Search

Background: Less invasive surfactant administration (LISA) is associated with better outcomes than InSurE (Intubation-Surfactant administration-Extubation). Video-laryngoscopy (VL) facilitates intubation in neonates, however safety and cost-effectiveness of VL-assisted LISA have not been evaluated., Methods: We compared the outcomes of infants receiving VL-assisted LISA (n = 67) with a historical cohort of infants who received InSurE (n = 52). Secondary aims were to evaluate safety and cost-effectiveness., Results: VL-assisted LISA was associated with reduced duration of non-invasive ventilation (NIV), reduced duration of oxygen therapy, reduced composite days on NIV and mechanical ventilation (MV), and shorter NICU stay with lower hospital costs for infants ≥29 weeks GA, compared to InSurE. In the VL-assisted LISA group, 66% of the tracheal catheters were placed on the first attempt and 16% of infants displayed desaturation during placement., Conclusion: In infants ≥29 weeks GA, VL-assisted LISA reduced exposure to NIV, oxygen, NIV and MV combined, length of stay, and cost of care compared to InSurE., Competing Interests: Competing interests: Dalibor Kurepa has been clinical consultant for Chiesi Farmaceutici S.p.A. since April 2024. This company produces surfactants, however Chiesi Farmaceutici S.p.A. had no role in the production of this manuscript and is unrelated to the present work. Ethics approval and consent to participate: The study was approved by the Northwell Health IRB (Feinstein Institutes, ID-21-1127-CCMC) as a quality improvement project, therefore no patient informed consent was needed for data collection., (© 2024. The Author(s).)

Study Design: Biomechanical analysis., Objective: To evaluate the depth of subsidence resulting from an expandable interbody cage at varying bone foam densities., Summary of Background Data: Expandable interbody cages have been shown to be associated with increased rates of subsidence. It is critical to evaluate all variables which may influence a patient's risk of subsidence following the placement of an expandable interbody cage., Methods: In the first stage of the study, subsidence depth was measured with 1 Nm of input expansion torque. In the second stage, the depth of subsidence was measured following 150 N output force exerted by an expandable interbody cage. Within each stage, different bone foam densities were analyzed, including 5, 10, 15, and 20 pounds per cubic foot (PCF). Five experimental trials were performed for each PCF material, and the mean subsidence depths were calculated. Trials which failed to reach 150 N output force were considered outliers and were excluded from the analysis., Results: There was an overall decrease in subsidence depth with increasing bone foam density. The mean subsidence depths at 150 N output force were 2.0±0.3 mm for 5 PCF, 1.8±0.2 mm for 10 PCF, 1.1±0.2 mm for 15 PCF, and 1.1±0.2 mm for 20 PCF bone foam. The mean subsidence depths at 1 Nm of input torque were 2.3±0.5 mm for 5 PCF, 2.3±0.5 mm for 10 PCF, 1.2±0.2 mm for 15 PCF, and 1.1±0.1 mm for 20 PCF bone foam., Conclusions: Depth of subsidence was negatively correlated with bone foam density at both constant input torque and constant endplate force. Because tactile feedback of cage expansion into the subsiding bone cannot be reliably distinguished from true expansion of disc space height, surgeons should take bone quality into account when deploying expandable cages., Competing Interests: D.N., V.C., and J.R. are employed by Stryker Spine, who helped to conduct this study. The other authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Most physicians appreciate that practicing medicine is a commitment to continuous learning. However, "learning" can be mistakenly understood as simply the acquisition of facts and new knowledge. But learning also necessitates the constant re-examination and challenging of one's existing body of knowledge, as misinformation persists when one's beliefs are not challenged or questioned in the light of new information. One example is the pervasive belief that postoperative atelectasis causes fever despite ample evidence to the contrary. Herein we examine the imaging characteristics of atelectasis, and the means of differentiation of atelectasis from consolidation. We also explore the history of this persistent myth and review the existing literature on the actual causes of postoperative fever., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that have influenced the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The importance of ethanol-based hand rubs (EBHR) to prevent health care-associated infections is undisputed. However, there is a lack of meaningful data regarding the influence of EBHRs on skin microbiome., Methods: Four nurses in a neonatal intensive care unit were included. After a leave of 14 days, samples were taken before the first hand rubbing action and at the end of shift, with continued sampling on days 1, 7 and 28. To analyze the hand microbiome, microbial cells were collected using the glove-juice technique. Pro- and eukaryotic community profiles were created using amplicon sequencing of 16S and 18S rRNA gene markers., Results: On average, hand antisepsis was performed 108 times per 8-hour work shift. Microbial communities were dominated by typical taxa found on human skin. In addition, a clear nurse-specific (i.e. individual) microbiome signature could be observed. For Prokaryota, daily exposure led to the end-of-the-day microbiomes being more similar to each other across nurses. In contrast, longitudinal effect of 28 day-application revealed more similarity of the Eukaryotic community., Conclusions: Frequent occupational use of EBHR did not adversely affect the composition of the human hand microbiome. Thus, daily hand antisepsis retains its significance as the most important procedure for infection control., (Copyright © 2024. Published by Elsevier Inc.)

