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Introduction: Thallium is a highly toxic metal, with most publications demonstrating poisoning from thallium salts. We report on a patient with elevated serum and urine thallium concentrations from an intentional ingestion of elemental thallium purchased from the internet for self-harm. Case Report: The regional poison center was contacted about an 18-year-old man who ingested a fragment from a 100-gram bar reported to be elemental thallium. Serial serum and urine thallium concentrations were obtained. Prussian blue was started on hospital day (HD) 2. A metal fragment was seen on abdominal x-ray and removed via colonoscopy on HD3. The ingested fragment was analyzed via inductively coupled plasma mass spectrometry (ICP-MS) and found to be 87.0% elemental thallium. The initial serum thallium concentration obtained on HD1 was 423.5 mcg/L (reference range < 5.1 mcg/L), which subsequently decreased to 4.5 mcg/L, 29 days after the ingestion. An initial random urine thallium concentration obtained on HD 3 was 1850.5 mcg/g creatinine (reference range < 0.4 mcg/g creatinine). The patient remained hospitalized for 23 days and, when seen in follow-up, had not developed any signs or symptoms of thallium toxicity. Discussion: Elemental thallium ingestion is a rare toxicologic exposure, with limited published clinical and analytical experience to guide management. This case report describes a patient with ingestion of elemental thallium who developed elevated serum and urine thallium concentrations and was treated with Prussian blue. Despite having elevated serum and urine thallium concentrations consistent with previous fatal exposures, more evidence is needed to understand the differences between elemental thallium and thallium salts. [ABSTRACT FROM AUTHOR]

Aims Methods and results Conclusions The American Society of Clinical Oncology and College of American Pathologists HER2‐guidelines recommend repeat testing for most grade 1 mammary carcinomas that are HER2‐positive in the core biopsy. This study aimed to assess the value of repeat HER2‐testing and the histological features of HER2‐positive grade 1 carcinomas.A case‐series of HER2‐results of grade 1 carcinomas was conducted of patients with no pre‐operative systemic treatment over a 5‐year period. HER2‐positive carcinomas had histological review. Twelve HER2‐positive carcinomas were initially reported as grade 1. On review, two were reclassified as grade 2. The remaining 10 carcinomas represented 2% of the 508 grade 1 carcinomas. Eight HER2‐positive grade 1 carcinomas from other years were also studied. HER2‐positive carcinomas more often had marked nuclear pleomorphism (50 versus 6%) and were more often oestrogen receptor‐negative (17 versus 0.8%) and progesterone receptor‐negative (28 versus 8%) compared with HER2‐negative grade 1 carcinomas. Six carcinomas that were HER2 3+ in the core biopsy were also 3+ on repeat assessment. Five of seven carcinomas that were 2+ amplified in the core biopsy were also HER2‐positive in the excision.HER2‐positive grade 1 carcinomas are uncommon, and more often have marked nuclear pleomorphism and lack oestrogen receptor and progesterone receptor expression compared with HER2‐negative grade 1 carcinomas. A HER2‐poitive result in the core biopsy was confirmed in 11 of 13 tumours that had repeat testing. [ABSTRACT FROM AUTHOR]

The neurons of the three cerebellar nuclei (CN) are the primary output neurons of the cerebellum. The excitatory neurons (e) of the medial (m) CN (eCNm) were recently divided into molecularly defined subdomains in the adult; however, how they are established during development is not known. We define molecular subdomains of the mouse embryonic eCNm using single-cell RNA-sequencing and spatial expression analysis, showing that they evolve during embryogenesis to prefigure the adult. Furthermore, eCNm are transcriptionally divergent from cells in the other nuclei by embryonic day 14.5. We previously showed that loss of the homeobox genes En1 and En2 leads to loss of approximately half of the embryonic eCNm. We demonstrate that mutation of En1/2 in the embryonic eCNm results in death of specific posterior eCNm molecular subdomains and downregulation of TBR2 (EOMES) in an anterior embryonic subdomain, as well as reduced synaptic gene expression. We further reveal a similar function for EN1/2 in mediating TBR2 expression, neuron differentiation and survival in the other excitatory neurons (granule and unipolar brush cells). Thus, our work defines embryonic eCNm molecular diversity and reveals conserved roles for EN1/2 in the cerebellar excitatory neuron lineage. [ABSTRACT FROM AUTHOR]

This article discusses the ethical considerations surrounding informed consent in psychedelic-assisted psychotherapy (PAP). PAP involves the use of psychedelic substances in conjunction with psychotherapy to treat conditions such as posttraumatic stress disorder and major depressive disorder. The article highlights the importance of supporting participants during challenging psychedelic experiences and the need for clear guidelines on the use of rescue medications. It also explores issues related to capacity and consent during the psychedelic experience and suggests strategies for strengthening the informed consent process, such as the use of psychiatric advance directives and dynamic consent. The article emphasizes the importance of trustworthiness and cultural responsiveness in the therapeutic relationship and calls for further research on consent models and the termination of psychedelic sessions. [Extracted from the article]

The stable extended and coiled states of thin-shelled composite booms with parabolic cross sections are investigated in this paper. These conic shapes potentially offer greater stiffness properties when compared to circular cross sections, which is critical for improving the load-bearing performance of deployed booms. Inducing bistability through composite layups in parabolic booms would allow for controllable self-deployment due to a less energetic coiled state when compared to monostable booms. An inextensional analytical model is used to predict the stable coiled diameters of tape spring and collapsible tubular mast (CTM) booms with parabolic cross sections. The parabolic section is discretized into circular segments using biarc spline interpolation, which allows them to be integrated into the strain energy minimization procedure used to obtain the equilibrium states. When the parabolic booms are parametrically compared against circular booms with identical layups, flattened height, and mass, the former are found to generally have better stiffness performance while being less efficient in stowed volume, as evidenced by larger coiled diameters. Analytical coiled diameters and their strain energy are verified with finite element simulations for an optimal parabolic tape spring and CTM booms. Additional validation of the parabolic tape spring's coiled diameter is provided by experimental measurements of boom specimens. [ABSTRACT FROM AUTHOR]

The author discusses a study by Khan and colleagues on the multiple system strategy by the U.S. Centers for Disease Control and Prevention (CDC) for mortality surveillance during the COVID-19 pandemic. Topics include reason that the true incidences of disease and disease mortality at any given time were difficult to determine with exact certainty, how the CDC's approach is compared with those used in other countries, and key questions that need to be answered.

