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Purpose To compare corneal endothelial damage from longitudinal and torsional ultrasound during phacoemulsification. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental Study. Methods Nine New Zealand white rabbits underwent bilateral surgery. After incision, the Intrepid Balanced tip of the Centurion (Alcon) Ozil handpiece was inserted into the anterior chamber and the following settings were used: 50 mL/minute flow, 70 mmHg intraocular pressure, 600 mmHg vacuum, and 60% longitudinal (one eye) or torsional (contralateral eye) ultrasound for 30 seconds. Cumulative dissipated energy (CDE) was noted. After euthanasia and enucleation, the corneas were removed, stained with trypan blue/alizarin red, and photographed (X400 photographs from 5 specific areas, and 1 overview photograph from each corneal button). The ImageJ program was used to evaluate cell damage and loss in the photographs obtained from each cornea. Results Cavitation bubbles around the phaco tip was generally observed in the longitudinal group. CDE was 17.4 +/- 0.58 and 6.93 +/- 0.15 in the longitudinal and torsional groups, respectively (P = 0.003). The percentage of intact cells was statistically higher in the torsional group, and the percentage of lost cells was statistically higher in the longitudinal group (P = 0.003). This was observed in the analysis of the X400 photographs, as well as the overview photographs. Conclusion This study suggests that torsional ultrasound was associated with significantly less corneal endothelial cell damage than classical longitudinal tip motion, providing further insight on mechanisms of corneal endothelial damage during phacoemulsification.

Purpose A "dead bag syndrome" has been recently described, in which the capsular bag appears to be clear many years after surgery, becoming diaphanous and floppy, and unable to support the intraocular lens (IOL) within it. The aim of this study was to describe findings of this syndrome. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Case series with clinicopathological correlation. Methods Out of 10 cases suspected to be from dead bag syndrome, 8 IOLs/7 capsular bags were removed due to subluxation/dislocation. The seven capsular bags available for analysis were fixed in formalin and submitted to histopathological examination (hematoxylin/eosin and Masson's trichrome stains). The associated explanted IOLs in 5 cases were also examined microscopically. Results Histopathologic examination of the seven capsular bags showed capsular thinning and/or splitting. Lens epithelial cells (LECs) were completely absent on two specimens while the other five specimens had rare LECs on the inner surface of the capsule. Explanted IOLs were three-piece silicone lenses or single-piece hydrophobic acrylic lenses. One IOL optic showed a small amount of granular pigment deposition, but the optics of the other four lenses were unremarkable. Conclusions In this syndrome, there appears to be an absence of secondary proliferation of LECs, as well as fibrotic changes. The capsule shows some signs of degradation, such as thinning and/or splitting. Weakness of zonular attachments appears to be an associated finding, with subsequent in-the-bag IOL dislocation. Further studies are necessary to ascertain the etiology of this condition.

Objective The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities. Design Longitudinal, prospective cohort study. Setting 2019 Salt Lake City Marathon. Participants Recreational half-marathon and full-marathon runners. Assessment of risk factors The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event. Main outcome measures Development of pain based on the presence of asymptomatic tendon abnormalities. Results One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon. Conclusions The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.

To determine whether a newly modified capsular tension ring (CTR) is effective at preventing toric intraocular lens (TIOL) rotation and misalignment.John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.Experimental study.Ten human cadaver eyes were used to test the ease or difficulty of TIOL rotation in the capsular bag under 3 experimental conditions: a TIOL alone, a TIOL with a standard CTR, or a TIOL with a newly modified CTR with indentations in a sinusoidal pattern. Scores for the ease of IOL rotation were compared by using the nonparametric Friedman analysis of variance test. In addition, both anterior and posterior Miyake-Apple views were filmed to observe the rotational stability of TIOLs in the capsular bag under the 3 test conditions.In the ten eyes of five patients, the rotational stability improved with a standard CTR, but further improvement was statistically observed (P.05) with the newly modified CTR under all test conditions. This was true for both IOLs used (AcrySof and TECNIS toric IOLs), with or without ophthalmic viscosurgical device, and for either clockwise or counterclockwise rotations.A newly designed CTR prototype represents a new technology for improving the rotational stability of a TIOL in the capsular bag. Under all test conditions, the prototype performed significantly better than a standard CTR. The results support the use of this new CTR design to improve the accuracy and refractive success of TIOLs.

Objective US-based descriptions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have focused on patients with severe disease. Our objective was to describe characteristics of a predominantly outpatient population tested for SARS-CoV-2 in an area receiving comprehensive testing. Methods We extracted data on demographic characteristics and clinical data for all patients (91% outpatient) tested for SARS-CoV-2 at University of Utah Health clinics in Salt Lake County, Utah, from March 10 through April 24, 2020. We manually extracted data on symptoms and exposures from a subset of patients, and we calculated the adjusted odds of receiving a positive test result by demographic characteristics and clinical risk factors. Results Of 17 662 people tested, 1006 (5.7%) received a positive test result for SARS-CoV-2. Hispanic/Latinx people were twice as likely as non-Hispanic White people to receive a positive test result (adjusted odds ratio [aOR] = 2.0; 95% CI, 1.3-3.1), although the severity at presentation did not explain this discrepancy. Young people aged 0-19 years had the lowest rates of receiving a positive test result for SARS-CoV-2 (Conclusions We found disparities by race/ethnicity and age in access to testing and in receiving a positive test result among outpatients tested for SARS-CoV-2. Further research and public health outreach on addressing racial/ethnic and age disparities will be needed to effectively combat the coronavirus disease 2019 pandemic in the United States.

There has been an increasing body of literature analyzing eviction in different cities and contexts in urban studies, public health, sociology, geography, and housing studies. Still, little has bee...

OBJECTIVES Host gene expression signatures discriminate bacterial and viral infection but have not been translated to a clinical test platform. This study enrolled an independent cohort of patients to describe and validate a first-in-class host response bacterial/viral test. DESIGN Subjects were recruited from 2006 to 2016. Enrollment blood samples were collected in an RNA preservative and banked for later testing. The reference standard was an expert panel clinical adjudication, which was blinded to gene expression and procalcitonin results. SETTING Four U.S. emergency departments. PATIENTS Six-hundred twenty-three subjects with acute respiratory illness or suspected sepsis. INTERVENTIONS Forty-five-transcript signature measured on the BioFire FilmArray System (BioFire Diagnostics, Salt Lake City, UT) in ~45 minutes. MEASUREMENTS AND MAIN RESULTS Host response bacterial/viral test performance characteristics were evaluated in 623 participants (mean age 46 yr; 45% male) with bacterial infection, viral infection, coinfection, or noninfectious illness. Performance of the host response bacterial/viral test was compared with procalcitonin. The test provided independent probabilities of bacterial and viral infection in ~45 minutes. In the 213-subject training cohort, the host response bacterial/viral test had an area under the curve for bacterial infection of 0.90 (95% CI, 0.84-0.94) and 0.92 (95% CI, 0.87-0.95) for viral infection. Independent validation in 209 subjects revealed similar performance with an area under the curve of 0.85 (95% CI, 0.78-0.90) for bacterial infection and 0.91 (95% CI, 0.85-0.94) for viral infection. The test had 80.1% (95% CI, 73.7-85.4%) average weighted accuracy for bacterial infection and 86.8% (95% CI, 81.8-90.8%) for viral infection in this validation cohort. This was significantly better than 68.7% (95% CI, 62.4-75.4%) observed for procalcitonin (p < 0.001). An additional cohort of 201 subjects with indeterminate phenotypes (coinfection or microbiology-negative infections) revealed similar performance. CONCLUSIONS The host response bacterial/viral measured using the BioFire System rapidly and accurately discriminated bacterial and viral infection better than procalcitonin, which can help support more appropriate antibiotic use.

