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Mechanical unloading during microgravity causes skeletal muscle atrophy and impairs mitochondrial energetics. The elevated production of reactive oxygen species (ROS) by mitochondria and Nox2, coupled with impairment of stress protection (e.g., SIRT1, antioxidant enzymes), contribute to atrophy. We tested the hypothesis that the SIRT1 activator, SRT2104 would rescue unloading-induced mitochondrial dysfunction. Mitochondrial function in rat gastrocnemius and soleus muscles were evaluated under three conditions (10 days): ambulatory control (CON), hindlimb unloaded (HU), and hindlimb-unloaded-treated with SRT2104 (SIRT). Oxidative phosphorylation, electron transfer capacities, H2O2 production, and oxidative and antioxidant enzymes were quantified using high-resolution respirometry and colorimetry. In the gastrocnemius, (1) integrative (per mg tissue) proton LEAK was lesser in SIRT than in HU or CON; (2) intrinsic (relative to citrate synthase) maximal noncoupled electron transfer capacity (ECI+II) was lesser, while complex I-supported oxidative phosphorylation to ECI+II was greater in HU than CON; (3) the contribution of LEAK to ECI+II was greatest, but cytochrome c oxidase activity was lowest in HU. In both muscles, H2O2 production and concentration was greatest in SIRT, as was gastrocnemius superoxide dismutase activity. In the soleus, H2O2 concentration was greater in HU compared to CON. These results indicate that SRT2104 preserves mitochondrial function in unloaded skeletal muscle, suggesting its potential to support healthy muscle cells in microgravity by promoting necessary energy production in mitochondria.

Type II porous liquids, comprising intrinsically porous molecules dissolved in a liquid solvent, potentially combine the adsorption properties of porous adsorbents with the handling advantages of liquids. Previously, discovery of appropriate solvents to make porous liquids had been limited to direct experimental tests. We demonstrate an efficient screening approach for this task that uses COSMO-RS calculations, predictions of solvent p

Background Disparity in cancer survival across countries has been linked to variation in cancer policy delivery but there is lack of empirical evidence for this association. We traced the evolution of cancer policies in 20 jurisdictions in Australia, Canada, Denmark, Ireland, Norway, New Zealand and the UK since 1995 and present the findings of an exploratory analysis linking cancer policy consistency to cancer survival. Methods We systematically searched and analysed national/regional cancer plans and strategies, mapping timelines of cancer policy evolution. For 10 jurisdictions, evidence was synthesised into five categories: oversight function; cancer plan; implementation plan; budget for plan implementation; and evaluation. We assigned scores evaluating whether a category was present or absent, and weighted scores for consistency. Summed scores were correlated with trends in survival from seven cancers between 1995-2014. Results All ten jurisdictions had implemented a high-level structure overseeing, steering or delivering cancer control policies (1995 - 2014); all had also published at least one major cancer plan. There was great variation in oversight mechanisms, ranging from institutionalising cancer control (New South Wales, Ontario) to cancer steering groups or taskforces (Denmark, Northern Ireland, Wales). Frequency and consistency of cancer plans also varied, from a succession of plans that build on each other (Denmark, New South Wales, Ontario) to the publication of isolated plans (New Zealand, Northern Ireland). We found a positive, albeit weak, correlation of cancer policy consistency and improvements in survival over time for six of the seven cancers. Conclusions Jurisdictions that have implemented consistent cancer control policies over time tended to be more successful in improving survival for a wide range of cancers. Our findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes. Key messages • Sustained and consistent strategic cancer planning and investment are crucial for ensuring better patient outcomes, and this requires strong and sustained commitment at all levels. • The findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.

