews–Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar will be searched from inception as well as key journals and grey literature. Randomised controlled trials involving adults with TMD that compare the effect of any type of CMMT (e.g. mobilisation) on pain and range of motion with a placebo intervention, controlled care intervention or other types of treatment will be included. Two reviewers will independently screen articles for inclusion, extract data, assess risk of bias (revised Cochrane risk of bias tool) for included studies and evaluate overall quality of evidence (Grading of Recommendations Assessment, Development and Evaluation). A meta-analysis will be conducted if possible. If not, a narrative synthesis will be conducted reporting the effectiveness of CMMT according to disorder type (TMJ disorders, masticatory muscle disorders and mixed disorders). Discussion In this review, the effectiveness of MT applied to craniomandibular structures for the treatment of TMD will be evaluated. Results will be submitted for publication in a peer-reviewed journal and presented at conferences. We expect our findings will facilitate treatment planning for manual therapists managing patients with TMD and provide future clinical research implications. Systematic review registration PROSPERO CRD42019160213

Background Backed by over 20 years of research development, the Wheelchair Skills Program (WSP) has proven to be a safe and effective program to improving wheelchair skills for adult wheelchair users. However, evidence is lacking for the pediatric population, which may help to explain the limited use of the WSP in pediatric settings. While additional evidence specific to the pediatric population is needed, concurrent implementation of the WSP into pediatric clinical practice is equally prudent to allow those users to benefit from the years of accumulated WSP evidence. To facilitate implementation of evidence-based programs into practice, adaptation is also often required to improve the fit between the program and the local context. Therefore, the objective of this study was to understand what adaptations, if any, are required for the WSP to be implementable in a pediatric setting. Methods A deductive qualitative descriptive study design was used, guided by the Knowledge to Action Framework and Consolidated Framework for Implementation Research (CFIR). Occupational Therapists (OTs) from a pediatric rehabilitation center and two specialized schools in Montreal, Canada were invited to participate in a 90-min focus group. The Framework Method was followed for the data analysis. Results One focus group in each site (n = 3) was conducted with a total of 19 participants. From the OTs’ perspectives, our analysis revealed benefits of WSP use and various issues (e.g. some skills seem unrealistic) affecting its uptake in relation to the constructs of the CFIR Intervention Characteristics domain. The results provided guidance for the recommendations of adaptations (e.g. addition of a caregiver assistance score) to enhance implementation of the WSP in pediatric rehabilitation settings and helped to identify the need for the production of new knowledge and knowledge translation (KT) tools. Conclusions Implementation of the WSP with the adaptations and KT tools proposed could allow pediatric manual wheelchair users to improve their wheelchair skills.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

To gain an in-depth understanding of the experience of pediatric intensive care unit (PICU) clinicians caring for children with chronic critical illness (CCI), we conducted, audiotaped, and transcribed in-person interviews with PICU clinicians. We used purposive sampling to identify five PICU patients who died following long admissions, whose care generated substantial staff distress. We recruited four to six interdisciplinary clinicians per patient who had frequent clinical interactions with the patient/family for interviews. Conventional content analysis was applied to the transcripts resulting in the emergence of five themes: nonbeneficial treatment; who is driving care? Elusive goals of care, compromised personhood, and suffering. Interventions directed at increasing consensus, clarifying goals of care, developing systems allowing children with CCI to be cared for outside of the ICU, and improving communication may help to ameliorate this distress.

Determine the incidence of metallosis around MAGEC rods. A multicentre explant database was searched to identify cases with complete intraoperative findings at rod removal. Surgeons removing rods detailed the presence or absence of tissue metallosis associated with rods. More recently surgeons measured the ‘length’ of tissue metallosis. Prior to rod disassembly, the majority underwent testing with an external remote controller (ERC). The impact of clinical and explant variables on metallosis was assessed. Sixty-six cases were identified. Mean age at insertion was 8.1 ± 2.3 years with mean duration of implantation 37.6 ± 15.1 months. Tissue metallosis was noted at revision surgery in 52/66 cases (79%). Metallosis was noted more commonly when rods were removed during fusion surgery than rod removal/exchange (97% vs. 58% (p =

The use of subpalpebral lavage systems is commonplace in equine ophthalmology and its use has also been described in humans, llamas and a harbour seal. However, reports of this drug delivery technique in dogs are lacking. This case study describes four cases of corneal ulceration in fractious dogs, where a subpalpebral lavage system was used to apply topical medication. Clinical presentation, surgical techniques and the outcomes are described. All dogs were successfully treated by their owners using this technique, and no major complications were reported.