// Connor Willis 1 , Michelle Fiander 1 , Dao Tran 2 , Beata Korytowsky 3 , John-Michael Thomas 3 , Florencio Calderon 3 , Teresa M. Zyczynski 3 , Diana Brixner 1 and David D. Stenehjem 1 , 2 1 Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA 2 Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, Duluth, MN, USA 3 Bristol-Myers Squibb Company, Lawrenceville, NJ, USA Correspondence to: David Stenehjem, email: stene032@d.umn.edu Keywords: biomarkers; chemotherapy; immunotherapy; lung cancer; PD-L1 Received: June 14, 2019 Accepted: September 16, 2019 Published: November 12, 2019 ABSTRACT Purpose: To assess the association of tumor mutational burden (TMB) with clinical outcomes, other biomarkers and patient/disease characteristics in patients receiving therapy for lung cancer. Results: In total, 4,303 publications were identified; 81 publications were included. The majority of publications assessing clinical efficacy of immunotherapy reported an association with high TMB, particularly when assessing progression-free survival and objective response rate. High TMB was consistently associated with TP53 alterations, and negatively associated with EGFR mutations. High TMB was also associated with smoking, squamous cell non-small cell lung carcinoma, and being male. Methods: A systematic literature review based upon an a priori protocol was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane methodologies. Searches were conducted in EMBASE, SCOPUS, Ovid MEDLINE ® , and Emcare (from January 2012 until April 2018) and in two clinical trial registries. Conference abstracts were identified in EMBASE, and in targeted searches of recent major conference proceedings (from January 2016 until April 2018). Publications reporting data in patients receiving therapy for lung cancer that reported TMB and its association with clinical efficacy, or with other biomarkers or patient/disease characteristics, were included. Results are presented descriptively. Conclusion: This systematic literature review identified several clinical outcomes, biomarkers, and patient/disease characteristics associated with high TMB, and highlights the need for standardized definitions and testing practices. Further studies using standardized methodology are required to inform treatment decisions.

// Elgilda Musi 1 , Gary K. Schwartz 1 , 2 , Jae Hyuk Yoo 3 , Shannon J. Odelberg 3 , 4 , 6 , Dean Y. Li 3 , 5 , 6 , 7 , Michael Y. Bonner 8 , Ponniah Selvakumar 9 , Shikha Rao 8 , Linda C. Gilbert 8 , 10 , Justin Elsey 8 and Jack L. Arbiser 8 , 10 1 Department of Medicine, Columbia University Medical Center, New York, New York, USA 2 Herbert Irving Comprehensive Cancer Center, Columbia University College of Medicine, New York, New York, USA 3 Department of Medicine, Program in Molecular Medicine, University of Utah, Salt Lake City, Utah, USA 4 Department of Neurobiology and Anatomy, University of Utah, Salt Lake City, Utah, USA 5 Department of Human Genetics, University of Utah, Salt Lake City, Utah, USA 6 Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah, USA 7 Department of Oncological Sciences, University of Utah, Salt Lake City, Utah, USA 8 Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA 9 Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada 10 Veterans Affairs Medical Center, Decatur, Georgia, USA Correspondence to: Jack L. Arbiser, email: jarbise@emory.edu Keywords: melanoma; chemotherapy Received: April 09, 2019 Accepted: June 05, 2019 Published: July 09, 2019 ABSTRACT Uveal melanoma is a rare but often lethal malignancy and is the leading cause of death due to an ophthalmic condition. Uveal melanoma is often diagnosed at a late stage and has a strong propensity to hepatic metastasis. Recently, the most common driver mutations in uveal melanoma have been identified, predominantly in the G-proteins GNAQ. This pattern differs from that of cutaneous melanoma in which Braf and Nras predominate. There are no current clinically used agents that target GNAQ mutations, unlike the use of Braf inhibitors in cutaneous melanoma. We tested the novel agent Tris DBA palladium and found that it was markedly more effective against GNAQ mutant melanomas than wild type uveal melanomas. Given that ARF6 has recently been discovered as a node in GNAQ mutations, we evaluated the efficacy of Tris DBA palladium on ARF6 signaling and found that it was effective in inhibiting ARF6 activation. Finally, Tris DBA palladium was orally effective against GNAQ mutant melanoma in vivo . Tris DBA Palladium deserves further evaluation as a systemic agent for uveal melanoma.

The coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented toll on clinical diagnostic testing, and the need for PCR-based testing remains to be met. Nucleic acid amplification testing (NAAT) is the recommended method for the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the inherent advantages in sensitivity and specificity. In this study, we evaluated the performance of the MatMaCorp COVID-19 2SF test, a reverse transcription-PCR (RT-PCR) assay for the qualitative detection of SARS-CoV-2 from nasopharyngeal (NP) swabs, run on the Solas 8 instrument (MatMaCorp, Lincoln, NE). The Solas 8 device is portable, and the kit is a lab-in-a-box design which provides reagents in a shelf-stable lyophilized powder format. A total of 78 remnant clinical specimens were used to evaluate the COVID-19 2SF test. Sixty-two clinical specimens originally tested by the Xpert Xpress SARS-CoV-2 assay (Cepheid, Inc., Sunnyvale, CA) were used to evaluate the clinical accuracy of the COVID-19 2SF test. The negative percent agreement (NPA) was 100% (95% confidence interval [CI], 83.9% to 100%), and the positive percent agreement (PPA) was 85.4% (95% CI, 70.8% to 94.4%). Sixteen remnant specimens positive for other common respiratory pathogens (FilmArray respiratory panel 2.0; BioFire, Salt Lake City, UT) were assayed on the Solas 8 device to evaluate specificity. No cross-reactivity with other respiratory pathogens was identified. The unique lab-in-a-box design and shelf-stable reagents of the MatMaCorp COVID-19 2SF test offer laboratories a rapid option for a diagnostic NAAT for SARS-CoV-2 that can help meet diagnostic needs. IMPORTANCE The demand for molecular testing for COVID-19 remains to be met. This study of the MatMaCorp Solas 8 device and COVID-19 test provides the first evaluation of this platform.

* Abbreviations: COVID-19 — : coronavirus disease 2019 NICS — : National Instant Criminal Background Check System In this issue of Pediatrics, Cohen et al1 address the epidemic of pediatric firearm injuries through the lens of the coronavirus disease 2019 (COVID-19) pandemic. The authors used the National Instant Criminal Background Check System (NICS) to identify new gun purchases and the Gun Violence Archive to identify firearm injuries in children

School closures affected more than 55 million students across the United States when implemented as a strategy to prevent the transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Reopening schools requires balancing the risks for SARS-CoV-2 infection to students and staff members against the benefits of in-person learning (2). During December 3, 2020-January 31, 2021, CDC investigated SARS-CoV-2 transmission in 20 elementary schools (kindergarten through grade 6) that had reopened in Salt Lake County, Utah. The 7-day cumulative number of new COVID-19 cases in Salt Lake County during this time ranged from 290 to 670 cases per 100,000 persons.† Susceptible§ school contacts¶ (students and staff members exposed to SARS-CoV-2 in school) of 51 index patients** (40 students and 11 staff members) were offered SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) testing. Among 1,041 susceptible school contacts, 735 (70.6%) were tested, and five of 12 cases identified were classified as school-associated; the secondary attack rate among tested susceptible school contacts was 0.7%. Mask use among students was high (86%), and the median distance between students' seats in classrooms was 3 ft. Despite high community incidence and an inability to maintain ≥6 ft of distance between students at all times, SARS-CoV-2 transmission was low in these elementary schools. The results from this investigation add to the increasing evidence that in-person learning can be achieved with minimal SARS-CoV-2 transmission risk when multiple measures to prevent transmission are implemented (3,4).

