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Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.

ObjectivesThe objective of this study is to evaluate the user-defined optimization settings in the Fast Inverse Planning (FIP) optimizer in Leksell GammaPlan® and determine the parameters that result in the best stereotactic radiosurgery (SRS) plan quality for brain metastases, benign tumors, and arteriovenous malformations (AVMs).MethodsThirty patients with metastases and 30 with benign lesions-vestibular schwannoma, AVMs, pituitary adenoma, and meningioma-treated with SRS were evaluated. Each target was planned by varying the low dose (LD) and beam-on-time (BOT) penalties in increments of 0.1, from 0 to 1. The following plan quality metrics were recorded for each plan: Paddick conformity index (PCI), gradient index (GI), BOT, and maximum organ-at-risk (OAR) doses. A novel objective score matrix was calculated for each target using a linearly weighted combination of the aforementioned metrics. A histogram of optimal solutions containing the five best scores was extracted.ResultsA total of 7260 plans were analyzed with 121 plans per patient for the range of LD/BOT penalties. The ranges of PCI, GI, and BOT across all metastatic lesions were 0.58-0.97, 2.1-3.8, and 8.8-238 min, respectively, and were 0.13-0.97, 2.1-3.8, and 8.8-238 min, respectively, for benign lesions. The objective score matrix showed unique optimal solutions for metastatic lesions and benign lesions. Additionally, the plan metrics of the optimal solutions were significantly improved compared to the clinical plans for metastatic lesions with equivalent metrics for all other cases.ConclusionIn this study, FIP optimizer was evaluated to determine the optimal solution space to maximize PCI and minimize GI, BOT and OAR doses simultaneously for single metastatic/benign/non-neoplastic targets. The optimal solution chart was determined using a novel objective score which provides novice and expert planners a roadmap to generate the most optimal plans efficiently using FIP.

Abstract A major barrier to climate change mitigation is the political polarization of climate change beliefs. In a global experiment conducted in 60 countries (N = 51,224), we assess the differential impact of eleven climate interventions across the ideological divide. At baseline, we find political polarization of climate change beliefs and policy support globally, with people who reported being liberal believing and supporting climate policy more than those who reported being conservative (Cohen’s d = 0.35 and 0.27, respectively). However, we find no evidence for a statistically significant difference between these groups in their engagement in a behavioral tree planting task. This conceptual-behavioral polarization incongruence results from self-identified conservatives acting despite not believing, rather than self-identified liberals not acting on their beliefs. We also find three interventions (emphasizing effective collective actions, writing a letter to a future generation member, and writing a letter from the future self) boost climate beliefs and policy support across the ideological spectrum, and one intervention (emphasizing scientific consensus) stimulates the climate action of people identifying as liberal. None of the interventions tested show evidence for a statistically significant boost in climate action for self-identified conservatives. We discuss implications for practitioners deploying targeted climate interventions.

Abstract Background To examine potential changes and socioeconomic disparities in utilization of telemedicine in non-urgent outpatient care in Nevada since the COVID-19 pandemic. Methods This retrospective cross-sectional analysis of telemedicine used the first nine months of 2019 and 2020 electronic health record data from regular non-urgent outpatient care in a large healthcare provider in Nevada. The dependent variables were the use of telemedicine among all outpatient visits and using telemedicine more than once among those patients who did use telemedicine. The independent variables were race/ethnicity, insurance status, and language preference. Results Telemedicine services increased from virtually zero (16 visits out of 237,997 visits) in 2019 to 10.8% (24,159 visits out of 222,750 visits) in 2020. Asians (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.85,0.94) and Latinos/Hispanics (OR = 0.89; 95% CI = 0.85, 0.94) were less likely to use telehealth; Spanish-speaking patients (OR = 0.68; 95% CI = 0.63, 0.73) and other non-English-speaking patients (OR = 0.93; 95% CI = 0.88, 0.97) were less likely to use telehealth; and both Medicare (OR = 0.94; 95% CI = 0.89, 0.99) and Medicaid patients (OR = 0.91; 95% CI = 0.87, 0.97) were less likely to use telehealth than their privately insured counterparts. Patients treated in pediatric (OR = 0.76; 95% CI = 0.60, 0.96) and specialty care (OR = 0.67; 95% CI = 0.65, 0.70) were less likely to use telemedicine as compared with patients who were treated in adult medicine. Conclusions Racial/ethnic and linguistic factors were significantly associated with the utilization of telemedicine in non-urgent outpatient care during COVID-19, with a dramatic increase in telemedicine utilization during the onset of the pandemic. Reducing barriers related to socioeconomic factors can be improved via policy and program interventions.

