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OBJECTIVE To investigate the therapeutic effects of topical equine amniotic membrane (eAM) suspension following corneal wounding in a controlled experimental setting. PROCEDURES Equine amniotic membrane was collected, gamma irradiated, homogenized for topical suspension preparation, and cryopreserved. Corneoscleral rims harvested from fresh rabbit globes were wounded via keratectomy and were maintained in an air-liquid interface ex vivo corneal culture model. Treatment groups included topical gamma irradiated eAM suspension (n = 20) and a control group (n = 20). Re-epithelialization of the wound was assessed with daily photographic evaluation of area of fluorescein uptake (mm2 ). Corneal wound haze after a 21-day period was assessed by photographic analysis of haze area (mm2 ) and pixel intensity (0-255). Histologic processing of corneal tissue was performed, and protein identification of eAM suspension using Liquid chromatography-mass spectrometry (LC-MS). RESULTS The average day of complete corneal re-epithelialization in controls (5.5 ± 1.1) and topically treated (5.5 ± 0.6) corneas, and rates of reduction in area of fluorescein uptake over time did not significantly differ (p = .44). The corneal wound haze was significantly reduced in mean area by approximately 52% and intensity by 57% in corneas treated with topical eAM suspension (p

Background Although a variety of standardized measurements have been described to evaluate acetabular dysplasia, no single measurement is without limitations. We describe the Sourcil Index (SI), a novel measure of the weight-bearing surface of the acetabulum on anteroposterior pelvis films. The SI is the angle formed by the medial and lateral margins of the sourcil and the center of rotation of the femoral head. Methods Anteroposterior pelvis radiographs of skeletally mature patients from 2015 were reviewed. Studies with fractures or implants were excluded. Films were read by 2 orthopedic surgeons and a radiologist 3 times each, 8 weeks apart. The SI, Sharp's Angle (SA), and lateral center edge angle (LCEA) were recorded. Pearson intraclass correlation coefficients with 95% confidence intervals were calculated. The SI was then compared to the SA and LCEA to preliminarily assess diagnostic accuracy. Results Five hundred thirty-five hips in 292 patients met inclusion. Intraobserver reliability is as follows: SI = 0.95 (0.93-0.98), LCEA = 0.89 (0.82 -0.96), and SA = 0.90 (0.85-0.96). Interobserver reliability is as follows: SI = 0.90 (0.84-0.94), SA = 0.78 (0.64-0.86), and LCEA = 0.73 (0.56-0.82). There were 51 dysplastic hips within this cohort. Conclusion The SI is a reproducible measurement on plain radiographs. The SI is a two-dimensional representation of the size of the weight-bearing surface of the acetabulum and could provide an estimation of joint contact pressures. Used with existing measures, the SI may provide a more nuanced understanding of acetabular morphology.

Background In keeping with nation-wide efforts to contain the spread of COVID-19, Universiti Brunei Darussalam (UBD) transformed fully its pedagogical delivery to online mode, where we investigated teaching and learning experiences, physical and mental health of undergraduate students and lecturers during the COVID-19 pandemic. Methods We conducted a cross-sectional study on undergraduate students and lecturers in a health science faculty using a self-developed pretested questionnaire through anonymous online data collection method. Results Fifty-six lecturers (100% response rate) and 279 students (93.3% response rate) participated. The positive experiences reported by students include becoming independent (72.8%) and adapting to online learning (67.4%), while lecturers learned new teaching techniques (50.0%) and became more innovative (50.0%) by learning new tools (48.2%). However, studying at home caused students to feel more distracted (72.0%) with a feeling of uncertainty towards examinations (66.7%), while lecturers felt that students’ laboratory skills were compromised (44.6%). Even though online delivery of assessments enabled lecturers to explore all options (50.0%), they found it difficult to maintain appropriate questions (41.1%) and fair assessments (37.5%). Majority of students missed eating out (68.8%) and felt a lack of participation in extracurricular activities (64.9%), while lecturers reported more time for exercise (51.8%), despite having more screen time (50.0%) and computer-related physical stress (44.6%). In terms of mental health, increased stress in students was reported (64.9%), though they had more time for self-reflection (54.8%). Although lecturers reported a closer relationship with family (44.6%), they also felt more stressed due to deadlines, unexpected disruptions and higher workloads (44.6%) as well as concerns related to work, family and self (39.3%). Conclusion In this abrupt shift to online teaching, students and lecturers in our study identified both positive and negative experiences including the impact on their physical and mental health. Our findings are important to provide the evidence for online pedagogical benefits and can serve to promote the enhancement and adaptation of digital technology in education. Our findings also aim to promote the importance of addressing physical and mental health issues of the university community’s well-being through provision of emotional and mental health support and appropriate programs.

As the world endures a viral pandemic superimposed on a diabetes pandemic, the latter incorporates most of the comorbidities associated with the former, thereby exacerbating risk of death in both. An essential approach to both pandemics is prevention and unrealized earlier treatment. Thus, in this Perspective relating to diabetes, we emphasize a paradigm of, first, reversible β-cell organ dysfunction and then irreversible β-cell organ failure, which directly indicate the potential for earlier prevention, also unrealized in current guidelines. Four pillars support this paradigm: epidemiology, pathophysiology, molecular pathology, and genetics. A substantial worldwide knowledge base defines each pillar and informs a more aggressive preventive approach to most forms of the disorder. This analysis seeks to clarify the temporal and therapeutic relationships between lost β-cell function and content, illuminating the potential for earlier diagnoses and, thus, prevention. We also propose that myriad pathways leading to most forms of diabetes converge at the endoplasmic reticulum, where stress can result in β-cell death and content loss. Finally, genetic and nongenetic origins common to major types of diabetes can inform earlier diagnosis and, potentially, prevention, with the aim of preserving β-cell mass.