Reflections from the Book of the Dead: Weighing the Impact of Epicardial Fat on Atrial Fibrillation Vulnerability T. Jared Bunch MDDepartment of Medicine, School of Medicine, University of Utah, Salt Lake City, UtahAddress for correspondence: T. Jared Bunch, M.D.University of Utah School of Medicine Department of Internal Medicine Division of Cardiovascular Medicine 30 North 1900 East, Room 4A100 Salt Lake City, UT 84132 Phone: 801-213-2387 E-mail: jared.bunch@hsc.utah.edu

Neurological manifestations are commonly reported in patients with celiac disease (CD). We aimed to characterize epilepsy features in a pediatric population with CD and the effect of a gluten-free diet (GFD) on seizure burden.A retrospective chart review was performed on pediatric patients treated at the University of Utah and Primary Children's Hospital in Salt Lake City, Utah, with both epilepsy and CD and compared with a control group with epilepsy only.We identified 56 patients with epilepsy and biopsy-confirmed CD (n = 36, 64%) or elevated tissue transglutaminase antibodies (tTG-Ab) without biopsy-confirmed CD (n = 20, 36%). Age- and gender-matched controls were selected from patients with epilepsy only (n = 168). Patients with biopsy-proven CD or positive tTG-Ab had high percentage of drug-resistant epilepsy (DRE) compared with the control group (P0.05). Age at seizure onset preceded the diagnosis of CD on average by 5.9 years for patients with DRE (P0.01) compared with 2.2 years for those with drug-responsive epilepsy. Adhering to a GFD reduced seizure frequency or resulted in weaning dosage or weaning off of one or more antiseizure medications in a majority of patients with DRE.DRE was more prevalent in pediatric patients with biopsy-confirmed CD and positive tTG-Ab compared with the control group (which included childhood epilepsy syndromes), but comparable with the prevalence of DRE in the general population. Adherence to a GFD in combination with antiseizure medications appears to reduce seizure burden for those with CD and DRE.

* Abbreviations: IMV — : invasive mechanical ventilation NIV — : noninvasive ventilation Noninvasive ventilation (NIV) is appealing for the treatment of severe asthma because it likely avoids the potential airway and lung trauma of intubation and invasive mechanical ventilation (IMV). In this issue of Pediatrics , Smith et al1 illustrate the compelling appeal of NIV in clinical use, showing that centers with high use of NIV in 2014 doubled their use of NIV in the next 4 years and that NIV is more common as a mode of respiratory support than IMV. … Address correspondence to Michael D. Johnson, MD, MS, Primary Children’s Hospital, 100 N Mario Capecchi Dr, Salt Lake City, UT 84108. E-mail: mike.johnson{at}hsc.utah.edu

Unsheltered homelessness in the United States forces hundreds of thousands of people to sleep, eat, and live in the public sphere. Urban parks often become temporary homes for individuals ...

PURPOSE To evaluate the ease of replacement and capsular stability of a new fluid-filled, modular, accommodating intraocular lens (IOL) system composed of a monofocal base lens with a fluid lens clipped inside of it. SETTING John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN Experimental study. METHODS Five New Zealand rabbits underwent bilateral phacoemulsification with implantation of the test lens (Juvene, LensGen, Inc.) in both eyes (4 rabbits), or a control IOL in 1 eye (AcrySof, Alcon Laboratories, Inc.) and the test IOL in the other (1 rabbit). At 2 weeks, the 4 rabbits with bilateral Juvene IOLs had the clipped-in fluid lens exchanged for a new fluid lens in 1 eye, and the base and fluid lenses exchanged for a control lens in the contralateral eye. Slitlamp examinations were performed weekly for 4 weeks. The globes were enucleated and evaluated with ultrasound biomicroscopy, grossly from the posterior Miyake-Apple view, and histopathologically. RESULTS Explantation/exchange of the fluid lens was considered straightforward by the surgeon. Explantation of the base lens (4) was also safely performed, albeit more demanding, without any signs of damage to the capsular bag under clinical, ultrasound biomicroscopy, and pathological examination in the exchanged eyes. Less capsular bag opacification was observed with the Juvene lens system. CONCLUSIONS Explantation/exchange of the fluid lens component, or both fluid and base lenses, of this new lens system can be safely accomplished if necessary, because of its modular design and the relative lack of postoperative capsular bag opacification associated with it.

Hypogonadism affects hepatic lipid metabolism and is expected to promote nonalcoholic fatty liver disease (NAFLD). The aims of this study were to determine (1) the prevalence of NAFLD in hypogonadal males and (2) the impact of correction of hypogonadism by LPCN 1144 (Lipocine, Inc., Salt Lake City, UT), an oral testosterone prodrug, on NAFLD in this population. Data were derived from a multicenter open‐label single‐arm trial of LPCN 1144 for hypogonadal males, in which a subset (n = 36) had serial magnetic resonance imaging–proton density fat fraction measurements (National Clinical Trial 03868059). NAFLD prevalence, defined by magnetic resonance imaging–proton density fat fraction ≥5%, was 66%. Eighty‐one percent of those with baseline liver fat (BL) ≥5% had improvement in liver fat content, and NAFLD resolved in 33% of subjects at 8 weeks (mean relative reduction: 45%) and 48% (mean relative reduction: 55%) after 16 weeks of LPCN 1144 therapy. The reduction in liver fat was greater in those with higher BL (BL ≥5%: 71%; BL ≥8%: 80%; and BL ≥10%: 75%). Normalization rate of alanine aminotransferase and gamma‐glutamyltransferase greater than the upper limit of normal range were 100% and 50% of treated patients, respectively. LPCN 1144 was not associated with major adverse events. Conclusion: Treatment with LPCN 1144 (oral T prodrug) in hypogonadal males with NAFLD resolved NAFLD in approximately half of the affected patients without any safety signals. Further studies are needed to validate its use in hypogonadal males with nonalcoholic steatohepatitis.

Objectives The Clinical Practice Guideline of the American Academy of Otolaryngology-Head & Neck Surgery (2014) stated that clinicians should not recommend dietary supplements for the treatment of tinnitus. The aim of this study is to characterize over-the-counter tinnitus remedies (OTCTR) on the U.S. market, describe the ingredients and prices, and characterize the methods of promoting these products. Methods OTCTR were identified via Web search and visits to retail establishments. Information was collected regarding OTCTR chemical composition, product labeling, advertisements and marketing, price, and customers reviews. Results A wide array of unproven OTCTR exist on today's market. All make unfounded claims of relief from ear ringing. Most of the products considered in this study consist of mixtures of inexpensive and common vitamins, minerals, and/or herbs sold at a premium compared to similar preparations not expressly advertised for tinnitus. Certain brands, most notably Arches Tinnitus Formula (Arches Natural Products Inc., Salt Lake City, UT) and Lipo-Flavonoid (Clarion Brands Inc., Solon, OH), target otolaryngologists by advertising in specialty journals and prominently featuring supposed endorsement by "Ear-Nose-and-Throat Doctors" in their marketing. Conclusion It is important for otolaryngologists who are caring for tinnitus sufferers to be aware that a robust and diverse market exists for unproven OTC tinnitus remedies. It is troubling that heavily advertised brands profess support by otolaryngologists. Responsible specialty organizations in the field should consider opposing such commercially motivated representations. Otolaryngology journals may wish to adopt a policy along the lines of The Journal of the American Medical Association publications to decline advertisements of dietary supplements that make unproven therapeutic claims. Level of evidence 5 Laryngoscope, 129:1898-1906, 2019.