Background The rVSVΔG-ZEBOV-GP vaccine (ERVEBO®) is a single-dose, live-attenuated, recombinant vesicular stomatitis virus vaccine indicated for the prevention of Ebola virus disease (EVD) caused by Zaire ebolavirus in individuals 12 months of age and older. Methods The Partnership for Research on Ebola VACcination (PREVAC) is a multicenter, phase 2, randomized, double-blind, placebo-controlled trial of 3 vaccine strategies in healthy children (ages 1–17) and adults, with projected 5 years of follow-up (NCT02876328). Using validated assays (GP-ELISA and PRNT), we measured antibody responses after 1-dose rVSVΔG-ZEBOV-GP, 2-dose rVSVΔG-ZEBOV-GP (given on Day 0 and Day 56), or placebo. Furthermore, we quantified vaccine virus shedding in a subset of children's saliva using RT-PCR. Results In total, 819 children and 783 adults were randomized to receive rVSVΔG-ZEBOV-GP (1 or 2 doses) or placebo. A single dose of rVSVΔG-ZEBOV-GP increased antibody responses by Day 28 that were sustained through Month 12. A second dose of rVSVΔG-ZEBOV-GP given on Day 56 transiently boosted antibody concentrations. In vaccinated children, GP-ELISA titers were superior to placebo and non-inferior to vaccinated adults. Vaccine virus shedding was observed in 31.7% of children, peaking by Day 7, with no shedding observed after Day 28 post-dose 1 or any time post-dose 2. Conclusions A single dose of rVSVΔG-ZEBOV-GP induced robust antibody responses in children that was non-inferior to the responses induced in vaccinated adults. Vaccine virus shedding in children was time-limited and only observed after the first dose. Overall, these data support the use of rVSVΔG-ZEBOV-GP for the prevention of EVD in at-risk children. Clinical Trials Registration. The study is registered at ClinicalTrials.gov (NCT02876328), the Pan African Clinical Trials Registry (PACTR201712002760250), and the European Clinical Trials Register (EudraCT number: 2017-001798-18). [ABSTRACT FROM AUTHOR]

Disease surveillance is an essential public health function needed to prevent, detect, monitor and respond to health threats. Integrated disease surveillance (IDS) enhances its utility and has been advocated for decades by the World Health Organization. This study sought to examine the state of IDS implementation worldwide. The study used a concurrent mixed methods approach consisting of a systematic scoping review of the literature on IDS, a survey of International Association of National Public Health Institutes (IANPHI) members and qualitative deep dive case studies in seven countries. This report collates, analyses and synthesises the findings from the three components. The scoping review consisted of a review of summarised evidence on IDS. Eight reviews and five primary studies were included. The cross-sectional survey was conducted of 110 IANPHI members representing ninety-five countries. Qualitative case studies were conducted in Malawi, Mozambique, Uganda, Pakistan, Canada, Sweden, and England, which involved thirty-four focus group discussions and forty-eight key informant interviews. In the different countries, IDS is conceptualised differently and there are differing levels of maturity of IDS functions. Although the role of National Public Health Institutes has not been well defined in the IDS, they play a significant role in IDS in many countries. Fragmentation between sectors and resourcing (human and financial) issues were common. Good governance measures such as appropriate legislative and regulatory frameworks and roles and responsibilities for IDS were often unclear. The COVID-19 pandemic has strengthened some surveillance systems, often through leveraging existing respiratory surveillance systems. In some instances, improvements were seen only for COVID-19 related data but these changes were not sustained. Evaluation of IDS was also reported to be weak. Integration should be driven by a clear purpose and contextualised. Political commitment, clear governance, and resourcing are needed. Technology and the establishment of technical communities of practice may help. However, the complexity and cost of integration should not be under-estimated, and further economic and impact evaluations of IDS are needed. [ABSTRACT FROM AUTHOR]

Simple Summary: Recurrent and/or metastatic head and neck squamous-cell carcinoma (R/M HNSCC) is a clinically challenging disease with a poor prognosis. Despite advances in survival through the use of immune-checkpoint blockade, only a minority of patients experience benefit from such treatments, and it is difficult to identify the patients most likely to benefit. Machine learning approaches integrating clinical and genomic data can predict response to immune-checkpoint blockade across all cancers; however, the performance of this model in HNSCC has not been examined. Here, we validate this previously described immune-checkpoint blockade response prediction model in R/M HNSCC patients. This model was able to predict response as well as overall survival following immune-checkpoint blockade in patients with R/M HNSCC. Further investigation will be needed to further delineate the importance of HNSCC-specific features. Head and neck squamous-cell carcinoma (HNSCC) is a disease with a generally poor prognosis; half of treated patients eventually develop recurrent and/or metastatic (R/M) disease. Patients with R/M HNSCC generally have incurable disease with a median survival of 10 to 15 months. Although immune-checkpoint blockade (ICB) has improved outcomes in patients with R/M HNSCC, identifying patients who are likely to benefit from ICB remains a challenge. Biomarkers in current clinical use include tumor mutational burden and immunohistochemistry for programmed death-ligand 1, both of which have only modest predictive power. Machine learning (ML) has the potential to aid in clinical decision-making as an approach to estimate a tumor's likelihood of response or a patient's likelihood of experiencing clinical benefit from therapies such as ICB. Previously, we described a random forest ML model that had value in predicting ICB response using 11 or 16 clinical, laboratory, and genomic features in a pan-cancer development cohort. However, its applicability to certain cancer types, such as HNSCC, has been unknown, due to a lack of cancer-type-specific validation. Here, we present the first validation of a random forest ML tool to predict the likelihood of ICB response in patients with R/M HNSCC. The tool had adequate predictive power for tumor response (area under the receiver operating characteristic curve = 0.65) and was able to stratify patients by overall (HR = 0.53 [95% CI 0.29–0.99], p = 0.045) and progression-free (HR = 0.49 [95% CI 0.27–0.87], p = 0.016) survival. The overall accuracy was 0.72. Our study validates an ML predictor in HNSCC, demonstrating promising performance in a novel cohort of patients. Further studies are needed to validate the generalizability of this algorithm in larger patient samples from additional multi-institutional contexts. [ABSTRACT FROM AUTHOR]