Rotator cuff tears are a common cause of shoulder pain. The incidence of these tears has increased significantly over the years, with the demands of an increasingly active elderly population. Therefore, a detailed understanding of rotator cuff tears will help doctors manage their patients' condition. This field has rapidly advanced over the past decade and this review provided an insight into the latest developments.

Background Ethical challenges in clinical practice significantly affect frontline nurses, leading to moral distress, burnout, and job dissatisfaction, which can undermine safety, quality, and compassionate care. Objectives To examine the impact of a longitudinal, experiential educational curriculum to enhance nurses’ skills in mindfulness, resilience, confidence, and competence to confront ethical challenges in clinical practice. Methods A prospective repeated-measures study was conducted before and after a curricular intervention at 2 hospitals in a large academic medical system. Intervention participants (192) and comparison participants (223) completed study instruments to assess the objectives. Results Mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly after the intervention. Resilience and mindfulness were positively correlated with moral competence and work engagement. As resilience and mindfulness improved, turnover intentions and burnout (emotional exhaustion and depersonalization) decreased. After the intervention, nurses reported significantly improved symptoms of depression and anger. The intervention was effective for intensive care unit and non–intensive care unit nurses (exception: emotional exhaustion) and for nurses with different years of experience (exception: turnover intentions). Conclusions Use of experiential discovery learning practices and high-fidelity simulation seems feasible and effective for enhancing nurses’ skills in addressing moral adversity in clinical practice by cultivating the components of moral resilience, which contributes to a healthy work environment, improved retention, and enhanced patient care.

This essay explores what to make of the various kinds of moral distress and moral injury increasingly discussed in multiple disciplines and fields of work. It argues for transdisciplinary cooperation and inquiry and proposes a common name "moral suffering" to embrace the diversity of morally fracturing experiences that negatively impact those in health care and other helping professions. The authors offer important insights into the phenomenological relationship between moral conscience and traumatic experience, presenting questions and offering a possible hypothesis for those who want to pursue this discussion further. The essay reviews the diversity of theories regarding moral distress and moral injury advanced by health-care researchers, military clinicians, and educators. It names questions that transdisciplinary engagement can help address, such as what do the disciplines of health humanities, psychology, and education have to teach each other about prevention of moral harm and the healing of invisible wounds?

Background Poor recovery from periods of disuse accelerates age‐related muscle loss, predisposing individuals to the development of secondary adverse health outcomes. Exercise prior to disuse (prehabilitation) may prevent muscle deterioration during subsequent unloading. The present study aimed to investigate the effect of short‐term resistance exercise training (RET) prehabilitation on muscle morphology and regulatory mechanisms during 5 days of bed rest in older men. Methods Ten healthy older men aged 65–80 years underwent four bouts of high‐volume unilateral leg RET over 7 days prior to 5 days of inpatient bed rest. Physical activity and step‐count were monitored over the course of RET prehabilitation and bed rest, whilst dietary intake was recorded throughout. Prior to and following bed rest, quadriceps cross‐sectional area (CSA), and hormone/lipid profiles were determined. Serial muscle biopsies and dual‐stable isotope tracers were used to determine integrated myofibrillar protein synthesis (iMyoPS) over RET prehabilitation and bed rest phases, and acute postabsorptive and postprandial myofibrillar protein synthesis (aMyoPS) rates at the end of bed rest. Results During bed rest, daily step‐count and light and moderate physical activity time decreased, whilst sedentary time increased when compared with habitual levels (P

Total intravenous anesthesia (TIVA) using a mixture of propofol and remifentanil in the same syringe has become an accepted technique in Pediatric Anesthesia. A survey by a group of respected UK anesthetists demonstrated a low incidence of serious complications, related to the pharmacology and dose of the drugs. However, a current guideline for the safe use of TIVA recommends against this practice. Pharmaceutical concerns include the physical stability of the emulsion when remifentanil is mixed with propofol; changes in drug concentration over time; nonuniform mixing of propofol and remifentanil; the risk of bacterial contamination; and the potential for drug administration errors. Propofol and remifentanil have markedly different pharmacokinetic profiles. When remifentanil is mixed with propofol and delivered as a target-controlled infusion (TCI) of propofol, remifentanil delivery is not target-controlled but passively follows the variable infusion rates calculated by the syringe driver to deliver predicted plasma or effect-site concentrations of propofol. The pharmacokinetic consequences can be illustrated using pharmacokinetic modeling similar to that used in TCI pumps. The clinical consequences reflect the dose-dependent pharmacodynamics of remifentanil. Increasing the target propofol concentration produces a rapid increase and peak in remifentanil concentration that risks apnea, bradycardia, and hypotension, especially with higher concentrations of remifentanil. The faster decline in remifentanil concentration with falling propofol concentrations risks inadequate narcosis and unwanted responses to surgical stimuli. Remifentanil delivery is inflexible and dosing cannot be adjusted to the clinical need and responses of individual patients. The medicolegal considerations are stark. In UK and EU Law, mixing propofol and remifentanil creates a new, unlicensed drug and the person mixing takes on the responsibilities of manufacturer. If a patient receiving anesthesia in the form of a mixed propofol-remifentanil infusion suffered a critical incident or actual harm, the clinician's practice may come under scrutiny and criticism, potentially involving a legal challenge and the Medical Regulator.