To evaluate long-term capsular clarity with a modified disk-shaped 1-piece hydrophilic acrylic monofocal intraocular lens (IOL) (Zephyr) suspended between 2 complete haptic rings connected by a pillar of the haptic material.John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.Experimental study.Study and control (1-piece hydrophobic acrylic) IOLs were implanted into the right and left eyes, respectively, of 8 New Zealand rabbits. Eyes were examined at the slitlamp at set intervals for 6 months. At the end of the clinical follow-up, the globes were enucleated and capsular clarity was scored from the posterior view (Miyake-Apple technique). Then, all the eyes were processed for a complete histopathological evaluation.At 6 months, the slitlamp evaluation showed a posterior capsule opacification score of 0.28 ± 0.26 (SD) in the study group and 4 ± 0 in the control (P .0001, paired t test). The anterior capsule was generally clear in the study group. This parameter was difficult to analyze in the control group because of synechiae formation and poor pupil dilation.The degree of capsular bag clarity observed at 6 months postoperatively in the study eyes in this rabbit model was exceptional. It was likely because of the IOL design, keeping the capsular bag open and expanded, and minimizing contact between the IOL and the anterior capsule.

PURPOSE To examine capsular tension ring (CTR) implantation to establish whether there are predictable movements of the CTR during deployment, indicating complicated vs uneventful implantation. SETTING Intermountain Ocular Research Center, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. DESIGN Experimental study. METHODS Nine cadaver eyes were prepared using standard Miyake-Apple protocol with digital video recording. A 4 o'clock-hour zonular dialysis was created, followed by a capsulorhexis and hydrodissection. In 4 eyes, a suture-guided CTR (SGCTR) injector and 8-0 nylon suture through the leading eyelet served as a visible tracer for the CTR. In 5 eyes, a standard CTR was used. The movements of the CTR during implantation were observed. RESULTS In all eyes, SGCTR and CTR movements were predictable during implantation. All CTRs displayed cardinal movements within the injector, initially adjacent to the side of the inner diameter of the CTR. As the CTR made contact with lens or capsule, it shifted first to the center and then to the opposite side of the injector lumen. The appearance of an S-curve in the surgeon's view coincided with an obstruction of the leading eyelet and stress on the zonular fibers, as viewed with Miyake-Apple analysis. CONCLUSIONS Traumatic CTR implantation might be avoided by understanding the characteristics of uneventful insertion vs an insertion complicated by entrapment or entanglement of the CTR. By recognizing the abnormal movements of the CTR associated with an obstruction, a surgeon might avoid iatrogenic complications.

Objectives To explore the feasibility and acceptability of use of a smartphone medication reminder application to promote adherence to oral medications among adolescents and young adults (AYAs) with cancer. . Sample & setting 23 AYAs with cancer from a Children's Oncology Group-affiliated children's hospital and a National Cancer Institute-designated comprehensive cancer center in Salt Lake City, UT. . Methods & variables Participants were asked to use the application for eight weeks. Data on application usage were obtained from a cloud-based server hosted by the application developers. Weekly self-report questionnaires were completed. Feasibility was assessed through participants' usage and responses. Acceptability was assessed through participants' perceived ease of use and usefulness. . Results Almost all participants used the application at least once. More than half reported that they took their medications immediately when they received reminders. Participants also reported that the application was easy to set up and use, and that it was useful for prompting medication taking. . Implications for nursing Nurses could continue to test the efficacy of integrating e-health modalities, such as smartphone applications, into efforts to promote medication adherence.

To determine if Gadolinium-based enhanced Magnetic Resonance Imaging (GdMRI) can be used to predict sensorineural hearing loss (SNHL) in pediatric patients diagnosed with bacterial meningitis.Design: Retrospective chart review.Primary Children's Hospital, Salt Lake City, Utah.and Methods: We studied forty-two pediatric patients diagnosed with bacterial meningitis who underwent brain GdMRI during their index hospital admission and for whom ear specific audiometric data were available (August 2008-July 2018). A pediatric neuroradiologist, blinded to both disease and audiometric data, rated cochlear enhancement of each GdMRI (0-3; none to markedly enhanced).Ear specific MRI scores were statistically significantly related to ear specific hearing outcomes (p 0.01). SNHL occurred in 19 out of 82 ears (12 out of 42 patients; 2 ears were excluded due to pre-existing SNHL in one ear and inability to read the GdMRI on the other ear). Ten of 19 ears (53%) that developed SNHL showed mild/moderate/marked enhancement (MRI score of 1, 2, or 3 respectively). Fifty-three of the 63 unaffected ears (84%) showed no enhancement (MRI score of 0). Ten of 13 (77%) ears that developed severe to profound SNHL showed mild/moderate/marked enhancement. GdMRI was 58% sensitive and 84% specific in predicting which ears would develop SNHL. GdMRI was 77% sensitive and 84% specific in identifying severe to profound SNHL.Our study demonstrates that GdMRI is a promising tool for predicting specifically severe-profound hearing loss in pediatric patients following bacterial meningitis infection.

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Trauma-Resiliency Collaborative (TRC), established in May 2014 in Salt Lake City, UT, is an ad hoc, and open, community-interest group comprised of multidisciplinary professionals and paraprofessionals. The initial meetings and kick-off event were instrumental to the synergy of the organization. The TRC’s organic growth and minimal time commitment by members facilitates participation and maximizes efficiencies. The success of the TRC model is dependent on highly skilled individuals and/or experts in trauma- and resiliency-related work, who enjoy collaboration by contributing insights, resources, contacts, etc. to further other colleagues’ ad hoc projects and objectives. The TRC has evolved into a model that promotes both individuals and organizations by encouraging an atmosphere of success for all.