Abstract To assess the aetiologies, clinical characteristics, treatment regimens, and outcomes of acute chemical injuries treated at an emergency eye clinic. Retrospective, observational study of all cases of chemical eye injury that presented acutely to the Greenlane Clinical Centre in Auckland, New Zealand from 1 January 2012 through 31 December 2021. Patient demographics, activity at the time of injury, causative chemical, clinical characteristics of injury at presentation, severity (Dua) classification, admission and discharge best corrected visual acuity (BCVA), treatment regimen, time to epithelisation and number of follow-up appointments were recorded. In total, 1522 cases involving 1919 eyes were studied. The mean age was 40.6 ± 18.8 years and 65% were male. The majority of cases occurred at home (62%) and cleaning was the most common activity (38%). There were 1490 Grade I (98%), 22 Grade II (1.5%), 5 Grade III (0.3%), 1 Grade IV (0.07%), 0 Grade V, and 4 Grade VI (0.3%) cases. An epithelial defect was noted in 409 cases (26.9%), of which re-epithelialisation occurred within one week for 378 cases (92%) and within 30 days for 384 cases (94%). Moderate vision loss (BCVA ≤ 6/12) attributed to the injury occurred in 152 (10%), while severe vision loss (BCVA ≤ 6/60) occurred in 30 (2%). Lack of irrigation at the scene was associated with an increased risk of severe injury and longstanding visual impairment (p = 0.0001). Most acute chemical injuries are mild with good clinical outcomes. Although rare, severe injuries are associated with a lack of irrigation at the scene and worse visual outcomes.

Abstract Background Lack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers. Methods This was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method. Results The sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%—58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% – 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%). Conclusions This method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

BackgroundStreptococcus pneumoniae (Spn) has been a leading cause of bacterial meningitis in children. The most recent estimation of the global burden of Spn meningitis indicates a positive trajectory in eliminating Spn through the implementation of pneumococcal conjugate vaccines. However, continuous monitoring and assessment of the disease burden are necessary due to the evidence of serotype replacement, antibiotic resistance, and the impact of the recent COVID-19 pandemic. ObjectiveThe aim of this systematic review is to provide an updated and focused assessment of the global and regional burden of Spn meningitis in children, which can guide policies and strategies to reduce the disease burden. MethodsPopulation-based studies published from January 1, 2000, to January 1, 2022, were preliminarily searched from the electronic databases PubMed, Embase, Global Health (CABI), and CINAHL Plus without any language restrictions. Studies were included if they reported the incidence, prevalence, mortality, or case-fatality ratio (CFR) for Spn meningitis in children aged 0-4 years; meningitis was confirmed by cerebrospinal fluid culture; the study period was a minimum of 1 year; the number of reported cases was at least 10; and the study had no methodological ambiguities. The article screening process follows the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Characteristics including study period, setting, World Health Organization region, income level, vaccination information, and participant data (age, number of cases, deaths, sequelae, and risk factors) will be extracted from the included studies. Search results will be updated and incorporated into our review prior to finalizing the extraction of data. Generalized linear mixed models meta-analysis will be performed to estimate the pooled incidence and CFR. We will further assess the risk of bias and heterogeneity, and will perform subgroup and sensitivity analyses to provide a meaningful interpretation of the current burden and literature for pneumococcal meningitis. ResultsOur preliminary search in December 2021 yielded 9295 articles. Out of 275 studies that were assessed with our eligibility criteria, 117 articles were included. Data extraction and analysis are expected to be complete by January 2025. We plan to publish the results from the full study, including an updated search in 2024, by March 2025. ConclusionsGiven that the major burden of Spn meningitis affects children under the age of 5 years, this systematic review will provide a thorough understanding of the global burden of Spn meningitis in this vulnerable population over a span of 2 decades. Insights into incidence trends, geospatial distribution, risk factors, and sequelae will be valuable for stakeholders, policy makers, and the academic community. This information will aid in the ongoing monitoring of the disease and in enhancing targeted vaccine programs to further mitigate the impact of the disease on children worldwide. Trial RegistrationPROSPERO CRD42021293110; https://tinyurl.com/kc3j5k4m International Registered Report Identifier (IRRID)DERR1-10.2196/50678