Background and objective Chronic pain following musculoskeletal trauma is common, which may partially be attributed to the early presence of central sensitisation (CS). Multiple measures are suggested to assess clinical features of CS, yet no systematic review has evaluated the measurement properties of these measures in a musculoskeletal trauma population. Databases and data treatment This systematic review, which followed a published and PROSPERO registered protocol (CRD42018091531), aimed to establish the scope of CS measures used within a musculoskeletal trauma population and evaluate their measurement properties. Searches were conducted in two stages by two independent reviewers. The Consensus-based Standards for the selection of Health Measurement instruments (COSMIN) checklist was used to evaluate risk of bias and overall quality was assessed using the modified Grading of Recommendations Assessment, Development and Evaluation. Results From 86 studies, 30 different CS outcome measures were identified. Nine studies evaluated measurement properties of nine outcome measures; eight evaluated reliability and one evaluated construct validity. Measures included seven quantitative sensory testing methods (pressure, cold and electrical pain thresholds; warm, cold and vibration detection thresholds; vibration perception thresholds), pain drawings and a pinwheel. Risk of bias was assessed as doubtful/inadequate for all but one study, overall quality of evidence was low/very low for all measures. Reliability of measures ranged from poor to excellent. Conclusions Many measures are used to evaluate CS but with limited established measurement properties in musculoskeletal trauma. High quality research to establish measurement properties of CS outcome measures is required.

Summary Background The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI. Methods A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA). Results We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4–36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4–11.4, p = 0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0–10.0, p = 0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p = 0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p = 0.010). Conclusions Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients. Summary table . Association of circumcision status with dilating VUR and hydronephrosis (HN). Abnormalities Prevalence in uncircumcised boys Prevalence in circumcised boys Unadjusted Prevalence ratio (95% CI) P value Adjusted a Prevalence ratio (95% CI) P value Grade ≥III VUR 6.3% 23.1% 3.7 (1.8, 7.6) 5.3 (2.4, 11.4) Grade 3–4 HN 4.4% 8.6% 1.9 (0.8, 4.7) 0.148 3.1 (1.0, 10.0) 0.050 Grade ≥III VUR or Grade 3–4 HN 11.2% 28.2% 2.5 (1.4, 4.6) 0.003 3.6 (1.9, 6.8) a Adjusted for age, race, ethnicity, and UTI organisms.

BACKGROUND In response to a growing number of patients on the UK urgent heart transplant waiting list, the UK donor heart allocation scheme was revised in October 2016 with the introduction of a new super-urgent category. Patients with temporary mechanical circulatory support (tMCS) became eligible for super-urgent registration. The aim of this study was to compare activity, indications, and outcomes before and after the change. METHODS Data on adult (aged ≥16 years) heart transplant registrations and recipients in the 2 years before (Era 1: July 1, 2014–June 30, 2016) and after (Era 2: January 2017–December 2018) the introduction of the new scheme were extracted from the UK Transplant Registry and analyzed using competing risks analysis, Kaplan–Meier analysis, and Cox proportional-hazards regression. RESULTS There were 525 waiting-list registrations in Era 1 and 594 in Era 2, including 14% super-urgent registrations, with 90% having some form of tMCS. Median waiting time to transplant was 41 days for all urgent registrations in Era 1 compared with 17 days for super-urgent registrations and 71 days for urgent registrations in Era 2. Numbers of non-urgent transplants were not affected. Deaths on the waiting list significantly decreased from 5% to 2% at 6 months between Era 1 and Era 2 (adjusted hazard ratio = 0.29, 95% CI = 0.13–0.62). In addition, total number of patients with tMCS were not different between both eras, suggesting no significant change in this area of clinical decision making. Post-transplant survival at 1 year for super-urgent recipients was not significantly different from post-transplant survival at 1 year for other categories. CONCLUSIONS The Introduction of a super-urgent heart allocation scheme in the UK reduces waiting time to transplant for the sickest patients, with comparable post-transplant survival while reducing deaths on the waiting list.