// Martha L. Slattery 1 , Andrew J. Pellatt 2 , Frances Y. Lee 2 , Jennifer S. Herrick 3 , Wade S. Samowitz 4 , John R. Stevens 5 , Roger K. Wolff 6 and Lila E. Mullany 7 1 Department of Medicine, University of Utah, Salt Lake City, Utah, USA 2 Tulane Medical School, New Orleans, Louisiana, USA 3 Department of Medicine, University of Utah, Salt Lake City, Utah, USA 4 Department of Pathology, University of Utah, Salt Lake City, Utah, USA 5 Department of Mathematics and Statistics, Utah State University, Logan, Utah, USA 6 Department of Medicine, University of Utah, Salt Lake City, Utah, USA 7 Department of Medicine, University of Utah, Salt Lake City, Utah, USA Correspondence to: Martha L. Slattery, email: marty.slattery@hsc.utah.edu Keywords: colorectal cancer, miRNAs, survival, stage, prognosis Received: May 16, 2017 Accepted: July 25, 2017 Published: August 03, 2017 ABSTRACT Half of miRNAs expressed in colorectal tissue are expressed < 50% of the population. Many infrequently expressed miRNAs have low levels of expression. We hypothesize that less frequently expressed miRNAs, when expressed at higher levels, influence both disease stage and survival after diagnosis with colorectal cancer (CRC); low levels of expression may be background noise. We examine 304 infrequently expressed miRNAs in 1893 population-based cases of CRC with paired carcinoma and normal mucosa miRNA profiles. We evaluate miRNAs with disease stage and survival after adjusting for age, study center, sex, MSI status, and AJCC stage. These miRNAs were further evaluated with RNA-Seq data to identify miRNA::mRNA associations that may provide insight into the functionality of miRNAs. Eleven miRNAs were associated with advanced disease stage among colon cancer patients ( Q value = 0.10). Eight infrequently expressed miRNAs influenced survival if highly expressed in overall CRC. Of these, five increased likelihood of dying if they were highly expressed, i.e. miR-124-3p, miR-143-5p, miR-145-3p, miR31-5p, and miR-99b-5p, while three were associated with better survival if highly expressed, i.e. miR-362-5p, miR-374a-5p, and miR-590-5p. Thirteen miRNAs infrequently expressed in colon-specific carcinoma tissue were associated with CRC survival if highly expressed. Evaluation of miRNAs::mRNA associations showed that mRNA expression influenced by infrequently expressed miRNA contributed to networks and pathways shown to influence disease progression and prognosis. Our large study enabled us to examine the implications of infrequently expressed miRNAs after removal of background noise. These results require replication in other studies. Confirmation of our findings in other studies could lead to important markers for prognosis.

The 2020 AUA Virtual Experience included expert insight on the new AUA Guideline for Advanced Prostate Cancer from 2 experts on the panel that created the guideline. In their discussion during the AUA virtual platform, William Lowrance, MD, MPH, investigator, Huntsman Cancer Institute and associate professor, Division of Urology, University of Utah in Salt Lake City; and Michael S. Cookson, MD, professor and chairman Department of Urology, the Stephenson Cancer Center and University of Oklahoma College of Medicine in Oklahoma City, highlighted the core components of the consensus guideline for urologists to follow in their daily practice.

Introduction: Timely defibrillation of shockable rhythms during out of hospital cardiac arrest (OHCA) is an important link in the chain of survival. In 2011 the Salt Lake City Fire Department (SLCFD) adopted ECG filtering technology to allow rhythm interpretation during CPR and a protocol to defibrillate shockable rhythms immediately upon identification. Hypothesis: We hypothesized that, under the new protocol, time from observing VF to defibrillation would, on average, be less than the 2 minutes expected by guidelines. We also hypothesized that increased shock latency would be associated with intra-arrest transport and decreased survival. Methods: Prospectively collected and abstracted defibrillator data from non-traumatic cardiac arrest cases treated by ALS providers from SLCFD between Dec 2011 and June 2019 were analyzed along with Utstein variables and outcomes. Using the defibrillator manufacturer’s review software, the timing of observed rhythm changes and defibrillation events was manually abstracted based on post-incident physician interpretation. Generalized linear and Poisson mixed models were used for analysis. Results: A total of 696 cardiac arrests with 965 shocks delivered to shockable rhythms were analyzed after excluding pediatric cases, non-ALS cases, and cases in which the defibrillator file was lost or corrupted. Median time to defibrillation was 67 sec (IQR 30-143 sec) with mixed-effects grand mean of 106 sec (95% CI 96-117 sec). Delayed defibrillation (> 2 min) occurred in 293/965 (30%) of shocks. Transport of patients in arrest was associated with an increase in shock latency of 42 sec (95% CI 21-63 sec) compared to patients treated on scene. Among patients with an initial shockable rhythm, time from VF appearance to defibrillation was, on average, 40 sec (95% CI 15-66 sec) shorter among survivors than non-survivors. Conclusions: Use of an aggressive defibrillation protocol enabled by ECG filtering software resulted in a median time to defibrillation of under 2 minutes. Increasing shock latency was associated with intra-arrest transport providing a causal hypothesis for the poor outcomes observed in this population. We observed a negative association between survival and average time to defibrillation of shockable rhythms.

OBJECTIVES Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision-making (SDM) processes. This study investigated SDM-related outcomes through turn analysis and an assessment of patient-centred dialogue. DESIGN Multi-centre prospective cohort study analysing audio- and video-recorded patient/parent-physician interactions. SETTING Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah. PARTICIPANTS Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy. MAIN OUTCOME MEASURES Medical dialogue measures (turn analysis, patient-centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM-Q-9). RESULTS Turn density was significantly higher for physicians than patients/parents (P

Objectives/Hypothesis 1) Determine feasibility of smartphone-based mobile technology to measure noise exposure; and 2) measure noise exposure in exercise spin classes. Study Design Observational Study. Methods The SoundMeter Pro app (Faber Acoustical, Salt Lake City, UT) was installed and calibrated on iPhone and iPod devices in an audiology chamber using an external sound level meter to within 2 dBA of accuracy. Recording devices were placed in the bike cupholders of participants attending spin classes in Boston, Massachusetts (n = 17) and used to measure sound level (A-weighted) and noise dosimetry during exercise according to National Institute for Occupational Safety and Health (NIOSH) guidelines. Results The average length of exposure was 48.9 ± 1.2 (standard error of the mean) minutes per class. Maximum sound recorded among 17 random classes was 116.7 dBA, which was below the NIOSH instantaneous exposure guideline of 140 dBA. An average of 31.6 ± 3.8 minutes were spent at >100 dBA. This exceeds NIOSH recommendations of 15 minutes of exposure or less at 100 dBA per day. Average noise exposure for one 45-minute class was 8.95 ± 1.2 times the recommended noise exposure dose for an 8-hour workday. Conclusions Preliminary data shows that randomly sampled cycling classes may have high noise levels with a potential for noise-induced hearing loss. Mobile dosimetry technology may enable users to self-monitor risk to their hearing and actively engage in noise protection measures. Level of Evidence NA Laryngoscope, 127:1873–1877, 2017

To evaluate the effect of vacuum and aspiration rates on phacoemulsification efficiency and chatter using a monitored forced infusion system.In vitro animal study.John A. Moran Eye Center, University of Utah, Salt Lake City, Utah.Formalin-soaked porcine lenses were divided into 2 mm cubes (tip diameter, 0.9 mm). Vacuum levels were tested at 200, 300, 400, and 500 mm Hg; aspiration rates at 20, 35, and 50 mL/min. Torsional power was set at 60% and intraocular pressure at 50 mm Hg.Increasing vacuum increased efficiency regardless of aspiration rates (R(2) = 0.92; P = .0004). Increasing aspiration further increased efficiency when vacuum was at 400 and 500 mm Hg (P = .004 for 20 vs 35 mL/min, P = .0008 for 35 vs 50 mL/min). At 200 and 300 mm Hg, efficiency only improved when increasing aspiration to 35 mL/min (P.0001 with 20 vs 35 + 50 mL/min). Chatter improved with increasing vacuum, up to 400 mm Hg (P = .003 for 200 vs 300 mm Hg and P = .045 for 300 vs 500 mm Hg). A similar trend of improved chatter was seen with increasing levels of aspiration.Vacuum improved efficiency up to 500 mm Hg independent of flow. Flow has an additive effect on efficiency through 50 mL/min, when vacuum is at 400 mm Hg or higher, and only up to 35 mL/min at vacuums less than 400 mm Hg. Chatter correlated with both vacuum and flow such that increasing either parameter decreases chatter, up to 400 mm Hg with vacuum.

