Search

We demonstrate, to our knowledge, the first bright circularly polarized high-harmonic beams in the soft X-ray region of the electromagnetic spectrum, and use them to implement X-ray magnetic circular dichroism measurements in a tabletop-scale setup. Using counterrotating circularly polarized laser fields at 1.3 and 0.79 μm, we generate circularly polarized harmonics with photon energies exceeding160 eV. The harmonic spectra emerge as a sequence of closely spaced pairs of left and right circularly polarized peaks, with energies determined by conservation of energy and spin angular momentum. We explain the single-atom and macroscopic physics by identifying the dominant electron quantum trajectories and optimal phasematching conditions. The first advanced phase-matched propagation simulations for circularly polarized harmonics reveal the influence of the finite phase-matching temporal window on the spectrum, as well as the unique polarization-shaped attosecond pulse train. Finally, we use, to our knowledge, the first tabletop X-ray magnetic circular dichroism measurements at the N4,5 absorption edges of Gd to validate the high degree of circularity, brightness, and stability of this light source. These results demonstrate the feasibility of manipulating the polarization, spectrum, and temporal shape of high harmonics in the soft X-ray region by manipulating the driving laser waveform.

The purpose of this study was to evaluate prediction of methane emissions from finishing beef cattle using an extant mechanistic model with pH-independent or pH-dependent volatile fatty acid (VFA) stoichiometries, a recent stoichiometry adjustment for the use of monensin, and adaptation of the underlying model structure, to see if prediction improvements could be made for beef cattle. The database used for independent evaluation of methane predictions consisted of 74 animal means from six studies. For the "Bannink" stoichiometries, pH-dependence of stoichiometry improved the root mean square prediction error (RMSPE) statistic (38.8 to 36.6%) but the concordance correlation coefficient (CCC) statistic was reduced (0.509 to 0.469). Inclusion of monensin in the stoichiometry improved both pH-independent and pH-dependent predictions. For the "Murphy" stoichiometries, pH-dependence worsened the RMSPE (31.2 to 33.7%) as well as the CCC (0.611 to 0.465) statistic. Inclusion of monensin in the stoichiometry improved predictions with the pH-independent but not with the pH-dependent stoichiometry. Results indicate that although improvements have been made to the mechanistic model, further improvement in the representation of VFA stoichiometry, and likely the representation and prediction of pH and neutral detergent fiber digestibility, are required for more accurate prediction of methane emissions for finishing beef cattle. However, inclusion of an adjustment for monensin feeding generally lead to improved methane predictions.

A meta-analysis investigation based on literature data was conducted to estimate the effect size of nutritional and animal factors on phosphorus (P) excretion in feces and concentrations of P in milk. Two data sets were created for statistical analysis: One to derive prediction equations for P in feces (25 studies; 130 treatments) and another for P in milk (19 studies; 94 treatments). Prediction equations were derived using mixed model regression analysis with a random effect for study, and equations were evaluated based on values for Bayesian information criterion (BIC), root mean square prediction error (RMSPE), and concordance correlation coefficient (CCC) statistics. In terms of RMSPE and CCC values, fecal P excretion was best predicted by P intake, where P in feces (g/d)=-3.8(±3.45) + 0.64(±0.038) × P intake (g/d) (RMSPE: 18.3%, CCC: 0.869). However, significant effects of crude protein [g/kg of dry matter (DM)], neutral detergent fiber (g/kg of DM), and milk yield (kg/d) on fecal P excretion were also found. Despite a lack of improvement in terms of RMSPE and CCC values, these parameters may still explain part of the variation in fecal P excretion. For milk P, expressed as a fraction of P intake, the following equation had the highest CCC and the lowest RMSPE value: P in milk as a fraction of P intake (g/g)=0.42(±0.065) + 0.23(±0.018) × feed efficiency (i.e., fat- and protein-corrected milk yield/dry matter intake) - 0.11(±0.0199) × P in feed (g/kg of DM) (RMSPE: 19.7%; CCC: 0.761). Equations derived to predict fecal P as a fraction of P intake (g/g) or milk P content (g/kg) could not adequately explain the observed variation and did not perform well in terms of RMSPE and CCC values. Examination of the residuals showed that P balance was a seemingly confounding factor in some of the models. The results presented here can be used to estimate P in feces and milk based on commonly measured dietary and milk variables, but could also be used to guide development of mechanistic models on P metabolism in lactating dairy cattle. Factors to consider in future research and modeling efforts regarding efficiency of P use include the effects of dietary neutral detergent fiber, crude protein, starch, variation in P content of milk, and effects of P resorption from bone and body tissues during early lactation.

A major challenge in health care today is to provide high-quality care that results in the best outcomes possible for patients and residents within the limits of available resources. Throughout the past decade, there has been a call from ethicists for health care institutions to integrate the ethics and quality improvement processes. This article describes how a transitional/extended care facility integrated the quality improvement process within an ethical framework to achieve high-quality care while controlling cost. Copyright © 2002 by Aspen Publishers, Inc. [ABSTRACT FROM AUTHOR]

Objective: Neurilemomas are classically described as fusiform tumors that eccentrically displace the undisturbed neural fascicles. The authors seek to clarify the relationship of cervical neurilemomas to their nerve of origin and assess the functional outcome of surgical extirpation.Study Design: A retrospective review of clinical, intraoperative, and histopathologic data of six patients with cervical extracranial neurilemomas.Methods: Additional histochemical staining of the pathologic specimens was performed to evaluate the tumor for neurites. A comprehensive literature review of cervical neurilemoma cases and meta-analysis of clinical outcomes in these cases were performed.Results: In the series of five consecutive cervical neurilemomas, only one was an eccentric mass pushing the undisturbed nerve aside. In the five other cases, excision of the neurilemoma required complete nerve excision. Neural elements traveling through the central portions of the tumor were clearly demonstrated histologically. Collective analysis of the literature on cervical neurilemomas revealed that although some cases allow nerve preservation, preservation of function is frequently poor.Conclusions: This experience and that reported in the literature suggest that it is frequently impossible to preserve the function of the nerve of origin with surgical treatment of cervical neurilemomas. [ABSTRACT FROM AUTHOR]