The geometry and sharpness of the cutting tool have a substantial impact on the final product’s quality. The geometry of cutting edges is altered throughout the machining process, and wear causes the cutting edge to become dull. This causes increased surface roughness, dimensional inaccuracy, cutting forces, chatter, and vibration. The present research focuses on tool wear (Vb) under dry machining conditions during ball end milling of Ti6Al4V alloy. The experiments are conducted using the full factorial design of experiments with three parameters, viz. feed (f), depth of cut (A t), and rotational speed (S) at three levels. A total of 27 experiments are conducted with one replicate. Artificial neural network (ANN) with 3-18-2-1 architecture is used for the study of the tool wear monitoring (TWM) system. Results revealed that the TWM model is highly adequate, with R 2 = 99.89% and R 2adj = 99.65%. The percentage contribution of A t is the highest, amounting to 80.6%, followed by feed of 12.46%. The rotational speed has the least contribution to tool wear, amounting to 1.5%. From ANN modeling, R 2 value testing is found to be 0.9974, which is close to unity and reveals that the trained model excellently fitted the testing data. The model accuracy is also found to be 96.46%.

Multiple functions are associated with HSV-1 latency associated transcript (LAT), including establishment of latency, virus reactivation, and antiapoptotic activity. LAT encodes two sncRNAs that are not miRNAs and previously it was shown that they have antiapoptotic activity in vitro. To determine if we can separate the antiapoptotic function of LAT from its latency-reactivation function, we deleted sncRNA1 and sncRNA2 sequences in HSV-1 strain McKrae, creating ΔsncRNA1&2 recombinant virus. Deletion of the sncRNA1&2 in ΔsncRNA1&2 virus was confirmed by complete sequencing of ΔsncRNA1&2 virus and its parental virus. Replication of ΔsncRNA1&2 virus in tissue culture or in the eyes of WT infected mice was similar to that of HSV-1 strain McKrae (LAT-plus) and dLAT2903 (LAT-minus) viruses. The levels of gB DNA in trigeminal ganglia (TG) of mice latently infected with ΔsncRNA1&2 virus was intermediate to that of dLAT2903 and McKrae infected mice, while levels of LAT in TG of latently infected ΔsncRNA1&2 mice was significantly higher than in McKrae infected mice. Similarly, the levels of LAT expression in Neuro-2A cells infected with ΔsncRNA1&2 virus was significantly higher than in McKrae infected cells. Reactivation in TG of ΔsncRNA1&2 infected mice was similar to that of McKrae and time of reactivation in both groups were significantly faster than dLAT2903 infected mice. However, levels of apoptosis in Neuro-2A cells infected with ΔsncRNA1&2 virus was similar to that of dLAT2903 and significantly higher than that of McKrae infected cells. Our results suggest that the antiapoptotic function of LAT resides within the two sncRNAs, which works independently of its latency-reactivation function and it has suppressive effect on LAT expression in vivo and in vitro.

