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Background A thrombus in the M1 segment of the middle cerebral artery (MCA) can occlude this main stem only or extend into the M1- M2 bifurcation. The occlusion pattern may affect endovascular treatment (EVT) success, as a bifurcated thrombus may be more prone to fragmentation during retrieval. Objective To investigate whether bifurcated thrombus patterns are associated with EVT procedural and clinical outcomes. Methods Occlusion patterns of MCA thrombi on CT angiography from MR CLEAN Registry patients were classified into three groups: main stem occlusion, bifurcation occlusion extending into one M2 branch, and bifurcation occlusion extending into both M2 branches. Procedural parameters, procedural outcomes (reperfusion grade and embolization to new territory), and clinical outcomes (24- 48 hour National Institutes of Health Stroke Scale [NIHSSFU] score, change in NIHSS scores between 24 and 48 hours and baseline Δ [NIHSS], and 90- day modified Rankin Scale [mRS] scores) were compared between occlusion patterns. Results We identified 1023 patients with an MCA occlusion of whom 370 (36%) had a main stem occlusion, 151 (15%) a single branch, and 502 (49%) a double branch bifurcation occlusion. There were no statistically significant differences in retrieval method, procedure time, number of retrieval attempts, reperfusion grade, and embolization to new territory between occlusion patterns. Patients with main stem occlusions had lower NIHSSFU scores than patients with single (7 vs 11, p=0.01) or double branch occlusions (7 vs 9, p=0.04). However, there were no statistically significant differences in Δ NIHSS or in 90- day mRS scores. Conclusions In our population, EVT procedural and long- term clinical outcomes were similar for MCA bifurcation occlusions and MCA main stem occlusions. [ABSTRACT FROM AUTHOR]

The authors show how multimarket data can be used to make predictions about brand performance in markets for which no or poor data exist. To obtain these predictions, the authors propose a model for market similarity that incorporates the structure of the U.S. retailing industry and the geographic location of markets. The model makes use of the idea that if two markets have the same retailers or are located close to each other, then branded goods in these markets should have similar sales performance (other factors being held constant). In holdout samples, the proposed spatial prediction method improves greatly on naive predictors such as global-market averages, nearest neighbor predictors, or local averages. In addition, the authors show the spatial model gives more plausible estimates of price elasticities. It does so for two reasons. First, the spatial model helps solve an omitted variables problem by allowing for unobserved factors with a cross-market structure. An example of such unobserved factors is the shelf-space allocations made at the retail-chain level. Second, the model deals with uninformative estimates of price elasticities by drawing them toward their local averages. The authors discuss other substantive issues as well as future research. [ABSTRACT FROM PUBLISHER]

The article focuses on the human rights and freedom of scientists in the U.S. These include the right to communicate to other scientists, to participate in cultural and intellectual life of the community, and to accept the duties and responsibilities of citizenship. The Universal Declaration of Human Rights proclaimed by the General Assembly of the United Nations on December 10, 1948 is discussed. Furthermore, list of duties of scientist are to maintain a spirit of honesty, integrity and cooperation, to examine the meaning and purposes of the work performed, and to promote the development of science in the benefits of humanity.

This article discusses the marketing of brand name products. The article examines geographic differences in performance that many brands face in the United States, and the author attempts to determine reasons that this trend occurs. The article notes that brand managers often account for these differences, while also relying on feedback loops between brand share and retail distribution.

The global distribution of the soil-dwelling bacterium Burkholderia pseudomallei, causative agent of melioidosis, is poorly understood. We used established culturing methods developed for B. pseudomallei to isolate Burkholderia species from soil collected at 18 sampling sites in three states in the southern United States (Arizona (n = 4), Florida (n = 7), and Louisiana (n = 7)). Using multi-locus sequence typing (MLST) of seven genes, we identified 35 Burkholderia isolates from these soil samples. All species belonged to the B. cepacia complex (Bcc), including B. cenocepacia, B. cepacia, B. contaminans, B. diffusa, B. metallica, B. seminalis, B. vietnamiensis and two unnamed members of the Bcc. The MLST analysis provided a high level of resolution among and within these species. Despite previous clinical cases within the U.S. involving B. pseudomallei and its close phylogenetic relatives, we did not isolate any of these taxa. The Bcc contains a number of opportunistic pathogens that cause infections in cystic fibrosis patients. Interestingly, we found that B. vietnamiensis was present in soil from all three states, suggesting it may be a common component in southern U.S. soils. Most of the Burkholderia isolates collected in this study were from Florida (30/35; 86%), which may be due to the combination of relatively moist, sandy, and acidic soils found there compared to the other two states. We also investigated one MLST gene, recA, for its ability to identify species within Burkholderia. A 365bp fragment of recA recovered nearly the same species-level identification as MLST, thus demonstrating its cost effective utility when conducting environmental surveys for Burkholderia. Although we did not find B. pseudomallei, our findings document that other diverse Burkholderia species are present in soils in the southern United States. [ABSTRACT FROM AUTHOR]