Background: We sought to examine the potential role of race and insurance status on the presentation, management, and outcomes of high-grade renal trauma (HGRT) in a large trauma registry., Methods: A retrospective cohort study of a large, multi-center registry of high-grade pediatric renal trauma was performed. Patients < 18 years of age with HGRT (grades III, IV, and V) from 2007 to 2020 were included. Patient demographics, presenting characteristics, hospital courses, outcomes, and follow-ups were extracted and compared., Results: A total of 341 patients were initially identified, 32 were excluded. 66.3% were Caucasian(C), 27.5% were African American(AA), and 6.2% were Other races(O). 43.7% had public insurance,49.8% had private insurance and 6.5% were self-pay. Association of Race: AA patients had a higher rate of penetrating trauma (9% AA vs. 4% C, 0% Others, p = 0.002). Those with O and AA races presented at a younger age (9.5 yo O vs. 12.5 yo AA vs. 14 yo C, p = 0.001). However, no differences were found between race groups in the hospital course or outcome. Association of Insurance status: Those with public insurance presented with higher rates of bowel injury and blood transfusion, no differences were found in hospital course or outcome. Private insurance had higher Urology follow up rates (49% Private vs. 34.6% Public vs. 35% Self pay, p = 0.041)., Conclusions: Race and insurance status was associated with differences found on the mechanism of injury, transfusion rate and urology follow-up rate; however, they do not influence rates of surgical intervention, post-injury complications or mortality., Competing Interests: Declarations. Ethical approval: This study was approved by each institution’s Institutional Review Board. Competing interests: The authors declare no competing interests. Conflict of interest: The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Active surveillance (AS) is a management strategy for patients with favorable risk prostate cancer. Multi-parametric magnetic resonance imaging (mpMRI) may impact upgrading rates, but there is mixed evidence on the appropriate timing to introduce mpMRI. We evaluated timing of initial mpMRI use for patients on AS and compared upgrading and intervention rates for AS candidates who received initial mpMRI before diagnostic biopsy vs. confirmatory biopsy., Subjects and Methods: Patients enrolled in AS captured by the Prospective Loyola Urology mpMRI (PLUM) Prostate Biopsy Cohort which captures men undergoing MRI-fusion prostate biopsy. We included patients enrolled in AS between January 2014 and October 2022. We conducted a retrospective analysis of patients who underwent MRI-fusion prostate biopsy while on AS at our institution. The cohort was stratified by men who underwent first mpMRI prior to diagnostic biopsy (MRI-DBx), confirmatory biopsy (MRI-CBx), or a subsequent surveillance biopsy. Oncologic outcomes including pathologic reclassification, intervention-free survival, progression-free survival, and overall survival were evaluated., Results: Of 346 patients identified on AS, 94 (27.2%) received mpMRI at the time of diagnostic biopsy, 182 (52.6%) at confirmatory biopsy, and 70 (20.2%) at a later biopsy. At confirmatory biopsy (median 14 months), there was no difference in upgrading (HR 0.95, P = 0.78) or intervention rates (HR 0.97, P = 0.88) between MRI-DBx and MRI-CBx. PI-RADS score on initial mpMRI was associated with upgrading during AS follow-up relative to men with negative mpMRI (HR 4.20 (P = 0.04), 3.24 (P < 0.001), and 1.99 (P < 0.001) for PI-RADS 5, 4, and 3, respectively), and PSA density was associated with intervention (HR 1.52, P = 0.03)., Conclusion: mpMRI can serve as a prognostic tool to select and monitor AS patients, but there was no difference in upgrading or intervention rates based on initial timing of MRI., Competing Interests: Declaration of competing interest The authors have no conflicts to disclose., (Published by Elsevier Inc.)

To properly formulate diets, the ability to accurately estimate feed intake is critical as the amount of feed consumed will influence the amount of nutrients delivered to the animal. Inaccurate intake estimates may lead to under- or over-feeding of nutrients to the animal. Individual differences in equine forage intake are well-known, but predictive equations based on animal and nutritional factors are not comprehensive. The objective of the present study was to consolidate the current body of knowledge in the published literature on voluntary forage DM intake (VFDMI) in equines and conduct a meta-analysis to identify driving factors, sources of heterogeneity, and develop predictive equations. Therefore, a systematic literature search was applied and identified 61 publications which met the inclusion criteria. From each study, the outcomes of interest (e.g., forage intake), diet composition (e.g., forage information, nutrient composition), and animal factors (e.g., sex, age, breed, BW, exercise level) were extracted. Forage intake was analyzed as two different outcome variables: (1) VFDMI in kg/d and (2) VFDMI in g/kg BW. Linear mixed model analysis treating study as a random effect was applied, using a backward-stepping approach to identifying potential driving variables for VFDMI (both units) where all terms have P < 0.1. The best fitting models for VFDMI included similar factors (also across kg/d and g/kg BW) such as forage quality (i.e., neutral detergent fiber or CP content), forage type (i.e., grass, legume, or mixed), the animals' size category (i.e., horses vs ponies), and some management factors (i.e., pasture access). As anticipated, forage intake increased when higher quality forages were fed (i.e., lower neutral detergent fiber or higher CP), potentially due to improved digestibility. Additionally, VFDMI increased as BW increased but ponies increased their VFDMI more per every kg increase in BW compared to horses. Lastly, pasture access (i.e., grazing) may influence VFDMI such that pastured animals consume less than stalled animals, possibly due to the time it takes to graze forage. In conclusion, equations to predict equine VFDMI with high accuracy and precision (concordance correlation coefficient  = 0.82 - 0.95; root mean squared error RMSE = 0.82-5.49) were developed which could be applied in practice by equine nutritionists or owners and managers. The results of this meta-analysis confirm that animal traits and forage quality have a significant impact on the VFDMI of equines and should be accounted for when formulating diets to ensure nutritional requirements are met., (Copyright © 2024. Published by Elsevier B.V.)

It is shown that the psychometric test reliability, based on any true-score model with randomly sampled items and uncorrelated errors, converges to 1 as the test length goes to infinity, with probability 1, assuming some general regularity conditions. The asymptotic rate of convergence is given by the Spearman-Brown formula, and for this it is not needed that the items are parallel, or latent unidimensional, or even finite dimensional. Simulations with the 2-parameter logistic item response theory model reveal that the reliability of short multidimensional tests can be positively biased, meaning that applying the Spearman-Brown formula in these cases would lead to overprediction of the reliability that results from lengthening a test. However, test constructors of short tests generally aim for short tests that measure just one attribute, so that the bias problem may have little practical relevance. For short unidimensional tests under the 2-parameter logistic model reliability is almost unbiased, meaning that application of the Spearman-Brown formula in these cases of greater practical utility leads to predictions that are approximately unbiased., (© 2024. The Author(s).)