An acute reduction in plasma osmolality causes rapid uptake of water by astrocytes but not by neurons, whereas both cell types swell as a consequence of lost blood flow (ischemia). Either hypoosmolality or ischemia can displace the brain downwards, potentially causing death. However, these disorders are fundamentally different at the cellular level. Astrocytes osmotically swell or shrink because they express functional water channels (aquaporins), whereas neurons lack functional aquaporins and thus maintain their volume. Yet both neurons and astrocytes immediately swell when blood flow to the brain is compromised (cytotoxic edema) as following stroke onset, sudden cardiac arrest, or traumatic brain injury. In each situation, neuronal swelling is the direct result of spreading depolarization (SD) generated when the ATP-dependent sodium/potassium ATPase (the Na+/K+ pump) is compromised. The simple, and incorrect, textbook explanation for neuronal swelling is that increased Na+ influx passively draws Cl− into the cell, with water following by osmosis via some unknown conduit. We first review the strong evidence that mammalian neurons resist volume change during acute osmotic stress. We then contrast this with their dramatic swelling during ischemia. Counter-intuitively, recent research argues that ischemic swelling of neurons is non-osmotic, involving ion/water cotransporters as well as at least one known amino acid water pump. While incompletely understood, these mechanisms argue against the dogma that neuronal swelling involves water uptake driven by an osmotic gradient with aquaporins as the conduit. Promoting clinical recovery from neuronal cytotoxic edema evoked by spreading depolarizations requires a far better understanding of molecular water pumps and ion/water cotransporters that act to rebalance water shifts during brain ischemia.

Background Coronary microvascular dysfunction (CMD) is associated with heart failure with preserved ejection fraction (HFpEF); however, pathophysiology is not well described. Hypothesis We hypothesized that CMD in women with suspected ischemia with no obstructive coronary artery disease (INOCA) is associated with cardiomyocyte dysfunction reflected by plasma levels of a cardiomyocyte calcium handling protein, cardiac bridge integrator 1 (cBIN1). Methods Women with suspected INOCA undergoing coronary function testing were included. Coronary flow reserve, vasodilation to nitroglycerin, change in coronary blood flow (ΔCBF), and vasodilation to acetylcholine (ΔAch) were evaluated. cBIN1 score (CS) levels in these women (n = 39) were compared to women with HFpEF (n = 20), heart failure with reduced ejection fraction (HFrEF) (n = 36), and reference controls (RC) (n = 50). Higher CS indicates cardiomyocyte tubule dysfunction. Results INOCA, HFpEF, and HFrEF women were older than RC (p

INTRODUCTION Limited data are available about the outcomes of transcatheter mitral valve replacement (TMVR) using transseptal approach in patients with prior mitral valve repair (valve-in-ring) or replacement (valve-in-valve) (TMViVR) and on modes of the prior surgical valve failures. We report our tertiary center TMVR experience in high surgical risk patients with prior mitral valve repair or replacement. METHODS From December 2016 to January 2020, patients with symptomatic severe mitral valve stenosis and/or insufficiency at increased redo surgical risk were included. TMViVR was performed off-label with Sapien S3 valve (Edwards Lifesciences). Patients were followed within 30-days and 1-year from the procedure. RESULTS Twenty-seven patients underwent transcatheter mitral valve-in-valve (n = 21) or valve-in-ring (n = 6) replacement. Mean ± SD age was 71.8 ± 11 years with Society of Thoracic Surgeons' calculated mortality 7.1 ± 4.6%. The etiology of valve failure was stenosis in 17 (63%) patients, insufficiency in 4 (14.8%) patients, and both in 6 (22.2%) patients. TMViVR technical success was 100% in all patients. Left ventricular outflow track (LVOT) obstruction was observed in only one (3.7%) patient. Zero patients had moderate or severe central mitral valve regurgitation or paravalvular leak. All patients had symptomatic improvement at 30 days. The mean transmitral diastolic pressure gradient decreased from 14.1 ± 4.6 to 6.9 ± 4.6 mm Hg (p

Avalanche Photodiodes (APDs) are key semiconductor components that amplify weak optical signals via the impact ionization process, but this process’ stochastic nature introduces ‘excess’ noise, limiting the useful signal to noise ratio (or sensitivity) that is practically achievable. The APD material’s electron and hole ionization coefficients (α and β respectively) are critical parameters in this regard, with very disparate values of α and β necessary to minimize this excess noise. Here, the analysis of thirteen complementary p-i-n/n-i-p diodes shows that alloying GaAs with ≤ 5.1 % Bi dramatically reduces β while leaving α virtually unchanged—enabling a 2 to 100-fold enhancement of the GaAs α/β ratio while extending the wavelength beyond 1.1 µm. Such a dramatic change in only β is unseen in any other dilute alloy and is attributed to the Bi-induced increase of the spin-orbit splitting energy (∆so). Valence band engineering in this way offers an attractive route to enable low noise semiconductor APDs to be developed., An avalanche photodiode is an opto-electronic amplifier that uses impact ionization to provide enhanced sensitivity at the expense of excess noise. In this manuscript, the authors demonstrate that a small amount of Bismuth (Bi) in Gallium Arsenide (GaAs) avalanche photodiodes significantly reduces this excess noise.

OBJECTIVE The goal of this study was to evaluate the clinical and radiographic outcomes of a novel multidirectional in situ expandable minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF) cage. METHODS A retrospective analysis of 69 consecutive patients undergoing a 1- or 2-level MIS TLIF using an expandable cage was performed over a 2-year period. Standard MIS techniques with pedicle screw fixation were used in all cases. Upright lateral dynamic flexion/extension radiographs were reviewed prior to and at 1 year after surgery. Clinical metrics included numeric rating scale for back and leg pain, Oswestry Disability Index, and the SF-12 and VR-12 physical and mental health surveys. Radiographic parameters included anterior and posterior disc height, neuroforaminal height, spondylolisthesis, segmental lordosis, lumbar lordosis, and fusion rate. RESULTS A total of 69 patients representing 75 operative levels met study inclusion criteria. The mean patient age at surgery was 63.4 ± 1.2 years, with a female predominance of 51%. The average radiographic and clinical follow-ups were 372 and 368 days, respectively. A total of 63 patients (91%) underwent 1-level surgery and 6 patients (9%) underwent 2-level surgery. Significant reductions of numeric rating scale scores for back and leg pain were observed—from 6.1 ± 0.7 to 2.5 ± 0.3 (p < 0.0001) and 4.9 ± 0.6 to 1.9 ± 0.2 (p < 0.0001), respectively. A similar reduction in Oswestry Disability Index from 38.0 ± 4.6 to 20.0 ± 2.3 (p < 0.0001) was noted. Likewise, SF-12 and VR-12 scores all showed statistically significant improvement from baseline (p < 0.001). The mean anterior and posterior disc heights improved from 8.7 ± 1.0 mm to 13.4 ± 1.5 mm (p = 0.0001) and 6.5 ± 0.8 mm to 9.6 ± 1.1 mm (p = 0.0001), respectively. Neuroforaminal height improved from 17.6 ± 2.0 mm to 21.9 ± 2.5 mm (p = 0.0001). When present, spondylolisthesis was, on average, reduced from 4.3 ± 0.5 mm to 1.9 ± 0.2 mm (p = 0.0001). Lumbar lordosis improved from 47.8° ± 5.5° to 58.5° ± 6.8° (p = 0.2687), and no significant change in segmental lordosis was observed. The overall rate of radiographic fusion was 93.3% at 1 year. No perioperative complications requiring operative revision were encountered. CONCLUSIONS In this series of MIS TLIFs, use of this novel interbody cage was shown to be safe and effective. Significant improvements in pain and disability were observed. Effective and durable restoration of disc height and neuroforaminal height and reduction of spondylolisthesis were obtained, with concurrent gains in lumbar lordosis. Taken together, this device offers excellent clinical and radiographic outcomes via an MIS approach.