We argue that, over the past several decades, the adoption and diffusion of 'modern retailing technology' represents a substantial advance in productivity, providing greater product variety, enhanced convenience, and lower prices. We first describe modern retailing, highlighting the role of modern formats, scale (often transcending national boundaries), and increased coordination with upstream and downstream partners in production and distribution. In developed markets, the transition to modern retailing is nearly complete. In contrast, many low-income and emerging markets continue to rely on traditional retail formats, that is, a collection of independent stores and open air markets supplied by small-scale wholesalers, although modern retail has begun to spread to these markets as well. E-commerce is a notable exception: the penetration of e-commerce in China and several developing nations in Asia has already surpassed that of high-income countries for some types of consumer goods. To understand the forces governing the adoption of modern technology and the unique role of e-commerce, we propose a framework that emphasizes the importance of scale and coordination in facilitating the transition from traditional to modern retailing. We conclude with some conjectures regarding the likely impact of increased retail modernization for the developing world. [ABSTRACT FROM AUTHOR]

The article offers information on a survey on the evolution of "Marketing Science" journal as a discipline in the U.S. It mentions that the journal has grown into a large global network of scholars, vendors, and client practitioners that are proudly associated with this label. It also mentions that the journal has a scope of improvement among two tangential audiences along with the core audience including nonquantitative researchers within marketing and quantitative researchers in other fields.

The article focuses on the study regarding the assessment of the sustained virological response (SVR) in the mortality of the patients who are suffering with chronic Hepatitis C Virus (HCV) infection and advanced hepatic fibrosis. It informs that HCV infection is the major cause of cirrhosis, hepatocellular carcinoma (HCC) and liver diseases and mentions that approximately 25 percent of the patients in the U.S. with HCV infection have cirrhosis. The study reveals that SVR is associated with improved survival in patients with chronic HCV infections and advanced hepatic fibrosis. It also presents several tables which lists the virological response with SVR and without SVR in the patients.

The article discusses developments in the pathogenesis, diagnostics and treatment of melioidosis. The condition is caused by the environmental gram-negative bacillus Burkholderia pseudomallei and characterized by pneumonia and multiple abscesses. The bacterium was also classified by the U.S. Centers for Disease Control and Prevention as a category B bioterrorism agent. The virulence factors involved in melioidosis, as well as its global distribution, are also discussed.

The article presents updated guidelines on clinical practices for diagnosis and management of infections related to intravascular catheter in the U.S. It states that the updated guidelines replaces the management guidelines that were published in 2001 and intended to be used by health care providers for patients with infections or at risks. The guidelines contain an overview on general management of catheter-related infections, a discussion of epidemiology and pathogenesis, and several charts depicting various types of intravascular device and comments on their usage.

We document evidence of a persistent "early entry" advantage for brands in 34 consumer packaged goods industries across the 50 largest U.S. cities. Current market shares are higher in markets closest to a brand's historic city of origin than in those farthest. For six industries, we know the order of entry among the top brands in each of the markets. We find an early entry effect on a brand's current market share and perceived quality across U.S. cities. The magnitude of this effect typically drives the rank order of market shares and perceived quality levels across cities. [ABSTRACT FROM AUTHOR]

Background: In Europe, driving a passenger car is prohibited if binocular best corrected visual acuity (BCVA) is below 0.5 (20/40). Some US states allow people with reduced visual acuity to use a bioptic telescope system when driving. The aim of our study is to introduce a bioptic telescope system for driving in the Netherlands and to investigate whether it enables people with reduced visual acuity to gain sufficient practical fitness to drive in a European setting. Results: Out of 378 persons who applied for information following media attention for the project, 160 candidates volunteered to participate. Based on the available information, 36 subjects (binocular BCVA: 0.16-0.5 [20/125-20/40]) were invited for assessment (vision, mobility, cognitive function, and driving skills). Of these, 16 did not meet the inclusion criteria and 2 decided not to participate. The remaining 18 subjects were trained in the use of a monocular bioptic telescope (3× magnification). They all completed the predriving training successfully and received driving lessons from specialized professional driving instructors. Eventually, 9 subjects passed the official on-road test of practical fitness to drive, 7 were excluded after a number of driving lessons, and another 2 withdrew on their own initiative. Conclusion: This is the first study in Europe to prepare subjects with reduced visual acuity to drive with the use of a bioptic telescope system. About 55% of the preselected subjects fulfilled all inclusion criteria. Half of the subjects who entered the bioptic training program passed the official fitness to drive test, demonstrating that they could drive smoothly and safely in Dutch traffic using a bioptic telescope system. [ABSTRACT FROM AUTHOR]

Background: In many US states, people with moderately reduced visual acuity (eg, 20/50-20/200) can legally drive with the aid of a small, spectacle-mounted (“bioptic”) telescope. We conducted a demonstration project to assess the viability of implementing bioptic driving in the Netherlands. In this article, we describe the framework of the project from conception through to realization of our primary objective—the introduction of bioptic driving as a legal option for visually impaired people in the Netherlands. Methods: The project was based on bioptic driving programs in the United States, which were adapted to fit into current driving training and assessment practices in the Netherlands. The project convened a consortium of organizations including the Netherlands Bureau of Driving Skills Certificates, service organizations for the visually impaired, and research departments at universities investigating driving and vision. All organizations were educated about bioptic driving and participating professionals were trained in their specific aspects of the project. Media publicity led to significant interest and helped recruitment that enabled the screening and selection of potential participants. Outcomes: The project demonstrated that people with moderately reduced visual acuity can be trained to achieve an adequate level of proficient and safe driving (as assessed by the local official driving licensing professionals) when using a bioptic telescope for the road conditions in the Netherlands. Based on the successful project outcomes, a request was made to the minister to allow bioptic driving in the Netherlands. This request has been accepted; the legal procedures for implementation are in process. [ABSTRACT FROM AUTHOR]

The article discusses an investigation on measles outbreak associated with an International Youth Sporting event in Pennsylvania, Michigan and Texas from August-September 2007. The investigation was conducted by state and local health departments in coordination with the U.S. Centers for Disease Control and Prevention (CDC), using standard measles surveillance case definitions and classifications. The investigation identified six cases that were linked epidemiologically to the index case and two generations of secondary transmission.