Anthracyclines are frequently used in adjuvant treatment for early-stage breast cancer (ESBC). The purpose of this study was to evaluate cardiotoxic effects in the first five years after treatment with different anthracycline-based regimens. CCTG MA.21 (NCT000142) was a phase III trial in ESBC that compared cyclophosphamide (75 mg/m2) orally for 14 days, epirubicin (60 mg/m2) and fluorouracil, IV days one and eight (CEF) for six cycles; dose-dense epirubicin (120 mg/m2) and cyclophosphamide, IV every 2 weeks for six cycles with concurrent G-CSF then paclitaxel every 2 weeks for four cycles (ddEC/T); doxorubicin (60 mg/m2) and cyclophosphamide (600 mg/m2) every 3 weeks for four cycles then four cycles q3 weekly paclitaxel (175 mg/m2) (AC/T). Endpoints: LVEF decline; LV function changes (heart failure), or Grade 3–4 cardiac ischemia/infarction. A competing risk analysis was performed with endpoints of cardiotoxicity or recurrence in first 5 years after completion of chemotherapy. 2104 women were randomized. Compliance with cardiac LVEF assessments was 70% at 5 years in all arms. The 5-year cumulative risks of any cardiac event for CEF, ddECT, and AC/T were 22.3% (95%CI 18.9 to 25.7), 14.2% (95%CI 11.0 to 17.3), and 8.1% (95%CI 5.8 to 10.4), respectively, p

The importance of how classroom discourse can be used to support science learning has gained national attention with respect to both science teaching and research across K12 and higher education. In this review article, we examine a commonly referenced set of nine frameworks for use in science classrooms. Specifically, we examine the ways in which various frameworks emphasize the structure (i.e., form) or practical use (i.e., function) of language across classroom settings, and the impact of such an emphasis on the facilitation and analysis of science classroom discourse. The findings from this review should help researchers investigate and educators facilitate classroom discourse in ways that ensure that all students can participate in and demonstrate their scientific understanding.

BackgroundYouth athletes are under increasing pressures to excel in their chosen sport and many turn to nutritional supplements in order to enhance sports performance. However, athletes may obtain their nutritional information via illegitimate sources such as the internet, media, and other athletes, representing miscommunication between sound scientific information and anecdotal experiences. The objective of this investigation was to examine nutrition knowledge of elite youth athletes from a non-residential regional academy of sport.MethodsA previously validated two-part nutrition knowledge questionnaire (NKQ) was administered to 101 (37 male and 64 female) non-residential regional Academy of Sport elite youth athletes at an annual training camp. Part 1 of the NKQ presented demographic questions. Part 2 presented 90 sports nutrition knowledge questions in seven knowledge subcategories (1) Nutrients; (2) Dietary reference intakes (DRI); (3) Fluids/Hydration; (4) Recovery; (5) Weight gain; (6) Weight loss; and (7) Supplements.ResultsThe mean NKQ score of all athletes was 43.8% (± 11.4). No gender differences observed between nutritional knowledge total scores, however female athletes recorded more ‘correct’ responses than males (p = 0.02) in the Nutrients subcategory. Majority of athletes had difficulty identifying correct DRI with this subcategory featuring the lowest percentage of ‘correct’ to ‘incorrect’ responses (27.1% ± 2.3;p = 0.02). Supplements subcategory displayed much uncertainty with significantly more ‘unsure’ than ‘incorrect’ responses (42.4% ± 20.3;p ConclusionsIn agreement with previous research, results of the current study indicate that elite youth athletes lack fundamental nutritional knowledge, specifically related to DRI and supplementation. These data provide further support of current recommendations that Academy of Sport youth athletes may benefit from integrated nutrition education conducted by qualified nutrition professionals.

Background: Crotalinae (pit viper) envenomations are frequently encountered in North American emergency departments. Cases can be complicated by ambiguity in initial species identification as well ...