Single photon avalanche diodes (SPADs) are key enabling technologies for a wide range of applications in the near-infrared wavelength range. Recently, AlAs0.56 Sb0.44 (hereafter AlAsSb) lattice-matched to InP has been demonstrated for extremely low excess noise avalanche photodiodes (APDs) due to its large disparity between electron and hole ionization coefficients ( $\alpha $ and $\beta $ respectively). The $\alpha /\beta $ ratio also plays a role in Geiger mode operation as it affects the avalanche breakdown probability and hence detection efficiency. In this work, we theoretically investigate the performance of AlAsSb based SPADs. The probability of breakdown for electron-initiated Geiger mode operation increases more sharply with multiplication region width due to progressively more dissimilar ionization coefficients. In comparison with other common avalanche materials, such as InAlAs, InP and Si, our result also suggests that SPADs based on AlAsSb have a sharper breakdown probability than the other three materials under similar low overbias ratio. The calculated breakdown probability of 0.81 in AlAsSb is 0.18 and 0.28 higher than that of InAlAs/Si and InP respectively at 5% overbias ratio and with avalanche region width of 1500 nm.

Aim Heart failure following myocardial infarction (MI) is a potentially lethal problem with a staggering incidence. The CardiAMP Heart Failure trial represents the first attempt to personalize marrow-derived cell-based therapy to individuals with cell characteristics associated with beneficial responses in prior trials. Before the initiation of the randomized pivotal trial, an open-label “roll-in cohort” was completed to ensure the feasibility of the protocol's procedures. Methods Patients with chronic post-MI heart failure (NYHA class II-III) receiving stable, guideline-directed medical therapy with a left ventricular ejection fraction between 20 and 40% were eligible. Two weeks prior to treatment, a ~ 5 mL bone marrow aspiration was performed to examine “cell potency”. On treatment day, a 60 mL bone marrow aspiration, bone marrow mononuclear cell (BM MNC) enrichment and transendocardial injection of 200 million BM MNC's was performed in a single, point of care encounter. Patients were then followed to assess clinical outcomes. Results The cell potency small volume bone marrow aspirate, the 60 mL bone marrow aspirate, and transendocardial injections were well tolerated in 10 patients enrolled. There were no serious adverse events related to bone marrow aspiration or cell delivery. Improvement in 6-min walk distance was observed at 6 months (+47.8 m, P = 0.01) and trended to improvement at 12 months (+46.4, P = 0.06). Similarly, trends to improved NYHA heart failure functional class, quality of life, left ventricular ejection fraction and recruitment of previously akinetic left ventricular wall segments were observed. Conclusion All CardiAMP HF protocol procedures were feasible and well tolerated. Favorable functional, echo and quality of life trends suggest this approach may offer promise for patients with post MI heart failure. The randomized CardiAMP Heart Failure pivotal trial is underway to confirm the efficacy of this approach. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02438306

Introduction Mental illness is a well-known risk factor for injury and injury recidivism. The impact of pre-existing psychiatric illness on trauma outcomes, however, has received less attention. Our study examines the relationship of pre-existing psychiatric illness on trauma outcomes including length of stay, cost, and mortality. Methods Patient data were obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database. All patients admitted for trauma in the Detroit metropolitan area from 1/1/2006 to 12/31/2014 were included. The relationship between individual psychiatric comorbidities (depression, psychosis, and other neurological disorders) and outcomes were evaluated with logistic regression (mortality) and generalized linear modeling (length of stay and cost). Results Over 260,000 records were reviewed. Approximately one-third (29.9%) of patients had one or more psychiatric diagnoses. Patients with depression had longer hospital stays (RR = 1.12, p Conclusion Patients with a psychiatric disorder required longer care and incurred greater costs, whereas mortality was higher for only those with a neurological disorder. Identifying patients’ psychiatric comorbidities at the time of admission for trauma may help optimize treatment. Addressing these conditions may help reduce the cost of trauma care.

We study the use of nonlinear semiconductor optical amplifier (SOA) for generating optical phase conjugate towards compensation of distortions in short distance optical fiber transmission due to Kerr nonlinearity and chromatic dispersion in coherent multi-carrier lightwave signals. We experimentally demonstrate the effectiveness of the SOA-based phase conjugator to improve the link budget with a 100 km standard single mode fiber link for 20 GHz coherent OFDM signals, with QPSK and 16QAM modulations and a corresponding net bit-rate of 40 Gbps and 80 Gbps respectively. Mid-span spectral inversion scheme is employed where the optical phase conjugate is generated through a partially degenerate four-wave mixing process in a nonlinear SOA. We demonstrate a bit error rate performance within $2\times 10^{-2}$ for an average launched power of up to 12 dBm (9 dBm) for QPSK (16QAM) coherent OFDM signals, in a 100 km fiber link. We also investigate the possible improvement in link budget using numerical simulation for 16QAM and 64QAM CO-OFDM signals with the proposed scheme.