Purpose: Few studies have quantified differences in histology and implications for survival between male children and adults with germ cell tumors (GCT). We evaluated these differences and associations with cancer-specific survival (CSS) using Surveillance, Epidemiology, and End Results (SEER) cancer registries., Methods: SEER (1988-2016) was used to identify male patients 0 to 40 years of age diagnosed with seminoma and nonseminomatous GCT (NSGCT). Demographic and tumor characteristics were tabulated with histology distributions compared by age group (0-4, 12-18, 19-40 years old). CSS was evaluated in multivariable Cox proportional hazards regression models., Results: Among 27,204 patients identified, 1,538 (5.7%) were pediatric (0-18 years). Seminoma (54.3%) predominated in adult patients (ages 19-40). Among 0 to 4 years-old, yolk sac tumor (71.2%) and teratoma (21.5%) were most common. Mixed GCT (52.7%) was most prevalent among 12 to 18 years-old with seminoma, embryonal, and teratoma occurring in 12 to 15% each. Relative to pediatric patients, adult patients had similar CSS for seminoma but worse CSS for NSGCT on Kaplan-Meier curves with 9 years mean follow-up. Choriocarcinoma and yolk sac tumors carried the worst prognosis relative to seminoma for both children (HR 5.7 and HR 11.1, respectively, both P < 0.01) and adults (HR 4.6 and HR 4.6, respectively, both P < 0.01) adjusted for stage., Conclusion: Histology of GCTs vary by age with yolk sac tumors and teratoma predominating for male patients 0 to 4 years, mixed GCT for 12 to 18 years, and seminoma for 19 to 40 years. Pediatric patients with NSGCT had higher CSS than their adult counterparts. Mixed GCT represented an increasing proportion of GCT over the study period. Age, stage, and histology impact CSS in both pediatric and adult populations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The link between the prostate microbiome and prostate cancer remains unclear. Few studies have analyzed the microbiota of prostate tissue, and these have been limited by potential contamination by transrectal biopsy. Transperineal prostate biopsy offers an alternative and avoids fecal cross-contamination. We aim to characterize the prostate microbiome using transperineal biopsy., Methods: Patients with clinical suspicion for prostate cancer who were to undergo transperineal prostate biopsy with magnetic resonance imaging (MRI) fusion guidance were prospectively enrolled from 2022 to 2023. Patients were excluded if they had Prostate Imaging Reporting and Data System lesions with scores ≤ 3, a history of prostate biopsy within 1 year, a history of prostate cancer, or antibiotic use within 30 days of biopsy. Tissue was collected from the MRI target lesions and nonneoplastic transitional zone. Bacteria were identified using 16S ribosomal RNA gene sequencing., Results: Across the 42 patients, 76% were found to have prostate cancer. Beta diversity indices differed significantly between the perineum, voided urine, and prostate tissue. There were no beta diversity differences between cancerous or benign tissue, or between pre- and postbiopsy urines. There appear to be unique genera more abundant in cancerous versus benign tissue. There were no differences in alpha diversity indices relative to clinical findings including cancer status, grade, and risk group., Conclusions: We demonstrate a rigorous method to better characterize the prostate microbiome using transperineal biopsy and to limit contamination. These findings provide a framework for future large-scale studies of the microbiome of prostate cancer., (© 2024 Wiley Periodicals LLC.)

Objective: Vascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency., Methods: This was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 to July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 to January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 to February 2024 and fiscal data from fiscal year 2019 to fiscal year 2024 were conducted. A washout period from January 2020 to January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes., Results: There were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8 ± 12.0 vs 68.7 ± 12.7 years; P = .03) with higher rates of coronary artery disease (34.6% vs 14.8%; P < .01), hypertension (88.4% vs 82.2%; P = .01), and tobacco history (84.4% vs 78.2%; P = .02). Thirty-day mortality (2.4% pre-vs 0.8% post-VACS; P = .18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (P = .07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.9; P = .01). Operative efficiency improved post-VACS (median, 850.0; interquartile range [IQR], 765.7-916.3 vs median, 918.0; IQR, 881.0-951.1 RVU/cFTE-month; P = .03). Daytime operating minutes increased (469.1 ± 287.5 vs 908.2 ± 386.2 minutes; P < .01), whereas non-daytime minutes (420.0; IQR, 266.0-654.0 vs 469.5; IQR, 242.0-738.3 minutes; P = .40) and weekend minutes (129.0; IQR, 0.0-298.0 vs 113.5; IQR, 0.0-279.5 minutes; P = .59) remained stable., Conclusions: A VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care., Competing Interests: Disclosures A.J.D. has received an educational grant from Gore Medical., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Vascular surgeons have one of the highest rates of burnout among surgical specialties, often attributed to high patient acuity and clinical workload. Acute Care Surgery models are a potential solution used among general and trauma surgeons., Methods: This is a retrospective analysis of prospectively collected Accreditation Council for Graduate Medical Education survey results from faculty and residents before and after implementation of a vascular Acute Care Surgery (VACS) model. The VACS model assigns a weekly rotation of an attending surgeon with no elective cases or clinic responsibilities and a monthly rotating resident team. Residents and attendings are in-house to cover all urgent and emergent vascular daytime consultations and procedures, whereas nights and weekend coverage remain a typical rotating schedule. Survey question results were binned into domains consistent with the Maslach Burnout Inventory., Results: Both residents and faculty reported an increase in median scores in Maslach Burnout Inventory domains of emotional exhaustion (Faculty: 2.9 vs 3.4; P < .001; Residents: 3.1 vs 3.6; P < .001) and faculty reported higher personal accomplishment scores (Faculty: 3.3 vs 3.8; P = .005) after the VACS model implementation., Conclusions: A VACS model is a tangible practice change that can address a major problem for current vascular surgeons, as it is associated with decreased burnout for faculty and residents through improvement in both emotional exhaustion and personal accomplishment. Improved longitudinal assessment of resident and faculty burnout is needed and future work should identify specific practice patterns related to decreased burnout., Competing Interests: Disclosures The divisions has received an educational grant from Gore Medical., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The standard approach to hemostasis during partial nephrectomy (PN) is to perform suture renorrhaphy (SR). Application of a hemostatic bandage (HB) is an alternative to minimize blood loss and devitalized renal parenchyma. We aim to evaluate perioperative outcomes of PN with tumor enucleation (TE) comparing SR to HB., Methods: We analyzed a retrospective cohort of 195 patients undergoing robot-assisted laparoscopic PN with TE performed at a tertiary referral center (2012-2022). Hemostasis was obtained with SR in 54 patients while 141 patients underwent application of HB consisting of Surgicel®, Gelfoam® soaked in thrombin, and Floseal®., Results: SR patients had tumors of greater complexity by RENAL nephrometry score compared to HB patients (p < 0.001). Operative time (141 vs. 183 min, p < 0.001), warm ischemia time (11.6 vs. 24.2 min, p < 0.001), estimated blood loss (37 vs. 214 mL, p < 0.001), and length of stay (1.2 vs. 1.8 days, p < 0.001) favored HB. There was no significant difference in Clavien-Dindo grade ≥3 complications (p = 0.22). Renal function was comparable with mean estimated glomerular filtration rate decrease of 0.66 and 0.54 mL/min/1.73 m 2 at 3 months postoperatively for HB and SR, respectively (p = 0.93)., Conclusions: Application of an HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients., (© 2024 Wiley Periodicals LLC.)