OBJECTIVE: To evaluate the individual effectiveness of needling therapy using the Dermapen (Dermapen, Salt Lake City, Utah) and topical therapy with silicone gel (Kelo-cote, Sinclair Pharma, London, England), and their combined effectiveness for the treatment of linear surgical scars, hypertrophic scars, and keloids. MATERIALS AND METHODS: Twenty patients were randomly selected and equally divided into 2 groups (A and B), with each group of 10 including 6 patients with keloids and 4 with hypertrophic scars. Treatment assignments were random. In group A, the entire scar was treated by skin needling, with silicone gel applied to half of the scar. Patients in group B were treated with silicone gel on the whole scar, with only half of the scar also treated with skin needling. During follow-up visits, clinical photographs, evaluation of the scars' thickness, skin ultrasound, and modified Vancouver Scar Scale were performed. RESULTS: Group A showed an average improvement of 68% (P < .01) on the half of the scar with the combination treatment (skin needling plus silicone gel) compared with a 52% improvement on the half of the scar that was treated with only skin needling. Group B showed an average improvement of 63% (P < .01) where the combination treatment was performed, compared with 47% improvement on the area treated with only the silicone gel. CONCLUSIONS: In conclusion, the combination of these 2 treatments is safe and effective for the treatment of hypertrophic scars and keloids. These modalities achieved favorable results with each patient adhering to the study paramenters.

Purpose To optimize phacoemulsification efficiency by varying the intraocular pressure (IOP) using the Centurion Vision System, a monitored forced-infusion system. Setting John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA. Design Laboratory investigation. Methods Porcine lenses were soaked in formalin and divided into 2.0 mm cubes; 0.9 mm balanced tips were used. Intraocular pressure levels were tested from 30 to 110 mm Hg at 10 mm Hg intervals. Vacuum was set at 500 mm Hg, aspiration at 35 mL/min, and torsional power at 60%. Efficiency (time to lens removal) and chatter (number of lens fragment repulsions from the tip) were measured. Results There was a linear relationship between efficiency and IOP. Increasing IOP led to an increase in efficiency (ie, to a decrease in time necessary to remove the lens fragment) (R2 = .5769, P = .0176). Chatter correlated with IOP in the range of 30 to 50 mm Hg (R2 = .4506, P = .0448) and was minimal at higher IOPs. Conclusions Increasing IOP in the monitored forced-infusion system improved efficiency. Chatter was also decreased or eliminated with increasing IOP. Additional studies will be required to understand the reasons for these findings. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Introduction/Objective CAP accounts for approximately 124,000 pediatric hospitalizations annually. Those patients often have received antibiotics prior to admission. Many have concurrent viral infections. Bacterial infections accompanying viral respiratory infections are known to increase morbidity and mortality. Traditional bacterial culture methods are often negative because of previous antibiotic therapy. The BCID, a multiplex polymerase chain reaction(PCR) assay, can identify 19 bacterial pathogens in approximately 90 minutes. It is FDA approved for blood culture isolates. We hypothesized it would detect bacterial pathogens in pleural effusions. Methods BCID panels were done on residual pleural fluid samples from 10 patients with severe community acquired pneumonia during the period 5/2018 – 12/2019. The patients had positive radiographic findings of pneumonia, were inpatients, had intact immune systems by clinical history and had received antibiotic therapy for more than 8 hours before specimen collection. Treatment required 133 inpatient days. 6 of 10 were diagnosed with viral respiratory pathogens. 1 of 9 had a positive blood culture. 1 of 10 had a positive pleural fluid culture. Results 10 of 10 pleural fluid specimens were positive for a pathogen on the BCID panel – 8, Streptococcus pneumoniae, 1, Staphylococcus aureus and I, Streptococcus pyogens. Two of ten had confirmatory positive cultures. Also, one pleural fluid gram stain showed gram positive cocci in chains and clusters. The BCID detected Streptococcus pyogens. Anti Streptolysin O was strongly positive, 964(0 – 70) IU/mL. Conclusion The yield of bacterial culture plummets with previous antibiotic treatment. FDA approved multiplex PCR panels have narrowly defined specimen requirements. That increases the cost and decreases test applicability. Despite a history of appropriate immunizations in the sample population Streptococcus pneumoniae may be prevalent in the complex pediatric pneumonia population. The BCID may be effective at pathogen detection in cases of complex pneumonia where patients have received prior antibiotic treatment.

OBJECTIVE To identify whether a single session of postrace dry needling can decrease postrace soreness and quantity of postrace leg cramps in half-marathon and full-marathon runners. DESIGN Single-blind, prospective, randomized, controlled trial. SETTING Finish line of 2018 Salt Lake City Marathon & Half-Marathon. PARTICIPANTS Runners aged 18 years or older who completed a marathon or half-marathon. INTERVENTIONS True or sham dry needling of the bilateral vastus medialis and soleus muscles within 1 hour of race completion by 2 experienced practitioners. MAIN OUTCOME MEASURES The primary outcome measure was numeric pain rating improvements for soreness on days 1, 2, 3, and 7 compared to immediately postrace. Secondary outcome measures included number of postrace cramps and subjective improvement of soreness. RESULTS Sixty-two runners were included with 28 receiving true and 34 receiving sham dry needling. Objective pain scores showed an increase in pain of the soleus muscles at days 1 and 2 (P ≤ 0.003 and P ≤ 0.041, respectively) in the dry needling group. No differences were seen in postrace pain in the vastus medialis muscles (P > 0.05). No association was seen between treatment group and presence of postrace cramping at any time point (P > 0.05). Subjectively, there was a nonsignificant trend for those receiving dry needling to feel better than expected over time (P = 0.089), but no difference with cramping (P = 0.396). CONCLUSIONS A single postrace dry needling session does not objectively improve pain scores or cramping compared to sham therapy.

* Abbreviations: ciTBI — : clinically important traumatic brain injury CT — : computed tomography ED — : emergency department LOC — : loss of consciousness PECARN — : Pediatric Emergency Care Applied Research Network TBI — : traumatic brain injury In this month’s Pediatrics , Burstein et al1 report disappointing statistics in their work entitled “Use of CT for Head Trauma: 2007–2015.” Using the National Hospital Ambulatory Medical Care Survey, a representative data set for emergency department (ED) visits,2 they found that 32% of pediatric patients presenting for head trauma had computed tomography (CT) imaging as part of their evaluation. This proportion was unchanged over the study period despite publication of algorithms3–5 and an international effort intended to safely decrease unnecessary radiation exposure from head CTs among infants and children with head injuries. Additionally, they reported that ∼90% of US children received their trauma care at general (nonteaching and nonchildren’s) hospitals, where CT use was higher.1 Some history regarding CT use for pediatric head injury is helpful. In 1999, the American Academy of Pediatrics reviewed treatment of minor head injury and divided recommended evaluation and treatment by whether there was brief loss of consciousness (LOC).6 Head CT imaging was recommended for patients with LOC. If the LOC was … Address correspondence to Susan L. Bratton, MD, MPH, Department of Pediatrics, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108. E-mail: susan.bratton{at}hsc.utah.edu

Purpose This cross-sectional study described how school-aged children with cancer represent their symptoms and associated characteristics using draw-and-tell interviews. Participants & setting 27 children aged 6-12 years receiving treatment for cancer at the Cancer Transplant Center at Primary Children's Hospital, a tertiary pediatric hospital in Salt Lake City, Utah. Methodologic approach Children participated in draw-and-tell interviews while completing drawings depicting days when they felt well and days when they felt sick. Children's drawings and accompanying explanations were analyzed qualitatively. Findings Children's drawings related symptoms and the strategies children used to self-manage those symptoms. Nausea, fatigue, pain, and sadness were the most frequently reported symptoms. Strategies to manage symptoms most often included physical and psychosocial care strategies. Implications for nursing Children with cancer were able to relate detailed descriptions of their symptoms and symptom self-management strategies when presented with developmentally sensitive approaches. Healthcare providers are well positioned to integrate arts-based approaches to symptom assessment and to support children in implementing their preferred strategies to alleviate symptoms.