Background Applicants to integrated plastic and reconstructive surgery (PRS) residency in the United States spend exorbitant amounts of time and money throughout the interview process. Outside of first-hand experience through a visiting rotation, applicants utilize various resources in learning about a program. Today’s applicants are “Millennials,” the demographic cohort raised during the information age and proficient with digital technology. The authors evaluated whether programs have a presence on social media, and whether applicants are following these accounts. Methods An online survey was sent to applicants to a single integrated plastic surgery program evaluating basic demographics, social media utilization, and sources of information accessed throughout the residency application process. A manual search of popular social media platforms (Instagram, Facebook, and Twitter) was performed in October 2019. Accounts affiliated with integrated PRS programs were identified and analyzed. Results Eighty-four of 222 applicants (37.8%) completed the survey. Ninety-six percent of applicants were within the Millennial demographic. Ninety-six percent of applicants had some form of social media presence, with Facebook (90%) and Instagram (87%) being the most popular platforms. Seventy-three percent of applicants reported following a PRS residency social media account. As of October 2019, 59 integrated residency programs (73%) have active Instagram accounts. Conclusions Applicants still rely on the program website when researching potential residencies, but social media is being rapidly adopted by programs. Program social media accounts should be used as a dynamic form of communication to better inform applicants of program strengths and weaknesses.

The research aim of this work is to analyse the characteristics of R. David Case Sound waves that are posited to have positive effects on people suffering from tinnitus. Moreover, the participants who listened to these sound wave files using specific headsets or headphones of the Koss models (ktx Pro, ksc-75) showed improved health condition such as alleviating tinnitus that they are suffering from. Therefore, these discoveries have encouraged R. David Case to pursue positively his journey into finding out what is special about those sounds when being listened specifically with Koss models. In this research, we focus mainly on the technical aspects of R. David Case sound signals which he has recorded. These specific sound waves were analysed using time domain, frequency domain as well as the effect of using the Koss Pro headphone frequency response characteristics applied to the sound. Results obtained from the analysis demonstrated that the generation of ultrasound can be the underlying reason for the treatment of the tinnitus.

Objective: We examined changes in opioid prescriptions after outpatient laparoscopic cholecystectomy (LC) before and after (1) an educational intervention for surgical residents and (2) subsequent changes in state regulations for handling these prescriptions. Design: A single-institution retrospective review evaluated opioids prescribed on discharge in morphine milligram equivalents (MMEs) over three periods: Period 1, prior to educational intervention (October 1, 2017 to January 31, 2018); Period 2, after intervention and before regulation changes occurred (February 1, 2018 to May 31, 2018); and Period 3, after changes in regulations went into effect (June 1, 2018 to September 30, 2018). Setting: A large urban teaching hospital in Detroit, Michigan. Patients: All adults receiving outpatient LC during one of the study periods. Patients with a history of regular opioid use prior to surgery were excluded. There were 49 patients in Period 1, 57 in Period 2, and 51 in Period 3. Interventions: All general surgery residents participated in an education session focusing on problems related to opioid addiction, prescribing trends, and multimodal pain control options in February 2018. Main outcome measure: Mean MME per patient was compared between time periods. Results: Average MME was reduced from 87.11 in Period 1 to 65.96 in Period 2 to 51.80 in Period 3. Analysis of variance showed MME differed significantly among the periods. Scheffe post hoc t-tests showed MME prescribed during Periods 2 and 3 were each significantly lower than Period 1, whereas Periods 2 and 3 did not differ significantly. Conclusions: MME prescribed after outpatient LC significantly decreased after the educational intervention and remained low after state mandate went into effect.

Purpose Brachytherapy (BT) after surgical resection of keloids reduces the risk of local recurrence, but standardization of dose/technique is lacking. Typical keloid BT treatment utilizes a single-channel source prescribed to 5-mm depth. We investigated the dosimetry of a volume-based target definition for interstitial high-dose-rate BT treatment of keloids. Methods and Materials We retrospectively identified consecutive 14 patients who had a total of 20 keloids treated with interstitial high-dose-rate BT for keloids at our institution between 2004 and 2014. Keloids were treated with a single 8 Gy fraction prescribed to 5 mm beneath the scar within 36 h of surgery. Retrospectively, a 3-mm skin high-risk clinical target volume (HR-CTV) was contoured under the scar for volume-based dose calculations. Results Mean (SD) HR-CTV was 3.91 cm3 (3.1) and mean (SD) HR-CTV dose was 11.3 Gy (3.6). Mean D90 (SD) was 62.9% (25.8) and mean V100 (SD) was 56.5% (26.4). The mean V150 (SD), V200 (SD), and V300 (SD) were as follows: 37.6% (19.9), 25.1% (14.4), and 11.3% (6.5), respectively. No local failures were reported at 9 months median followup. There were no Grade 2 or higher late toxicities. Conclusions Using a volume-based target definition, a wide range of target coverage was observed. This is likely a consequence of the curvature of the skin and the challenges of keeping the catheter equidistant from the skin across the target. Additional data are needed to define the potential clinical impact on outcomes/toxicities of dosimetric correlates with single-catheter BT keloid treatment.

It is clear that existing cardiovascular disease is a major risk factor for COVID-19 and related adverse outcomes. In addition to acute respiratory syndrome, a large cohort also develop myocardial or vascular dysfunction, in part from inflammation and renin angiotensin system activation with increased sympathetic outflow, cardiac arrhythmias, ischemia, heart failure, and thromboembolic complications that portend poor outcomes related to COVID-19. We summarize recent information for hospitalists and internists on the front line of this pandemic regarding its cardiovascular impacts and management and the need for cardiovascular consultation.

Introduction: This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. Methods: Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. Results: The spring-assisted group was older at both time points ( P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively ( P < .01). However, the change in CVV did not differ between the groups ( P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. Conclusions: Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.