David Lewis—famously—never tasted vegemite. Did he have any knowledge of what it's like to taste vegemite? Most say 'no'; I say 'yes'. I argue that knowledge of what it's like varies along a spectrum from more exact to more approximate, and that phenomenal concepts vary along a spectrum in how precisely they characterize what it's like to undergo their target experiences. This degreed picture contrasts with the standard all‐or‐nothing picture, where phenomenal concepts and phenomenal knowledge lack any such degreed structure. I motivate the degreed picture by appeal to (1) limits in epistemic abilities such as recognition, imagination, and inference, and (2) the semantics of 'knows what it's like' expressions. I argue that approximate phenomenal knowledge cannot be explained merely via determinable or vague phenomenal concepts. I develop a framework for systematizing approximate knowledge of phenomenal character. And I explain how my view challenges some standard assumptions about the acquisition conditions, requirements for mastery, and referential mechanisms of phenomenal concepts. [ABSTRACT FROM AUTHOR]

Is a human more conscious than an octopus? In the science of consciousness, it's oftentimes assumed that some creatures (or mental states) are more conscious than others. But in recent years, a number of philosophers have argued that the notion of degrees of consciousness is conceptually confused. This paper (1) argues that the most prominent objections to degrees of consciousness are unsustainable, (2) examines the semantics of 'more conscious than' expressions, (3) develops an analysis of what it is for a degreed property to count as degrees of consciousness, and (4) applies the analysis to various theories of consciousness. I argue that whether consciousness comes in degrees ultimately depends on which theory of consciousness turns out to be correct. But I also argue that most theories of consciousness entail that consciousness comes in degrees. [ABSTRACT FROM AUTHOR]

Aims: The method of diagnosis of ductal carcinoma in situ (DCIS) has changed since the 1980s. The aim of this audit was to assess changes in the preoperative diagnosis of DCIS since the introduction of needle core biopsy, particularly the proportion with a preoperative biopsy diagnosis of DCIS. Methods and results: The preoperative diagnoses of patients with a final diagnosis of DCIS in the surgical specimen were reviewed (i) in 809 patients who presented through breast screening from 1997 to 2021, and (ii) in all patients in 5 individual years at 5‐year intervals from 2000 to 2020 (254 in total). For screening‐detected DCIS the proportion with a preoperative diagnosis of DCIS increased from 75% to 98% over the study period. In a detailed analysis of all cases of DCIS in 5 separate years the proportion with a preoperative diagnosis of DCIS increased from 68% in 2000 to 96% in 2020. For high‐grade DCIS the proportion increased from 87% to 97%, and for low‐ or intermediate‐grade DCIS from 48% to 93%. The proportion of women who had vacuum‐assisted biopsy increased from 7% in 2000 to 58% in 2015. There was a small increase in the number of biopsies that had basal cytokeratin and oestrogen receptor immunohistochemistry to aid diagnosis. Conclusion: There has been an increase in the preoperative diagnosis of DCIS, particularly of low‐ or intermediate‐grade, over the last two decades. The increasing use of vacuum‐assisted biopsy is likely to be a major contributory factor to this increase. [ABSTRACT FROM AUTHOR]

For undergraduate mathematical modeling courses, a successful semester project can reinforce key learning objectives while enabling creativity and developing critical thinking skills. However, course directors often struggle in developing novel project ideas and balancing the tradeoff between grading burden and project complexity. At the U.S Military Academy, we take an open-ended and discovery-learning approach to the freshman level math modeling project. This article outlines one successful project involving a Zombie Apocalypse scenario along with student responses. To assist the students, we promote flexibility, scaffold the modeling process with in-progress reviews, and train students on how to write concise executive summaries. [ABSTRACT FROM AUTHOR]

The present study investigated the effects of different types of form-focused instruction (FFI) on the acquisition of French grammatical gender attribution. A quasi-experimental study was conducted with 140 participants in six intact French as a second language (L2) classes. The classes received six 80-minute instructional sessions consisting of FFI on only sublexical cues, FFI on both sublexical cues and pronunciation, or the control condition (two classes per condition). To measure the effects of the instructional conditions, a pretest, an immediate posttest, and a delayed posttest were administered. Results showed that the participants receiving FFI on only sublexical cues showed significant improvement in binary-choice, text-completion, and listening tasks, but not in an oral picture-description task. In contrast, those receiving FFI on both sublexical cues and pronunciation showed significantly higher scores on all tasks after the instructional sessions. The present study highlights the importance of pronunciation instruction in L2 grammar acquisition and its interdependence with lexical and morphological domains. [ABSTRACT FROM AUTHOR]

This case report examines the initial experience of Poland in responding to the refugee crisis triggered by the war in Ukraine. In the first 2 months of the crisis, more than 3 million Ukrainian refugees fled to Poland. The large influx of refugees rapidly overwhelmed local services and led to a complex humanitarian emergency. The initial priorities were to address basic human needs, such as shelter, infectious disease concerns and healthcare access, but evolved to include mental health, non-communicable diseases and protection needs. This necessitated a 'whole of society' response involving multiple agencies and civil society. Emerging lessons learned include the need for ongoing needs assessments, robust disease monitoring and surveillance, as well as flexible multisectoral responses that are culturally sensitive. Finally, Poland's efforts to integrate refugees may help mitigate some of the adverse consequences of the conflict-related migration. [ABSTRACT FROM AUTHOR]

This paper develops a theory of analog representation. We first argue that the mark of the analog is to be found in the nature of a representational system's interpretation function, rather than in its vehicles or contents alone. We then develop the rulebound structure theory of analog representation, according to which analog systems use interpretive rules that map syntactic structural features onto semantic structural features. The theory involves three degree‐theoretic measures that capture three independent ways in which a system can be more or less analog. We explain how our theory improves upon prior accounts of analog representation, provides plausible diagnoses for novel challenge cases, extends to hybrid systems that are partially analog and partially symbolic, and accounts for some of the advantages and disadvantages of representing analogically versus symbolically. [ABSTRACT FROM AUTHOR]