Introduction: Architectural characteristics of skeletal muscles are used to inform biomechanical analysis and candidacy for tendon transfer surgeries. Tendons of non-typical skeletal muscles may serve as optimal grafts, yet a thorough comparison of their parameters to those of typical musculature is not well represented in current literature. This study aims to analyze accessory extensor carpi radialis longus (aECRL) and accessory carpi radialis brevis (aECRB) muscles for their functional impact and suitability for use in tendon transfer surgeries. Methods: Out of 122 dissected forearms examined, one right aECRB and one left aECRL were discovered and photographed in situ. The accessory muscles, along with eleven other muscles associated with ECRL and ECRB tendon transfers from the same forearms, were analyzed for their sarcomere contraction states, structural properties, and maximal isometric force (Fmax) generating capacities. An architectural difference index was then calculated between each muscle to determine and discuss possible candidates for tendon transfer surgeries. Results: The Fmax of aECRL, ECRL, aECRB, and ECRB were determined to be 11.78 N, 57.24 N, 28.21 N, and 78.64 N, respectively. In this regard, aECRL and aECRB represented a 20.58% and 35.87% increase to ECRL and ECRB Fmax, respectively. The aECRL inserted with ECRB, and the aECRB inserted with ECRL. The aECRL and aECRB tendons, measuring 188.33 mm × 2.98 mm and 217.17 mm × 3.00 mm respectively, coursed independently with the ECRL and ECRB tendons to their shared insertions. The aECRL and aECRB muscles were each most structurally similar to the extensor pollicis longus and adductor pollicis muscles. Conclusions: Based on their morphology and structural characteristics, the aECRL and aECRB may be suitable grafts in adductorplasty or for extensor pollicis longus muscle/tendon repair. As the aECRL and aECRB tendons were relatively superficial and considerably long and wide, they may also be suitable for other musculotendon-based surgeries elsewhere in the body. This report may contribute new and beneficial insights for healthcare providers and medical educators when presented with cases where upper extremity musculotendinous reconstruction is warranted and/or non-typical musculoskeletal morphologies – particularly aECRL and aECRB – are present.

We evaluated the effect of lesion number and volume for brain metastasis treated with SRS using GammaKnife® ICON™ (GK) and CyberKnife® M6™ (CK). Four sets of lesion sizes (10-15 mm, and >15 mm) were contoured and prescribed a dose of 20 Gy/1 fraction. The number of lesions was increased until a threshold mean brain dose of 8 Gy was reached; then individually optimized to achieve maximum conformity. Across GK plans, mean brain dose was linearly proportional to the number of lesions and total GTV for all sizes. The numbers of lesions needed to reach this threshold for GK were 177, 57, 29, and 10 for each size group, respectively; corresponding total GTVs were 3.62 cc, 20.37 cc, 30.25 cc, and 57.96 cc, respectively. For CK, the threshold numbers of lesions were 135, 35, 18, and 8, with corresponding total GTVs of 2.32 cc, 12.09 cc, 18.24 cc, and 41.52 cc respectively. Mean brain dose increased linearly with number of lesions and total GTV while V8 Gy, V10 Gy, and V12 Gy showed quadratic correlations to the number of lesions and total GTV. Modern dedicated intracranial SRS systems allow for treatment of numerous brain metastases especially for ≤10 mm; clinical evidence to support this practice is critical to expansion in the clinic.

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p

BackgroundCurrent guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy.MethodsThe Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions.ResultsA total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death.ConclusionIndex admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

Introduction/aimsNeuralgic amyotrophy (NA) is a multifocal neuropathy involving the nerves of the upper extremity, limiting functional capability and reducing range of motion. The reachable workspace (RWS) is a computerized three-dimensinal analysis system that evaluates the relative surface area (RSA) of an individual's arm reachability and has shown utility in several neuromuscular disorders. The aims of this study were to examine the ability of the RWS to quantitatively detect limitations in upper extremity active range of motion in patients with NA, and correlate these with other upper extremity functional outcome measures.MethodsForty-seven patients with NA and 25 healthy age- and sex-matched controls were measured with the RWS. Study participants' RSAs were correlated with scores on the Shoulder Rating Questionnaire (SRQ), the Disabilities of Arm Shoulder and Hand (DASH) questionnaire, and upper extremity strength measurements using hand-held dynamometry.ResultsPatients with NA showed significantly lower values in the affected arm for all quadrants (except for the ipsilateral lower quadrant) and total RSA compared with controls (P