Craniosynostosis (CSS), the premature fusion of calvarial sutures, most commonly involves the sagittal suture. Cranial vault remodeling (CVR) is a traditional method of CSS correction. Minimally invasive methods are becoming widely accepted, including spring-assisted surgery (SAS). The equipment required for SAS is minimal therefore adaptable to resource challenged health systems. This paper outlines the experience of SAS in Moldova.A retrospective study was performed for patients treated with SAS for sagittal CSS from 2011 to 2018 in Moldova. Perioperative data were recorded including age, length of surgery, blood loss, volume transfused and length of stay. Four patients had pre- and post-operative computed tomography (CT) scans which were used to calculate changes in cephalic index, normative cephalic index, and intracranial volume.Thirteen patients underwent SAS. Diagnoses were made clinically and confirmed with CT. Mean age at surgery was 4.0 months, and length of surgery 62.7 minutes. All but one patient received a blood transfusion, as is standard of practice in Moldova. The mean length of post-operative recovery in ICU was 30.9 hours. No complications required surgical revision. Springs were removed after 4 to 5 months. All patients had a subjective improvement in scaphocephaly. Based on the available CT scans, an increase in cephalic index (7.3%), normative cephalic index (11.8%), and intracranial volume (38.1%) was observed. One patient underwent SAS at 11 months and required cranioplasty for asymmetry at the time of spring removal.SAS is a safe and cost-effective method of CSS correction that can be utilized in countries with limited health system resources.

Background Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). Methods Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. Results There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ± 10.27) compared to the SAS cohort (54.64 ± 10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. Conclusions Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.

Objective: To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]–approved multidisciplinary teams or from community providers). Design: Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015. Setting/Patients and Main Outcome Measures: Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as “Team” versus “Community,” and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care. Results: Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance. Conclusions: American Cleft Palate Craniofacial Association –approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.

Aims/hypothesis We aimed to characterise the immunogenic background of insulin-dependent diabetes in a resource-poor rural African community. The study was initiated because reports of low autoantibody prevalence and phenotypic differences from European-origin cases with type 1 diabetes have raised doubts as to the role of autoimmunity in this and similar populations. Methods A study of consecutive, unselected cases of recently diagnosed, insulin-dependent diabetes (n = 236, ≤35 years) and control participants (n = 200) was carried out in the ethnic Amhara of rural North-West Ethiopia. We assessed their demographic and socioeconomic characteristics, and measured non-fasting C-peptide, diabetes-associated autoantibodies and HLA-DRB1 alleles. Leveraging genome-wide genotyping, we performed both a principal component analysis and, given the relatively modest sample size, a provisional genome-wide association study. Type 1 diabetes genetic risk scores were calculated to compare their genetic background with known European type 1 diabetes determinants. Results Patients presented with stunted growth and low BMI, and were insulin sensitive; only 15.3% had diabetes onset at ≤15 years. C-peptide levels were low but not absent. With clinical diabetes onset at ≤15, 16–25 and 26–35 years, 86.1%, 59.7% and 50.0% were autoantibody positive, respectively. Most had autoantibodies to GAD (GADA) as a single antibody; the prevalence of positivity for autoantibodies to IA-2 (IA-2A) and ZnT8 (ZnT8A) was low in all age groups. Principal component analysis showed that the Amhara genomes were distinct from modern European and other African genomes. HLA-DRB1*03:01 (p = 0.0014) and HLA-DRB1*04 (p = 0.0001) were positively associated with this form of diabetes, while HLA-DRB1*15 was protective (p p = 1.60 × 10−7). Interestingly, despite the modest sample size, autoantibody-positive patients revealed evidence of association with SNPs in the well-characterised MHC region, already known to explain half of type 1 diabetes heritability in Europeans. Conclusions/interpretation The majority of patients with insulin-dependent diabetes in rural North-West Ethiopia have the immunogenetic characteristics of autoimmune type 1 diabetes. Phenotypic differences between type 1 diabetes in rural North-West Ethiopia and the industrialised world remain unexplained.

Objectives The aim of this study was to investigate the impact of spontaneous coronary artery dissection (SCAD) on 30-day readmission rates following hospitalization with acute myocardial infarction (AMI) using a national database. Background AMI in the setting of SCAD represents an uncommon type of myocardial infarction with limited data on short-term outcomes. Methods All hospitalizations with primary or index diagnoses of AMI from 2010 to 2015 in the Nationwide Readmissions Database were queried. The primary outcome was overall 30-day readmission rates in both SCAD and non-SCAD cohorts. Propensity score matching (1:2) was conducted. Results A total of 2,654,087 patients with AMI were included in the final analysis, of whom 1,386 (0.052%) were diagnosed with SCAD. SCAD was associated with a higher readmission rate in the SCAD cohort (12.3% vs. 9.9%; p = 0.022). The main causes of readmissions in the SCAD cohort were cardiac causes (80.6%), and AMI was the most common cardiac cause (44.8%), followed by chest pain (20.1%) and arrhythmia (12.7%). Among the SCAD readmissions, 50.6% patients were readmitted in the first week post-discharge, with 54.5% of AMI readmissions occurring in the first 2 days post-discharge. Conclusions The incidence of 30-day readmission following AMI and SCAD is nontrivial and occurs early post-discharge. Most readmissions are due to cardiac causes, especially AMI. Targeted management approaches are needed to diminish the high rates of readmission and early recurrent AMI.

Purpose/objectives In response to the growing number of violent acts on college/university campuses in the US, a pilot safety awareness and violence prevention (SAVP) training was developed and collaboratively implemented for first-year dental and pharmacy students at a US academic health center. The study assessed student knowledge of violent behavior, warning signs emphasizing active shooter situations, response strategies when witnessing or experiencing violence, and awareness of available violence prevention resources. Methods In 2014, a presurvey/postsurvey design was approved by the Institutional Review Board and used to assess knowledge before and after SAVP training by the university police department. As part of the new student orientation, 90% of the dental students and 100% of the pharmacy students simultaneously participated in the training and afterwards completed both number-coded surveys. This resulted in a 96% response rate. Data were analyzed using SAS. Results A comparison of presurvey/postsurvey responses show notable increases on 4 key topics: awareness of actions to take if witnessing violent crime (+49%) or encountering active shooter situation (+74%), awareness of violent behavior warning signs (+63%), and knowledge of available violence prevention resources (+86%). Conclusions Findings from this study demonstrate that integrating SAVP training in new student orientation can increase safety awareness among dental and pharmacy students. SAVP training can augment the uptake of current campus resources given there was an observed increase in knowledge of availability. Collaborating with the university police department is key to this replicable proactive SAVP program for dental and pharmacy students.

We experimentally demonstrate the simultaneous compensation of both dispersion and nonlinear effects in a 100 km optical fiber link using optical phase conjugation of a 21 GB aud QPSK and 16QAM signal with nonlinear SOAs. Error-free performance is recorded for a launched power of up to 12 dBm, without any digital signal processing to compensate for distortions due to chromatic dispersion and nonlinear effects in fiber. The performance is verified for operation across the C-band.