In this rejoinder to McNeish (2024) and Mislevy (2024), who both responded to our focus article on the merits of the simple sum score (Sijtsma et al., 2024), we address several issues. Psychometrics education and in particular psychometricians' outreach may help researchers to use IRT models as a precursor for the responsible use of the latent variable score and the sum score. Different methods used for test and questionnaire construction often do not produce highly different results, and when they do, this may be due to an unarticulated attribute theory generating noisy data. The sum score and transformations thereof, such as normalized test scores and percentiles, may help test practitioners and their clients to better communicate results. Latent variables prove important in more advanced applications such as equating and adaptive testing where they serve as technical tools rather than communication devices. Decisions based on test results are often binary or use a rather coarse ordering of scale levels, hence, do not require a high level of granularity (but nevertheless need to be precise). A gap exists between psychology and psychometrics which is growing deeper and wider, and that needs to be bridged. Psychology and psychometrics must work together to attain this goal., (© 2024. The Author(s).)

Introduction: Renal parenchymal volume loss from standard partial nephrectomy (SPN) is a significant prognosticator for postoperative renal function. Tumor enucleation (TE) minimizes parenchymal loss compared to SPN. Little is known regarding discrete changes in renal function associated with volume loss. We sought to quantify the differences between SPN and TE in preserving parenchymal volume and estimated glomerular filtration rate (eGFR)., Methods: We identified 420 patients who underwent robotic partial nephrectomy (SPN or TE) at our tertiary care center from 2009 to 2022. Parenchymal volumes were calculated using TeraRecon 3D reconstruction software from axial imaging performed preoperatively and within 6 months postoperatively. Renal volume preserved and renal function were evaluated with multivariable linear and logistic regression models., Results: At 1 year, eGFR was 7% lower in patients undergoing SPN compared to TE (P < 0.01). Across both SPN and TE, only volume of preserved parenchyma was predictive of eGFR and chronic kidney disease (CKD) progression (both P < 0.01). TE preserved more healthy parenchymal volume compared to SPN (median percentage 97.6% vs 89.2%; P < 0.001). Each 1% of volumetric loss corresponded to a 0.35% decrease in eGFR at 1 year postoperatively (P < 0.01)., Conclusions: Volume of preserved renal parenchyma was the strongest factor associated with preserved eGFR and reduced odds of CKD progression. TE preserved more parenchyma than SPN, which translated to higher eGFR preservation at 1 year postoperatively., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In psychophysiology, an interesting question is how to estimate the reliability of event-related potentials collected by means of the Eriksen Flanker Task or similar tests. A special problem presents itself if the data represent neurological reactions that are associated with some responses (in case of the Flanker Task, responding incorrectly on a trial) but not others (like when providing a correct response), inherently resulting in unequal numbers of observations per subject. The general trend in reliability research here is to use generalizability theory and Bayesian estimation. We show that a new approach based on classical test theory and frequentist estimation can do the job as well and in a simpler way, and even provides additional insight to matters that were unsolved in the generalizability method approach. One of our contributions is the definition of a single, overall reliability coefficient for an entire group of subjects with unequal numbers of observations. Both methods have slightly different objectives. We argue in favor of the classical approach but without rejecting the generalizability approach., Competing Interests: Declarations. Data Availability Statement: The data of Tables 2 and 4 and Figures S1-S5 and the code that generated it are available in the Open Science Framework repository at https://doi.org/10.17605/OSF.IO/KZY3D Conflict of interest: We have no conflict of interest to disclose., (© 2024. The Author(s).)

Objective: To evaluate the contribution of the standardized letter of recommendation (SLOR) to the likelihood of matching in urology residency by applying a novel scoring system and characterize utilization in the 2022 application cycle., Methods: We conducted an investigation of all applicants to our urology residency program during the 2022 cycle. We developed a scoring system to assess SLOR strength across all templates. Match outcomes were verified with the Society of Academic Urologists listing. Statistical analysis was performed to assess for factors predictive of a successful match., Results: Out of 386 total applicants, 239 (61.9%) had at least 1 SLOR in their application. SLOR utilization was more prevalent in MD applicants, in those with higher Step 2 scores, and in those who matched (P <.01). The majority of SLOR scores (66.5%) were above a 3.5/5 in our cohort. Step 1 score, number of research entries, and presence of an SLOR were predictive of successful match. However, a SLOR score of <3 was strongly associated with not matching (OR 0.021, P <.01)., Conclusion: The presence of a SLOR in our cohort overall was associated with a successful match. A poor SLOR score was highly deleterious to an applicant's chance of matching in urology. Our SLOR scoring system can be used across all letter templates and demonstrates that strength of SLOR can significantly impact an applicant's chance of matching., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: In surgically excising renal masses, studies have demonstrated that tumor enucleation is an effective option. However, there is limited literature comparing off-clamp to on-clamp tumor enucleation., Materials and Methods: We retrospectively reviewed the charts of 189 patients who underwent robotic-assisted laparoscopic partial nephrectomy via tumor enucleation by a single surgeon from March 2012 and April 2022. Patients were stratified based on use of renal hilar clamping intraoperatively. Surgical, oncologic, and renal functional outcomes were captured. Variables were analyzed and compared between the two groups using Student's T-tests and Chi-square tests., Results: Of 189 procedures analyzed, 124 were performed on-clamp and 65 were performed off-clamp. There were no differences in patient demographics or average length of follow-up. There were no differences in estimated blood loss, complications, or hospital length of stay. Recurrence rates were similar for the two groups. The absolute difference in estimated glomerular filtration rate change between the two groups at time of first follow-up was not significant (p = 0.25)., Conclusions: There is no significant difference in perioperative outcomes such as surgical time, blood loss, or complications between the two groups. Furthermore, there was no significant difference in postoperative kidney function between the two techniques., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Objective: Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA., Methods: A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression., Results: After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively)., Conclusions: The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Endovenous thermal ablation (EVTA) is a prevalent treatment option for patients with severe venous disease. However, the decision to intervene for patients with less severe disease (CEAP [clinical, etiology, anatomy, pathophysiology] C2 and C3) is less clear and becomes further complicated for patients with obesity, a pathology known to increase venous disease symptom severity. Therefore, the objective of this study was to use the Society for Vascular Surgery Vascular Quality Initiative database to evaluate outcomes after EVTA in obese patients with CEAP C2 and C3 venous insufficiency., Methods: Using the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed the initial procedure of all patients with a CEAP clinical class of C2 or C3 who underwent EVTA from January 2015 to December 2021. Patients were grouped by obesity, defined as a body mass index of ≥30 kg/m 2 . The primary outcome was the change in venous clinical severity score (VCSS) from the procedure to the patient's initial follow-up. The secondary outcomes included the change in patient-reported outcomes at follow-up via the HASTI (heaviness, achiness, swelling, throbbing, itching) score, incidence of follow-up complications, and recanalization of treated veins. The change in the VCSS and HASTI score were analyzed using Student t tests, and complications and recanalization were assessed using the Fisher exact test. Significant outcomes were confirmed by multiple variable logistic regression. The remaining significant variables were then analyzed, with obesity categorized using the World Health Organization classification system to analyze how increasing obesity levels affect outcomes., Results: There were 8146 limbs that met the inclusion criteria, of which 5183 (63.6%) were classified as nonobese and 2963 (36.4%) as obese. Obesity showed no impact on improvement in the VCSS (-3.29 vs -3.35; P = .408). Obesity was found to be associated with a larger improvement in overall symptoms, as evidence by a greater improvement in the HASTI score (-7.24 vs -6.62; P < .001). Obese limbs showed a higher incidence of superficial phlebitis (1.5% vs 0.7%; P = .001), but no difference was found in recanalization or any other complication., Conclusions: These data suggest that obese patients with CEAP clinical class C2 or C3 experience greater improvement in their perceived symptoms after EVTA with little difference in clinical improvement and complications compared with nonobese patients. Although obesity has been associated with increased severity of venous disease symptoms, obese patients are able to derive significant relief after treatment during the short term and may experience greater relief of symptoms than nonobese patients when treated at more mild disease presentations., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Although postruminal glucose infusion into dairy cows has increased milk protein yield in some past experiments, the same trend has not been observed in others. A meta-regression of 64 sets of observations from 29 previously published glucose and propionate infusion studies in dairy cattle, treating study and experiment (study) as random effects, was performed to establish the general effects of glucose equivalent (GlcE) infusion rate on milk true protein (MTP) yield and content, if any, and to identify independent, fixed-effect variables that accounted for the changes in MTP yield and content that were observed. Candidate explanatory variables included rate and site of infusion, diet composition and intake, body weight and lactation stage of the cows, and the change in nutrient intake between GlcE and control treatments. Across all studies, according to a model containing only the random effects of study and experiment, GlcE infusion at an average of 954 g/d increased MTP yield by 26 g/d, on average, whereas mean MTP content was not affected. Backward stepwise elimination of potential explanatory variables from a full mixed model produced a final, reduced model for MTP yield that retained a positive, second-order quadratic effect of infusion rate of GlcE and a positive, linear effect of the change in crude protein intake (CPI) between GlcE treatment and control. This change in CPI due to GlcE infusion ranged from -0.546 to 0.173 kg/d in the dataset. The model fit indicated that when CPI was allowed to drop during GlcE infusion, the effect of GlcE on MTP yield was smaller than when CPI was maintained or increased, in a manifestation of the classic protein:energy interaction. The final reduced model for MTP content contained the same explanatory variables as for MTP yield, plus a negative effect of intravenous compared with gastrointestinal infusion. Overall, the meta-analysis revealed that both MTP yield, and content were positively related to GlcE infusion rate and to the change in CPI between glucose treatment and control., (The Authors. Published by Elsevier Inc. on behalf of the American Dairy Science Association®. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).)