Delivery of therapeutic molecules to pathogenic cells is often hampered by unintended toxicity to normal cells. In principle, this problem can be circumvented if the therapeutic effector molecule is split into two inactive components, and only assembled on or within the target cell itself. Such an in situ process can be realized by exploiting target-specific molecules as templates to direct proximity-enhanced assembly. Modified nucleic acids carrying inert precursor fragments can be designed to co-hybridize on a target-specific template nucleic acid, such that the enforced proximity accelerates assembly of a functional molecule for antibody recognition. We demonstrate the in vitro feasibility of this adaptation of nucleic acid-templated synthesis (NATS) using oligonucleotides bearing modified peptides (“haplomers”), for templated assembly of a mimotope recognized by the therapeutic antibody trastuzumab. Enforced proximity promotes mimotope assembly via traceless native chemical ligation. Nevertheless, titration of participating haplomers through template excess is a potential limitation of trimolecular NATS. In order to overcome this problem, we devised a strategy where haplomer hybridization can only occur in the presence of target, without being subject to titration effects. This generalizable NATS modification may find future applications in enabling directed targeting of pathological cells.

Studies have shown a significant relationship between low oral health literacy (OHL) and poor oral health outcomes. National calls for action include better training of dental providers to meet the needs of the low OHL public. The purpose of this research was to determine the extent OHL education is being included in US dental hygiene (DH) education programs.In fall of 2020, a 23-item digital survey was sent to 321 Commission on Dental Accreditation-accredited DH schools in the US.Survey generated 90 eligible responses (28%). Respondents reported that OHL education is being included in DH curricula to some degree. Communication strategies (82.4%) were the most likely OHL concept to be taught. Subject areas included community health (89%), cultural competency (78%), and special populations (78%). Respondents ranked lack of assessment instruments, lack of concrete activities, lack of clear understanding of OHL, and difficulty in implementing OHL concepts as the top barriers to incorporating OHL education in the DH curriculum.OHL is an established determinant of oral health. As prevention and patient education experts, dental hygienists play an important role in improving patient OHL. More fully integrating OHL into DH curricula would provide future DHs with the training needed to improve oral health outcomes and would better align DH education programs with national OHL initiatives.

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts. By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees. The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

Previously institutionalized children on average show persistent deficits in physiological and behavioral regulation, as well as a lack of normative reticence towards strangers, or disinhibited social engagement (DSE). Post-adoption parenting, specifically a combination of supportive presence and structure/limit-setting, may protect against DSE over time via better adrenocortical functioning. This study examined the impact of adrenocortical activity and post-adoption parenting on DSE across the first two years post-adoption (age at adoption: 16-36 months) and observed kindergarten social outcomes in previously institutionalized children (n = 94) compared to non-adopted children (n = 52). Path analyses indicated a developmental cascade from institutional care (operationalized as a dichotomous group variable, age at adoption, and months of institutionalization) to blunted adrenocortical activity, increased DSE, and lower kindergarten social competence. Consistent with a permissive parenting style, higher parental support was associated with increased DSE, but only when not accompanied by effective structure/limit-setting. Further, parental structure reduced the association between blunted adrenocortical activity and DSE behaviors.

The current study examined concurrent relationships between children's self-regulation, measured behaviorally and by parent-report, and children's internalizing and externalizing symptoms. The aim was to distinguish which components of self-regulation (attention vs. inhibitory control, "hot" vs. "cool" regulation) best predict dimensional symptomatology and clinical disorders in young children. The participants were 120 children, ages 4-8 years old. Results showed that greater parent-reported attention was associated with fewer internalizing and externalizing symptoms. Behaviorally-measured hot inhibitory control related to fewer internalizing symptoms, whereas parent-reported inhibitory control related to fewer externalizing symptoms. Similar patterns emerged for clinical diagnoses, with parent-rated attention most strongly predicting disorders across domains. Results support prior evidence implicating self-regulatory deficits in externalizing problems, while also demonstrating that components of self-regulation are impaired with internalizing symptoms. Further, different sub-components of self-regulation relate to different dimensions of psychopathology in children. Interventions should target these areas in children at-risk for disorders.

During space missions that travel beyond the cocoon of the Earth’s magnetosphere, astronauts are subjected to the microgravity and radiation stressors of outer space [...]