Background: Few eligible patients in the United States participate in lung cancer screening (LCS) with low-dose computed tomography (LDCT)., Objective: What is the efficacy of interventions to increase LCS participation?, Design: We performed a systematic review following a prespecified protocol registered in PROSPERO (CRD42021283984). In June/July of 2021, we searched Ovid MEDLINE, Embase, Cochrane, CENTRAL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Epistemonikos from 1946 to October 2021 to identify studies evaluating interventions to increase LCS participation., Participants: Thirteen of 2761 studies met inclusion criteria for data extraction. Of these, six had results available (five RCTs and one prospective observational study). The studies had predominantly White and non-Hispanic participants., Main Measures: An intention-to-treat analysis was used to calculate each study's relative risk (RR) to increase LCS. Effect sizes were pooled using a random-effects model with a subgroup analysis for multi- versus single-step interventions. Risk of bias was evaluated with the revised Cochrane risk-of-bias tool (RoB 2) and risk of bias in non-randomized studies of interventions (ROBINS-I)., Key Results: Overall, the proportion of screening LDCTs performed did not improve in the intervention group relative to the comparator group (RR [95% CI] of 1.30 [0.74, 2.29]), and meta-analysis indicated high heterogeneity of studies (I 2  = 91%). Subgroup analysis suggests that interventions targeting multiple barriers may increase LCS participation (RR [95% CI] for multistep vs single-step; 2.68 [1.77, 4.05] vs 0.99 [0.89, 1.10], P < 0.01). Quality assessment revealed that three of five RCTs showed some concerns or high risk of bias., Conclusion: Evidence on efficacy of interventions to increase LCS participation is limited due to a small number of prospective studies performed in non-diverse populations with critical risk of bias. Further, overall, studied interventions did not improve lung cancer screening participation, though interventions targeting multiple barriers may have some benefit., Competing Interests: Declarations: Conflict of Interest: The authors declare that they do not have a conflict of interest., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: SARS-CoV-2 infection during pregnancy and pandemic circumstances could negatively impact infant development. This study aimed to investigate the physical development, common pediatric illness incidence, and healthcare utilization over the first 2 years of life of infants born to COVID+ and COVID- patients. Comparisons were also made with infants born pre-pandemic., Methods: This is a retrospective observational study at a major academic health system in New York City. Participants include all infants born to birthing persons with SARS-CoV-2 infection during pregnancy ( N = 758) and without ( N = 9,345) from 03/01/2020 to 08/17/2022, infants born pre-pandemic ( N = 3,221) from 03/01/2017 to 08/17/2019, and birthing persons of all infants., Results: There were no differences in weight, length, or head circumference curves between pandemic infants born to COVID+ and COVID- patients over the first 2 years of life ( p > 0.05, repeated ANOVA). Annualized incidence of illness occurrence and healthcare utilization were similar between groups. Compared to pre-pandemic infants, the length of pandemic (COVID-) infants was lower from birth to 9 months ( p < 0.0001). Pandemic infants additionally had more adverse perinatal outcomes including increased stillbirth (0.75% vs . 0.12%, p = 0.0001) and decreased gestational age (38.41 ± 2.71 vs . 38.68 ± 2.55 weeks, Cohen's d = -0.10, p < 0.0001), birthweight (2,597 ± 335 vs . 3,142 ± 643 g, Cohen's d = -1.06, p < 0.0001), and birth length (48.08 ± 4.61 vs . 49.09 ± 3.93 cm, Cohen's d = -0.24, p < 0.0001)., Conclusions: Birthing persons' SARS-CoV-2 infection status, birthing persons' profiles, and pandemic circumstances negatively affected perinatal outcomes, newborn physical development, and healthcare utilization. These findings draw clinical attention to the need to follow infants closely and implement enrichment to ensure optimal developmental outcomes., Competing Interests: The authors declare that they have no competing interests., (© 2024 Eligulashvili et al.)

Background: At present, parents lack objective methods to evaluate their child's postoperative recovery following discharge from the hospital. As a result, clinicians are dependent upon a parent's subjective assessment of the child's health status and the child's ability to communicate their symptoms. This subjective nature of home monitoring contributes to unnecessary emergency department (ED) use as well as delays in treatment. However, the integration of data remotely collected using a consumer wearable device has the potential to provide clinicians with objective metrics for postoperative patients to facilitate informed longitudinal, remote assessment., Objective: This multi-institutional study aimed to evaluate the impact of adding actual and simulated objective recovery data that were collected remotely using a consumer wearable device to simulated postoperative telephone encounters on clinicians' management., Methods: In total, 3 simulated telephone scenarios of patients after an appendectomy were presented to clinicians at 5 children's hospitals. Each scenario was then supplemented with wearable data concerning or reassuring against a postoperative complication. Clinicians rated their likelihood of ED referral before and after the addition of wearable data to evaluate if it changed their recommendation. Clinicians reported confidence in their decision-making., Results: In total, 34 clinicians participated. Compared with the scenario alone, the addition of reassuring wearable data resulted in a decreased likelihood of ED referral for all 3 scenarios (P<.01). When presented with concerning wearable data, there was an increased likelihood of ED referral for 1 of 3 scenarios (P=.72, P=.17, and P<.001). At the institutional level, there was no difference between the 5 institutions in how the wearable data changed the likelihood of ED referral for all 3 scenarios. With the addition of wearable data, 76% (19/25) to 88% (21/24 and 22/25) of clinicians reported increased confidence in their recommendations., Conclusions: The addition of wearable data to simulated telephone scenarios for postdischarge patients who underwent pediatric surgery impacted clinicians' remote patient management at 5 pediatric institutions and increased clinician confidence. Wearable devices are capable of providing real-time measures of recovery, which can be used as a postoperative monitoring tool to reduce delays in care and avoidable health care use., (©Michela Carter, Samuel C Linton, Suhail Zeineddin, J Benjamin Pitt, Christopher De Boer, Angie Figueroa, Ankush Gosain, David Lanning, Aaron Lesher, Saleem Islam, Chethan Sathya, Jane L Holl, Hassan MK Ghomrawi, Fizan Abdullah. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 12.11.2024.)