Hydrogen embrittlement remains a barrier to widespread adoption of hydrogen as a carbon-neutral energy source. Here, hydrogen embrittlement mechanisms are investigated across length scales in iron using transmission X-ray microscopy (TXM), digital image correlation (DIC), and notched tensile testing during in-situ electrochemical hydrogen charging. TXM reveals void size and spatial distribution ahead of a propagating crack. We find hydrogen charging leads to voids within ∼10 μm of the crack tip and suppression of voids beyond this distance. Near the crack tip, voids are elongated in the direction of the crack and are smaller than voids in an uncharged sample. In the presence of hydrogen, these voids lead to quasi-cleavage fracture and a sharper crack tip. DIC shows localization and reduction of plastic strain with hydrogen charging, and tensile testing reveals a reduction in fracture energy and elongation at failure. These results are discussed in the context of hydrogen embrittlement mechanisms. • Hydrogen-induced change in void distribution ahead of a propagating crack. • Rich, internal microstructural information revealed through x-ray microscopy. • Digital image correlation confirms localization and reduction in plastic strain. • Novel in-situ straining and charging stages supply hydrogen during characterization. [ABSTRACT FROM AUTHOR]

How best to integrate migrant workers in host societies has been a longstanding question in the study of migration and globalisation. Scholars have been conceptualising new modes of transnational mobilities that point to the politics of differential inclusion to address encounters between migrants and locals in Asian global cities. This article uses an instructive case study of temporary, low-wage male migrant workers in Singapore and the issue of their recreational spaces to show that the politics of inclusion/exclusion are layered onto the question of integration/segregation. We take integration to mean the incorporation of migrants into local society to give full access to social institutions of protection and care, and inclusion to refer to the acceptance of migrants into social relationships that define urban life. Segregation and exclusion are their respective corollaries. We focus on state-provisioned recreation centres sited near the dormitories, which were expanded to function as segregating spaces to keep migrant workers away from the city after the Little India riot in 2013. We show that they have instead become contact zones producing accidental diversities of urban encounters between migrants, locals and state-linked agents. We discuss how these contact zones have developed differently across the centres built before and after the riot, the transformation of the accidental diversities in the recreational centres by state-linked agents into a new migrant grassroots sector and the ongoing intensification of this during the COVID-19 pandemic. The new relationalities offer the promise of transcending the layered binaries of integration/segregation and inclusion/exclusion. [ABSTRACT FROM AUTHOR]

The widespread application of metal additive manufacturing (AM) is limited by the ability to control the complex interactions between the energy source and the feedstock material. Here, we develop a generalizable process to introduce nanoscale grooves to the surface of metal powders which increases the powder absorptivity by up to 70% during laser powder bed fusion. Absorptivity enhancements in copper, copper-silver, and tungsten enable energy-efficient manufacturing, with printing of pure copper at relative densities up to 92% using laser energy densities as low as 83 joules per cubic millimeter. Simulations show that the enhanced powder absorptivity results from plasmon-enabled light concentration in nanoscale grooves combined with multiple scattering events. The approach taken here demonstrates a general method to enhance the absorptivity and printability of reflective and refractory metal powders by changing the surface morphology of the feedstock without altering its composition. [ABSTRACT FROM AUTHOR]

Objective: To describe the perspectives of healthcare professionals regarding the implementation of Shared decision‐making (SDM) in primary healthcare centres (PHCCs) in Saudi Arabia. Methods: Qualitative semi‐structured interviews were conducted with a purposive and snowball sample of healthcare professionals in PHCCs. Interviews have been recorded, transcribed, translated and thematically analysed. Themes were mapped to the COM‐B model. Results: Sixteen healthcare professionals were interviewed. The data analysis identified six themes and 14 sub‐themes. The six themes are patient related factors, health professional related factors, environmental context and resources, patient–physician communication, patient–physician preferences toward SDM and physicians' perceived value and benefits of SDM. Physicians are unlikely to practice SDM in the context of time pressures, shortage of physicians, lack of treatment options, and decision‐making aids. The findings also underscored the importance of building a trustworthy physician‐patient relationship through the use of effective conversation techniques. Conclusions: There are multiple barriers to SDM in primary care. Unless these barriers are addressed, it is unlikely that physicians will effectively or fully engage in SDM with patients. [ABSTRACT FROM AUTHOR]

Introduction: Management of humerus nonunions with previously failed fixation presents a complex problem. There are multiple revision fixation strategies, of which compression plating is a mainstay. The aim of this study was to assess the results of open reduction and direct compression plating without the need for autograft or allograft in the setting of revision humerus open reduction internal fixation. Methods: This study is a retrospective analysis of 19 patients treated between 2008 and 2017 for humerus nonunions following failed fixation who were treated by a single surgeon using direct compression plating with bone graft substitutes. Patients were treated with neurolysis of the radial nerve, hardware removal, debridement of the nonunion site with shortening osteotomies, compression plating, and augmentation with bone graft substitutes. All patients were followed until radiographic and clinical union. Results: Nineteen patients were identified for the study and 17 had adequate follow-up for final analysis. Humeral union was achieved in 16/17 (94.1%) patients with a mean time to union of 23 weeks. Two patients required a repeat compression plating with bone graft substitute to achieve union. The one patient with a nonunion radiographically reported minimal clinical symptoms and opted for no revision surgery. An association with the index procedure was seen, as three out of four of the patients who experienced radial nerve palsies after their index procedure subsequently experienced a radial nerve palsy after the procedure to repair their nonunion. All patient's all experienced a return of function in their radial nerve either back to baseline or improved from before the revision nonunion surgery. Conclusion: The use of humeral shortening osteotomy and compression plating without autograft or allograft is a viable option for management of humeral nonunions which avoids the morbidity associated with autograft harvest. The patients with radial nerve palsy after the index procedure are likely to have a transient radial nerve palsy as well after the revision surgery necessitating proper informed consent prior to the operation. [ABSTRACT FROM AUTHOR]