Importance: Magnetic resonance imaging (MRI)-based risk calculators can replace or augment traditional prostate cancer (PCa) risk prediction tools. However, few data are available comparing performance of different MRI-based risk calculators in external cohorts across different countries or screening paradigms., Objective: To externally validate and compare MRI-based PCa risk calculators (Prospective Loyola University Multiparametric MRI [PLUM], UCLA [University of California, Los Angeles]-Cornell, Van Leeuwen, and Rotterdam Prostate Cancer Risk Calculator-MRI [RPCRC-MRI]) in cohorts from Europe and North America., Design, Setting, and Participants: This multi-institutional, external validation diagnostic study of 3 unique cohorts was performed from January 1, 2015, to December 31, 2022. Two cohorts from Europe and North America used MRI before biopsy, while a third cohort used an advanced serum biomarker, the Prostate Health Index (PHI), before MRI or biopsy. Participants included adult men without a PCa diagnosis receiving MRI before prostate biopsy., Interventions: Prostate MRI followed by prostate biopsy., Main Outcomes and Measures: The primary outcome was diagnosis of clinically significant PCa (grade group ≥2). Receiver operating characteristics for area under the curve (AUC) estimates, calibration plots, and decision curve analysis were evaluated., Results: A total of 2181 patients across the 3 cohorts were included, with a median age of 65 (IQR, 58-70) years and a median prostate-specific antigen level of 5.92 (IQR, 4.32-8.94) ng/mL. All models had good diagnostic discrimination in the European cohort, with AUCs of 0.90 for the PLUM (95% CI, 0.86-0.93), UCLA-Cornell (95% CI, 0.86-0.93), Van Leeuwen (95% CI, 0.87-0.93), and RPCRC-MRI (95% CI, 0.86-0.93) models. All models had good discrimination in the North American cohort, with an AUC of 0.85 (95% CI, 0.80-0.89) for PLUM and AUCs of 0.83 for the UCLA-Cornell (95% CI, 0.80-0.88), Van Leeuwen (95% CI, 0.79-0.88), and RPCRC-MRI (95% CI, 0.78-0.87) models, with somewhat better calibration for the RPCRC-MRI and PLUM models. In the PHI cohort, all models were prone to underestimate clinically significant PCa risk, with best calibration and discrimination for the UCLA-Cornell (AUC, 0.83 [95% CI, 0.81-0.85]) model, followed by the PLUM model (AUC, 0.82 [95% CI, 0.80-0.84]). The Van Leeuwen model was poorly calibrated in all 3 cohorts. On decision curve analysis, all models provided similar net benefit in the European cohort, with higher benefit for the PLUM and RPCRC-MRI models at a threshold greater than 22% in the North American cohort. The UCLA-Cornell model demonstrated highest net benefit in the PHI cohort., Conclusions and Relevance: In this external validation study of patients receiving MRI and prostate biopsy, the results support the use of the PLUM or RPCRC-MRI models in MRI-based screening pathways regardless of European or North American setting. However, tools specific to screening pathways incorporating advanced biomarkers as reflex tests are needed due to underprediction.