Generative artificial intelligence (generative AI) is a new technology with potentially broad applications across important domains of healthcare, but serious questions remain about how to balance the promise of generative AI against unintended consequences from adoption of these tools. In this position statement, we provide recommendations on behalf of the Society of General Internal Medicine on how clinicians, technologists, and healthcare organizations can approach the use of these tools. We focus on three major domains of medical practice where clinicians and technology experts believe generative AI will have substantial immediate and long-term impacts: clinical decision-making, health systems optimization, and the patient-physician relationship. Additionally, we highlight our most important generative AI ethics and equity considerations for these stakeholders. For clinicians, we recommend approaching generative AI similarly to other important biomedical advancements, critically appraising its evidence and utility and incorporating it thoughtfully into practice. For technologists developing generative AI for healthcare applications, we recommend a major frameshift in thinking away from the expectation that clinicians will "supervise" generative AI. Rather, these organizations and individuals should hold themselves and their technologies to the same set of high standards expected of the clinical workforce and strive to design high-performing, well-studied tools that improve care and foster the therapeutic relationship, not simply those that improve efficiency or market share. We further recommend deep and ongoing partnerships with clinicians and patients as necessary collaborators in this work. And for healthcare organizations, we recommend pursuing a combination of both incremental and transformative change with generative AI, directing resources toward both endeavors, and avoiding the urge to rapidly displace the human clinical workforce with generative AI. We affirm that the practice of medicine remains a fundamentally human endeavor which should be enhanced by technology, not displaced by it., Competing Interests: Declarations Conflict of Interest BC reports employment and equity with Solera Health outside the submitted work. MD reports consulting on ethics policy issues for the American College of Physicians via an institutional contract. JAR reports serving as a consultant for the Association of American Medical Colleges. EK reports funding from the NIH through K23HL163498 unrelated to the current work. LR reports research funding from FeelBetter Inc, the Agency for Healthcare Research and Quality, the Physicians Foundation, and the American Medical Association. She also serves on the AI Advisory Council for Augmedix, Inc and has received honoraria from Phreesia, Inc. AR reports funding from the Gordon and Betty Moore foundation for research on large language models. JC reports research funding support in part by NIH/National Institute of Allergy and Infectious Diseases (1R01AI17812101), NIH/National Institute on Drug Abuse Clinical Trials Network (UG1DA015815 - CTN-0136), Gordon and Betty Moore Foundation (Grant #12409), Stanford Artificial Intelligence in Medicine and Imaging - Human-Centered Artificial Intelligence (AIMI-HAI) Partnership Grant, American Heart Association - Strategically Focused Research Network - Diversity in Clinical Trials. Additionally, JC reports being co-founder of Reaction Explorer LLC that develops and licenses organic chemistry education software, paid consulting fees from Sutton Pierce, Younker Hyde MacFarlane, and Sykes McAllister as a medical expert witness and paid consulting fees from ISHI Health. RGM reports advisory committee role with Elsevier, outside of this work. All other authors have no conflicts to report., (© 2024. The Author(s).)

Melanosomes play a pivotal role in skin color and photoprotection. In contrast to the well-elucidated pathway of melanosome biogenesis, the process of melanosome degradation, referred to as melanophagy, is largely unexplored. Previously, we discovered that 3,4,5-trimethoxycinnamate thymol ester (TCTE) effectively inhibits skin pigmentation by activating melanophagy. In this study, we discovered a new regulatory signaling cascade that controls melanophagy in TCTE-treated melanocytes. ITCH (itchy E3 ubiquitin protein ligase) facilitates ubiquitination of the melanosome membrane protein MLANA (melan-A) during TCTE-induced melanophagy. This ubiquitinated MLANA is then recognized by an autophagy receptor protein, OPTN (optineurin). Additionally, a phospho-kinase antibody array revealed that TCTE activates PTK2 (protein tyrosine kinase 2), which phosphorylates ITCH, enhancing the ubiquitination of MLANA. Furthermore, inhibition of either PTK2 or ITCH disrupts the ubiquitination of MLANA and the MLANA-OPTN interaction in TCTE-treated cells. Taken together, our findings highlight the critical role of the PTK2-ITCH-MLANA-OPTN cascade in orchestrating melanophagy progression. Abbreviations : α-MSH: alpha-melanocyte-stimulating hormone; dichlone: 2,3-dichloro-1,4-naphthoquinone; ITCH: itchy E3 ubiquitin protein ligase; MITF: melanocyte inducing transcription factor; MLANA: melan-A; NBR1: NBR1 autophagy cargo receptor; OPTN: optineurin; PINK1: PTEN induced kinase 1; PTK2: protein tyrosine kinase 2; SQSTM1/p62: sequestosome 1; TCTE: 3,4,5-trimethoxycinnamate thymol ester; TPC2: two pore segment channel 2; VDAC1: voltage dependent anion channel 1.

Background: Exacerbations of noncystic fibrosis bronchiectasis (bronchiectasis) are associated with reduced health-related quality of life and increased mortality, likelihood of hospitalisation and lung function decline. This study investigated patient clinical characteristics associated with exacerbation frequency., Methods: A cross-sectional cohort study of patients ≥18 years with bronchiectasis enrolled in the US Bronchiectasis and Nontuberculous Mycobacteria (NTM) Research Registry (BRR) September 2008-March 2020. Patients were stratified by exacerbation frequency in their 2 years before enrolment. Patient demographics, respiratory symptoms, healthcare resource utilisation, microbiology, modified bronchiectasis severity index (mBSI) and select comorbidities were collected at enrolment. Patient characteristics associated with exacerbation frequency were assessed using a negative binomial model., Results: The study included 2950 patients (mean age 65.6 years; 79.1% female). Frequency of moderate to severe airway obstruction (forced expiratory volume in 1 s (FEV 1 ) % predicted <50%; most recent measure) was 15.9%, 17.8%, and 24.6% in patients with 1, 2, and ≥3 exacerbations versus 8.9% in patients with 0 exacerbations; severe disease (mBSI) was 27.8%, 24.2% and 51.1% versus 13.2%; respiratory hospitalisation was 24.5%, 33.0% and 36.5% versus 4.1%; and Pseudomonas   aeruginosa infection was 18.8%, 23.4% and 35.2% versus 11.9%. In multivariable model analysis, respiratory hospitalisation, cough, haemoptysis, P.   aeruginosa , younger age, lower FEV 1 % predicted, asthma, and gastro-oesophageal reflux disease were associated with more exacerbations., Conclusions: These findings demonstrate a high disease burden, including increased respiratory symptoms, healthcare resource utilisation, and P.   aeruginosa infection in patients with bronchiectasis and multiple exacerbations., Competing Interests: Conflict of interest: N.C. Lapinel reports receiving consulting fees and serving on the advisory board panel for Insmed Incorporated and that Louisiana State University Health Sciences Center received clinical trial support from Insmed Incorporated. R. Choate and A. Schmid have nothing to disclose. T.R. Aksamit reports no personal grant/research support from Insmed Incorporated or other pharma; clinical trial design and participation with AstraZeneca, Insmed Incorporated, Johnson & Johnson, Redhill Biopharma, Spero Therapeutics and Zambon, with all support going to the Mayo Foundation for Medical Education and Research; and is the Medical Director of Bronchiectasis and NTM 360 for the COPD Foundation. J. Feliciano and S. Fucile are employees and shareholders of Insmed Incorporated. K.L. Winthrop reports grant/research support and consulting fees from AN2 Therapeutics, Insmed Incorporated, Paratek, Red Hill Biopharma, Renovion, and Spero Therapeutics and participation on a data safety monitoring board or advisory board for Red Hill Biopharma. M.L. Metersky reports receiving consulting fees from AN2 Therapeutics, Boehringer Ingelheim, Insmed Incorporated, Renovion, and Zambon., (Copyright ©The authors 2024.)