Accessible Summary: Adults with learning disabilities and diabetes are more likely to have health problems than people with diabetes who do not have learning disabilities.This research had two aims. One was to find out what stops adults with learning disabilities from getting help with their diabetes. The other was to find out what things help them get the best care for their diabetes.We found 12 things that stop adults with learning disabilities from getting good care for their diabetes and 14 things that help them get good care.The findings from this research can be used to improve the lives of adults living with learning disabilities and diabetes. Background: Individuals with diabetes and a learning disability have poorer health outcomes than those without a learning disability. In the UK, the health inequalities faced by people with learning disabilities are often the result of barriers they face in accessing timely, appropriate and effective health care. The aim of the study was to review relevant literature to identify the barriers and enablers to optimal diabetes care for adults with learning disabilities. Methods: Systematic review methodology was used to answer the research question: What barriers and enablers to optimal diabetes care exist for adults with learning disabilities? This review is reported according to PRISMA guidelines. Key databases were searched using relevant terms. Included studies were synthesised using thematic analysis and were quality appraised. Findings: This review identified 12 barriers to optimal diabetes care for adults with learning disabilities and 14 enablers to optimal care from 10 diverse publications. Low level of diabetes knowledge and understanding and systems that do not allow reasonable adjustments were the barriers considered to have the greatest reliability. The enabler identified to have the highest reliability was person‐centred planning and reasonable adjustments. Conclusion: This work highlights key actions that can be undertaken to address inequalities in diabetes care for people with learning disabilities. With additional research in this field, further progress can be made to improve the lives of those adults living with learning disabilities and diabetes. [ABSTRACT FROM AUTHOR]

Introduction: Clinical experience is a crucial component of dental education as it prepares students for real-world practice. Our study aimed to investigate the transition from preclinical to clinical training experiences of dental students at a regional Australian dental school. Materials and methods: A mixed-methods study was conducted using a survey and focus groups. Participants were dental students who recently transitioned into clinical training. Survey data were analysed quantitatively using descriptive statistics, whilst the qualitative data were thematically analysed using the conceptual framework of organisational socialisation theory (OST). Results: Forty-eight of the 69 students in the cohort completed the survey and 10 participated in the focus groups. The quantitative findings revealed that the transition was perceived to be abrupt and associated with a heavy workload. However, orientation sessions and engaging in chairside teaching made transitioning into clinical studies easier. The qualitative findings revealed that the transition process occurred in three phases. In phase 1, participants navigated the educational and social challenges using developmental characteristics such as resilience and positivity. Lessons learnt in phase 1 were used to make necessary learning adjustments in phase 2 and this subsequently enhanced developmental growth in the final phase, which helped ease the transition. Conclusion: This study confirms that transitioning into clinical training can be complex. However, the educational and socialisation challenges associated with the transition can provide stimulating developmental learning opportunities that advance students' adjustments to the clinical environment with positive, empowering and motivational outcomes that facilitate a smooth transition. [ABSTRACT FROM AUTHOR]

Evidence for a cerebellar role during cardiopulmonary challenges has long been established, but studies of cerebellar involvement in eupneic breathing have been inconclusive. Here we investigated temporal aspects of eupneic respiration in the Atoh1‐En1/2 mouse model of cerebellar neuropathology. Atoh1‐En1/2 conditional knockout mice have conditional loss of the developmental patterning genes Engrailed1 and 2 in excitatory cerebellar nuclear neurons, which leads to loss of a subset of medial and intermediate excitatory cerebellar nuclear neurons. A sample of three Atoh1‐derived extracerebellar nuclei showed no cell loss in the conditional knockout compared to control mice. We measured eupneic respiration in mutant animals and control littermates using whole‐body unrestrained plethysmography and compared the average respiratory rate, coefficient of variation, and the CV2, a measure of intrinsic rhythmicity. Linear regression analyses revealed that Atoh1‐En1/2 conditional knockouts have decreased overall variability (p = 0.021; b = −0.045) and increased intrinsic rhythmicity compared to their control littermates (p < 0.001; b = −0.037), but we found no effect of genotype on average respiratory rate (p = 0.064). Analysis also revealed modestly decreased respiratory rates (p = 0.025; b = −0.82), increased coefficient of variation (p = 0.0036; b = 0.060), and increased CV2 in female animals, independent of genotype (p = 0.024; b = 0.026). These results suggest a cerebellar involvement in eupneic breathing by controlling rhythmicity. We argue that the cerebellar involvement in controlling the CV2 of respiration is indicative of an involvement of coordinating respiration with other orofacial rhythms, such as swallowing. [ABSTRACT FROM AUTHOR]

While the COVID-19 pandemic is likely evolving into an endemic stage, there are continuing threats related to the waning of immunity and emergence of immune escape variants. Are we coming out from the COVID-19 pandemic? Keywords: COVID-19; endemic stage; herd immunity; pandemic EN COVID-19 endemic stage herd immunity pandemic 1022 1024 3 11/21/22 20221201 NES 221201 Key points After nearly 3 years of intensive circulation, SARS-CoV-2 is showing signs of adaptation to the new human host. [Extracted from the article]

Inappropriate activation of the renin-angiotensin system decreases glucose uptake in peripheral tissues. Chronic angiotensin receptor type 1 (AT1) blockade (ARB) increases glucose uptake in skeletal muscle and decreases the abundance of large adipocytes and macrophage infiltration in adipose. However, the contributions of each tissue to the improvement in hyperglycemia in response to AT1 blockade are not known. Therefore, we determined the static and dynamic responses of soleus muscle, liver, and adipose to an acute glucose challenge following the chronic blockade of AT1. We measured adipocyte morphology along with TNF-a expression, F4/80- and CD11c-positive cells in adipose and measured insulin receptor (IR) phosphorylation and AKT phosphorylation in soleus muscle, liver, and retroperitoneal fat before (T0), 60 (T60) and 120 (T120) min after an acute glucose challenge in the following groups of male rats: 1) Long-Evans Tokushima Otsuka (LETO; lean control; n = 5/time point), 2) obese Otsuka Long Evans Tokushima Fatty (OLETF; n = 7 or 8/time point), and 3) OLETF þ ARB (ARB; 10 mg olmesartan/kg/day; n = 7 or 8/time point). AT1 blockade decreased adipocyte TNF-a expression and F4/80- and CD11c-positive cells. In retroperitoneal fat at T60, IR phosphorylation was 155% greater in ARB than in OLETF. Furthermore, in retroperitoneal fat AT1 blockade increased glucose transporter-4 (GLUT4) protein expression in ARB compared with OLETF. IR phosphorylation and AKT phosphorylation were not altered in the liver of OLETF, but AT1 blockade decreased hepatic Pck1 and G6pc1 mRNA expressions. Collectively, these results suggest that chronic AT1 blockade improves obesity-associated hyperglycemia in OLETF rats by improving adipocyte function and by decreasing hepatic glucose production via gluconeogenesis. [ABSTRACT FROM AUTHOR]