CONTEXT: Few studies have examined the clinical characteristics that predict durable, long-term diabetes remission after bariatric surgery. OBJECTIVE: To compare diabetes prevalence and remission rates during 7-year follow-up after Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LAGB). DESIGN: An observational cohort of adults with severe obesity recruited between 2006 and 2009 who completed annual research assessments for up to 7 years after RYGB or LAGB. SETTING: Ten US hospitals. PARTICIPANTS: A total sample of 2256 participants, 827 with known diabetes status at both baseline and at least 1 follow-up visit. INTERVENTIONS: Roux-en-Y gastric bypass or LAGB. MAIN OUTCOME MEASURES: Diabetes rates and associations of patient characteristics with remission status. RESULTS: Diabetes remission occurred in 57% (46% complete, 11% partial) after RYGB and 22.5% (16.9% complete, 5.6% partial) after LAGB. Following both procedures, remission was greater in younger participants and those with shorter diabetes duration, higher C-peptide levels, higher homeostatic model assessment of β-cell function (HOMA %B), and lower insulin usage at baseline, and with greater postsurgical weight loss. After LAGB, reduced HOMA insulin resistance (IR) was associated with a greater likelihood of diabetes remission, whereas increased HOMA-%B predicted remission after RYGB. Controlling for weight lost, diabetes remission remained nearly 4-fold higher compared with LAGB. CONCLUSIONS: Durable, long-term diabetes remission following bariatric surgery is more likely when performed soon after diagnosis when diabetes medication burden is low and beta-cell function is preserved. A greater weight-independent likelihood of diabetes remission after RYGB than LAGB suggests mechanisms beyond weight loss contribute to improved beta-cell function after RYGB. Trial Registration clinicaltrials.gov Identifier: NCT00465829.

BackgroundThe present study examined the efficacy of the Michigan Model of Infant Mental Health-Home Visiting (IMH-HV) infant mental health treatment to promote the socioemotional wellbeing of infants and young children. Science illuminates the role of parental “co-regulation” of infant emotion as a pathway to young children’s capacity for self-regulation. The synchrony of parent–infant interaction begins to shape the infant’s own nascent regulatory capacities. Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, and who struggle with symptoms of post-traumatic stress may have greater challenges in co-regulating their infant, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression, and depression. Early intervention that targets the infant–parent relationship may help buffer the effect of parental risk on child outcomes.MethodsParticipants were 58 mother–infant/toddler dyads enrolled in a longitudinal randomized control trial testing the efficacy of the relationship-based IMH-HV treatment model. Families were eligible based on child age (ResultsMaternal ACEs predicted more toddler emotional problems through their effect on maternal PTSD symptoms. Parents who received IMH-HV treatment reported more positive toddler socioemotional wellbeing at follow-up relative to the control condition. The most positive socioemotional outcomes were for toddlers of mothers with low to moderate PTSD symptoms who received IMH-HV treatment.ConclusionResults indicate the efficacy of IMH-HV services in promoting more optimal child socioemotional wellbeing even when mothers reported mild to moderate PTSD symptoms. Results also highlight the need to assess parental trauma when infants and young children present with socioemotional difficulties.

Background There is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty. Methods We retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization. Results The most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS. Conclusions Prolonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

Little is known about intimate partner violence-related fatalities among young people. This study comprehensively identifies and describes intimate partner violence-related homicides, homicide-suicides, legal intervention deaths, and suicides among young people.Data from the 2014-2018 National Violent Death Reporting System were analyzed for all decedents aged 0-24 years in 38 states, the District of Columbia, and Puerto Rico with known circumstances of death (n=29,702). Intimate partner violence-related deaths were identified using National Violent Death Reporting System variables across all manners of death and supplementary narrative review for suicides. This article reports the proportion of intimate partner violence versus non-intimate partner violence-related deaths by manner of death, descriptive statistics, and rate of intimate partner violence-related death per 100,000 person years. To examine disparities in intimate partner violence-related deaths, generalized estimating equations were used with robust standard errors to account for clustering of deaths within states and fixed effects for years. Statistical analyses were conducted May and August 2021.A total of 1,927 intimate partner violence-related deaths were identified, which represents 6.5% of violent deaths with known circumstances, at a rate of 0.35 per 100,000 person years. Supplementary narrative review identified 44.7% of all intimate partner violence-related deaths. There were significant differences by race/ethnicity and whether a firearm inflicted the fatal injury for male and female decedents by manner of death.If the National Violent Death Reporting System does not assess whether intimate partner violence was a precipitating factor across all death manners, the true magnitude of intimate partner violence's contribution to violent death will be underestimated. Future research that identifies factors associated with all manners of intimate partner violence-related deaths among young people will help inform intervention and prevention strategies to save young lives.