Background: Clinical outcomes of chronic hepatitis C infection in patients with advanced fibrosis include liver failure, hepatocellular carcinoma, and death. Objective: To investigate whether sustained virologic response to treatment for hepatitis C is associated with improved clinical outcomes. Design: Retrospective cohort study. Setting: 5 hepatology units of tertiary care centers in Europe and Canada caring for patients with chronic hepatitis C treated between 1990 and 2003. Patients: Consecutively treated patients with chronic hepatitis C who had biopsy-proven advanced fibrosis or cirrhosis (Ishak score, 4 to 6). Measurements: Sustained virologic response, defined as absence of detectable hepatitis C virus RNA at 24 weeks after the end of treatment, and clinical outcomes, defined as death (liver-related or non—liver-related), liver failure, and hepatocellular carcinoma. Results: Of 479 patients, 29.6% had sustained virologic response and 70.3% did not. Median follow-up was 2.1 years (interquartile range, 0.8 to 4.9 years). Four patients with and 83 without sustained virologic response had at least 1 outcome event. Sustained virologic response was associated with a statistically significant reduction in the hazard of events (adjusted hazard ratio, 0.21 [95% CI, 0.07 to 0.58]; P = 0.003). The effect was largely attributable to a reduction in liver failure, which developed in no patients with and 42 patients without sustained virologic response (5-year occurrence, 0% vs. 13.3% [CI, 8.4% to 18.2%]; unadjusted hazard ratio, 0.03 [CI, 0.00 to 0.91]). Limitations: Because few events occurred in the sustained virologic response group, the study had limited ability to detect differences between groups in individual outcomes. In addition, the study was retrospective; selection and survival biases may therefore influence estimates of effect. Conclusion: Sustained virologic response to treatment is associated with improved clinical outcomes, mainly prevention of liver failure, in patients with chronic hepatitis C and advanced fibrosis. [ABSTRACT FROM AUTHOR]

The article examines the epidemiology of injuries among adults in the U.S. who engage in sports and recreational activities. It focuses on basketball-related injuries among adults presenting to ambulatory settings. It is stated that majority of the 507,000 adults who were treated in an ambulatory care setting for injuries related to playing basketball have sought treatment in physicians' offices. The diagnosis found that sprains and strains to the lower leg and ankle region and fractures of the hand, wrist, or fingers were the common injuries found. Detailed information regarding the methods and analysis used in the study, as well as the results, is discussed.

Objectives: To determine the magnitude and causes of unintentional burn injuries attributed to hot objects or substances among children aged birth to 4 years in the United States. Methods: Data were obtained from the National Hospital Ambulatory Medical Care System. Results: Annually, 78,000 infants and toddlers were treated in ambulatory care settings for injuries due to contact with a hot object or substance. Hot foods, curling irons, or clothing irons were the main causes of burns. Conclusions: Due to the varied causes of burns, a combination of health education and product design interventions are likely necessary to prevent these injuries. [ABSTRACT FROM AUTHOR]

Background: Since the mid-1980's there has been a worldwide resurgence of severe disease from group A streptococcus (GAS), with clonal clusters implicated in Europe and the United States. However GAS associated sepsis and rheumatic fever have always remained at high levels in many less developed countries. In this context we aimed to study GAS necrotising fasciitis (NF) in a region where there are high background rates of GAS carriage and disease. Methods: We describe the epidemiology, clinical and laboratory features of 14 consecutive cases of GAS NF treated over a seven year period from tropical northern Australia. Results: Incidence rates of GAS NF in the Aboriginal population were up to five times those previously published from other countries. Clinical features were similar to those described elsewhere, with 7/14 (50%) bacteremic and 9/14 (64%) having associated streptococcal toxic shock syndrome. 11/14 (79%) had underlying chronic illnesses, including all four fatalities (29% mortality overall). Important laboratory differences from other series were that leukocytosis was absent in 9/14 (64%) but all had substantial lymphopenia. Sequence typing of the 14 NF-associated GAS isolates showed no clonality, with only one emm type 1 and two emm type 3 strains. Conclusions: While NF clusters can occur from a single emergent GAS clone, this was not evident in our tropical region, where high rates of NF parallel high overall rates of GAS infection from a wide diversity of strains. The specific virulence factors of GAS strains which do cause NF and the basis of the inadequate host response in those patients who develop NF on infection with these GAS require further elucidation. [ABSTRACT FROM AUTHOR]

Examines the volcanic ash belts in the Middle Jurassic period in the Carmel and Temple Cap formations in southwestern Utah. Volcanic pulse range; Ages of formations; Abundance of phenocryst; Feldspar composition; Biotite; Pyroxene; Amphibole; Apatite; Titanite; Mineral content; Zicon morphology.

Provides a solid framework for determining biostratigraphy of Morrison Formation in the United States. Evidence of volcanic ash layers and ashy beds in the Morrison Formation; Composition of the Tidwell Member; Use of isotopic ages to redefine age formation.