Background: New York State implemented CFTR gene sequencing into the Cystic Fibrosis newborn screening (CF NBS) algorithm on 12/1/2017 to reduce false positive screens. With addition of sequencing, infants with 2 CFTR variants but low or intermediate sweat chloride levels classified as CFTR-related metabolic syndrome/CF screen-positive, inconclusive diagnosis (CRMS/CFSPID) are identified at a higher frequency, posing challenges to clinicians and families., Methods: Data from 375 screen-positive newborns between 12/1/2017 and 11/30/2020 were analyzed. We summarized 1-3 years of clinical follow-up for babies with CRMS/CFSPID following implementation of the IRT-DNA-SEQ algorithm., Results: Among 375 newborns referred, 223 (59.5 %) were classified as CRMS/CFSPID. Overall, 195/223 (87.4 %) had a CF-causing/pathogenic/likely pathogenic CFTR variant and a variant of varying clinical consequence (VCC) or uncertain significance (VUS). The most common VCC or VUS was 5T-12TG [n = 90/223 (40 %)]. All initial and repeat sweat chloride test (SCT) values for this cohort were <60 mmol/L after 1-3 years follow-up. Ninety-nine infants had ≥1 repeat SCT. Forty-two (18.8 %) had ≥1 SCT in the intermediate range (30-59 mmol/L) and 181 (81.2 %) were <30 mmol/L. Twenty-nine infants had sweat chloride increasing ≥5 mmol/L per year (29.3 % of infants with repeat testing). Fecal elastase was reported for 114/223 infants; none were abnormal. There were no conversions to CF during the 3-year follow-up period, however 2 infants have subsequently converted with diagnostic SCTs., Conclusions: The New York experience may help inform updates to clinical guidelines, which are needed to optimize care, management, counseling, and long-term follow-up of infants and children with CRMS/CFSPID., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Introduction: Despite rapid shifts in consultation-liaison psychiatry (CLP) training in residency, including increasing general residency training requirements from the Accreditation Council for Graduate Medical Education, greater utilization of advanced practice providers, and effects of the coronavirus-2019 pandemic, the Academy of Consultation-Liaison Psychiatry (ACLP) has not updated recommendations for residency training in CLP since 2014. A national survey of residency program directors in 2021 suggested many changes to the structure of CLP rotations at individual programs over the past decade., Methods: We convened a workgroup of 8 ACLP members holding leadership positions in residency and fellowship education on local and national levels. The project was approved by the ACLP Executive Council and conducted via a three-stage iterative process., Results: Consensus was reached on 34 recommendations across four domains, including structural issues, faculty supervsion, formal curriculum and evaluations, and elective experiences., Discussion: Residents must spend sufficient time on CLP rotations to achieve relevant milestones. Given that consultants are expected to offer unique insight, the ideal placement of core CLP rotations comes at a time in residency where residents are able to provide expert opinion and lead teams. Faculty expertise in CLP and availability to provide direct supervision and oversight to trainees is essential. A separate and formal CLP didactic curriculum should exist, and elective opportunities should be offered to supplement training., Conclusions: These recommendations are intended to guide residency program directors towards optimizing CLP training for all residents, including those who will eventually pursue CLP fellowship. Establishing a strong CLP foundation for all residents is essential for ensuring competency in providing psychiatric care for medically complex patients and collaborating with our colleagues in other specialties, as well as fostering trainee interest in pursuing a career in CLP., Competing Interests: Conflict of Interest The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Indicators, such as mortality and complications, are commonly used to measure the quality of care. However, a more comprehensive assessment of surgical quality is captured using composite outcome measures such as Textbook Outcome (TO), Optimal Pancreatic Surgery, and a newer 'Ideal Outcome' (IO) measure. We reviewed our institutional experience to assess the impact of demographics, comorbidities, and operative variables on IO after pancreatoduodenectomy (PD)., Methods: A retrospective study was conducted on PD patients at Northwell Health between 2009 and 2023. IO was determined by the absence of six adverse outcomes, including in-hospital mortality, Clavien-Dindo ≥ III complications, clinically-relevant postoperative pancreatic fistula, reoperation, hospital stay > 75th percentile, and readmission within 30 days. Logistic regression analyzed the effects of various factors on achieving IO., Results: Of the 578 patients who underwent PD, 248 (42.91%) achieved the IO. On multivariable analysis, factors associated with increased odds of achieving IO included neoadjuvant chemotherapy (OR 1.30, 95% CI 1.05-1.62) and the presence of neuroendocrine tumors (OR 3.37, 95% CI 1.35-8.41). Percutaneous transhepatic biliary drainage (PTBD) (OR 0.34, 95% CI 0.14-0.80) and older age (≥ 70 years) (OR 0.48, 95% CI 0.32-0.74) were associated with decreased odds of achieving IO. Patients with IO had significantly improved survival on Kaplan-Meier log-rank test (p = 0.001) as well as adjusted Cox analysis (HR 0.62 95% CI: 0.39-0.97)., Conclusion: IO may offer a comprehensive metric for assessing PD outcomes, highlighting the impact of age, chemotherapy, biliary drainage, and tumor types. These findings suggest targeted interventions and quality improvements could enhance PD outcomes by addressing modifiable factors and refining clinical strategies., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Of 319 children with invasive candidiasis, 67 (21%) transitioned from intravenous to enteral antifungal therapy. Eight (12%) transitioned back to intravenous antifungal therapy, one due to perceived treatment failure defined by clinical progression or worsening. Global treatment response at study completion was success in 66 participants transitioned to enteral therapy., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