Introduction The error‐related negativity (ERN) is a neural response that reflects error monitoring. Contradictorily, an enlarged (more negative) ERN has been cited as both a risk factor and a protective factor, which hinders its utility as a predictive indicator. The aim of the current study was to examine the associations between ERN measured in early childhood with the development of cognitive control (CC), emotion regulation, and internalizing/externalizing symptoms over 1–2 years. Methods When children were ages 5–7, EEG was collected during a Go/No‐Go task. A subset of the original participants (n = 30) were selected based on their baseline ERN in an extreme‐case design: half with high‐amplitude ERN, matched by age and sex with another group with low‐amplitude ERN. Results At follow‐up, children in the High‐Amplitude group showed better executive function, less self‐reported anxiety and depression, less affect dysregulation, more parent‐rated CC, less lability/negativity, and fewer parent‐reported externalizing problems. Many results held even when accounting for baseline levels. Further, emotion dysregulation mediated the relationship between the ERN and both anxiety and externalizing problems, while CC mediated the ERN's relationship with externalizing problems only. Conclusions These results can inform identification and intervention efforts for children at risk for psychopathology., High‐amplitude error‐related negativity (ERN), measured in early childhood, predicts better self‐control, including executive function and cognitive control and less affect dysregulation in middle childhood, and predicts fewer anxiety, depression, and externalizing symptoms over time. Emotion dysregulation mediated the relationship between the ERN and both anxiety and externalizing problems, while cognitive control mediated the ERN's relationship with externalizing problems only.

There have been 77 TNOs discovered to be librating in the distant trans-Neptunian resonances (beyond the 2:1 resonance, at semimajor axes greater than 47.7 au) in four well-characterized surveys: the Outer Solar System Origins Survey (OSSOS) and three similar prior surveys. Here, we use the OSSOS Survey Simulator to measure their intrinsic orbital distributions using an empirical parameterized model. Because many of the resonances had only one or very few detections, j:k resonant objects were grouped by k in order to have a better basis for comparison between models and reality. We also use the Survey Simulator to constrain their absolute populations, finding that they are much larger than predicted by any published Neptune migration model to date; we also find population ratios that are inconsistent with published models, presenting a challenge for future Kuiper Belt emplacement models. The estimated population ratios between these resonances are largely consistent with scattering–sticking predictions, though further discoveries of resonant TNOs with high-precision orbits will be needed to determine whether scattering–sticking can explain the entire distant resonant population or not.

This study examined changes in parental reflective functioning (PRF) among mothers enrolled in Infant Mental Health-Home Visiting (IMH-HV) and explored whether parental risk, treatment dosage or therapist experience predicted change in PRF. Participants included 75 mothers and their children who were enrolled in IMH-HV delivered by Community Mental Health therapists. Results indicated significant improvements in PRF from baseline to 12-months. Maternal demographic and psychosocial risk, therapist experience and treatment dosage were not directly associated with changes in PRF. However, Mothers who received more treatment sessions from therapists with six or more years of experience demonstrated the greatest improvements in PRF, while mothers who received more treatment sessions from therapists who had been practicing IMH for less than 15 months showed a decline in PRF. Therapists working with very high-risk families may need specific training and ongoing reflective supervision over a period of years to promote improvement in PRF.