Background: Optimal care for persons with multiple chronic conditions (MCC) requires primary and specialty care continuity, access to multiple providers, social risk assessment, and self-management support. The COVID-19 pandemic abruptly changed primary care delivery to increase reliance on telehealth and virtual care. We report on the experiences of individuals with MCC and their family caregivers on managing their health and receiving health care during the initial pandemic., Methods: Semistructured qualitative interviews with 30 patients (19 English speaking, 11 Spanish speaking) plus 9 accompanying care partners, who had 2+ primary care encounters between March 1, 2020, and November 30, 2020, 2+ chronic conditions, and 1 or more self-reported social risks. Questions focused on access to and experiences with care, roles for care partners, and self-management during the first 6 months of the pandemic., Results: Participants experienced substantial changes in care delivery. The most commonly reported changes were a shift to more virtual relative to in-person care and shifting roles for care partners. Changes fostered new perspectives on self-management and an appreciation of personal resilience and self-reliance. Virtual care was an acceptable complement to in-person care, though not a substitute for periodic in-person visits. It was more acceptable for English speakers and with a usual provider., Conclusion: New models of care delivery that recognize patient and family resilience and resourcefulness, emphasize provider continuity, and combine virtual and in-person care may support self-management for individuals with MCC and social needs., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)

The sum score on a psychological test is, and should continue to be, a tool central in psychometric practice. This position runs counter to several psychometricians' belief that the sum score represents a pre-scientific conception that must be abandoned from psychometrics in favor of latent variables. First, we reiterate that the sum score stochastically orders the latent variable in a wide variety of much-used item response models. In fact, item response theory provides a mathematically based justification for the ordinal use of the sum score. Second, because discussions about the sum score often involve its reliability and estimation methods as well, we show that, based on very general assumptions, classical test theory provides a family of lower bounds several of which are close to the true reliability under reasonable conditions. Finally, we argue that eventually sum scores derive their value from the degree to which they enable predicting practically relevant events and behaviors. None of our discussion is meant to discredit modern measurement models; they have their own merits unattainable for classical test theory, but the latter model provides impressive contributions to psychometrics based on very few assumptions that seem to have become obscured in the past few decades. Their generality and practical usefulness add to the accomplishments of more recent approaches., (© 2024. The Author(s).)

Robotic nephron-sparing surgery is traditionally performed via a transperitoneal (TP) approach. However, the retroperitoneal (RP) approach has gained popularity, particularly for posterolateral renal masses. The RP approach is associated with shorter operative time, less blood loss, and shorter length of stay, while preserving oncologic outcomes in selected masses. Here, we aim to assess the feasibility of the RP approach in excising anterior renal masses. Patients ≥ 18 years of age who underwent robotic nephron-sparing surgery for anterior renal masses were retrospectively identified (2008-2022). Baseline demographics, tumor characteristics, and perioperative data were collected and characterized based on TP vs RP approaches. Wilcoxon rank sum test and Pearson's Chi-squared test were used to compare continuous and categorical variables, respectively. Two hundred and sixteen patients were included-178 (82.4%) underwent TP approach and 38 (17.6%) underwent RP approach. Baseline demographics, preoperative tumor size, and renal nephrometry scores were similar. The RP approach was associated with shorter operative (150 vs 203 min, p < 0.001) and warm ischemia time (12 vs 21 min, p < 0.001), and less blood loss (20 vs 100 cc, p = 0.002) (Table 1). The RP approach was associated with shorter length of stay (1 vs 2 days, p < 0.001) and less total complications (5.3% vs 19.1%, p = 0.038). Major complication (Clavien-Dindo Grade > 3) rates were similar. There was no difference in positive surgical margin rates or pathologic characteristics. Robotic RP approach for nephron-sparing surgery is feasible for eligible anterior tumors and is associated with favorable perioperative outcomes with preserved negative surgical margin rates. Table 1 Patient baseline demographics Overall Transperitoneal Retroperitoneal p value Median/N IQR/% Median/N IQR/% Median/N IQR/% N 216 178 82.4% 38 17.6% Age (years) 60.5 (52.1-67.7) 60.4 (52.8-67.7) 61.6 (49.1-69.2) 0.393 Sex Male 126 58.3% 100 56.2% 26 68.4% Female 90 41.7% 78 43.8% 12 31.6% 0.165 Race White 162 75.0% 137 77.0% 25 65.8% Asian 4 1.9% 2 1.1% 2 5.3% Black 21 9.7% 18 10.1% 3 7.9% Hispanic 26 12.0% 18 10.1% 8 21.1% Other 2 0.9% 2 1.1% 0 0.0% 0.197 Body mass index (kg/m 2 )  < 25 32 14.8% 25 14.0% 7 18.4% 25-30 68 31.5% 55 30.9% 13 34.2% 30-35 60 27.8% 50 28.1% 10 26.3% 35 +  56 25.9% 48 27.0% 8 21.1% 0.808 Prior abdominal surgery Yes 118 54.6% 104 58.4% 14 36.8% No 98 45.4% 74 41.6% 24 63.2% 0.015 Prior kidney surgery Yes 10 4.6% 9 5.1% 1 2.6% No 206 95.4% 169 94.9% 37 97.4% 0.518 Chronic kidney disease stage ≥ 3 Yes 45 20.8% 38 21.3% 7 18.4% No 171 79.2% 140 78.7% 31 81.6% 0.687 Charlson comorbidity index 0 138 63.9% 116 65.2% 22 57.9% 1 46 21.3% 38 21.4% 8 21.1% 2 19 8.8% 13 7.3% 6 15.8%  ≥ 3 13 6.0% 11 6.2% 2 5.3% 0.412 Tumor size (cm) 2.7 (2-3.6) 2.8 (2-3.5) 2.55 (2-3.7) 0.796 Tumor laterality Left 100 46.3% 78 43.8% 22 57.9% Right 116 53.7% 100 56.2% 16 42.1% 0.114 Clinical T stage cT1a 186 86.1% 152 85.4% 34 89.5% cT1b 30 13.9% 26 14.6% 4 10.5% 0.509 RENAL Nephrometry score Low (4 to 6) 94 43.5% 76 42.7% 18 47.4% Intermediate (7 to 9) 112 51.9% 94 52.8% 18 47.4% High (≥ 10) 19 4.6% 8 4.5% 2 5.3% 0.829 TE tumor enucleation, SPN standard margin partial nephrectomy, IQR interquartile range., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Partial nephrectomy (PN) is the gold standard for the resection of amenable small renal masses. Some surgeons have adopted tumor enucleation (TE) over the standard margin PN (SPN) technique based on preservation of healthy renal parenchyma by following the tumor pseudocapsule. However, TE may also confer additional advantages due to avoidance of sharp incision including reduction in perioperative and bleeding complications. Therefore, we evaluated the rate of pseudoaneurysms and other complications following TE vs. SPN. A retrospective cohort study of patients undergoing PN (TE and SPN) between 2008 and 2020 was conducted. Baseline characteristics were compared between the TE and SPN cohorts with univariable and multivariable logistic regression models. A total of 534 patients were included, 195 (36.5%) receiving TE and 339 (63.5%) SPN. There were no differences in baseline patient demographics. There was no difference in RENAL nephrometry scores between the two groups (p = 0.47). TE had lower rates of postoperative complications (11.3 vs. 21.5%, p = 0.002). TE had less bleeding complications (2.1 vs. 8.0%, p = 0.002) with no pseudoaneurysm events following TE compared to 12 following SPN (0.0 vs. 3.5%, p = 0.008). Need for interventional radiology largely reflected pseudoaneurysm differences (0 (0.0%) TE vs. 13 (3.8%) SPN, p = 0.006. Readmission occurred less often after TE vs. SPN (4.1 vs. 8.3%, p = 0.07). Patients receiving TE experienced no clinically significant pseudoaneurysm formation and were less likely to have any bleeding complication or major complication postoperatively. TE may be preferred when minimizing morbidity aligns with patient selection and preferences., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Despite Phe being an indispensable amino acid for cats, the minimum Phe requirement for adult cats has not been empirically defined. The objective of study 1 was to determine the minimum Phe requirement, where Tyr is in excess, in adult cats using the direct amino acid oxidation (DAAO) technique. Four adult male cats were used in an 8 × 4 Latin rectangle design. Cats were adapted to a basal diet for 7 d, top dressed with Phe to meet 140% of the adequate intake (NRC, 2006. Nutrient requirements of dogs and cats. Washington, DC: Natl. Acad. Press). Cats were randomly assigned to one of eight experimental Phe diets (0.29%, 0.34%, 0.39%, 0.44%, 0.54%, 0.64%, 0.74%, and 0.84% Phe in the diet on a dry matter [DM] basis). Following 1 d of diet adaptation, individual DAAO studies were performed. During each DAAO study, cats were placed into individual indirect calorimetry chambers, and 75% of the cat's daily meal was divided into 13 equal meals supplied with a dose of L-[1-13C]-Phe. Oxidation of L-[1-13C]-Phe (F13CO2) during isotopic steady state was determined from the enrichment of 13CO2 in breath. Competing models were applied using the NLMIXED procedure in SAS to determine the effects of dietary Phe on 13CO2. The mean population minimum requirement for Phe was estimated at 0.32% DM and the upper 95% population confidence limit at 0.59% DM on an energy density of 4,200 kcal of metabolizable energy/kg DM calculated using the modified Atwater factors. In study 2, the effects of a bolus dose of Phe (44 mg kg-1 BW) on food intake, gastric emptying (GE), and macronutrient metabolism were assessed in a crossover design with 12 male cats. For food intake, cats were given Phe 15 min before 120% of their daily food was offered and food intake was measured. Treatment, day, and their interaction were evaluated using PROC GLIMMIX in SAS. Treatment did not affect any food intake parameters (P > 0.05). For GE and macronutrient metabolism, cats were placed into individual indirect calorimetry chambers, received the same bolus dose of Phe, and 15 min later received 13C-octanoic acid (5 mg kg-1 BW) on 50% of their daily food intake. Breath samples were collected to measure 13CO2. The effect of treatment was evaluated using PROC GLIMMIX in SAS. Treatment did not affect total GE (P > 0.05), but cats receiving Phe tended to delay time to peak enrichment (0.05 < P ≤ 0.10). Overall, Phe at a bolus dose of 44 mg kg-1 BW had no effect on food intake, GE, or macronutrient metabolism. Together, these results suggest that the bolus dose of Phe used may not be sufficient to elicit a GE response, but a study with a greater number of cats and greater food intake is warranted., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society of Animal Science. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: We aimed to assess utilization of neoadjuvant chemotherapy (NAC) and etiologies for lack of NAC receipt among patients with muscle-invasive bladder cancer (MIBC)., Methods: Patients diagnosed with MIBC undergoing radical cystectomy at a single institution (2005-2021) were included. Patients were categorized by receipt of NAC, and reasons for no NAC were categorized into eligibility and elective factors. Overall survival was analyzed using univariable and multivariable Cox proportional hazards regression models and modeled with Kaplan-Meier curves., Results: Three hundred eighty patients with MIBC were included; 154 (40.5%) received NAC. Patients were not candidates for NAC due to renal dysfunction (16.6%), clinical contraindications (4.7%), salvage setting (2.1%), and histology (5.3%; total N = 109). Among 271 (71.3%) who were eligible, utilization increased from early (2005-2016) to recent (2016-2021) time periods (34.2% to 85.7% among NAC-eligible, P < .001; 22.8% vs 67.1% among all MIBC, P < .001). Elective factors for not receiving NAC included patient symptoms (7.8%), disease progression concern (7.0%), patient preference/refusal (20.3%) and provider discretion (8.1%) among 271 NAC-eligible patients. Notably, patient preference/refusal decreased from 33.6% to 3.4% in recent years ( P < .001). On multivariable analysis, lack of NAC utilization due to renal dysfunction (HR 2.18, P = .002), clinical contraindications (HR 2.62, P = .01), and elective factors (HR 1.88, P = .01) were associated with worse overall survival., Conclusions: NAC utilization increased over time with 85.7% of eligible patients with MIBC receiving NAC in recent years. Renal dysfunction, patient preference, and clinical contraindications were primary etiologies for lack of NAC. Fewer patients refused NAC in recent years leading to a potential ceiling for NAC utilization.

Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC., (© 2023 The Authors. Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Within poultry production systems, models have provided vital decision support, opportunity analysis, and performance optimization capabilities to nutritionists and producers for decades. In recent years, due to the advancement of digital and sensor technologies, 'Big Data' streams have emerged, optimally positioned to be analyzed by machine-learning (ML) modeling approaches, with strengths in forecasting and prediction. This review explores the evolution of empirical and mechanistic models in poultry production systems, and how these models may interact with new digital tools and technologies. This review will also examine the emergence of ML and Big Data in the poultry production sector, and the emergence of precision feeding and automation of poultry production systems. There are several promising directions for the field, including: (1) application of Big Data analytics (e.g., sensor-based technologies, precision feeding systems) and ML methodologies (e.g., unsupervised and supervised learning algorithms) to feed more precisely to production targets given a 'known' individual animal, and (2) combination and hybridization of data-driven and mechanistic modeling approaches to bridge decision support with improved forecasting capabilities., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Nowadays, vast amounts of data representing feed intake, growth, and environmental impact of individual animals are being recorded in on-farm settings. Despite their apparent use, data collected in real-world applications often have missing values in one or several variables, due to reasons including human error, machine error, or sampling frequency misalignment across multiple variables. Since incomplete datasets are less valuable for downstream data analysis, it is important to address the missing value problem properly. One option may be to reduce the dataset to a subset that contains only complete data, but considerable data may be lost via this process. The current study aimed to compare imputation methods for the estimation of missing values in a raw dataset of dairy cattle including 454 553 records collected from 629 cows between 2009 and 2020. The dataset was subjected to a cleaning process that reduced its size to 437 075 observations corresponding to 512 cows. Missing values were present in four variables: concentrate DM intake (CDMI, missing percentage = 2.30%), forage DM intake (FDMI, 8.05%), milk yield (MY, 15.12%), and BW (64.33%). After removing all missing values, the resulting dataset (n = 129 353) was randomly sampled five times to create five independent subsets that exhibit the same missing data percentages as the cleaned dataset. Four univariate and nine multivariate imputation methods (eight machine learning methods and the MissForest method) were applied and evaluated on the five repeats, and average imputation performance was reported for each repeat. The results showed that Random Forest was overall the best imputation method for this type of data and had a lower mean squared prediction error and higher concordance correlation coefficient than the other imputation methods for all imputed variables. Random Forest performed particularly well for imputing CDMI, MY, and BW, compared to imputing FDMI., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Current feed formulation and evaluation practices rely on static values for the nutritional value of feed ingredients and assume additivity. Hereby, the complex interplay among nutrients in the diet and the highly dynamic digestive processes are ignored. Nutrient digestion kinetics and diet × animal interactions should be acknowledged to improve future predictions of the nutritional value of complex diets. Therefore, an in silico nutrient-based mechanistic digestion model for growing pigs was developed: "SNAPIG" (Simulating Nutrient digestion and Absorption kinetics in PIGs). Aiming to predict the rate and extent of nutrient absorption from diets varying in ingredient composition and physicochemical properties, the model represents digestion kinetics of ingested protein, starch, fat, and non-starch polysaccharides, through passage, hydrolysis, absorption, and endogenous secretions of nutrients along the stomach, proximal small intestine, distal small intestine, and caecum + colon. Input variables are nutrient intake and the physicochemical properties (i.e. solubility, and rate and extent of degradability). Data on the rate and extent of starch and protein hydrolysis of different ingredients per digestive segment were derived from in vitro assays. Passage of digesta from the stomach was modelled as a function of feed intake level, dietary nutrient solubility and diet viscosity. Model evaluation included testing against independent data from in vivo studies on nutrient appearance in (portal) blood of growing pigs. When simulating diets varying in physicochemical properties and nutrient source, SNAPIG can explain variation in glucose absorption kinetics (postprandial time of peak, TOP: 20-100 min observed vs 25-98 min predicted), and predict variation in the extent of ileal protein and fat digestion (root mean square prediction errors (RMSPE) = 12 and 16%, disturbance error = 12 and 86%, and concordance correlation coefficient = 0.34 and 0.27). For amino acid absorption, the observed variation in postprandial TOP (61 ± 11 min) was poorly predicted despite accurate mean predictions (58 ± 34 min). Recalibrating protein digestion and amino acid absorption kinetics require data on net-portal nutrient appearance, combined with observations on digestion kinetics, in pigs fed diets varying in ingredient composition. Currently, SNAPIG can be used to forecast the time and extent of nutrient digestion and absorption when simulating diets varying in ingredient and nutrient composition. It enhances our quantitative understanding of nutrient digestion kinetics and identifies knowledge gaps in this field of research. Already useful as research tool, SNAPIG can be coupled with a postabsorptive metabolism model to predict the effects of dietary and feeding-strategies on the pig's growth response., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