IntroductionBladder preservation with concurrent chemoradiotherapy after maximum transurethral resection of bladder tumor is an alternative to radical cystectomy in select patients with muscle invasive bladder cancer (MIBC). Concurrent administration of radio-sensitizing chemotherapy and radiation therapy (RT) has been shown to have superior disease control compared with RT alone and can often be administered with modest added toxicity. We sought to describe national patterns of chemotherapy use.MethodsThe linked surveillance, epidemiology, and end results (SEER)-Medicare database was used to identify patients with cT2-4, N0/X, M0/X BC who received radiation between 2004 and 2018. Data on demographics, clinicopathologic factors, therapy and outcomes were extracted. Concurrent utilization of chemotherapy with RT was also identified (CRT). Multivariate logistic regression (MVA) models were used to explore factors associated with receipt of chemotherapy and overall survival (OS).Results2190 patients met inclusion criteria. Of these, 850 (38.8%) received no chemotherapy. Among those receiving chemotherapy, the most frequent regimens were single agent carboplatin, cisplatin, or gemcitabine. Factors that were independently associated with decreased likelihood of chemotherapy use were increasing age (OR 0.93, CI 0.92 – 0.95), Hispanic race (compared with White, OR 0.62, CI 0.39 – 0.99), cT3 or T4 (compared with cT2, OR 0.70, CI 0.55 – 0.90), and lower National Cancer Institute comorbidity index (OR 0.60, CI 0.51 – 0.70) (p < 0.05). Variables independently associated with increased likelihood of receipt of chemotherapy were married status (OR 1.28, CI 1.06 – 1.54), higher socioeconomic status (OR 1.31, CI 1.06 – 1.64), and later year of diagnosis (OR 1.09, CI 1.06 – 1.12). Receipt of concurrent chemotherapy with RT was associated with superior OS compared with RT alone.ConclusionOver a third of patients >/65 years old receiving curative-intent RT for MIBC do not receive concurrent chemotherapy. Considering the improvement in oncologic outcomes with CRT over RT alone and more options, such as low dose gemcitabine which can be administered with modest toxicity, efforts are needed to identify barriers to utilization and increase the use of radio-sensitizing chemotherapy.

Plants are remarkable in their ability to adapt to changing environments, with receptor-like kinases (RLKs) playing a pivotal role in perceiving and transmitting environmental cues into cellular responses. Despite extensive research on RLKs from the plant kingdom, the function and activity of many kinases, i.e., their substrates or “clients”, remain uncharted. To validate a novel client prediction workflow and learn more about an important RLK, this study focuses on P2K1 (DORN1), which acts as a receptor for extracellular ATP (eATP), playing a crucial role in plant stress resistance and immunity. We designed a Kinase-Client (KiC) assay library of 225 synthetic peptides, incorporating previously identified P2K phosphorylated peptides and novel predictions from a deep-learning phosphorylation site prediction model (MUsite) and a trained hidden Markov model (HMM) based tool, HMMER. Screening the library against purified P2K1 cytosolic domain (CD), we identified 46 putative substrates, including 34 novel clients, 27 of which may be novel peptides, not previously identified experimentally. Gene Ontology (GO) analysis among phosphopeptide candidates revealed proteins associated with important biological processes in metabolism, structure development, and response to stress, as well as molecular functions of kinase activity, catalytic activity, and transferase activity. We offer selection criteria for efficient further in vivo experiments to confirm these discoveries. This approach not only expands our knowledge of P2K1’s substrates and functions but also highlights effective prediction algorithms for identifying additional potential substrates. Overall, the results support use of the KiC assay as a valuable tool in unraveling the complexities of plant phosphorylation and provide a foundation for predicting the phosphorylation landscape of plant species based on peptide library results.