Purpose To evaluate the uveal and capsular biocompatibility as well as positioning stability of a new hydrophobic acrylic intraocular lens (IOL) in vivo in the rabbit model and compare it with a commercially available IOL. Setting John A Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental study. Methods Fifteen New Zealand rabbits had the new test IOL (Clareon CNA0T0) implanted in one eye and a control IOL (Acrysof SN60WF) implanted in the contralateral eye. The test IOL is manufactured from a new hydrophobic acrylic material incorporating ultraviolet blocker and blue light filter. Its design is based on the control IOL's platform. The rabbits were followed up with weekly slitlamp evaluations, which assessed inflammatory reactions as well as capsular bag opacification. Anterior chamber depth was measured at 1 and 4 weeks post-implantation (high-frequency ultrasound). After 4 weeks, the rabbits were killed humanely and the eyes were enucleated. The anterior segment was evaluated from the posterior or Miyake-Apple view, and was then processed for complete histopathology. Results There were no statistically significant differences between test and control eyes in terms of postoperative inflammation and capsular biocompatibility, including posterior capsule opacification (P = .34, paired t test), and anterior capsule opacification (P = .53, paired t test), as observed during clinical and pathological evaluation. In vivo axial positioning for the test IOL was comparable to the control IOL and stable over time (P = .531 versus P = .788). Conclusions The new IOL showed biocompatibility and stability comparable to the control IOL.

a Women' s Global Health Imperative, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Box 1224, 50 Beale St, Suite 1200, San Francisco, CA 94143-1224, USA b Women' s Division, Lhasa Municipal Hospital, East Beijing Road, Lhasa, TAR, 850000, PRC c Women' s Division, Mentsikhang Traditional Tibetan Medicine and Astrology Hospital, Nyang Re Road, Lhasa, TAR, 850000, PRC d Women' s Division, Lhasa Maternal Child Health Hospital, No. 12 Jiang Su Road, Lhasa, TAR, 850000, PRC e Maternal Fetal Medicine, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA

This study compared the patency of a split-tip self-centering catheter with a predesigned curve (CentrosFLO; Merit, Salt Lake City, Utah) and a standard split-tip catheter with straight distal limbs (Medcomp, Harleysville, Pennsylvania) catheter in patients requiring exchange of a dysfunctional tunneled dialysis catheter (TDC).A single-center retrospective chart review was performed between January 2013 and July 2014. Patients had an existing dysfunctional TDC that was exchanged over a wire using the same access site for either a split-tip self-centering catheter with a predesigned curve or a standard split-tip catheter with straight distal limbs catheter. The primary endpoint was catheter patency analyzed at 1, 3, and 6 months after initial exchange.A total of 73 patients met inclusion criteria (46 in the self-centering catheter group and 27 in the standard split-tipped group). Mean durations of the exchanged catheters were similar between groups. The mean 1-, 3-, and 6-month patency rates for the self-centering and split-tip catheters were 89%, 67.4%, and 23.9% and 81.5%, 40.7%, and 14.8%, respectively. Mean blood flow rates (BFRs) were similar between groups at 1 and 3 months; however, at 6 months, mean rates were 388 mL/min versus 352 mL/min for the self-centering group and split-tipped group, respectively (plt;0.01).These results demonstrate improved patency with the CentrosFLO self-centering catheter versus the split-tip catheter. This may be due to the unique design of the self-centering catheter, allowing for preserved BFRs and patency. These results should be further explored in prospective, randomized multicenter studies.

Objective A structured educational effort to train primary care providers (PCPs) to perform joint injections has been projected to be cost effective. The US Department of Veterans Affairs (VA) is developing a national continuing professional development program to train PCPs in the evaluation and management of patients with common musculoskeletal conditions. The objective of this pilot project was to confirm initial projections of cost effectiveness and to inform further efforts to develop this program on a national scale. Methods The Salt Lake City VA served as the national hub for this pilot project. The initial phase included 19 providers, who participated in a weeklong mixed-methods course. Evaluation was conducted by the VA Employee Education System. Assessments included anonymous surveys, structured telephone interviews, and a review of de-identified procedure codes. Results The survey response rate was 100%, with uniformly positive results. All participants recommended the expansion of this program. The mean number of joint injections performed each month increased from 0.3 (precourse) to 3.5 (postcourse), congruent with prior analyses projecting program cost effectiveness. Conclusion The musculoskeletal mini-residency is a well-received program, with early evidence of cost effectiveness and impact aligned with course objectives. This pilot program is a foundation for efforts in the national dissemination of this initiative.

The AmpliVue (Quidel, San Diego, CA, USA) and Illumigene (Meridian Biosciences, Cincinnati, OH, USA) molecular tests were compared for the detection of C. difficile toxin in fresh fecal samples from adult and pediatric patients. A total of 758 samples were collected, in 3 clinical sites: Nationwide Children's (Columbus, OH, USA), Penn State Hershey (Hershey, PA, USA), Primary Children's (Salt Lake City, UT, USA). Each site tested the fecal specimens using both assays. Any discordant results were resolved by performing toxigenic culture. There were 16 discordant samples among the 3 sites. Following discordant resolution, the combined performance for all 3 sites for sensitivity, specificity, PPV, and NPV for AmpliVue was 96.1%, 99.2%, 96.1%, and 99.2%, respectively, while for Illumigene was 96.1%, 99.8%, 99.2%, and 99.2%, respectively. The AmpliVue and Illumigene methods are both relatively rapid and simple to use, sensitive, and specific for detection of C. difficile toxin and demonstrate similar performance.

Devices for percutaneous closure of patent foramen ovale (PFO) are traditionally based on two opposing discs, leaving significant surface areas exposed in the left and right atrium. The FlatStent EF™ PFO Closure System (Coherex Inc., Salt Lake City, USA) represents a major departure from these devices because it is designed to focus primarily on the PFO tunnel, leaving minimal foreign material behind.To investigate the patient selection, effectiveness, and safety of in-tunnel closure with a FlatStent EF™ in patients with PFO of ≥ 4 mm tunnel length and12 mm diameter at preprocedural transoesophageal echocardiography (TEE).Among 46 consecutive patients undergoing PFO closure, a FlatStent EF™ could be implanted and resulted in initial successful closure (5 bubbles during Valsalva manoeuvre) in 21 (46%) patients. TEE at 162 ± 40 and 317 ± 162 days after implantation demonstrated functional closure in 90% and 95% of cases, respectively. No device or air embolisation, pericardial effusion, or thrombus formation was documented. Small in-tunnel peri-device colour Doppler left to right flow was documented in 10% and 2-6 mm protrusion of FlatStent EF™ along right atrial septum without any residual flow/bubble shunting in 14%. Patients with suboptimal closure (5 bubbles during Valsalva manoeuvre and/or in-tunnel colour flow) had shorter tunnel on preprocedural TEE (5.3 ± 1.5 vs. 10.8 ± 3.5 mm; p = 0.003). There was no difference in TEE diameter (1.8 ± 0.5 vs. 2.0 ± 0.5 mm; p = 0.38) and stretched diameter by sizing balloon (6.3 ± 2.5 vs. 6.3 ± 1.0 mm; p = 1.00).In-tunnel PFO closure with a FlatStent EF™ represents an effective and safe option only in carefully selected patients with long tunnel (4 mm) regardless of the diameter if it is12 mm. These criteria are fulfilled in50% of consecutive candidates for PFO closure. The new phenomenon of in-tunnel peri-device flow and FlatStent EF™ protrusion along the right atrial septum were documented during systematic TEE follow up.

