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Background:. Surgery has seen limited adoption of 360-degree feedback tools, and no current tools evaluate intraoperative performance from a technical, nontechnical, or teaching skill perspective. We sought to evaluate the overall findings and perceived value of a novel 360-degree feedback tool for surgeons from their operating room colleagues. Methods:. The ‘intraoperative 360’ (i360) combined 3 previously validated scales of surgeon performance. The electronic medical record at a single academic medical center was queried for perioperative staff involvement in recent cases for a cohort of surgeons. Staff with frequent surgeon case involvement were emailed a link to an anonymous i360 survey. Aggregated survey responses were provided to surgeons and surgical leadership. We performed semi-structured interviews with 10 surgeons and 5 surgical leaders. Combined inductive and deductive coding was used to determine their perceptions regarding the utility of and barriers to the i360. Results:. Over 2-years, a total of 960 surveys were completed for 88 surgeons. The composite rating of technical skills was 4.87/5 (SD: 0.36); nontechnical skills, 4.65/5 (SD: 0.55); and teaching skills, 2.92/3 (SD: 0.24). There was no difference in mean scores based on gender, age, or years of tenure. Six themes emerged from the interviews: initial reactions, utility, additional needs, other feedback mechanisms, reciprocal feedback, and logistical challenges. Conclusions:. A 360-degree feedback tool is feasible, and feedback is perceived as valuable and actionable for surgeons and surgeon leaders. The intraoperative focus provided surgeons with specific feedback on how to improve within the operating room to promote efficiency, teamwork, and patient safety.

Introduction: Transimpedance matrix measurement (TIM) is an electrophysiological measurement protocol of the impedance patterns of electrode contacts within the cochlea. Several studies have reported that TIM is an effective tool for the identification of abnormal electrode array placement. However, the normative values for properly inserted electrodes, as well as correlation of the TIM patterns with the electrode position, are not completely determined. Objectives: The first aim of this study is to establish normative values of TIM measurements obtained in children with proper electrode array insertion and tip fold-over, with proper inner ear anatomy and in congenital anomalies. The second aim of this study is to compare TIM measurements in Slim Modiolar (SM) and in Contour Advance (CA) electrodes, as their position is different according to the modiolus proximity. Methods: A total of 55 pediatric patients were included in the study and underwent cochlear implantation. 62 intraoperative measurements were conducted in this group—50 in children with normal inner ear anatomy and 12 in children with inner ear malformations. After each implantation, a plain x-ray was obtained. Results: There were clear statistically significant differences in TIM patterns in patients where electrode fold-over was confirmed and between SM and CA electrodes. Conclusions: TIM is a promising technique for intraoperative analysis of electrode placement. TIM patterns differ and correlate consistently with the different models of array implanted. This study is the first to report TIM patterns observed in children with normal inner ear anatomy and in inner ear malformations.

Abstract Biologists have long sought to quantify the number of species on Earth. Often missing from these efforts is the contribution of microorganisms, the smallest but most abundant form of life on the planet. Despite recent large‐scale sampling efforts, estimates of global microbial diversity span many orders of magnitude. It is important to consider how speciation and extinction over the last 4 billion years constrain inventories of biodiversity. We parameterized macroevolutionary models based on birth–death processes that assume constant and universal speciation and extinction rates. The models reveal that richness beyond 1012 species is feasible and in agreement with empirical predictions. Additional simulations suggest that mass extinction events do not place hard limits on modern‐day microbial diversity. Together, our study provides independent support for a massive global‐scale microbiome while shedding light on the upper limits of life on Earth.

Aneurysms of the iliac veins are very rare; thus, the best approach to management has not yet been defined. We have presented the case of a 17-year-old boy with incidentally identified large bilateral external iliac vein aneurysms. Given the risks of potentially fatal thromboembolism or rupture, he underwent definitive repair of his aneurysms using staple aneurysmorrhaphy combined with additional vein tailoring by suture venoplasty, a technique not previously described for these aneurysms. We have also discussed the etiology, presentation, and our surgical technique to manage this rare condition.