Discusses taxation of intercorporate dividends in the sale of a subsidiary in the United States. Review of Waterman Steamship Co. versus Commissioner case; Elimination of intercorporate dividends in computing gross income of an affiliated group; Taxation according to the substance of the transaction.

Burkholderia pseudomallei is a bacterium endemic to Southeast Asia and northern Australia, but it has not been found to occur endemically in the United States. We report an ostensibly autochthonous case of melioidosis in the United States. Despite an extensive investigation, the source of exposure was not identified. [ABSTRACT FROM AUTHOR]

The American College of Preventive Medicine (ACPM) is providing a set of recommendations designed to reduce the morbidity and mortality associated with distractions due to texting while driving. According to the National Highway Traffic Safety Administration, 12% of all fatal crashes involving at least one distracted driver are estimated to be related to cell phone use while driving. 1 Given the combination of visual, manual, and cognitive distractions posed by texting, this is an issue of major public health concern for communities. Therefore, the ACPM feels it is timely to discuss this issue and provide the following recommendations: 1 Encourage state legislatures to develop and pass legislation banning texting while driving, while simultaneously implementing comprehensive and dedicated law enforcement strategies including penalties for these violations. Legislatures should establish a public awareness campaign regarding the dangers of texting while driving as an integral part of this legislation. 2 Promote further research into the design and evaluation of educational tools regarding texting while driving that can be incorporated into the issuance of driver’s licenses. 3 Provide primary care providers with the appropriate tools to educate patients of all ages. 4 Conduct additional studies investigating the risks associated with cell phone usage while driving, particularly texting, with motor vehicle crashes. [ABSTRACT FROM AUTHOR]

Focuses on the deregulation of wholesale electricity prices in the United States. Purpose of the deregulation; Implications for the avoidance of the upward price hike of electricity supplies; Feasibility of decentralizing the demand side of the electricity market.

Objectives: Melioidosis is increasing in incidence with newly recognized foci of melioidosis in the Americas, Africa, and elsewhere. This review describes the demographics, management, and outcomes of a large cohort of critically ill patients with melioidosis.Design: Data were extracted from two prospective databases-the Menzies School of Health Research Melioidosis Database (1989-2013) and the Royal Darwin Hospital ICU Melioidosis Database (2001-2013).Setting and Patients: The Royal Darwin Hospital ICU is the only ICU in the tropical Top End of Northern Territory of Australia, an endemic area for melioidosis. The study included all patients with melioidosis admitted to Royal Darwin Hospital ICU from 1989 to 2013.Measurements and Main Results: From 1989 to 2013, 207 patients with melioidosis required admission to ICU. Mortality reduced from 92% (1989-1997) to 26% (1998-2013) (p < 0.001). The reduced mortality coincided with the introduction of an intensivist-led service, meropenem, and adjuvant granulocyte colony-stimulating factor for confirmed melioidosis sepsis in 1998. Pneumonia was the presenting illness in 155 of 207 (75%). ICU melioidosis patients (2001-2013) had an Acute Physiology and Chronic Health Evaluation II score of 23, median length of stay in the ICU of 7 days, and median ventilation hours of 130 and one third required renal replacement therapy.Conclusions: The mortality for critically ill patients with melioidosis in the Top End of the Northern Territory of Australia has substantially reduced over the past 24 years. The reduction in mortality coincided with the introduction of an intensivist-led model of care, the empiric use of meropenem, and adjunctive treatment with granulocyte colony-stimulating factor in 1998. [ABSTRACT FROM AUTHOR]

The Choosing Wisely(®) initiative is a national campaign led by the American Board of Internal Medicine Foundation, focused on quality improvement and advancing a dialogue on avoiding wasteful or unnecessary medical tests, procedures, and treatments. The American College of Preventive Medicine (ACPM) Prevention Practice Committee is an active participant in the Choosing Wisely project. The committee created the ACPM Choosing Wisely Task Force to lead the development of ACPM's recommendations with the intention of facilitating wise decisions about the appropriate use of preventive care. After utilizing an iterative process that involved reviewing evidence-based literature, the ACPM Choosing Wisely Task Force developed five recommendations targeted toward overused services within the field of preventive medicine. These include: (1) don't take a multivitamin, vitamin E, or beta carotene to prevent cardiovascular disease or cancer; (2) don't routinely perform prostate-specific antigen-based screening for prostate cancer; (3) don't use whole-body scans for early tumor detection in asymptomatic patients; (4) don't use expensive medications when an equally effective and lower-cost medication is available; and (5) don't perform screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease. The Task Force also reviewed some of the barriers to implementing these recommendations, taking into account the interplay between system and environmental characteristics, and identified specific strategies necessary for timely utilization of these recommendations. [ABSTRACT FROM AUTHOR]

Burkholderia pseudomallei, the causative agent of melioidosis has long been considered able to exist in a latent form. Seropositivity among U.S. soldiers returning from the Vietnam conflict led to melioidosis being dubbed "the Vietnamese time bomb." Cases assigned to "(re)activation from latency" over 30 years of the Darwin Prospective Melioidosis Study (DPMS) were reviewed and reassessed and additional cases from DPMS years 31-34 were added. Historical reports of melioidosis attributed to activation from latency were reviewed. Some earlier DPMS cases and most historical cases described as activation from latency more accurately reflect undiagnosed chronic melioidosis, often with relapsing-remitting courses, rather than truly latent, asymptomatic infection. Such protracted disease should now be diagnosable much earlier, provided melioidosis is considered and laboratory facilities are available. The longest plausible duration of asymptomatic latency remains 29 years. In conclusion, activation from latency is a rare event in melioidosis, accounting in our analysis for under 3% of DPMS cases, consistent with why the Vietnamese time bomb never eventuated.