The management of chylothorax remains challenging given the limited evidence and significant heterogeneity in practice. In addition, there are no practical guidelines on the optimal approach to manage this complex condition. We convened an international group of 27 experts from 20 institutions across five countries and four specialties (pulmonary, interventional radiology, thoracic surgery and nutrition) with experience and expertise in managing adult patients with chylothorax. We performed a literature and internet search for reports addressing seven clinically relevant PICO (Patient, Intervention, Comparison and Outcome) questions pertaining to the management of adult patients with chylothorax. This consensus statement, consisting of best practice statements based on expert consensus addressing these seven PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience. Panel members participated in the development of the final best practice statements using the modified Delphi technique. Our consensus statement aims to offer guidance in clinical decision making when managing patients with chylothorax while also identifying gaps in knowledge and informing future research., Competing Interests: Conflict of interest: Y.C.G. Lee receives drainage kits without charge for participants of a clinical trial he leads. J.S. Reisenauer has a research grant with Intuitive Surgical and is an educational consultant for Vergent, Isola, Medview and Imvaria, outside the submitted work. M.M. DeCamp is an educational consultant for PulmonX and is on the scientific advisory board for Pleural Dynamics. D.J. Feller-Kopman is an educational consultant for AstraZeneca, Noah Medical and Boston Scientific, outside the submitted work. H. Grosu has a sponsored research agreement with Known Medicine. J.F.B. Chick is an educational consultant and speaker for Inari Medical, Guerbet, C. R. Bard, Argon Medical Devices, Boston Scientific, NXT Biomedical and AiDoc, outside the submitted work. F. Maldonado received research funding from Medtronic and personal consulting fees from J&J and Intuitive, outside of the submitted work. The remaining authors do not have any disclosures or conflicts of interest to report., (Copyright ©The authors 2024. For reproduction rights and permissions contact permissions@ersnet.org.)

Twin pregnancies involving assisted reproductive technology, particularly among older women, are considered to be high risk and vulnerable to chemical exposures. Per- and polyfluoroalkyl substances (PFAS) can cross the placenta and affect the fetus, but their transplacental transfer (TPT) is not well characterized for twin pregnancies. We employed a subset of twin pregnancies from the Ideal Breast Milk (IBM) cohort and measured the levels of PFAS and related chemicals in maternal ( n = 78) and cord serum ( n = 156) samples. L-PFOS and PFOA were detected at higher levels in maternal serum, with geometric means of 4.22 and 2.80 ng/mL, respectively, while the level of Br-PFHxS was higher in cord serum (0.29 ng/mL). Higher maternal PFAS levels were associated with the occurrence of maternal vascular malperfusion. Greater differences in cord PFAS levels between twin newborns were associated with higher maternal PFAS levels and an asymmetrical placental perfusion. The TPT ratio exhibited a U-shaped pattern with the number of carbons of PFAS, similar to a singleton pregnancy. Moreover, those with eight carbon atoms, i.e., 9Cl-PF3ONS, PFOA, and PFOS, showed different TPT efficiencies with respect to their structure and functional group. While the twin pregnancy does not appear to influence exposure levels or TPT efficiencies of PFAS and related chemicals, the consequences of the exposure warrant further investigations in this population.