The extent of the application of the Individual and Family Self-Management Theory (IFSMT) in research has yet to be determined. The purpose of this analysis was to review the use of the IFSMT in published research and evaluate posited constructs and relationships. Dimensions and categories of the IFSMT and the interrelationships were generally supported in the 77 articles reviewed. A majority focused on self-management of chronic conditions in the adult population. More research on the strength, direction, and interaction of relationships is needed. Defining and exploring social constructs, including race, ethnicity, and gender, should be prioritized in future IFSMT research., Competing Interests: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Adults with chronic medical conditions complicated by food insecurity or physical limitations may have higher barriers to accessing telehealth implemented during the COVID-19 pandemic. Objective: To examine the relationships of self-reported food insecurity and physical limitations with changes in health care utilization and medication adherence comparing the year before (March 2019-February 2020) and the first year of the COVID-19 pandemic (April 2020-March 2021) among patients with chronic conditions insured by Medicaid or Medicare Advantage. Methods: A prospective cohort study of 10,452 Kaiser Permanente Northern California members insured by Medicaid and 52,890 Kaiser Permanente Colorado members insured by Medicare Advantage was conducted. Difference-in-differences (DID) between the pre-COVID and COVID years in telehealth versus in-person health care utilization and adherence to chronic disease medicines by food insecurity and by physical limitation status were measured. Results: Food insecurity and physical limitations were each associated with small but significantly greater shifts from in-person to telehealth. Medicare Advantage members with physical limitations also had significantly greater decline in adherence to chronic medications from year to year compared with those without physical limitations (DID from pre-COVID year to COVID year ranged from 0.7% to 3.6% greater decline by medication class, p < 0.01). Conclusions: Food insecurity and physical limitations did not present significant barriers to the transition to telehealth during the COVID pandemic. The greater decrease in medication adherence among older patients with physical limitations suggests that care systems must further address the needs of this high-risk population.

X-linked myotubular myopathy (XLMTM) is a fatal congenital disorder caused by mutations in the MTM1 gene. Currently, there are no approved treatments, although AAV8-mediated gene transfer therapy has shown promise in animal models and preliminarily in patients. However, 4 patients with XLMTM treated with gene therapy have died from progressive liver failure, and hepatobiliary disease has now been recognized more broadly in association with XLMTM. In an attempt to understand whether loss of MTM1 itself is associated with liver pathology, we have characterized what we believe to be a novel liver phenotype in a zebrafish model of this disease. Specifically, we found that loss-of-function mutations in mtm1 led to severe liver abnormalities including impaired bile flux, structural abnormalities of the bile canaliculus, and improper endosome-mediated trafficking of canalicular transporters. Using a reporter-tagged Mtm1 zebrafish line, we established localization of Mtm1 in the liver in association with Rab11, a marker of recycling endosomes, and canalicular transport proteins and demonstrated that hepatocyte-specific reexpression of Mtm1 could rescue the cholestatic phenotype. Last, we completed a targeted chemical screen and found that Dynasore, a dynamin-2 inhibitor, was able to partially restore bile flow and transporter localization to the canalicular membrane. In summary, we demonstrate, for the first time to our knowledge, liver abnormalities that were directly caused by MTM1 mutation in a preclinical model, thus establishing the critical framework for better understanding and comprehensive treatment of the human disease.

Warm dense matter (WDM) represents a highly excited state that lies at the intersection of solids, plasmas, and liquids and that cannot be described by equilibrium theories. The transient nature of this state when created in a laboratory, as well as the difficulties in probing the strongly coupled interactions between the electrons and the ions, make it challenging to develop a complete understanding of matter in this regime. In this work, by exciting isolated ∼8  nm copper nanoparticles with a femtosecond laser below the ablation threshold, we create uniformly excited WDM. Using photoelectron spectroscopy, we measure the instantaneous electron temperature and extract the electron-ion coupling of the nanoparticle as it undergoes a solid-to-WDM phase transition. By comparing with state-of-the-art theories, we confirm that the superheated nanoparticles lie at the boundary between hot solids and plasmas, with associated strong electron-ion coupling. This is evidenced both by a fast energy loss of electrons to ions, and a strong modulation of the electron temperature induced by strong acoustic breathing modes that change the nanoparticle volume. This work demonstrates a new route for experimental exploration of the exotic properties of WDM.