We present ShiftConvolvePoibin, a fast exact method to compute the tail of a Poisson-binomial distribution (PBD). Our method employs an exponential shift to retain its accuracy when computing a tail probability, and in practice we find that it is immune to the significant relative errors that other methods, exact or approximate, can suffer from when computing very small tail probabilities of the PBD. The accompanying R package is also competitive with the fastest implementations for computing the entire PBD. [ABSTRACT FROM AUTHOR]

Background: To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. Methods: Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. Results: Forty‐two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow‐up, long‐term clinical success with minimally invasive treatment (no surgery or re‐transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re‐transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non‐surgical management was associated with younger age at stricture diagnosis (p <.02). Conclusions: Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children. [ABSTRACT FROM AUTHOR]

Background: The increasing implementation of transcatheter aortic valve implantation (TAVI) in Australia warrants real-world data on the prevalence and outcomes of these patients. The aim of this study is to describe trends in case-volumes of TAVI in New South Wales (NSW), Australia and associated mortality outcomes.Methods: From the Centre of Health Record Linkage registry, all NSW residents who underwent TAVI between 5 June 2013 and 30 June 2018 were identified. Cause-specific mortality was tracked from the statewide death registry. Temporal trends in case-volumes between 2013 and 2018 were assessed by linear regression. Binary logistic regression was used to compare differences in in-hospital and 30-day mortality, while Cox proportional hazards regression was used to compare mortality beyond 30 days.Results: Case-volumes increased from 30 in 2013 to 345 by 2017. The cohort comprised 1,098 persons (mean[±SD] age: 83.3±7.7 yrs). Cumulative in-hospital, 180-day and at end-of-study (mean: 1.8±1.2 yrs) all-cause mortality were 1.3% (n=14), 4.9% (n=54) and 20.3% (n=224) respectively. Heart failure (14.3%, n=2), myocardial infarction (14.3%, n=2), and sepsis (14.3%, n=2) were the primary causes of in-hospital death. Post-discharge, sepsis (25.2%, n=53) was the main cause-specific death, while combined cardiovascular deaths accounted for 46% (n=97), mostly from heart failure (n=35). Heart failure, chronic kidney disease, and requirement for ventilation post-TAVI were independent predictors of in-hospital death and at 180 days. TAVI procedure in low-volume public centres was a predictor of mortality at 180 days.Conclusion: The number of TAVI procedures increased 10-fold between 2013 and 2017 state-wide, with mortality rates comparable to international cohorts at short and medium-term follow-up. Pre-existing comorbidities and site-specific caseloads may be important determinants of outcome, emphasising the importance of appropriate patient selection and treating centre. [ABSTRACT FROM AUTHOR]

Cobalt-blue spinel from two localities (Qila and Trailside) on Baffin Island, Nunavut, Canada, are compared with other spinels from 12 occurrences in the same geological terrane and to Co-bearing blue spinel from other localities worldwide. Qila spinel is suitable for cutting cabochons, which commonly incorporate small amounts of associated calcite, dolomite, corundum, fluorapatite, pargasite and other silicates, as well as secondary cobaltpentlandite and fluid inclusions. Trailside spinel can be faceted into small gemstones (generally <0.2 ct), which rarely contain magnesite, fluorapatite, muscovite and CO2-rich fluid inclusions. The bright blue colour of the spinels from Qila and Trailside is due to TCo2+, although they also contain other chromophoric elements such as Fe and traces of Cr, Mn and V. Compared with other Mg-Al spinels from Baffin Island, those from Qila and Trailside are generally enriched in Co, Ni, Mn, Li and Be, and depleted in Ti, V and Cr. In addition, the Qila and Trailside Co-blue spinels are fairly chemically distinct from those of other world localities: they are depleted in V and Ti, fairly poor in Cr and Zn, and considerably enriched in Co and Mn. A new approach for the preliminary chemical discrimination of gem spinels is proposed by plotting the weighted chromophore concentrations in a ternary diagram (i.e. Cr+V vs 40×Co vs Fe/8). These weighted percentage values are also plotted against the ppmw concentrations of the chromophoric elements in X-Y plots, which provide further correlations of high Co with vivid Co-blue spinel and elevated Fe with overly dark non-gem spinel. This method can be applied to samples that are difficult or inefficient to characterise using spectroscopy, such as spinel grains in heavy-mineral concentrates obtained during regional exploration programmes. [ABSTRACT FROM AUTHOR]

Background Coronavirus disease 2019 (COVID-19) is primarily an acute respiratory tract infection. Distinctively, a substantial proportion of COVID-19 patients develop olfactory dysfunction. Especially in young patients, loss of smell can be the first or only symptom. The roles of inflammatory obstruction of the olfactory clefts, inflammatory cytokines affecting olfactory neuronal function, destruction of olfactory neurons or their supporting cells, and direct invasion of olfactory bulbs in causing olfactory dysfunction are uncertain. Methods We investigated the location for the pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from the olfactory epithelium (OE) to the olfactory bulb in golden Syrian hamsters. Results After intranasal inoculation with SARS-CoV-2, inflammatory cell infiltration and proinflammatory cytokine/chemokine responses were detected in the nasal turbinate tissues. The responses peaked between 2 and 4 days postinfection, with the highest viral load detected at day 2 postinfection. In addition to the pseudo-columnar ciliated respiratory epithelial cells, SARS-CoV-2 viral antigens were also detected in the mature olfactory sensory neurons labeled by olfactory marker protein, in the less mature olfactory neurons labeled by neuron-specific class III β-tubulin at the more basal position, and in the sustentacular cells, resulting in apoptosis and severe destruction of the OE. During the entire course of infection, SARS-CoV-2 viral antigens were not detected in the olfactory bulb. Conclusions In addition to acute inflammation at the OE, infection of mature and immature olfactory neurons and the supporting sustentacular cells by SARS-CoV-2 may contribute to the unique olfactory dysfunction related to COVID-19, which is not reported with SARS-CoV-2. [ABSTRACT FROM AUTHOR]