Severe acute kidney injury (AKI), defined as requiring renal replacement therapy (RRT), is associated with higher mortality postheart transplantation, but its long-term renal consequences are not known. Anonymized data of 3365 patients, who underwent heart transplantation between 1995 and 2017, were retrieved from the UK Transplant Registry. Multivariable binary logistic regression was performed to identify risk factors for severe AKI requiring RRT, Kaplan-Meier analysis to compare survival and renal function deterioration of the RRT and non-RRT groups, and multivariable Cox regression model to identify predicting factors of mortality and end-stage renal disease (ESRD). 26.0% of heart recipients received RRT post-transplant. The RRT group has lower survival rates at all time points, especially in the immediate post-transplant period. However, conditional on 3 months survival, older age, diabetes and coronary heart disease, but not post-transplant RRT, were the risk factors for long-term survival. The predicting factors for ESRD were insulin-dependent diabetes, renal function at transplantation, eGFR decline in the first 3 months post-transplant, post-transplant severe AKI and transplantation era. Severe AKI requiring RRT post-transplant is associated with worse short-term survival, but has no impact on long-term mortality. It also accelerates recipients' renal function deterioration in the long term.

Objectives To explore the multidisciplinary team experience of Low Back Pain (LBP) in elite gymnastics. Design A qualitative focus group. Setting British Gymnastics. Participants Ten coaching, sports science and medicine multidisciplinary team members working with British gymnasts. Main outcome measures A topic guide informed by literature/expert opinion enabled discussion that was recorded/transcribed verbatim. Initial inductive analytic process developed theoretical insights. Manual coding using constant comparative methods categorised meaningful themes and sub-themes. Results Two key aspects were identified. Emerging themes for LBP presentation included: early identification LBP and influence of multidisciplinary team members on outcomes; factors influencing LBP reporting e.g. coach-athlete relationship; frequent presentations of LBP and accepted norms; athlete history and physical examination e.g. training load. Emerging themes for causation of LBP included: intrinsic risk factors e.g. growth and maturation; extrinsic risk factors e.g. equipment. Conclusions Individual responses of a gymnast to experiencing LBP were important across all themes. Some LBP was perceived as normal. The coach-athlete relationship and support team are crucial decision-makers around training load and adaptation. Early detection will help minimise time loss from training/performance to expedite healing.

Diffuse large B-cell lymphoma (DLBCL) patients are typically treated with immunochemotherapy containing rituximab (rituximab, cyclophosphamide, hydroxydaunorubicin-vincristine (Oncovin), and prednisone [R-CHOP]); however, prognosis is extremely poor if R-CHOP fails. To identify genetic mechanisms contributing to primary or acquired R-CHOP resistance, we performed target-panel sequencing of 135 relapsed/refractory DLBCLs (rrDLBCLs), primarily comprising circulating tumor DNA from patients on clinical trials. Comparison with a metacohort of 1670 diagnostic DLBCLs identified 6 genes significantly enriched for mutations upon relapse. TP53 and KMT2D were mutated in the majority of rrDLBCLs, and these mutations remained clonally persistent throughout treatment in paired diagnostic-relapse samples, suggesting a role in primary treatment resistance. Nonsense and missense mutations affecting MS4A1, which encodes CD20, are exceedingly rare in diagnostic samples but show recurrent patterns of clonal expansion following rituximab-based therapy. MS4A1 missense mutations within the transmembrane domains lead to loss of CD20 in vitro, and patient tumors harboring these mutations lacked CD20 protein expression. In a time series from a patient treated with multiple rounds of therapy, tumor heterogeneity and minor MS4A1-harboring subclones contributed to rapid disease recurrence, with MS4A1 mutations as founding events for these subclones. TP53 and KMT2D mutation status, in combination with other prognostic factors, may be used to identify high-risk patients prior to R-CHOP for posttreatment monitoring. Using liquid biopsies, we show the potential to identify tumors with loss of CD20 surface expression stemming from MS4A1 mutations. Implementation of noninvasive assays to detect such features of acquired treatment resistance may allow timely transition to more effective treatment regimens.

Burnout, a syndrome resulting from chronic job-related stress in the workplace, is an extensive problem among clinicians working in health care organizations. The 3 dimensions of burnout include emotional exhaustion, depersonalization, and loss of a sense of professional efficacy. Approximately 35% of all nurses experience symptoms of burnout. Critical care nurses are at risk for chronic job stress because of the complexity and pace of the critical care environment. Addressing the individual and systems-related factors that stem from the work environment is essential in order to achieve well-being among all clinicians. Strategies aimed at fostering individual resilience and well-being must be coupled with systemic solutions that create a work environment that removes impediments to ethically grounded practice, restores fulfillment achieved in clinical practice, and fosters resilience and well-being.

Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “Training and retention of specialist staff”, “Health education/awareness of injury severity”, “Geographical coverage of referral trauma centres”, and “Lack of protocol for bypass to referral centres”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

AimsSignificant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.MethodsA total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression.ResultsOf the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex.ConclusionOur study supports the ‘essential lordosis’ hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513–518.