Women with myocardial infarction with no obstructive coronary artery disease (MINOCA) are increasingly recognized. Women with MINOCA are at high risk for major adverse cardiovascular events. In this case, we focus on the importance of early identification and management of MINOCA to improve patients’ angina and related quality of life. (Level of Difficulty: Beginner.), Graphical abstract, Women with myocardial infarction with no obstructive coronary artery disease (MINOCA) are increasingly recognized…

Viral infections are an occupational health concern for office workers and employers. The objectives of this study were to estimate rotavirus, rhinovirus, and influenza A virus infection risks in an office setting and quantify infection risk reductions for two hygiene interventions. In the first intervention, research staff used an ethanol-based spray disinfectant to clean high-touch non-porous surfaces in a shared office space. The second intervention included surface disinfection and also provided workers with alcohol-based hand sanitizer gel and hand sanitizing wipes to promote hand hygiene. Expected changes in surface concentrations due to these interventions were calculated. Human exposure and dose were simulated using a validated, steady-state model incorporated into a Monte Carlo framework. Stochastic inputs representing human behavior, pathogen transfer efficiency, and pathogen fate were utilized, in addition to a mixed distribution that accounted for surface concentrations above and below a limit of detection. Dose-response curves were then used to estimate infection risk. Estimates of percent risk reduction using mean values from baseline and surface disinfection simulations for rotavirus, rhinovirus, and influenza A infection risk were 14.5%, 16.1%, and 32.9%, respectively. For interventions with both surface disinfection and the promotion of personal hand hygiene, reductions based on mean values of infection risk were 58.9%, 60.8%, and 87.8%, respectively. This study demonstrated that surface disinfection and the use of personal hand hygiene products can help decrease virus infection risk in communal offices. Additionally, a variance-based sensitivity analysis revealed a greater relative importance of surface concentrations, assumptions of relevant exposure routes, and inputs representing human behavior in estimating risk reductions.

Aims/hypothesis Type 1 and type 2 diabetes differ with respect to pathophysiological factors such as beta cell function, insulin resistance and phenotypic appearance, but there may be overlap between the two forms of diabetes. However, there are relatively few prospective studies that have characterised the relationship between autoimmunity and incident diabetes. We investigated associations of antibodies against the 65 kDa isoform of GAD (GAD65) with type 1 diabetes and type 2 diabetes genetic risk scores and incident diabetes in adults in European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct, a case-cohort study nested in the EPIC cohort. Methods GAD65 antibodies were analysed in EPIC participants (over 40 years of age and free of known diabetes at baseline) by radioligand binding assay in a random subcohort (n = 15,802) and in incident diabetes cases (n = 11,981). Type 1 diabetes and type 2 diabetes genetic risk scores were calculated. Associations between GAD65 antibodies and incident diabetes were estimated using Prentice-weighted Cox regression. Results GAD65 antibody positivity at baseline was associated with development of diabetes during a median follow-up time of 10.9 years (HR for GAD65 antibody positive vs negative 1.78; 95% CI 1.43, 2.20) after adjustment for sex, centre, physical activity, smoking status and education. The genetic risk score for type 1 diabetes but not type 2 diabetes was associated with GAD65 antibody positivity in both the subcohort (OR per SD genetic risk 1.24; 95% CI 1.03, 1.50) and incident cases (OR 1.97; 95% CI 1.72, 2.26) after adjusting for age and sex. The risk of incident diabetes in those in the top tertile of the type 1 diabetes genetic risk score who were also GAD65 antibody positive was 3.23 (95% CI 2.10, 4.97) compared with all other individuals, suggesting that 1.8% of incident diabetes in adults was attributable to this combination of risk factors. Conclusions/interpretation Our study indicates that incident diabetes in adults has an element of autoimmune aetiology. Thus, there might be a reason to re-evaluate the present subclassification of diabetes in adulthood. Electronic supplementary material The online version of this article (10.1007/s00125-019-05016-3) contains peer-reviwed but unedited supplementary material, which is available to authorised users.

Purpose We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve. Methods All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker . Results From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation ; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group ( p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46). Conclusions TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation.

Objective Elevated red blood cell distribution width (RDW) level has been shown to be associated with poor outcomes in patients with cardiovascular disease. Limited data are available regarding the prognostic value of RDW in transcatheter aortic valve replacement (TAVR) patients. Therefore, we aimed to investigate the impact of RDW variation on outcomes of TAVR patients. Methods From March 20, 2012, to February 20, 2020, the pre-TAVR RDW levels of 1,163 consecutive TAVR patients were examined. Receiver operating curves were set to define the most accurate cut-point, which was subsequently validated in our validation set. Associations of RDW levels with early and long-term outcomes were investigated. Results A total of 988 patients were eligible for the analysis. Patients with 30-day, 1-year, and 7-year mortality had significantly higher pre-TAVR RDW levels (15.8% [12.9-19.1] vs 14.7% [11.6-26.3], P = 0.01; 16% [12.3-26.3] vs 14.7% [11.6-24.3], P < 0.001; 15.6% [12.3-26.3] vs 14.6% [11.6-24.3], P < 0.001, respectively). A RDW of 14.5% was found as the most sensitive and specific cut-point for mortality at 1 and 7 years (HR = 2.6, 95% CI: 1.6-4.2, P < 0.001; HR = 1.8, 95% CI: 1.3-2.4, P < 0.001), with mortality of 22% versus 10% at 1 year ( P < 0.001) and 37% versus 27% at 7 years ( P < 0.001) in patients with RDW ≥14.5% versus those with RDW Conclusions RDW is an important prognostic factor in TAVR patients. A RDW level higher than 14.5% is significantly associated with post-TAVR early and late mortality. RDW levels should be incorporated into current risk assessment models as an additional variable to predict post-TAVR outcomes.