Background: Endovascular treatment (EVT) is standard of care in anterior circulation large vessel occlusions. In posterior circulation occlusions, data on EVT in isolated posterior cerebral artery (PCA) occlusions are limited, although PCA occlusions can cause severe neurological deficit., Objective: To describe in a prospective study the clinical manifestations, outcomes, and safety of EVT in isolated PCA occlusions., Methods: We used data (2014-2017) from the MR CLEAN Registry, a nationwide, prospective cohort of EVT-treated patients in the Netherlands. We included patients with acute ischemic stroke (AIS) due to an isolated PCA occlusion on CT angiography. Patients with concurrent occlusion of the basilar artery were excluded. Outcomes included change in National Institutes of Health Stroke Scale (ΔNIHSS) score, modified Rankin Scale (mRS) score 0-3 after 90 days, mortality, expanded Thrombolysis in Cerebral Infarction (eTICI), and periprocedural complications., Results: Twenty (12%) of 162 patients with posterior circulation occlusions had an isolated PCA occlusion. Median age was 72 years; 13 (65%) were women. Median baseline NIHSS score was 13 (IQR 5-21). Six (30%) patients were comatose. Twelve patients (60%) received IVT. Median ΔNIHSS was -4 (IQR -11-+1). At follow-up, nine patients (45%) had mRS score 0-3. Seven (35%) died. eTICI 2b-3 was achieved in 13 patients (65%). Nine patients (45%) had periprocedural complications. No symptomatic intracranial hemorrhages (sICH) occurred., Conclusions: EVT should be considered in selected patients with AIS with an isolated PCA occlusion, presenting with moderate-severe neurological deficits, as EVT was technically feasible in most of our patients and about half had good clinical outcome. In case of lower NIHSS score, a more conservative approach seems warranted, since periprocedural complications are not uncommon. Nonetheless, EVT seems reasonably safe considering the absence of sICH in our study., Competing Interests: Competing interests: CBLMM and YBWEMR received funds from the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie - TWIN) Foundation (related to this project, paid to institution). CBLMM received funds from CVON/Dutch Heart Foundation, Stryker, European Commission, Health Evaluation Netherlands (unrelated; all paid to institution). DWJD and AvdL received research grants from Dutch Heart Foundation, Brain Foundation Netherlands, the Netherlands Organisation for Health Research and Development and Health Holland Top Sector Life Sciences and Health, and unrestricted grants from AngioCare BV, Medtronic/Covidien/EV3, Medac Gmbh/Lamepro, Penumbra Inc, Stryker, Top Medical/Concentric, Thrombolytic Science LLC, Stryker European Operations BV and Cerenovus. YBWEMR and CBLMM are shareholders of Nico.laboratory. CBLMM, YBWEMR, and JMC were principal investigators of the MR CLEAN NO IV trial. DWJD and AvdL were principal investigators of the MR CLEAN MED trial. JMC reports grants from Medtronic, Boehringer Ingelheim, and Bayer outside the submitted work., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A thrombus in the M1 segment of the middle cerebral artery (MCA) can occlude this main stem only or extend into the M1-M2 bifurcation. The occlusion pattern may affect endovascular treatment (EVT) success, as a bifurcated thrombus may be more prone to fragmentation during retrieval., Objective: To investigate whether bifurcated thrombus patterns are associated with EVT procedural and clinical outcomes., Methods: Occlusion patterns of MCA thrombi on CT angiography from MR CLEAN Registry patients were classified into three groups: main stem occlusion, bifurcation occlusion extending into one M2 branch, and bifurcation occlusion extending into both M2 branches. Procedural parameters, procedural outcomes (reperfusion grade and embolization to new territory), and clinical outcomes (24-48 hour National Institutes of Health Stroke Scale [NIHSS FU ] score, change in NIHSS scores between 24 and 48 hours and baseline ∆ [NIHSS], and 90-day modified Rankin Scale [mRS] scores) were compared between occlusion patterns., Results: We identified 1023 patients with an MCA occlusion of whom 370 (36%) had a main stem occlusion, 151 (15%) a single branch, and 502 (49%) a double branch bifurcation occlusion. There were no statistically significant differences in retrieval method, procedure time, number of retrieval attempts, reperfusion grade, and embolization to new territory between occlusion patterns. Patients with main stem occlusions had lower NIHSS FU scores than patients with single (7 vs 11, p=0.01) or double branch occlusions (7 vs 9, p=0.04). However, there were no statistically significant differences in ∆ NIHSS or in 90-day mRS scores., Conclusions: In our population, EVT procedural and long-term clinical outcomes were similar for MCA bifurcation occlusions and MCA main stem occlusions., Competing Interests: Competing interests: This project has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 777072 (INSIST project), and the AMC medical Research BV, Amsterdam UMC, location AMC, under project No 21937. The MR CLEAN registry is partially funded by unrestricted grants from the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie), Erasmus Medical Center, Amsterdam University Medical Center and Maastricht University Medical Center. HAM reports co-founder and shareholder of Nicolab, a company that focuses on the use of artificial intelligence for medical image analysis. CBLMM reports grants from European Commission during the conduct of the study; grants from CVON/Dutch Heart Foundation, TWIN Foundation, and Stryker, outside the submitted work; and shareholder of Nicolab. IGHJ reports shareholder of Nicolab. DWJD and AvdL report unrestricted grants from Stryker, Penumbra, Medtronic, Cerenovus, Thrombolytic Science, LLC, Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and Thrombolytic Science, LLC for research, paid to institution. BvdW received funds from Bayer and LivaNova for consultancy, paid to his institution, and grants from the Dutch Heart Foundation, the Horizon 2020 programme, and Stryker, paid to his institution, all outside the work submitted. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Melioidosis, caused by the bacterium Burkholderia pseudomallei, is an uncommon infection that is typically associated with exposure to soil and water in tropical and subtropical environments. It is rarely diagnosed in the continental United States. Patients with melioidosis in the United States commonly report travel to regions where melioidosis is endemic. We report a cluster of four non-travel-associated cases of melioidosis in Georgia, Kansas, Minnesota, and Texas. These cases were caused by the same strain of B. pseudomallei that was linked to an aromatherapy spray product imported from a melioidosis-endemic area., (Copyright © 2022 Massachusetts Medical Society.)