Context Postbariatric hypoglycemia (PBH), characterized by enteroinsular axis overstimulation and hyperinsulinemic hypoglycemia, is a complication of bariatric surgery for which there is no approved therapy. Objective To evaluate efficacy and safety of avexitide [exendin (9-39)], a glucagon-like peptide-1 antagonist, for treatment of PBH. Methods A multicenter, Phase 2, randomized, placebo-controlled crossover study (PREVENT). Eighteen female patients with PBH were given placebo for 14 days followed by avexitide 30 mg twice daily and 60 mg once daily, each for 14 days in random order. The main outcome measures were glucose nadir and insulin peak during mixed-meal tolerance testing (MMTT) and hypoglycemic events captured by self-monitoring of blood glucose (SMBG), electronic diary, and blinded continuous glucose monitoring (CGM). Results Compared with placebo, avexitide 30 mg twice daily and 60 mg once daily raised the glucose nadir by 21% (P = .001) and 26% (P = .0002) and lowered the insulin peak by 23% (P = .029) and 21% (P = .042), corresponding to 50% and 75% fewer participants requiring rescue during MMTT, respectively. Significant reductions in rates of Levels 1 to 3 hypoglycemia were observed, defined, respectively, as SMBG Conclusion Avexitide administered for 28 days was well tolerated and resulted in robust and consistent improvements across multiple clinical and metabolic parameters, reinforcing the targeted therapeutic approach and demonstrating durability of effect. Avexitide may represent a first promising treatment for patients with severe PBH.

Megaconstellations of thousands to tens of thousands of artificial satellites (satcons) are rapidly being developed and launched. These satcons will have negative consequences for observational astronomy research, and are poised to drastically interfere with naked-eye stargazing worldwide should mitigation efforts be unsuccessful. Here we provide predictions for the optical brightnesses and on-sky distributions of several satcons, including Starlink, OneWeb, Kuiper, and StarNet/GW, for a total of 65,000 satellites on their filed or predicted orbits. We develop a simple model of satellite reflectivity, which is calibrated using published Starlink observations. We use this model to estimate the visible magnitudes and on-sky distributions for these satellites as seen from different places on Earth, in different seasons, and different times of night. For latitudes near 50 degrees North and South, satcon satellites make up a few percent of all visible point sources all night long near the summer solstice, as well as near sunrise and sunset on the equinoxes. Altering the satellites' altitudes only changes the specific impacts of the problem. Without drastic reduction of the reflectivities, or significantly fewer total satellites in orbit, satcons will significantly change the night sky worldwide., Comment: accepted to AJ

Reduced mechanical loading results in atrophy of skeletal muscle fibers. Increased reactive oxygen species (ROS) are causal in sarcolemmal dislocation of nNOS and FoxO3a activation. The Nox2 isoform of NADPH oxidase and mitochondria release ROS during disuse in skeletal muscle. Activation of the angiotensin II type 1 receptor (AT1R) can elicit Nox2 complex formation. The AT1R blocker losartan was used to test the hypothesis that AT1R activation drives Nox2 assembly, nNOS dislocation, FoxO3a activation, and thus alterations in morphology in the unloaded rat soleus. Male Fischer 344 rats were divided into four groups: ambulatory control (CON), ambulatory + losartan (40 mg kg−1 day−1) (CONL), 7 days of tail‐traction hindlimb unloading (HU), and HU + losartan (HUL). Losartan attenuated unloading‐induced loss of muscle fiber cross‐sectional area (CSA) and fiber‐type shift. Losartan mitigated unloading‐induced elevation of ROS levels and upregulation of Nox2. Furthermore, AT1R blockade abrogated nNOS dislocation away from the sarcolemma and elevation of nuclear FoxO3a. We conclude that AT1R blockade attenuates disuse remodeling by inhibiting Nox2, thereby lessening nNOS dislocation and activation of FoxO3a., Angiotensin receptor blockade (ARB) reduced unloading‐induced atrophy of skeletal muscle. Losartan mitigated assembly of the Nox2 complex, and thus oxidative stress ARB attenuated loss of sarcolemmal nNOSµ and nuclear levels of FoxO3a.