Aims/hypothesis It is important to differentiate the two major phenotypes of adult-onset diabetes, autoimmune type 1 diabetes and non-autoimmune type 2 diabetes, especially as type 1 diabetes presents in adulthood. Serum GAD65 autoantibodies (GADA) are the most sensitive biomarker for adult-onset autoimmune type 1 diabetes, but the clinical value of GADA by current standard radiobinding assays (RBA) remains questionable. The present study focused on the clinical utility of GADA differentiated by a new electrochemiluminescence (ECL) assay in patients with adult-onset diabetes. Methods Two cohorts were analysed including 771 diabetic participants, 30–70 years old, from the Action LADA study (n = 6156), and 2063 diabetic participants, 20–45 years old, from the Diabetes in Young Adults (DiYA) study. Clinical characteristics of participants, including requirement of early insulin treatment, BMI and development of multiple islet autoantibodies, were analysed according to the status of RBA-GADA and ECL-GADA, respectively, and compared between these two assays. Results GADA was the most prevalent and predominant autoantibody, >90% in both cohorts. GADA positivity by either RBA or ECL assay significantly discriminated clinical type 1 from type 2 diabetes. However, in both cohorts, participants with ECL-GADA positivity were more likely to require early insulin treatment, have multiple islet autoantibodies, and be less overweight (for all p Conclusions/interpretation Detection of GADA by ECL assay, given technical advantages over RBA-GADA, identified adult-onset diabetes patients at higher risk of requiring early insulin treatment, as did clinical phenotype, together allowing for more accurate clinical diagnosis and management. Graphical abstract

In today’s rapidly changing world, there is an increased need for excellent strategic planning. A firm’s survival may indeed hinge on the firm’s planning process being exemplary. Various aspects of the strategic planning process are under review today as organizations wrestle to compete more effectively. This paper reveals and describes five emerging trends or tools being utilized today by firms to more effectively engage in strategic planning. Specifically, the emerging trends and tools to be discussed in this paper are as follows: 1) Assure vision and mission statements include desired characteristics 2) Perform SWOT (Strengths-Weaknesses-Opportunities-Threats) analysis using AQCD (Actionable, Quantitative, Comparative, and Divisional) factors 3) Utilize varied sources to obtain AQCD information 4) Utilize QSPM (Quantitative Strategic Planning Matrix) analysis to determine the relative attractiveness of alternative strategies 5) Use excel-based software to facilitate and enhance the strategic planning process. The purpose of this paper is to familiarize readers with basic new tools and techniques being used by organizations to effectively develop an improved strategic plan for the firm. JEL Code: M21, O21 ARTICLE IN PRESS!

Strategic management has long been the capstone course for business majors at most colleges and universities globally. As originally designed, the capstone course sought to teach students an array of skills and tools needed to actually perform strategic planning, primarily through integration and application of functional business concepts and techniques. Times have changed, however, and business schools have come under scrutiny regarding their ineffectiveness in developing graduates’ skills commensurate with employers’ requirements. Such criticism is justified as academics teaching the capstone business course have partitioned their instruction efforts to focus increasingly on theory rather than practical applications. After a pertinent evaluation of current academic research, we illuminate how and why increased focus on practice is needed in strategic-management pedagogy. We delineate how the once well-designed business capstone course has evolved into a course that too often fails to impart practical competencies to graduating students. To facilitate closing the gap between graduates’ skills and employers’ requirements, we present a strategic management pedagogical model designed to promote student learning and development of hard and soft skills related to actually doing strategic planning. The proposed model can help reduce the gap between graduates’ skills and employers’ requirements with the intended purpose to provide increased interest for teaching practical tools that were developed by practitioners. Such tools include the BCG matrix, developed by the Boston Consulting Group, and the Internal-External (IE) portfolio matrix derived from the General Electric (GE) Business Screen developed by Jack Welch, former CEO of GE. The proposed model also reveals the process of including both internal and external aspects into strategic decision making as evidenced by countless organizations performing Strength-Weakness-Opportunity-Threat (SWOT) analyses. The proposed model significantly enhances previous theory-based approaches for teaching the capstone strategic-management course.

Background: In keeping with nation-wide efforts to contain the spread of COVID-19, Universiti Brunei Darussalam (UBD) made the move towards online teaching to ensure students continue to receive their education while minimizing the risks of exposure and community spread of COVID-19. We investigated teaching and learning experiences, physical and mental health of undergraduate students and academic staff during the COVID-19 pandemic.Methods: We conducted a cross-sectional study on undergraduate students and academic staff in a health science faculty using a self-developed pretested questionnaire through anonymous online data collection method.Results: 56 academics (100% response rate) and 279 students (83.3% response rate) participated. The positive experiences as reported by students include: becoming independent (72.8%), adapting to online learning (67.4%) and sudden changes (62.0%), learning to manage scheduling (58.8%), and being self-motivated (57.7%); while academics’ positive experiences included new teaching techniques (50.0%), flexible schedules (50.0%), remote teaching (48.2%) and improved teaching tools (46.4%). Students reported negative experiences as being distracted at home (72.0%), feeling of uncertainty with regards to examinations (66.7%), and getting a slow response from lecturers (55.6%). With regards to health, both students and academics reported stress, anxiety, loneliness, back problems, and eye strain.Conclusion: In this challenging period towards an abrupt shift to online teaching, students and academic staff of UBD identified both positive and negative experiences including the impact on their physical and mental health. Our findings are important to provide the evidence for online pedagogical benefits and can serve to promote the enhancement and adaptation of digital technology in education. Our findings also aim to promote the importance of addressing physical and mental health issues of the university community’s well-being through provision of emotional and mental health support and appropriate programs.

Background:. Resident cosmetic clinics (RCCs) are the training modality of choice among both residents and faculty and are a mainstay at most residency programs.1–4 Despite this, knowledge of RCCs among plastic surgery consumers remains untested. We hypothesize that the public would be aware of and receptive to RCCs. Methods:. Participants with prior cosmetic procedures or interest in future cosmetic procedures were recruited using Amazon Mechanical Turk and asked to complete a survey in September 2020. First, prior awareness of RCCs was assessed. After a brief description of RCCs, perceptions of safety and preferences for care were assessed. Results:. After screening for quality, 815 responses were included. Forty-five percent of consumers were aware of RCCs. Seventy-six percent of consumers believed that RCCs were just as safe as attending clinics and 65% were comfortable receiving care from fourth-year residents or higher. Belief in RCC safety was associated with 4.8 times higher odds of feeling comfortable receiving care at an RCC [95% confidence interval (3.3–7.1), P < 0.001]. When given a hypothetical choice between residents and attendings in two scenarios, 46% of consumers chose residents for abdominoplasty and 60% chose residents for Botox injections. Belief in RCC safety was associated with choosing a resident or being indifferent in both scenarios. Conclusions:. Consumer preference regarding RCCs has largely been untested. This study shows that belief in RCC safety influences consumers’ perceived comfort with receiving care at an RCC. This knowledge can help guide RCC practice and maximize learning opportunities for surgeons-in-training.