Background: Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However, outcomes after EVT in these late window patients without perfusion imaging are largely unknown. We assessed their characteristics and outcomes in routine clinical practice., Methods: The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, multicentre study in the Netherlands, included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017. CT perfusion was no standard imaging modality. We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age, prestroke modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, Alberta Stroke Programme Early CT Score (ASPECTS), collateral status, location of occlusion and treatment with intravenous thrombolysis. Outcomes included 3-month mRS score, functional independence (defined as mRS 0-2), and death., Results: Of 3264 patients who underwent EVT, 106 (3.2%) were treated beyond 6.5 hours (median 8.5, IQR 6.9-10.6), of whom 93 (87.7%) had unknown time of stroke onset. CT perfusion was not performed in 87/106 (80.2%) late window patients. Late window patients were younger (mean 67 vs 70 years, p<0.04) and had slightly lower ASPECTS (median 8 vs 9, p<0.01), but better collateral status (collateral score 2-3: 68.3% vs 57.7%, p=0.03). No differences were observed in proportions of functional independence (43.3% vs 40.5%, p=0.57) or death (24.0% vs 28.9%, p=0.28). After matching, outcomes remained similar (adjusted common OR for 1 point improvement in mRS 1.04, 95% CI 0.56 to 1.93)., Conclusions: Without the use of CT perfusion selection criteria, EVT in the 6.5-24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics. randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window., Competing Interests: Competing interests: Erasmus MC received funds from Stryker and Bracco Imaging by DWJD. MUMC received funds from Stryker and Codman for consultations by WHvZ. WHvZ and RJvO are principal investigators for the MR CLEAN-LATE trial. R-JBG and FAVP are coordinating researchers for MR CLEAN-LATE. CBLMM received funds from TWIN Foundation (related to this project, paid to institution) and from CVON/Dutch Heart Foundation, Stryker, European Commission, Health Evaluation Netherlands (unrelated; all paid to institution). YBWEMR, CBLMM and IGHJ are shareholders of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis. RL reports institutional fees from Ischamaview for consultancy. The other authors had no conflicting interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Purpose: In 2012, US Marines and Sailors began annual deployments to Australia to participate in joint training exercises with the Australian Defence Force and other partners in the region. During their training, US service members are exposed to a variety of infectious disease threats not normally encountered by American citizens. This paper describes a cohort of US Marines and Sailors enrolled during five rotations to Australia between 2016 and 2020., Participants: Study participation is strictly voluntary. Group informational sessions are held prior to deployment to describe the study structure and goals, as well as the infectious disease threats that participants may encounter while in Australia. All participants provided written informed consent. Consented participants complete a pre-deployment questionnaire to collect data including basic demographic information, military occupational specialty, travel history, family history, basic health status and personal habits such as alcohol consumption. Blood is collected for serum, plasma and peripheral blood mononuclear cells (PBMC) processing. Data and specimen collection is repeated up to three times: before, during and after deployment., Findings to Date: From the five rotations that comprised the 2016-2020 Marine Rotational Force-Darwin, we enrolled 1289 volunteers. Enrolments during this period were overwhelmingly white male under the age of 24 years. Most of the enrollees were junior enlisted and non-commissioned officers, with a smaller number of staff non-commissioned officers and commissioned officers, and minimal warrant officers. Over half of the enrollees had occupational specialty designations for infantry., Future Plans: In the future, we will screen samples for serological evidence of infection with Burkholderia pseudomallei , Coxiella burnetii , Ross River virus, SARS-CoV-2 and other operationally relevant pathogens endemic in Australia. Antigenic stimulation assays will be performed on PBMCs collected from seropositive individuals to characterise the immune response to these infections in this healthy American population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The prognostic value of cytonuclear grade in ductal carcinoma in situ (DCIS) is debated, partly due to high interobserver variability and the use of multiple guidelines. The aim of this study was to evaluate interobserver agreement in grading DCIS between Dutch, British, and American pathologists. Haematoxylin and eosin-stained slides of 425 women with primary DCIS were independently reviewed by nine breast pathologists based in the Netherlands, the UK, and the USA. Chance-corrected kappa (κ ma ) for association between pathologists was calculated based on a generalised linear mixed model using the ordinal package in R. Overall κ ma for grade of DCIS (low, intermediate, or high) was estimated to be 0.50 (95% confidence interval [CI] 0.44-0.56), indicating a moderate association between pathologists. When the model was adjusted for national guidelines, the association for grade did not change (κ ma = 0.53; 95% CI 0.48-0.57); subgroup analysis for pathologists using the UK pathology guidelines only had significantly higher association (κ ma = 0.58; 95% CI 0.56-0.61). To assess if concordance of grading relates to the expression of the oestrogen receptor (ER) and HER2, archived immunohistochemistry was analysed on a subgroup (n = 106). This showed that non-high grade according to the majority opinion was associated with ER positivity and HER2 negativity (100 and 89% of non-high grade cases, respectively). In conclusion, DCIS grade showed only moderate association using whole slide images scored by nine breast pathologists. As therapeutic decisions and inclusion in ongoing clinical trials are guided by DCIS grade, there is a pressing need to reduce interobserver variability in grading. ER and HER2 might be supportive to prevent the accidental and unwanted inclusion of high-grade DCIS in such trials., (© 2021 The Authors. The Journal of Pathology: Clinical Research published by The Pathological Society of Great Britain and Ireland & John Wiley & Sons, Ltd.)