A relationship between alcohol use and aggression is well-established; however, less is known about how these factors develop and influence each other over time. This study examined the immediate and delayed effects of alcohol use on aggression during adolescence. Alcohol use and aggression were measured in a subset of students (n = 1560) from the Climate and Preventure study, Australia. Participants completed self-report surveys across five assessments (ages 13, 13.5, 14, 15 and 16). In a two-stage analysis, parallel and auto-regressive latent growth curve models were applied to investigate person-specific trajectories (or between-person effects) of alcohol use and aggression and identify the time-varying impact (or within-person effects) of alcohol use on aggression. Average alcohol consumption increased between ages 13 and 16, while average aggression levels decreased over time. Overall growth in alcohol use was positively related to heightened aggression at age 16, and vice versa. Spikes (time-varying increases) in alcohol use were linked to corresponding increases in aggression at each time point. There was evidence of a prospective effect where aggression was associated with hazardous alcohol use a year later, but no evidence that alcohol use was associated with subsequent aggression. Change in hazardous alcohol consumption and aggression beginning early in adolescence are interrelated and are predictive of one another at age 16. The time-varying effects of alcohol on aggression appear to be immediate rather than delayed; however, there is evidence for a prospective relationship where aggression influences later alcohol use. Implications for the timing and nature of novel harm reduction intervention approaches for young people are discussed.

Although many children adopted internationally show remarkable recovery once placed in families, as a group they continue to exhibit persisting developmental deficits and delays in self-regulation. The current study uses a stratified, randomized, controlled trial to evaluate the effects of mindfulness-based and executive function trainings (EFTs) on internationally adopted (IA) children's self-regulation, including effortful/inhibitory control, attention, delay of gratification, and emotion-regulation. IA children ages 6–10 years were randomized into mindfulness training (MT), EFT, or no intervention (NI) groups. The MT and EFT groups attended 12 one-hour group sessions. Ninety-six children (MT, n = 33; EFT, n = 32; NI, n = 31) completed the study and were tested on computerized and non-computerized measures of self-regulation. Compared with the NI group, the MT group improved delay of gratification, and the EFT group improved inhibitory control and selective attention. There was no effect of either intervention on emotion regulation. MTs and EFTs show promise for improving self-regulation in IA children.

Introduction: Previously referred to as late dumping syndrome, post-bariatric hypoglycemia (PBH) is thought to represent at least 1% of all hospitalizations for hypoglycemia and 10% of all clinically recognized hypoglycemia cases. However, through the advent of CGM and more strict criteria over the last decade these numbers are likely an underestimate. As obesity continues to remain prevalent and with rising bariatric centers to help deal with this epidemic, endocrinologists will play an increasing role in managing PBH patients. Clinical Case: A 39-year female with a PMH of hypothyroidism and bariatric surgery (BS) in 2009 presented to our ER for a seizure. She has been having seizures nearly every 2 weeks for one year. Neurology started her on Keppra; however, no etiology was identified. EMS had documented a blood glucose of 40 mg/dL; the patient was given an amp of D50 with resolution of neuroglycopenic symptoms. TSH and cortisol levels were within normal range. A sulfonylurea panel in the ED was negative. The patient states the symptoms can occur while fasting but also mainly post-prandial. A 72-hr fast was conducted with the patient nadir POC glucose of 77. Subsequently, the patient had a mixed meal tolerance performed and after 2 hours had a seizure and was found to have a BG of 50 mg/dL with an insulin level of 49 uIU/mL and a c-peptide of 18.8 ng/mL. The patient was diagnosed with PBH, and was discharged with a CGM, started on acarbose and was seen by nutrition to discuss dietary modifications. She is now seen in our clinic with control of her symptoms with the addition of diazoxide. Conclusion: Altered anatomy after bariatric surgery, particularly after gastric bypass and sleeve gastrectomy is thought to play a major role in developing PBH. By bypassing normal anatomy, gastric emptying is increased 2–3 x, which leads to a higher and more rapid appearance of glucose in the distal foregut. This subsequently leads to an amplified incretin response leading to a hyperinsulinemic response in patients who have had bariatric surgery; however, for unclear reasons some patients develop an even more amplified hyperinsulinemic response that leads to subsequent hypoglycemia. History of neuroglycopenic symptoms 1–3 hours after eating in a patient who had a gastric bypass > 6–12 months and with relief of symptoms with carbohydrates should raise an endocrinologist’s suspicion of PBH. Fasting hypoglycemia is an atypical feature that should raise one’s suspicion of a broader differential. Altered nutrition habits is the cornerstone of therapy with which the primary aim is to reduce post-prandial glucose spikes in these patients after they eat carbohydrates. These spikes in turn lead to hyperinsulinism leading to subsequent hypoglycemia. Primary diet modifications include controlled carbohydrate consumption of less than 30g per meal, avoiding high glycemic carbs, and always taking in ample fat and proteins with every meal.