Study Design: Retrospective cohort study., Objective: This study aimed to compare perioperative outcomes of Rett syndrome and Cerebral palsy patients undergoing posterior spinal fusion for neuromuscular scoliosis., Summary of Background Data: Surgical correction in the treatment of scoliosis for patients with Rett syndrome (RS) has been shown to increase survival rate. Cerebral palsy (CP) patients, like RS patients, are often nonverbal, nonambulatory, with frequent surgical complications., Methods: Retrospective review of 36 RS and 80 CP patients undergoing PSF from 2005-2023. Data and x-ray measurements were collected pre- and post-operatively. Sub-analysis was performed comparing non-ambulatory patients (GMFCS IV-V). Wilcoxon-Rank Sum, Fisher's Exact, and Chi-square tests were utilized., Results: The primary outcome measure, complication rates, was similar between the groups (P=0.09). Preoperative Cobb angle, levels fused, fixation points, and LOS were similar (P>0.05). EBL was significantly higher in CP patients as was rate of transfusion (P=0.001) and surgical time (P=0.001). Postoperative Cobb angle (P=0.002) was significantly higher for CP patients. There was no significant difference between CP and RS patients in both preoperative (P=0.383) and postoperative (P=0.051) coronal decompensation. Nonambulatory status was associated with increased odds of having a postoperative complication (OR=6.17, 95% C.I. 1.36 - 28.04). Sub-analysis of non-ambulatory RS and CP patients revealed significantly higher postoperative Cobb (P=0.008), EBL (P=0.019) and surgical time (P=0.017) in CP patients compared to RS patients. There were no significant differences in preoperative Cobb, levels fused, fixation points, hospital stay, or complication rate (P>0.05)., Conclusion: RS patients are shown to have better outcomes to CP patients in terms of surgical, perioperative, and radiographic variables. Ambulatory status was identified as an independent risk factor for complications., Competing Interests: Conflicts of Interest and Source of Funding: Dr. Sarwahi received personal fees and royalties from Precision Spine, INC. outside the submitted work and not relevant to the study. All other authors declare they have no relevant financial or non-financial interests to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Plankton are fundamental to aquatic ecosystems, forming the base of the marine food web and playing a crucial role in the global carbon cycle. While the impact of environmental factors on marine plankton ecosystems has been widely studied, the seasonal variability in plankton diversity has received comparatively less attention. Here, we investigated the complexity and distribution of plankton species in Korean coastal waters in relation to seasonal environmental changes, particularly those linked to water mass characteristics and the presence of a thermocline, using alpha and beta diversity indices. A thermocline was observed at all stations in July, coinciding with the lowest diversity and richness, but was absent in September, when diversity indices peaked. In the upper layer above the thermocline, diatom species such as Pseudo-nitzschia delicatissima and Skeletonema costatum were dominant. Analysis of the Shannon index suggested that planktonic ecosystems in the South Sea of Korea from May to September 2021 were well-balanced. These findings enhance our understanding of the potential effects of environmental variability and thermal stratification on plankton biodiversity and community dynamics in Korean coastal waters., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose/objective(s): Dose-escalated radiotherapy is increasingly used in the treatment of pancreatic cancer, however approaches to target delineation vary widely. We present the first North American cooperative group consensus contouring atlas for dose-escalated pancreatic cancer radiotherapy., Materials/methods: An expert international panel comprising 15 radiation oncologists, 2 surgeons and 1 radiologist were recruited. Participants used MimCloud software to contour high and low risk clinical target volumes (CTV) on three pancreatic cancer cases: a borderline resectable head tumor, a locally advanced head tumor, and a medically inoperable tail tumor. Simultaneous truth and performance level estimation (STAPLE) volumes were created, and contours were analyzed using Dice similarity coefficients., Results: The contoured gross tumor volume (GTV) for the borderline head, locally advanced head, and unresectable tail tumor cases were 156.7, 58.2 and 9.0 cc, respectively, and the Dice similarity coefficients (SD) for the high- and low-risk CTV ranged from 0.45 to 0.82. Consensus volumes were agreed upon by authors. High-risk CTVs comprised the tumor plus abutting vessels. Low-risk CTVs started superiorly at (tail tumors) or 1 cm above (head tumors) the celiac takeoff and extended inferiorly to the superior mesenteric artery (SMA) at the level of the first jejunal takeoff. For head, neck, and proximal body tumors, the lateral volume encompassed the entire pancreas head and 5-10 mm around the celiac, superior mesenteric artery (SMA), superior mesenteric vein (SMV), including the common hepatic artery and medial portal vein, consistent with a "Triangle" volume-based approach. For distal body and tail tumors, the entire tail was included, along with the splenic vessels and the takeoffs of celiac artery., Conclusion: Through multidisciplinary collaboration, we created consensus contouring guidelines for dose-escalated pancreatic cancer radiotherapy. These volumes include not only gross disease, but also routine elective coverage, and can be used to standardize practice for future trials seeking to define the role of dose escalated radiotherapy in pancreatic cancer., (Copyright © 2024. Published by Elsevier Inc.)

The term "allergy" is inaccurate for the vast majority of the contents in the current allergy fields of electronic health records (EHRs). While EHRs have transformed access to health information and streamlined the delivery of care, their ability to reliably indicate medications, vaccines, or foods that mandate avoidance versus preferences or mild intolerances, is suboptimal. The current systems are reactive instead of being proactive and frequently fail to communicate the appropriate course of action. This Position Statement of the American Academy of Allergy, Asthma and Immunology (AAAAI) advocates for a change in terminology. The section of the EHR currently labeled "allergies" should be renamed "alerts." The term "alert" accurately captures the purpose of this section without incorrectly assigning an allergic mechanism, and prioritizes easily understood and actionable labels. This change has the potential to simultaneously improve patient safety and care. This shift will be the first step in the transformation of the alerts section of the EHR. This document provides a framework for categorizing what should be included in this section. Enacting these changes will require EHR and clinical decision support vendors, healthcare and data standard regulators, allergists, and the larger health care community to work together to bring about these important advances., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Diffuse alveolar hemorrhage (DAH) is a form of hemoptysis caused by disruption of the alveolar-capillary basement membrane causing alveolar bleeding. Inhalation of cocaine and other sympathomimetic agents are described as one of many pathologic causes. We describe what is to the author's knowledge the first reported case of DAH caused by inhalation of bupropion, a norepinephrine-dopamine reuptake inhibitor, which was successfully treated with systemic steroids. This case adds a novel agent to the known pathologic causes of DAH and introduces a novel form of bupropion toxicity, which should be considered as a cause in cases of DAH in the appropriate clinical context. The case also highlights the potential for further research into the pathologic interactions of bupropion at the alveolar basement membrane., Competing Interests: Financial/Nonfinancial Disclosures None declared, (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Increased endothelial cell proliferation is a hallmark of arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasia (HHT). Here, we report a cyclin-dependent kinase 6 (CDK6)-driven mechanism of cell cycle deregulation involved in endothelial cell proliferation and HHT pathology. Specifically, endothelial cells from the livers of HHT mice bypassed the G1/S checkpoint and progressed through the cell cycle at an accelerated pace. Phosphorylated retinoblastoma (pRB1)-a marker of G1/S transition through the restriction point-accumulated in endothelial cells from retinal AVMs of HHT mice and endothelial cells from skin telangiectasia samples from HHT patients. Mechanistically, inhibition of activin receptor-like kinase 1 signaling increased key restriction point mediators, and treatment with the CDK4/6 inhibitors palbociclib or ribociclib blocked increases in pRB1 and retinal AVMs in HHT mice. Palbociclib also improved vascular pathology in the brain and liver, and slowed cell cycle progression in endothelial cells and endothelial cell proliferation. Endothelial cell-specific deletion of CDK6 was sufficient to protect HHT mice from AVM pathology. Thus, clinically approved CDK4/6 inhibitors might have the potential to be repurposed for HHT., Competing Interests: Competing interests The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