Background Clinical outcomes of the interaction between the co-circulating pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and seasonal influenza viruses are unknown. Methods We established a golden Syrian hamster model coinfected by SARS-CoV-2 and mouse-adapted A(H1N1)pdm09 simultaneously or sequentially. The weight loss, clinical scores, histopathological changes, viral load and titer, and serum neutralizing antibody titer were compared with hamsters challenged by either virus. Results Coinfected hamsters had more weight loss, more severe lung inflammatory damage, and tissue cytokine/chemokine expression. Lung viral load, infectious virus titers, and virus antigen expression suggested that hamsters were generally more susceptible to SARS-CoV-2 than to A(H1N1)pdm09. Sequential coinfection with A(H1N1)pdm09 one day prior to SARS-CoV-2 exposure resulted in a lower lung SARS-CoV-2 titer and viral load than with SARS-CoV-2 monoinfection, but a higher lung A(H1N1)pdm09 viral load. Coinfection also increased intestinal inflammation with more SARS-CoV-2 nucleoprotein expression in enterocytes. Simultaneous coinfection was associated with delay in resolution of lung damage, lower serum SARS-CoV-2 neutralizing antibody, and longer SARS-CoV-2 shedding in oral swabs compared to that of SARS-CoV-2 monoinfection. Conclusions Simultaneous or sequential coinfection by SARS-CoV-2 and A(H1N1)pdm09 caused more severe disease than monoinfection by either virus in hamsters. Prior A(H1N1)pdm09 infection lowered SARS-CoV-2 pulmonary viral loads but enhanced lung damage. Whole-population influenza vaccination for prevention of coinfection, and multiplex molecular diagnostics for both viruses to achieve early initiation of antiviral treatment for improvement of clinical outcome should be considered. [ABSTRACT FROM AUTHOR]

The article discusses framework for modeling mental qualities. It mentions that understanding the structure of experience than has been previously appreciated by developing precision is a structural feature of experience, akin to similarity and magnitude. It also mentions that structure of the mental qualities of conscious experiences is fundamentally different from the structure of the perceptible qualities of external objects.

• Colistimethate sodium dry powder for inhalation (CMS-DPI) and comparator cohorts generally had similar rates of adverse events. • This study supports the long-term safety profile of CMS-DPI in people with cystic fibrosis (CF). • UK CF Registry data are suitable for long-term drug safety studies. As part of the risk management plan in Europe, a long-term observational study was conducted to monitor the safety of colistimethate sodium dry powder for inhalation (CMS-DPI) compared to other inhaled antibiotics. A cohort of CMS-DPI patients and a matched cohort were identified from the UK Cystic Fibrosis Registry (UKCFR) from 2014-2018. The primary outcome was a composite endpoint, defined as adverse events (AEs) or new cystic fibrosis (CF) complications. Other outcomes included pulmonary exacerbations and treatment discontinuations. Of 1466 and 3503 patients in the CMS-DPI and comparator cohorts, respectively, 82.7% and 79.4% had AEs. Among the most common new CF complications were osteopenia, CF-related diabetes, and increased liver enzymes. The adjusted event rate ratio (ERR) for the primary outcome was 1.25 (95% confidence interval [CI]: 1.18-1.33, p <0.001). After excluding new CF complications, there was no difference between cohorts (ERR=1.04, 95% CI: 0.79-1.38, p =0.785). Pulmonary exacerbations were common in CMS-DPI and comparator cohorts (78.0% and 79.9% of patients, respectively), with adjusted ERR of 1.02 (95% CI: 0.95-1.10, p =0.523). Rates of discontinuation were similar in the CMS-DPI and Tobramycin inhalation powder comparator cohorts (37.8% and 39.8% of patients, respectively). There was no difference in the rate of adverse events between CMS-DPI and comparator cohorts. The safety profile of CMS-DPI is similar to those of other inhaled antibiotics, supporting its long-term safety in people with CF. The UKCFR has developed a successful model for partnership with industry to conduct long-term studies aimed at assessing drug safety. [ABSTRACT FROM AUTHOR]

Objective: To provide a cogent summation of the evidence base of the key barriers and facilitators to implementing shared decision making (SDM).Methods: An umbrella review of existing reviews on SDM was adopted. Databases were searched from 1997 to December 2018. Studies were included if they performed a review of barriers and facilitators to SDM.Results: 7 eligible reviews were identified. The five themes identified were: patient factors, professional factors, environmental factors, relationship factors, and factors related to information provision. Lack of time was the main factor hindering the implementation of SDM. Encouragement and motivation of providers to use SDM was a significant enabler of SDM implementation.Conclusions: The provision of time and resources are insufficient if not accompanied by efforts to support and motivate providers to use SDM.Practice Implications: Healthcare providers need to be educated on the importance of building a relationship with their patients. To enhance this relationship, physicians may need to improve their interaction skills. They need to be curious and explore their patients' preferences, listen to them and respect their opinions, explain options and outcomes, and encourage them to participate in the decision making. [ABSTRACT FROM AUTHOR]

Mycetoma is a chronic granulomatous infection of the skin and underlying tissues, which affects remote populations in tropical and subtropical countries. We report the case of a 35-year-old male with an over 10 year history of left foot mycetoma, who initially presented with diffuse non-draining papules, edema, and dull chronic pain of the left foot. Radiographic imaging depicted erosive changes throughout the left midfoot and forefoot, while bone biopsy of the left navicular and first metatarsal confirmed actinomycetes. After being prescribed amoxicillin-clavulanate and trimethoprim-sulfamethoxazole and undergoing surgical debridement, the patient had marked improvements with less frequent pain and fewer blisters. One year later, the patient's ankle joint remained untouched by mycetoma, yet his condition began to deteriorate with the reemergence of draining granules and chronic pain. As of now, the patient has been scheduled for below-the-knee limb amputation. The treatment of mycetoma aims to preserve limb function and prevent recurrences, but further research and investigations are necessary. [ABSTRACT FROM AUTHOR]