Purpose To evaluate a single-piece hydrophobic acrylic intraocular lens (IOL) with ultraviolet–ozone (UV–O 3 ) treatment on the posterior surface and compare it with an identical untreated IOL in a rabbit model. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental study. Methods Study IOLs were implanted in the right eyes and control IOLs in the left eyes of 10 New Zealand rabbits. Slitlamp examinations were performed 1 to 6 weeks postoperatively. Neodymium:YAG (Nd:YAG) posterior capsulotomy was performed in both eyes of 5 rabbits after the 4-week slitlamp examination. At 6 weeks, the rabbits were killed humanely and their globes were enucleated. Capsular bag opacification was scored from the posterior aspect (Miyake-Apple view), and the eyes were processed for histopathology. Results At 4 weeks, the mean posterior capsule opacification (PCO) scores were 0.88 ± 0.33 (SD) in the study eyes and 2.55 ± 1.13 in the control eyes ( P =.003, 2-tailed paired t test). Performance of Nd:YAG posterior capsulotomy was similar in both groups. Gross postmortem examination also showed statistically less peripheral PCO in eyes with the study IOLs than in control eyes. There was no difference in histopathologic findings between study eyes and control eyes and no signs of untoward inflammation or toxicity in any eye evaluated. Conclusions Treatment of the posterior surface of a single-piece hydrophobic acrylic IOL with UV–O 3 appears to prevent PCO, likely by increasing adhesion between the posterior capsule and the IOL while retaining uveal biocompatibility. Performance of Nd:YAG posterior capsulotomy was similar between treated IOLs and untreated IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Current guidelines recommend all pediatric cancer survivors receive a survivor care plan (SCP) for optimal health management, yet clinical delivery of SCPs varies. We evaluated oncology providers’ familiarity with and preferences for delivering SCPs to inform the implementation of a future SCP program at our institution. From November 2013 to April 2014, oncology providers from the Primary Children’s Hospital in Salt Lake City, UT, completed a survey (n = 41) and a 45-min focus group (n = 18). Participants reported their familiarity with and training in SCP guidelines, opinions on SCPs, and barriers to delivering SCPs. As a secondary analysis, we examined differences in survey responses between physicians and nurses with Fisher’s exact tests. Focus group transcripts and open-ended survey responses were content analyzed. Participants reported high familiarity with late effects of cancer treatment (87.8 %) and follow-up care that cancer survivors should receive (82.5 %). Few providers had delivered an SCP (oncologists 35.3 % and nurses 5.0 %; p = 0.03). Barriers to providing SCPs included lack of knowledge (66.7 %), SCP delivery is not expected in their clinic (53.9 %), and no champion (48.7 %). In qualitative comments, providers expressed that patient age variation complicated SCP delivery. Participants supported testing an SCP intervention program (95.1 %) and felt this should be a team-based approach. Strategies for optimal delivery of SCPs are needed. Participants supported testing an SCP program to improve the quality of patient care. Team-based approaches, including nurses and physicians, that incorporate provider training on and support for SCP delivery are needed to improve pediatric cancer care.

From the *Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico; and †Utah Emergency Physicians, Intermountain Healthcare, Salt Lake City, Utah. Address reprint requests to Neal Stuart Gerstein, MD, University of New Mexico Department of Anesthesiology & Critical Care Medicine, MSC 10 60001, University of New Mexico, Albuquerque, NM 87120. E-mail: ngerstein@gmail.com © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.10.016

Evaluation of the effect of diminished pulsatility as seen in continuous flow ventricular assist devices on arterial endothelial cell phenotype and function Phani K. Patibandla, PhD, Namakkal S. Rajasekaran, PhD, Sandeep B. Shelar, PhD, Guruprasad A. Giridharan, PhD, Silvio H. Litovsky, MD, and Palaniappan Sethu, PhD From the Division of Cardiovascular Disease, Department of Medicine and Division of Molecular and Cellular Pathology, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama; Department of Bioengineering, Speed School of Engineering, University of Louisville, Louisville, Kentucky; Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama; Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and the Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama

BACKGROUND With outbreaks of new respiratory viruses such as the severe acute respiratory syndrome coronavirus and swine-origin influenza A/H1N1, the nucleic acid-based amplification test was introduced to identify causative agents. Multiplex PCR, which can simultaneously detect various respiratory pathogens, is currently used worldwide. Recently, a new type of multiplexed molecular test using a fully automated workflow system was developed, which was also adapted to our laboratory. In this study, we assessed improvements in laboratory practice brought about by the implementation of the rapid test for the detection of respiratory viruses. METHODS We investigated the number of routine and rapid tests conducted as well as the change in monthly test frequency of the routine test. We also analyzed the waiting time, turnaround time, and lead time for the routine and rapid tests. The Anyplex II RV16 detection kit (Seegene, Seoul, Korea) and Filmarray Respiratory Panel (BioFire Diagnostics, Inc., Salt Lake City, UT, USA) were used for the routine and rapid tests, respectively. RESULTS Compared to the routine test, the rapid test significantly (p < 0.01) decreased the mean waiting time (1 hour 46 minutes), turnaround time (1 hour 45 minutes), and lead time (3 hours 32 minutes). After the implementation of the rapid test, the number of routine tests conducted was reduced over the 5-month period, from 13 times a month to 3 times a month. CONCLUSIONS The implementation of the rapid test for the detection of respiratory viruses improved the diagnostic efficiency of the laboratory and greatly reduced lead time.

Kanekar, Shami, Olena V. Bogdanova, Paul R. Olson, Young-Hoon Sung, Kristen E. D'Anci, and Perry F. Renshaw. Hypobaric hypoxia induces depression-like behavior in female Sprague-Dawley rats, but not males. High Alt Med Biol 16:52–60, 2015—Rates of depression and suicide are higher in people living at altitude, and in those with chronic hypoxic disorders like asthma, chronic obstructive pulmonary disorder (COPD), and smoking. Living at altitude exposes people to hypobaric hypoxia, which can lower rat brain serotonin levels, and impair brain bioenergetics in both humans and rats. We therefore examined the effect of hypobaric hypoxia on depression-like behavior in rats. After a week of housing at simulated altitudes of 20,000 ft, 10,000 ft, or sea level, or at local conditions of 4500 ft (Salt Lake City, UT), Sprague Dawley rats were tested for depression-like behavior in the forced swim test (FST). Time spent swimming, climbing, or immobile, and latency to immobility were measured. Female rats housed at altitude display more depression-like behavior in the FST, with significantly more immobility, less swimming, and lower latency to immobility than those at sea level. In contrast, males in all four altitude groups were similar in their FST behavior. Locomotor behavior in the open field test did not change with altitude, thus validating immobility in the FST as depression-like behavior. Hypobaric hypoxia exposure therefore induces depression-like behavior in female rats, but not in males.