Using the high-cadence lightcurves collected from the FOSSIL survey, rotation periods of 17 small (diameter 1 km < D < 3 km) Hilda asteroids (hereinafter Hildas) were obtained. Combined with the previously measured rotation periods of Hildas, a spin-rate limit appears at around 3 hr. Assuming rubble-pile structures for the Hildas, a bulk density of ∼1.5 g cm−3 is required to withstand this spin-rate limit. This value is similar to that of the C-type asteroids (1.33 g cm−3) and higher than the ∼1 g cm−3 bulk density of the Jupiter Trojans. This suggests that the Hildas population may contain more C-type asteroids than expected, and the limit at 3 hr simply reflects the spin-rate limit for C-type asteroids. In addition, a Hilda superfast rotator was found, which has a rotation period of 1.633 hr and an estimated diameter of 0.7 km. This object is unlikely to be explained by a rubble-pile or monolithic structure.

As payment models shift toward a focus on value, an accurate understanding of surgical costs and preoperative correlates of high-cost patients is important for effective implementation of cost-saving strategies. This study used time-driven activity-based costing (TDABC) to explore inpatient cost of total shoulder arthroplasty (TSA) and to identify preoperative characteristics of high-cost patients.Using TDABC, we calculated the cost of inpatient care for 415 patients undergoing elective primary TSA between 2016 and 2017. Patients in the top decile of cost were defined as high-cost patients. Multivariable logistic regression modeling was employed to determine preoperative characteristics (e.g., demographics, comorbidities, American Society of Anesthesiologists [ASA] score, and American Shoulder and Elbow Surgeons [ASES] score) associated with high-cost patients.Implant purchase price was the main driver (57%) of total inpatient costs, followed by personnel cost from patient check-in through the time in the operating room (20%). There was a 1.3-fold variation in total cost between patients in the 90th percentile for cost and those in the 10th percentile; the widest cost variation was in personnel cost from the post-anesthesia care unit through discharge (2.5-fold) and in medication cost (2.4-fold). High-cost patients were more likely to be women and chronic opioid users and to have diabetes, depression, an ASA score of ≥3, a higher body mass index (BMI), and a lower preoperative ASES score than non-high-cost patients. After multivariable adjustment, the 3 predictors of high-cost patients were female sex, an ASA score of ≥3, and a lower ASES score. Total inpatient cost correlated strongly with the length of the hospital stay but did not correlate with operative time.Our study provides actionable data to contain costs in the perioperative TSA setting. From the hospital's perspective, efforts to reduce implant purchase prices may translate into rapid substantial cost savings. At the patient level, multidisciplinary initiatives aimed at reducing length of stay and controlling medication expenses for patients at risk for high cost (e.g., infirm women with poor preoperative shoulder function) may prove effective in narrowing the existing patient-to-patient variation in costs.Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