Aim: To explore fracture outcomes with tapentadol or oxycodone, two opioids with differing mechanisms of action. Materials & methods: Retrospective cohort pilot study, using MarketScan ® Commercial and Medicare Supplemental claims databases, on patients with postoperative pain, back pain, or osteoarthritis and ≥1 claim for tapentadol (n = 16,457), oxycodone (n = 1,356,920), or both (n = 15,893) between June 2009 and December 2015. Results: During 266,826 and 9,007,889 days of tapentadol and oxycodone treatment, patients evidenced 1080 and 72,275 fractures, respectively. Fracture rates per treatment-year were 1.512 for tapentadol and 3.013 for oxycodone. Conclusion: Examination of administrative claims has inherent limitations, but this exploratory analysis indicates a lower fracture rate with tapentadol than oxycodone in the analyzed dataset, which needs confirmation by further clinical trials.

Infection with the gram-negative bacterium Burkholderia pseudomallei can result in a life-threatening disease known as melioidosis. Historically, melioidosis was a common infection in military forces serving in Southeast Asia, and it has the potential to have a serious impact on force health readiness. With the U.S. Department of Defense's increasing strategic and operational focus across the Pacific Theater, melioidosis is an increasingly important issue from a force health protection perspective. U.S. Marines deploy annually to Darwin, Australia, a "hyperendemic" region for B. pseudomallei , to engage in training exercises. In an effort to assess the risk of B. pseudomallei infection to service personnel in Australia, 341 paired samples, representing pre- and post-deployment samples of Marines who trained in Australia, were analyzed for antibodies against B. pseudomallei antigens. Serological evidence of possible deployment-related infection with B. pseudomallei was found in 13 Marines. Future prospective studies are required to further characterize the risk to service members deployed to melioidosis endemic areas.