Aims: The aims of this study were to review the histological features useful for the identification of metastases to the breast and to investigate the impression that this diagnosis has become more common. Methods and results: The histological features of metastases to the breast from 2008 to 2018 were reviewed. Seventy‐four biopsies from 66 patients were identified: 1% compared with primary carcinoma of the breast. Non‐haematological metastases comprised 0.75% compared with 0.3% in a series from 1996 to 2005. The most common tumour types were pulmonary carcinoma (22), lymphoma (15), melanoma (13), gastrointestinal carcinoma (eight) and serous papillary carcinoma (four). In 73% there were histological features that were not typical of primary mammary carcinoma. Some metastases were histologically similar to breast cancer and the history was essential to making the correct diagnosis. Useful histological clues included small‐cell morphology for pulmonary carcinoma, glands containing necrosis for gastrointestinal carcinoma, intranuclear inclusions, marked pleomorphism and spindle cells for melanoma, clear cells for renal carcinoma, papillary architecture for serous papillary carcinoma and sheets of centroblasts or nodules of centroblasts and centrocytes for lymphoma. Useful immunohistochemical markers included TTF‐1 for pulmonary carcinoma, S100, melan‐A and HMB45 for melanoma, CK20 and CDX2 for colorectal carcinoma, PAX8 and WT1 for serous papillary carcinoma and lymphoid markers for lymphomas, in addition to the absence of expression of mammary markers ER, GATA3 and GCDFP‐15. Conclusion: The majority of metastases to the breast have histological clues to the diagnosis. Immunohistochemistry is helpful. This diagnosis is being made more frequently. [ABSTRACT FROM AUTHOR]

The incidence of Epstein-Barr virus (EBV) associated lymphoproliferative disorders has increased with greater use of immunomodulatory therapies. We present a woman who developed subacute cognitive decline and unilateral weakness while taking long-term mycophenolate mofetil for granulomatosis with polyangiitis; her postmortem brain histopathology confirmed an EBV-driven lymphoproliferative disorder. Clinicians must have a high index of suspicion for EBV-driven lymphoma in people taking long-term immunosuppression who develop new neurological problems. We review the role of mycophenolate mofetil in EBV-driven lymphoproliferative disorders, and discuss checking EBV status in all patients starting immunosuppression and in older people already taking immunosuppression. [ABSTRACT FROM AUTHOR]

Portal vein (PV) circulating tumor cells (CTCs) and elevated peripheral blood (PB) levels of biomarkers have been associated with poor outcomes in pancreatic ductal adenocarcinoma (PDAC). Although transforming growth factor-beta (TGFβ) is associated with CTCs in breast cancer, there are limited data evaluating a comprehensive biomarker panel and CTCs in PDAC patients. The authors hypothesized that tumor progression biomarkers would be associated with PV CTCs. PDAC patients at one institution were enrolled January to August 2018 and underwent preincision PB draws (T0) and on postoperative day 1 (T3), plus intraoperative PV draws before tumor manipulation (T1) and after resection (T2). CTCs were detected using CellSearch. Plasma biomarker levels (pg/mL) were measured with a multiplex bead assay. Patients were divided into two groups: high (≥3 CTCs/7.5 mL blood) versus low (<3). Clinicopathologic variables and biomarkers were compared in the two groups. Fourteen had complete blood draws with PDAC resection, with five demonstrating high CTCs. Fewer patients in the high-CTC group received preoperative radiation (78 versus 20%), whereas more of the high-CTC had pT3 tumors (80 versus 11%) (all P < 0.037). High-CTC patients demonstrated higher TGFβ-2 levels (T0 [906 versus 586], T1 [1337 versus 627], T2 [1149 versus 445]), as well as higher TGFβ-3 (T0 [320 versus 173], T2 [605 versus 120]) (all P < 0.021). PDAC patients with high CTCs demonstrated a distinct biomarker profile with elevated PB and PV levels of immunosuppressive cytokines (TGFβ-2 and TGFβ-3). These exploratory results prompt further study into interrupting TGFβ signaling. [ABSTRACT FROM AUTHOR]

We present a case where a 63-year-old right-handed man who presented with a 6-month history of progressive asymmetrical sensorimotor symptoms in lower limbs. This was associated with concomitant rash on the lower limbs, and mild sicca symptoms. MRI spine showed focal T2 hyperintensity in the left hemicord at C3-4 level. Skin biopsy of the rash revealed urticarial vasculitis, and lip biopsy revealed lymphocytic sialadenitis. Initial anti-Ro antibody was negative, but subsequent Ro52 antibody testing returned positive. There was also matched serum and cerebrospinal fluid oligoclonal bands. He was subsequently diagnosed as Sjogren's myelitis and treated with intravenous methylprednisolone, then transitioned to a steroid sparing agent. This case highlights the difficulties in reaching a rheumatological diagnosis in the early stages with typical negative antibodies, and shows a rare neurological manifestation of a systemic rheumatological condition. [ABSTRACT FROM AUTHOR]

Background: Microfracture is a commonly utilized cartilage restoration technique for articular cartilage defects. While the removal of the calcified cartilage layer (CCL) has been shown to be critical with in vivo models, little is known with regard to surgeon reliability to adequately perform the technique. Purpose: To evaluate surgeon reliability in removing the CCL utilizing open and arthroscopic techniques. Study Design: Controlled laboratory study. Methods: Eleven cadaveric knees were utilized to create four 12-mm diameter defects in the anterior and posterior medial femoral condyles. Eleven fellowship-trained surgeons were asked to perform the following procedures: remove the CCL open, retain the CCL open, remove the CCL arthroscopically, and retain the CCL arthroscopically. Samples underwent histologic staining and analysis with 3-dimensional micro–computed tomography. The latter was used to calculate the percentage of the CCL that was removed or retained across the entire defect. Results: When surgeons were asked to retain the CCL arthroscopically, 48% ± 41% (mean ± SD) remained. When surgeons were asked to remove the CCL arthroscopically, 24% ± 35% remained. There was no statistical difference between these groups (P >.05). When the CCL was retained during open preparation, 60% ± 39% remained. During attempts to remove the CCL in an open manner, 19% ± 28% remained. There was a significant difference in the amount of CCL remaining between the open removal and open retaining groups (P =.03). There were no significant differences in the percentage of CCL remaining between the open and arthroscopic preservation groups and between the open and arthroscopic removal groups. Conclusion/Clinical Relevance: This study highlights the significant variability in surgeon ability to reliably retain or remove the CCL. However, there appears to be improved ability of surgeons to more reliably remove or retain the CCL in an open fashion as compared with the arthroscopic approach. [ABSTRACT FROM AUTHOR]