As reimbursement becomes increasingly tied to quality and patient experience, there is growing interest in alleviation of postoperative pain combined with optimal opioid stewardship. We characterized predictors of severe inpatient pain after elective total shoulder arthroplasty and evaluated its association with opioid use, operative time, hospital length of stay, discharge disposition, and cost.We identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017 from our registry. Severe postoperative pain was defined as peak pain intensity ≥75th percentile. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with severe pain, including demographics, emotional health, comorbidities, and American Shoulder and Elbow Surgeons score. Opioid consumption was expressed as oral morphine equivalents (OMEs). Costs were calculated using time-driven activity-based costing.In decreasing order of magnitude, the predictors of severe postoperative pain were greater number of self-reported allergies, preoperative chronic opioid use, lower American Shoulder and Elbow Surgeons score, and depression. Patients reporting severe pain took more opioids (202 vs. 84 mg OMEs), stayed longer in the hospital (2.9 vs. 2.0 days), used postacute inpatient rehabilitation services more frequently (28% vs. 10%), and were more likely to be high-cost patients (23% vs. 5%; all P .001), but they did not have longer operations (166 vs. 165 minutes, P = .86).Efforts to address psychological and social determinants of health might do as much or more than technical improvements to alleviate pain, limit opioid use, and contain costs after shoulder arthroplasty. These findings are important in the redesign of care pathways and bundling initiatives.

Computed tomography (CT) is the standard assessment of glenoid morphology before shoulder arthroplasty and is commonly used to evaluate rotator cuff pathology in patients with glenohumeral osteoarthritis (GHOA). Magnetic resonance imaging (MRI) is not routinely used in this setting but has higher sensitivity in diagnosing full-thickness rotator cuff tears (RCT) and is considered the gold standard. The purpose of this study was to determine the sensitivity and specificity of CT in diagnosing full-thickness RCTs and compare the evaluation of fatty infiltration and muscle atrophy on CT vs. MRI in the setting of GHOA.In this retrospective case-controlled study, we identified 49 patients from a prospectively maintained 2-surgeon registry who received preoperative CT and MRI scans for the evaluation of GHOA between 2011 and 2016. Three fellowship-trained shoulder surgeons assessed rotator cuff integrity, fatty infiltration, and muscle atrophy in the CT and MRI scans.CT sensitivity and specificity were 20% and 95.5%, respectively. Fatty infiltration was significantly lower on CT for the supraspinatus (P = .003), infraspinatus (P .001), and subscapularis (P = .0182), whereas muscle atrophy was significantly lower on CT for only the supraspinatus (P = .0023).Our results suggest that CT underestimates the frequency of full-thickness RCTs and the severity of fatty infiltration and muscle atrophy in the setting of GHOA before total shoulder arthroplasty.

Background Childhood maltreatment and harsh parenting can have lasting effects on young children’s development, and home visiting interventions provide critical opportunities to mitigate this risk. Objective This study aimed to examine associations between participation in the Michigan Model of Infant Mental Health Home Visiting (IMH-HV) and both harsh parenting and child abuse potential. Participants and Setting Participants were 76 mothers and their infants/toddlers (M age = 9.9 months at baseline) receiving IMH-HV with Community Mental Health Service Provider agencies in Michigan. Methods Data were collected at baseline (shortly after initiation of services), and 3, 6, 9, and 12 months post baseline assessment. Mothers provided demographic information and completed several questionnaire measures including the Brief Child Abuse Potential Inventory (BCAP). Harsh parenting was rated by a trained research assistant using subscales from the Home Observation of Measurement of the Environment (HOME). Treatment dosage was collected from IMH-HV clinicians. Results Mothers with higher numbers of IMH-HV visits showed lower levels of observed harsh parenting over the three time points in the study (estimate = 0.050, p = 0.002) and higher cumulative societal factors associated with oppression (SFAO) predicted higher harsh parenting over the three time points. A higher number of IMH-HV visits also predicted lower child abuse potential across the time points of the study (estimate = −0.78, p = 0.043), controlling for SFAO. Conclusions Participation in the Michigan Model of IMH-HV, delivered in the community, is associated with reductions in both harsh parenting and child abuse potential.