Objectives: To summarize the evidence on the prevalence and preventability of drug-related hospital readmissions., Design: A systematic review was performed of studies that examined drug-related hospital readmissions. PubMed, EMBASE, and the Cochrane Library were searched from inception through August 2016. Reference lists and a citation analysis on Web of Science and Scopus were also consulted. Two reviewers extracted study data with dual assessment of risk of bias. Prevalence and preventability of readmission due to drugs were calculated. Data were qualitatively summarized according to outcome., Results: Nineteen studies met the eligibility criteria. Nine measured readmissions due to drug-related problems, seven due to adverse drug reactions, two due to adverse drug events, and one due to drug-drug interactions. Rates of readmissions due to drugs varied from 3% to 64% (median 21%, interquartile range (IQR) 14-23%). Readmissions were deemed preventable in 5% to 87% of cases (median 69%, IQR 19-84%). Evidence regarding the risk factors for drug-related readmissions and drugs causing these readmissions was inconsistent., Conclusion: Although studies show high variability in prevalence and preventability of drug-related hospital readmissions, readmissions due to drugs seem to occur often, especially in older adults. Further research is needed to specify the causes of preventable readmissions and implement effective interventions to reduce medication-related hospital admissions., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objective  To improve the selection of patients with acute ischaemic stroke for intra-arterial treatment using a clinical decision tool to predict individual treatment benefit. Design  Multivariable regression modelling with data from two randomised controlled clinical trials. Setting  16 hospitals in the Netherlands (derivation cohort) and 58 hospitals in the United States, Canada, Australia, and Europe (validation cohort). Participants  500 patients from the Multicenter Randomised Clinical Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands trial (derivation cohort) and 260 patients with intracranial occlusion from the Interventional Management of Stroke III trial (validation cohort). Main outcome measures  The primary outcome was the modified Rankin Scale (mRS) score at 90 days after stroke. We constructed an ordinal logistic regression model to predict outcome and treatment benefit, defined as the difference between the predicted probability of good functional outcome (mRS score 0-2) with and without intra-arterial treatment. Results  11 baseline clinical and radiological characteristics were included in the model. The externally validated C statistic was 0.69 (95% confidence interval 0.64 to 0.73) for the ordinal model and 0.73 (0.67 to 0.79) for the prediction of good functional outcome, indicating moderate discriminative ability. The mean predicted treatment benefit varied between patients in the combined derivation and validation cohort from -2.3% to 24.3%. There was benefit of intra-arterial treatment predicted for some individual patients from groups in which no treatment effect was found in previous subgroup analyses, such as those with no or poor collaterals. Conclusion  The proposed clinical decision tool combines multiple baseline clinical and radiological characteristics and shows large variations in treatment benefit between patients. The tool is clinically useful as it aids in distinguishing between individual patients who may experience benefit from intra-arterial treatment for acute ischaemic stroke and those who will not. Trial registration  clinicaltrials.gov NCT00359424 (IMS III) and isrctn.com ISRCTN10888758 (MR CLEAN)., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form. JPB received study medication for intra-arterial tissue type plasminogen activator from Genentech and catheters were supplied by EKOS Corporation, Concentric Medical, and Cordis. His research is funded by the Department of Neurology and Rehabilitation Medicine. He is remunerated by Genentech for his role on the Steering Committee for A Study of the Efficacy and Safety of Activase (Alteplase) in Patients With Mild Stroke (PRISMS) trial. SDY is remunerated by Genentech for her statistical role in the PRISMS trial. PK is remunerated by Genentech for her role as lead principal investigator of the PRISMS trial and by Penumbra for her role as neurology principal investigator of the Assess the Penumbra System in the Treatment of Acute Stroke trial. She has also received royalties from UpToDate and consulted for Grand Rounds, St Jude Medical, and Biogen. BJE is remunerated for his role as CE mark reviewer by DEKRA and by Novartis for educational lectures. Erasmus MC received funds from Stryker for consultations by DWJD and AL and for training courses by BJE, and from Bracco Imaging for consultations by DWJD. The Academic Medical Centre received funds from Stryker for consultations by CBLMM and YBWEMR. Maastricht University Medical Centre received funds from Stryker and Codman for consultations by WHZ., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The aim of this study was to assess prospectively 2-year outcomes of transoral incisionless fundoplication (TIF) in a multicenter setting. A 14-center U.S. registry was designed to evaluate the effects of the TIF 2.0 procedure on chronic gastroesophageal reflux disease (GERD) in over 100 patients. Primary outcome was symptom assessment. Secondary outcomes were proton pump inhibitor (PPI) use, degree of esophagitis, safety, and changes in esophageal acid exposure. One hundred twenty-seven patients underwent TIF between January 2010 and April 2011, 19 (15%) of whom were lost to follow-up. Eight patients undergoing revisional surgery were included, as failures, in the 108 remaining patients. No serious adverse events were reported. GERD Health-related Quality of Life and regurgitation scores improved by 50 per cent or greater in 63 of 96 (66%) and 62 of 88 (70%) patients who had elevated preoperative scores. The Reflux Symptom Index score normalized in 53 of 82 (65%) patients. Daily PPI use decreased from 91 to 29 per cent. In patients amenable to postoperative testing, esophagitis healed in 12 of 16 (75%) and esophageal acid exposure normalized in eight of 14 (57%). TIF safely achieved sustained symptomatic control over a 2-year period in two-thirds of patients with a virtual absence of de novo side effects.

Background: This study examined the impact of professional preparation and class structure on sexuality topics taught and use of practice-based instructional strategies in US middle and high school health classes., Methods: Data from the classroom-level file of the 2006 School Health Policies and Programs were used. A series of multivariable logistic regression models were employed to determine if sexuality content taught was dependent on professional preparation and /or class structure (HE only versus HE/another subject combined). Additional multivariable logistic regression models were employed to determine if use of practice-based instructional strategies was dependent upon professional preparation and/or class structure. Years of teaching health topics and size of the school district were included as covariates in the multivariable logistic regression models., Results: Findings indicated professionally prepared health educators were significantly more likely to teach 7 of the 13 sexuality topics as compared to nonprofessionally prepared health educators. There was no statistically significant difference in the instructional strategies used by professionally prepared and nonprofessionally prepared health educators. Exclusively health education classes versus combined classes were significantly more likely to have included 6 of the 13 topics and to have incorporated practice-based instructional strategies in the curricula., Conclusions: This study indicated professional preparation and class structure impacted sexuality content taught. Class structure also impacted whether opportunities for students to practice skills were made available. Results support the need for continued advocacy for professionally prepared health educators and health only courses., (© 2013, American School Health Association.)

Pyoderma, scabies, and tinea are common childhood skin disorders too often considered to be merely of nuisance value. More than 111 million children are believed to have pyoderma, with many also co-infected with scabies, tinea, or both. These skin disorders cannot be differentiated by ethnicity or socioeconomic status but, in high-prevalence areas, poverty and overcrowded living conditions are important underlying social determinants. Each is transmitted primarily through direct skin-to-skin contact. For many Indigenous children, these skin conditions are part of everyday life. Although rarely directly resulting in hospitalization or death, there is a high and largely unmet demand for effective management at the primary health-care level, particularly for pyoderma and scabies. Despite particularly high prevalence in some settings, treatment is not sought for many children, and when sought, the clinical benefit from such consultations is variable. The lack of standard, evidence-based recommendations is of much concern. The current evidence base for clinical diagnosis and treatment of these common childhood skin disorders is highlighted.

The Composite Health Care System II (CHCS II) is the Military's electronic Computer-based Patient Record, a clinical information system that will generate, maintain, and provide secure online access to a comprehensive and legible health record. In moving to CHCS II, the Department of Defense (DoD) is making the quantum leap from paper based medical records to computer based patient record (CPR). The CPR will enable DoD health care to meet its strategic goals for the 21st century and is paramount to providing comprehensive patient-focused information.