Purpose: This study assessed a functional protocol to identify myocarditis or myocardial involvement in competitive athletes following SARS-CoV2 infection. Methods: We prospectively evaluated competitive athletes (n = 174) for myocarditis or myocardial involvement using the Multidisciplinary Inquiry of Athletes in Miami (MIAMI) protocol, a median of 18.5 (IQR 16–25) days following diagnosis of COVID-19 infection. The protocol included biomarker analysis, ECG, cardiopulmonary stress echocardiography testing with global longitudinal strain (GLS), and targeted cardiac MRI for athletes with abnormal findings. Patients were followed for median of 148 days. Results: We evaluated 52 females and 122 males, with median age 21 (IQR: 19, 22) years. Five (2.9%) had evidence of myocardial involvement, including definite or probable myocarditis (n = 2). Three of the 5 athletes with myocarditis or myocardial involvement had clinically significant abnormalities during stress testing including ventricular ectopy, wall motion abnormalities and/or elevated VE/VCO2, while the other two athletes had resting ECG abnormalities. VO2max, left ventricular ejection fraction and GLS were similar between those with or without myocardial involvement. No adverse events were reported in the 169 athletes cleared to exercise at a median follow-up of 148 (IQR108,211) days. Patients who were initially restricted from exercise had no adverse sequelae and were cleared to resume training between 3 and 12 months post diagnosis. Conclusions: Screening protocols that include exercise testing may enhance the sensitivity of detecting COVID-19 related myocardial involvement following recovery from SARS-CoV2 infection.

Physicians will ultimately face the necessary but unpleasant task of caring for a dying patient at some point in their careers. Communicating with patients or their families during such dire times is very important especially when the patient or family members have unrealistic expectations. Herein, we have highlighted practical suggestions which if applied can prevent unnecessary draining encounters with patients and families; for example, incorporating ancillary staff such as palliative and pastoral care into the care team. We have also proposed a new concept of ‘physician optimism’. Based on this concept, the physician can be classified as a pessimist or an optimist with realistic or unrealistic expectations and communicate to patients with or without requisite empathy. To ensure the best outcomes, we conclude that physicians must be realistic optimists who always communicate with empathy. Unrealistic optimism, no matter how well-intentioned, is deceiving to patients and their families will never allow a culture of trust.

Venous aneurysms of the head and neck region are very uncommon. Aneurysms of the external jugular vein in children are exceedingly rare, and consequently the best approach to diagnosis and management has not been clearly defined. We present the case of a 15-year-old girl with a non-pulsatile, occasionally painful, enlarging fullness in her right supraclavicular fossa and neck. Imaging demonstrated a large and complex right external jugular vein aneurysm with thrombus. Given the symptomatic nature of this aneurysm, recurrent episodes of thrombosis, and the risk of thromboembolism, she underwent surgical excision. Thorough pre-operative planning with additional imaging to better understand the anatomy of this aneurysm was critical to a safe and successful intervention.

Abstract Background The clinical applications of transcranial focused ultrasound continue to expand and include ablation as well as drug delivery applications in the brain, where treatments are typically guided by MRI. Although MRI-guided focused ultrasound systems are also preferred for many preclinical investigations, they are expensive to purchase and operate, and require the presence of a nearby imaging center. For many basic mechanistic studies, however, MRI is not required. The purpose of this study was to design, construct, characterize and evaluate a portable, custom, laser-guided focused ultrasound system for noninvasive, transcranial treatments in small rodents. Methods The system comprised an off-the-shelf focused ultrasound transducer and amplifier, with a custom cone fabricated for direct coupling of the transducer to the head region. A laser-guidance apparatus was constructed with a 3D stage for accurate positioning to 1 mm. Pressure field simulations were performed to demonstrate the effects of the coupling cone and the sealing membrane, as well as for determining the location of the focus and acoustic transmission across rat skulls over a range of sizes. Hydrophone measurements and exposures in hydrogels were used to assess the accuracy of the simulations. In vivo treatments were performed in rodents for opening the blood–brain barrier and to assess the performance and accuracy of the system. The effects of varying the acoustic pressure, microbubble dose and animal size were evaluated in terms of efficacy and safety of the treatments. Results The simulation results were validated by the hydrophone measurements and exposures in the hydrogels. The in vivo treatments demonstrated the ability of the system to open the blood–brain barrier. A higher acoustic pressure was required in larger-sized animals, as predicted by the simulations and transmission measurements. In a particular sized animal, the degree of blood–brain barrier opening, and the safety of the treatments were directly associated with the microbubble dose. Conclusion The focused ultrasound system that was developed was found to be a cost-effective alternative to MRI-guided systems as an investigational device that is capable of accurately providing noninvasive, transcranial treatments in rodents.