The articles featured underscore the critical role of trust, strategic planning, and cross-sector partnerships in addressing health inequities, while emphasizing the need for further research on sustainable and cost-effective collaboration models. Tocco and colleagues from Northwell Health describe the formation of the Health Equity Taskforce (HET), initially aimed at equitable COVID-19 vaccine distribution on Long Island. The HET has since expanded to address broader health disparities, focusing on community involvement, strategic partnerships, and sustainability. Nemiroff and colleagues discuss collaborations with community partners and payors to address social determinants of health in underserved populations, highlighting opportunities that can facilitate collaborations such as the New York State's Medicaid 1115 Demonstration Waiver., Competing Interests: Declaration of Conflicting InterestThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The articles featured underscore the critical role of trust, strategic planning, and cross-sector partnerships in addressing health inequities, while emphasizing the need for further research on sustainable and cost-effective collaboration models. Tocco and colleagues from Northwell Health describe the formation of the Health Equity Taskforce (HET), initially aimed at equitable COVID-19 vaccine distribution on Long Island. The HET has since expanded to address broader health disparities, focusing on community involvement, strategic partnerships, and sustainability. Nemiroff and colleagues discuss collaborations with community partners and payors to address social determinants of health in underserved populations, highlighting opportunities that can facilitate collaborations such as the New York State's Medicaid 1115 Demonstration Waiver., Competing Interests: Declaration of Conflicting InterestThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The oncological efficacy of laparoscopic surgery for advanced gastric cancer (AGC) has been evaluated by several randomized trials. However, the inclusion of earlier-stage disease was a limitation in previous studies., Methods: Patients with cT3-4 gastric cancer, determined by surgical staging to minimize migration of earlier stages, treated at a tertiary cancer center from 2009 to 2018 were included. Based on the surgical approach, the patients were divided into two groups: the laparoscopic gastrectomy (LG) and the open gastrectomy (OG) and matched for age, sex, macroscopic appearance (type 4 or non-type 4), body mass index, estimated tumor size, clinical stage T3'T4, clinical N stage, pathologic T stage (T3 or T4), and type of surgery (total or distal gastrectomy)., Results: 588 patients (221 LG, 367 OG) were included in the analysis. After 1:1 propensity-score matching, 386 patients (193 LG, 193 OG) were assigned for analysis. In the LG group, operation time was longer with lower blood loss. The incidence of postoperative complications (≥ grade III) did not differ significantly between the groups (OG: 8.3%, vs. LG: 9.3%). Overall survival (OS) was longer in the LG group (5-year OS: 79.3 vs. 73% HR 0.66, 95% CI 0.44-0.99, P = 0.0497). Relapse-free survival (RFS) did not show a statistical difference (5-year RFS: 69.5 vs. 68.7 HR 0.88, 95% CI 0.62-1.26, P = 0.487). Subgroup analysis for OS also demonstrated equivalent outcomes., Conclusion: LG demonstrates comparable safety and efficacy to OG for advanced gastric cancer at surgical staging, with similar rates of severe complications and long-term oncological outcomes. Further research is needed to validate these findings, particularly for total gastrectomy and for patients from Western populations., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Oropharyngeal dysphagia (dysphagia) is highly prevalent (up to 86%) in hospitalized patients with Alzheimer disease and related dementias (ADRD). This study aims to describe the management and clinical course of dysphagia in hospitalized patients with ADRD., Design: Prospective observational cohort study., Setting and Participants: The study was conducted across 10 hospitals within a large health system in New York. Participants were older adults with ADRD admitted to the medicine service and diagnosed with dysphagia to liquids on speech-language pathologist (SLP) assessment and were recruited between January and June 2023., Methods: Baseline characteristics [eg, dementia Functional Assessment Staging Tool (FAST)], dysphagia management (eg, prescribed diet), and clinical course (eg, dysphagia improvement, respiratory complications) were collected., Results: Of patients with ADRD and dysphagia (n = 62), the average age was 86.5 and 66.1% were FAST Stage 7. On admission, 48.4% had pneumonia, 79.0% had delirium, and 69.4% were made nil per os (NPO) for aspiration risk. Of those who received SLP reassessment after diet initiation (n = 25), 76% demonstrated dysphagia improvement; 75% of patients with FAST stage 7 demonstrated improvement. Respiratory complications occurred in 21.0% of patients on the following diets: NPO, nasogastric tube feeding, dysphagia diets, and comfort feeds. In univariate analyses, hospital-acquired dehydration, no dysphagia improvement, and delirium were associated with respiratory complications., Conclusions and Implications: The potential for dysphagia improvement in hospitalized patients with ADRD (even those with advanced dementia) highlights the critical need for standardizing reassessment. Further studies are needed to evaluate factors associated with respiratory complications in this population., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Objective: To assess whether bioimpedance spectroscopy analysis (BIA) can be used as a tool to guide postoperative fluid management in patients undergoing cardiac surgery., Design: An observational study., Setting: A single tertiary hospital., Participants: Patients who underwent cardiac surgery with cardiopulmonary bypass between June and November 2023 who were able to undergo BIA measurements., Interventions: None., Measurements and Main Results: Correlations between BIA measurements of extracellular fluid (ECF) and total body water (TBW) volumes and daily changes in weight and 24-hour net intake and output (I/O) of fluids were assessed. Correlations between predischarge ECF volume as a percentage of TBW volume (ECF%TBW) and predischarge pro-B-type natriuretic peptide (Pro-BNP) levels and readmissions were analyzed. Changes in daily ECF volume significantly correlated with daily weight changes (p < 0.01) and 24-hour I/O (p < 0 .01). TBW volume significantly correlated with daily weight changes (p < 0.01) and with 24-hour I/O (p = 0.04). Daily weight changes did not correlate with 24-hour I/O (p = 0.06). The patients with predischarge ECF%TBW(%) greater than or equal to 51 had significantly higher predischarge Pro-BNP than those with ECF%TBW(%) less than 51 (p < 0.01). Patients who had heart failure revisits or admissions after discharge had a higher predischarge ECF%TBW(%) on index admission compared with patients who did not have heart failure readmissions (p = 0.01)., Conclusions: BIA measurements in postoperative cardiac surgery patients may be a valuable tool to quantitatively determine fluid status to help guide fluid management in this patient population. Further studies validating the use of BIA for postoperative care in this population are warranted., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Research has demonstrated negative environmental impacts from in-person conferences. Nonetheless, there are benefits to in-person meetings. The 2023 American Pediatric Surgical Association (APSA) meeting was mostly attended in-person. To understand the environmental impact, this study quantifies the travel emissions generated from that meeting., Methods: The 2023 APSA meeting was held in Orlando, FL. Using a de-identified list of attendees, the distance between the attendee's home city and Orlando was determined. If ≤ 200 miles, it was assumed the attendee drove. If > 200 miles, the distance between the closest airport and Orlando International Airport was determined. Travel emissions factors represent emissions per person-mile traveled. The Environmental Protection Agency (EPA) Greenhouse Gas Inventory emissions factors for carbon dioxide (CO 2 ), methane (CH 4 ), and nitrous oxide (N 2 O) were multiplied by travel distances to determine the emissions generated from each attendee. These were aggregated to determine the total meeting travel emissions. The EPA Greenhouse Gas Equivalencies Calculator was used to convert the emissions to a relatable outcome., Results: There were 757 in-person and 135 virtual attendees. Fifty attendees drove and 707 attendees flew. This generated 267,279 kg CO 2 , 1222 gm CH 4 , and 8486 gm N 2 O; equivalent to the emissions generated from the average annual use of 60 gasoline-powered passenger vehicles in the United States., Conclusion: Based on attendance to the 2023 APSA meeting, there is a preference for meeting in-person, though the associated environmental cost should be recognized. Based on these results, APSA should consider strategies to mitigate the environmental impact of its annual meeting., Levels of Evidence: N/A., Competing Interests: Conflicts of interest The authors have no conflicts of interest relevant to this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This article illustrates the use of locoregional perforator and pedicled flaps from the 2 main vascular systems of the head and neck area. The 2 authors combine their experiences and research findings to highlight clinical scenarios for these useful refined reconstructions and discuss their pros and cons., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