Objective The hypercoagulability seen in patients with novel coronavirus disease 2019 (COVID-19) likely contributes to the high temporary hemodialysis catheter (THDC) malfunction rate. We aim to evaluate prophylactic measures and their association with THDC patency. Methods A retrospective chart review of our institutions COVID-19 positive patients who required placement of a THDC between February 1 to April 30, 2020, was performed. The association between heparin locking, increased dosing of venous thromboembolism (VTE) prophylaxis and systemic anticoagulation on THDC patency was assessed. Proportional hazards modeling was used to perform a survival analysis to estimate the likelihood and timing of THDC malfunction with the three different prophylactic measures. We also determined the mortality, rate of THDC malfunction and its association with d -dimer levels. Results A total of 48 patients with a mortality rate of 71% were identified. THDC malfunction occurred in 31.3% of patients. Thirty-seven patients (77.1%) received heparin locking, 22 (45.8%) received systemic anticoagulation, and 38 (79.1%) received VTE prophylaxis. Overall, the rate of THDC malfunction was lower at a trend level of significance, with heparin vs saline locking (24.3% vs 54.6%; P = .058). The likelihood of THDC malfunction in the heparin locked group is lower than all other groups (hazard ratio [HR], 0.07; 95% confidence interval [CI], 0.01-0.45]; P = .005). The rate of malfunction in patients with subcutaneous heparin (SQH) 7500 U three times daily is significantly lower than of the rate for patients receiving none (HR, 0.03; 95% CI, 0.001-0.74; P = .032). A trend level significant association was found for SQH 5000 U vs none (P = .417) and SQH 7500 vs 5000 U (P = .059). Systemic anticoagulation did not affect the THDC malfunction rate (P = .240). Higher d -dimer levels were related to greater mortality (HR, 3.28; 95% CI, 1.16-9.28; P = .025), but were not significantly associated with THDC malfunction (HR, 1.79; 95% CI, 0.42, 7.71; P = .434). Conclusions Locking THDCs with heparin is associated with a lower malfunction rate. Prospective randomized studies will be needed to confirm these findings to recommend locking THDC with heparin in patients with COVID-19. Increased VTE prophylaxis suggested a possible association with improved THDC patency, although the comparison lacked sufficient statistical power.

Spring-assisted surgery has been a part of the craniofacial surgeon's armamentarium for more than 2 decades now. The development and implementation of this technique will be reviewed as well as the evolution of spring surgery at Wake Forest University.

Cardiovascular conditions are highly prevalent and particularly common in subsets of the population at high risk for traumatic injury. This study evaluates the extent to which cardiovascular comorbidity may increase risks of negative outcomes in patients receiving trauma treatment. Clinical data for all patients admitted for traumatic injury (defined by ICD-9 diagnosis codes) of all levels of severity between the years of 2006 and 2014 in the Detroit USA metropolitan area were obtained from the State Inpatient Database for Michigan. The association between four types of cardiovascular comorbidity (hypertension, congestive heart failure, pulmonary circulation disorders, and valvular heart disease), and three outcomes (mortality, length of hospital stay, and total charges), was assessed using generalized linear modeling, both alone and after controlling for injury severity, injury region, and demographic factors. All four comorbidities examined were related to worse outcomes on all three dimensions. The greatest magnitude of estimated effects with each outcome was associated with pulmonary circulation disorders (mortality OR = 2.99, length of stay IRR = 1.69, hospital charges IRR = 1.76), and the smallest magnitude of estimated effects was associated with hypertension (mortality OR = 1.20, length of stay IRR = 1.20, hospital charges IRR = 1.18). After adjustment for the presence of multiple comorbidities, injury severity and region, age, gender, and race, all effect estimates remained significant and in the same direction, except valvular heart disease which was unrelated to mortality, and hypertension was related to lower risk of mortality (OR = 0.76). Cardiovascular comorbidities are related to higher risk of negative outcomes among patients hospitalized due to traumatic injury. Screening for these comorbidities on admission may help to improve patient outcomes.

Graphical abstract, Highlights • Cor triatriatum dexter (CTD) can complicate percutaneous atrial septal interventions. • Clinically silent (forme fruste) CTD is detectable by new echocardiography techniques. • Using these techniques could improve patient selection and guide interventions.

SrTiO3 has been of interest as a photocatalyst for overall water splitting, but the energy conversion efficiency of this material is limited by recombination at surface and lattice defects. Here, w...

We have trained deep convolutional neural networks (DCNs) to accelerate the computation of seismic attributes by an order of magnitude. These results are enabled by overcoming the prohibitive memory requirements typical of 3D DCNs for segmentation and regression by implementing a novel, memory-efficient 3D-to-2D convolutional architecture and by including tens of thousands of synthetically generated labeled examples to enhance DCN training. Including diverse synthetic labeled seismic in training helps the network generalize enabling it to accurately predict seismic attribute values on field-acquired seismic surveys. Once trained, our DCN tool generates attributes with no input parameters and no additional user guidance. The DCN attribute computations are virtually indistinguishable from conventionally computed attributes while computing up to 100 times faster.

Fast, sensitive avalanche photodiodes (APDs) are required for applications such as high-speed data communications and light detection and ranging (LIDAR) systems. Unfortunately, the InP and InAlAs used as the gain material in these APDs have similar electron and hole impact ionization coefficients (α and β, respectively) at high electric fields, giving rise to relatively high excess noise and limiting their sensitivity and gain bandwidth product1. Here, we report extremely low excess noise in an AlAs0.56Sb0.44 lattice matched to InP. A deduced β/α ratio as low as 0.005 with an avalanche region of 1,550 nm is close to the theoretical minimum and is significantly smaller than that of silicon, with modelling suggesting that vertically illuminated APDs with a sensitivity of −25.7 dBm at a bit error rate of 1 × 10−12 at 25 Gb s−1 and 1,550 nm can be realized. These findings could yield a new breed of high-performance receivers for applications in networking and sensing.