Abstract Background Nifedipine is a generic, well-known and commonly-prescribed dihydropyridine calcium channel blocker used in the treatment of hypertension and Prinzmetal’s angina. A known but very rare and serious adverse effect of nifedipine is clinically-apparent hepatitis which can take months to resolve. Case presentation Here we present a case of nifedipine-induced hepatitis in a 78-year-old Caucasian female with no prior history of liver or autoimmune disease. We discuss our investigative and management approach, and present a review of prior cases. We offer an approach for patients who present with signs of acute liver injury with jaundice and high elevations in serum transaminases. Conclusion Not much is known about nifedipine-induced hepatitis due to its rare occurrence. Its prevalence is unknown. The disease appears to afflict older men and women. It can present acutely (within days) or subacutely (within 4–8 weeks after medication start) and in an idiosyncratic manner. Chronic or latent cases have also been described, some diagnosed as late as 3 years after medication start. Common symptoms include jaundice, nausea, chills, rigors, diaphoresis, fatigue, and abdominal pain. Laboratory investigations often reveal profound elevations in AST, ALT, GGT, and conjugated bilirubin. Peripheral blood smear may demonstrate eosinophilia. Histology from liver biopsy typically demonstrates infiltration of immune cells, cholestasis, and a picture of steatohepatitis. Treatment involves immediate discontinuation of the drug with supportive care. Thus far, all published instances of nifedipine-induced hepatitis were self-limiting without mortality due to fulminant liver failure. However, this disease can take months to resolve. There is no randomized evidence for other treatments such as corticosteroids.

We present a case of bullous cellulitis in a 75-year-old male caused by Pseudomonas putida (P. putida) acquired from contact with contaminated water. Careful documentation of P. putida soft tissue infection is warranted given the rise in infections, marked antimicrobial resistance, and fatalities observed in a limited number of cases.

Background: Bronchopleural fistulas (BPF) are abnormal sinus tracts connecting the bronchi and pleural cavity and form after surgical resection of a lung lobe. It is a complication with potentially disastrous sequelae including, failure of the bronchial stump to heal, ischemia of the affected area, and/or infection of the stump. Bronchopleural fistulas caused by surgical intervention most commonly present on the right side and within 7–12 days post-operatively, i.e., subacutely. While the fistula may initially be asymptomatic, they carry a mortality rate of 25–71% in the absence of other comorbidities. Case presentation: A 60-year-old female developed a BPF more than seven months after a left lower lobe lung lobectomy for non-small cell adenocarcinoma is presented. She was seen at our hospital on multiple occasions after her lobectomy with no evidence of a developing fistula on chest computer tomography (CT) during those visits. During her most recent presentation, roughly 7 months postoperatively, she was noted on imaging to have a new left-sided bronchopleural fistula. Bronchoscopy with lavage and culture of the fistula grew Pseudomonas Aeruginosa, for which she received appropriate treatment. Further surgical interventions were deferred due to poor prognosis. Her presentation differed from the typical BPF presentation in that it was left-sided and occurred out of the window of its usual occurrence. Conclusion: Late-onset BPF is an important diagnosis to consider in patients who have undergone lung resection, regardless of the type of surgery or postoperative duration, especially when patients are known to have multiple predisposing factors.

Damage to the liver or kidney can occur through direct toxic effects; however, damage can also be drug-induced immune-mediated. Levamisole-adulterated cocaine (LAC) is known to cause antineutrophil cytoplasmic antibody- (ANCA-) associated vasculitis and glomerulonephritis leading to acute kidney injury and end-stage renal disease. It remains unclear whether LAC is associated with hepatic duct damage. Here, we report a case with biopsy-proven evidence of intrahepatic duct damage months after being diagnosed with ANCA-associated crescentic and sclerosing glomerulonephritis caused by LAC use. This case represents the first report of LAC-induced ANCA-associated hepatic duct cholestasis in the setting of previous LAC-induced ANCA-positive glomerulonephritis.

Upper extremity peripheral artery aneurysms are rare, and have been previously reported in children to be associated with congenital malformations and infectious or inflammatory processes. In this case series, we present two unique cases of spontaneous isolated true aneurysms of the brachial artery in two children. Both cases were incidentally found on examination, diagnosed by ultrasonography, and successfully managed by surgical excision and micro-vascular repair with vein grafting.

Objective — studying dyssynchrony characteristics and evaluation correction effectiveness in patients with chronic heart failure (CHF) of ischemic origin.Materials and methods. The study included 125 patients with chronic heart failure of ischemic etiology, 28 of them — with coronary heart disease (CHD) who had undergone aorto-and / or mammarokoronary bypass and / or percutaneous coronary intervention, 42 — with coronary artery disease and postinfarction cardiosclerosis, 32 — with arrhythmic variant of coronary artery disease, 23 — with stable angina without evidence of arrhythmia. Among included patients, biventricular pacemakers were implanted for 17 patients. All patients underwent echocardiography with determination of the parameters of dyssynchrony.Results and conclusion. Among patients with CHF ischemic symptoms dyssynchrony was diagnosed in 36 (28.8 %) cases. Statistically significant association between patients with cardiac arrhythmias and dyssynchrony was determined. At the same time the incidence of dyssynchrony was not associated with various forms of ischemic heart disease, and did not depend on the anamnesis of cardiac surgery. Dependence of the frequency of occurrence of dyssynchrony on the severity of CHF was revealed. Patients selected for implantation of biventricular pacemakers, especially in view of echocardiographic signs of dyssynchrony had significant improvement after providing cardiac resynchronization therapy. Effect of the treatment does not depend on the atrial fibrillation rhythm presence.