Introduction: Variations in muscles of the pollex are common, and some can elicit significant clinical implications. The abductor pollicis longus (APL) frequently exhibits non-typical morphologies; however, descriptions of uncharacteristic distal fibers from APL (APLudf) that form a reticular tunnel around the tendons of extensor carpi radialis longus (ECRL) and brevis (ECRB) are scarce in current literature. The objective of this study is to investigate the prevalence of APLudf with concurrent report of in situ and cross-sectional gross imaging. Methods: The distal aspect of 110 APL muscles was examined for APLudf and reticular tunnel formation. Reticular tunnel length was measured over the long axis of the underlying ECRL tendon, and APLudf pennation angle was recorded. Characteristic APL and APLudf examples were photographed in situ, and one example of APLudf was cross-sectioned to show the bony attachment of the atypical fibers in relation to contiguous anatomy. A unique finding of an APLudf accessory tendon inserting onto an accessory abductor pollicis brevis muscle was removed, splayed, and photographed. Results: APLudf were present in 65 (59.1%) of upper limbs. The APLudf originated from a free origin over the ECRL and ECRB tendons and a fixed origin from the lateral margin of the distal radius and inserted onto the main APL tendon or an accessory tendon, creating a distinct reticular tunnel around the ECRL and ECRL with a mean length of 20.25 ± 5.55 mm (range = 11.09 mm–36.09 mm) and 12.99° ± 1.44° pennation. All APL muscles displayed one main tendon and at least one accessory tendon which originated solely from APLudf on 43 (39.1%) of the specimens. Conclusions: The present study suggests the prevalence of APLudf is 59.1% and often occurs bilaterally. The restriction of intersecting movements within the APLudf reticular tunnel could cause ECRL and ECRB tendon inflammation (i.e., intersection syndrome), directly affect respective functions (e.g., radial extension of the wrist, abduction and extension of the thumb), and complicate surgical management in the region. This report may inform educators and healthcare providers when deliberating diagnosis, treatment, and healing of associated forearm, wrist, and pollex conditions.

Summary: In this Viewpoint, we provide an overview of the worsening trend of traumatic injuries across the United States–Mexico border after its recent fortification and height extension to 30-feet. We further characterize the international factors driving migration and the current U.S. policies and political climate that will allow this public health crisis to progress. Finally, we provide recommendations involving prevention efforts, effective resource allocation, and advocacy that will start addressing the humanitarian and economic consequences of current U.S. border policies and infrastructure.

This observational study assesses the changes in morbidity and mortality of border wall injuries after construction of the 30-ft border wall in San Diego and Imperial Counties, California.

We compared the clinical outcomes of BM treated with mask immobilization with zero-SM (i.e., zero-PTV) to standard zero-SM frame immobilization SRS. Consecutive patients with BM, 0.5−2.0 cm in maximal diameter, treated with single-fraction SRS (22−24 Gy) during March 2019−February 2021 were included. Univariable and multivariable analysis were performed using the Kaplan−Meier method and Cox proportional hazards regression. A total of 150 patients with 453 BM met inclusion criteria. A total of 129 (28.5%) lesions were treated with a zero-SM mask immobilization and 324 (71.5%) with zero-SM frame immobilization. Frame immobilization treatments were associated with a higher proportion of gastrointestinal and fewer breast-cancer metastases (p = 0.024), and a higher number of treated lesions per SRS course (median 7 vs. 3; p < 0.001). With a median follow up of 15 months, there was no difference in FFLF between the mask and frame immobilization groups on univariable (p = 0.29) or multivariable analysis (p = 0.518). Actuarial FFLF at 1 year was 90.5% for mask and 92% for frame immobilization (p = 0.272). Radiation necrosis rates at 1 year were 12.5% for mask and 4.1% for frame immobilization (p = 0.502). For BM 0.5−2.0 cm in maximal diameter treated with single-fraction SRS using 22−24 Gy, mask immobilization with zero SM produces comparable clinical outcomes to frame immobilization. The initial findings support omitting a SM when using mask immobilization with this treatment approach on a Gamma Knife® Icon™.