A large wintertime increase in pollutants has been observed over the eastern parts of the Indo Gangetic Plains. We use improved version 4 carbon monoxide (CO) retrievals from the Measurements of Pollution in the Troposphere (MOPITT) along with latest version 3 aerosol data from the Cloud-Aerosol Lidar and Infrared Pathfinder Satellite Observations (CALIPSO) lidar instrument and the tropospheric ozone residual products to characterize this pollution pool. The feature is seen primarily in the lower troposphere from about November to February with strong concomitant increases in CO and aerosol optical depth (AOD). The signature of the feature is also observed in tropospheric ozone column data. The height resolved aerosol data from CALIPSO confirm the trapping of the pollution pool at the lowest altitudes. The observations indicate that MOPITT can capture this low altitude phenomenon even in winter conditions as indicated by the averaging kernels.

In view of the proposed geostationary satellite missions to monitor air quality from space, it is important to first assess the capability of the current suite of satellite instruments to provide information on the urban scale pollution. We explore the possibility of detecting urban signatures in the tropospheric column ozone data derived from Total Ozone Mapping Spectrometer (TOMS)/Solar Backscattered Ultraviolet (SBUV) and Ozone Monitoring Instrument (OMI)/Microwave Limb Sounder (MLS) satellite data. We find that distinct isolated plumes of tropospheric ozone near several large and polluted cities around the world may be detected in these data sets. The ozone plumes generally correspond with the tropospheric column NO2 plumes around these cities as observed by the Scanning Imaging Absorption Spectrometer for Atmospheric Chartography (SCIAMACHY) instrument. Similar plumes are also seen in tropospheric mean ozone mixing ratio distribution after accounting for the surface and tropopause pressure variations. The total column ozone retrievals indicate fairly significant sensitivity to the lower troposphere over the polluted land areas, which might help explain these detections. These results indicate that ultraviolet (UV) measurements may, in principle, be able to capture the urban signatures and may have implications for future missions using geostationary satellites.

Using the empirically-corrected tropospheric ozone residual (TOR) technique, which utilizes coincident observations of total ozone from the Total Ozone Mapping Spectrometer (TOMS) and stratospheric ozone profiles from the Solar Backscattered Ultraviolet (SBUV) instruments, the seasonal and regional distribution of tropospheric ozone across the North Atlantic from 1979-2000 is examined. Its relationship to the North Atlantic Oscillation (NAO) is also analyzed as a possible transport mechanism across the North Atlantic. Monthly climatologies of tropospheric ozone for five different regions across the North Atlantic exhibit strong seasonality. The correlation between these monthly climatologies of the TOR and ozonesonde profiles at nearby sites in both eastern North America and western Europe are highly significant (R values of +0.98 and +0.96 respectively) and help to validate the use of satellite retrievals of tropospheric ozone. Distinct springtime interannual variability over North Atlantic Region 5 (eastern North Atlantic-western Europe) is particularly evident and exhibits similar variability to the positive phase of the NAO (R=+0.61, r=

Using coincident observations of total ozone from the Total Ozone Mapping Spectrometer (TOMS) and stratospheric ozone profiles from the Solar Backscattered Ultraviolet (SBUV) instruments, detailed maps of tropospheric ozone have been derived on a daily basis over a time period spanning more than two decades. The resultant climatological seasonal depictions of the tropospheric ozone residual (TOR) show much more detail than an earlier analysis that had used coincident TOMS and Stratospheric Aerosol and Gas Experiment (SAGE) ozone profiles, although there are many similarities between the TOMS/SAGE TOR and the TOMS/SBUV TOR climatologies. In particular, both TOR seasonal depictions show large enhancements in the southern tropics and subtropics in austral spring and at northern temperate latitudes during the summer. The much greater detail in this new data set clearly defines the regional aspect of tropospheric ozone pollution in northeastern India, eastern United States, eastern China, and west and southern Africa. Being able to define monthly climatologies for each year of the data record provides enough temporal resolution to illustrate significant interannual variability in some of these regions.