Study Design: Retrospective cohort study., Objectives: This study aimed to (1) evaluate for any temporal trends in the rates of VTE, deep venous thrombosis (DVT), pulmonary embolism (PE), and mortality from 2011 to 2020 and (2) identify the predictors of VTE following lumbar fusion surgery., Methods: Annual incidences of 30-day VTE, DVT, PE, and mortality were calculated for each of the operation year groups from 2011 to 2020. Multivariable Poisson regression was utilized to test the association between operation year and primary outcomes, as well as to identify significant predictors of VTE., Results: A total of 121,205 patients were included. There were no statistically significant differences in VTE, DVT, PE, or mortality rates among the operation year groups. Multivariable regression analysis revealed that compared to 2011, operation year 2019 was associated with significantly lower rates of DVT. Age, BMI, prolonged operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking status, functional dependence, and chronic steroid use were identified as independent predictors of VTE following lumbar fusion. Female sex, Hispanic ethnicity, and outpatient surgery setting were identified as protective factors from VTE in this cohort., Conclusions: Rates of VTE after lumbar fusion have remained mostly unchanged between 2011 and 2020. Older age, higher BMI, longer operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking, functional dependence, and steroid use were independent predictors of VTE after lumbar fusion, while female sex, Hispanic ethnicity, and outpatient surgery were the protective factors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: While understanding racial/ethnic disparities in mental health services use is a growing priority in colleges and universities, little is known the attitudes that may contribute to these disparities. Methods: This study investigates the relationship between clinic diversity, ethnic-racial identity, discrimination, and treatment attitudes. College students n  = 250 (Asian 21%, Black 11%, Latinx 23%, and White 45%) participated in an online experimental task rating hypothetical clinic websites that varied by clinician diversity and completed a series of self-report questionnaires. Results: Clinician diversity did not influence treatment attitudes, but discrimination and ethnic-racial identity were significantly related to treatment attitudes. Additionally, the relationship between public regard and treatment attitudes was moderated by race/ethnicity. Conclusions: By focusing on treatment attitudes rather than behaviors, this study addresses potential areas of intervention to address racial/ethnic disparities in college mental health.

Introduction: Radiology scoring systems are critical to the success of lung cancer screening (LCS) programs, impacting patient care, adherence to follow-up, data management and reporting, and program evaluation. LungCT ScreeningReporting and Data System (Lung-RADS) is a structured radiology scoring system that provides recommendations for LCS follow-up that are utilized (a) in clinical care and (b) by LCS programs monitoring rates of adherence to follow-up. Thus, accurate reporting and reliable collection of Lung-RADS scores are fundamental components of LCS program evaluation and improvement. Unfortunately, due to variability in radiology reports, extraction of Lung-RADS scores is non-trivial, and best practices do not exist. The purpose of this project is to compare mechanisms to extract Lung-RADS scores from free-text radiology reports., Methods: We retrospectively analyzed reports of LCS low-dose computed tomography (LDCT) examinations performed at a multihospital integrated healthcare network in New York State between January 2016 and July 2023. We compared three methods of Lung-RADS score extraction: manual physician entry at time of report creation, manual LCS specialist entry after report creation, and an internally developed, rule-based natural language processing (NLP) algorithm. Accuracy, recall, precision, and completeness (i.e., the proportion of LCS exams to which a Lung-RADS score has been assigned) were compared between the three methods., Results: The dataset includes 24,060 LCS examinations on 14,243 unique patients. The mean patient age was 65 years, and most patients were male (54 %) and white (75 %). Completeness rate was 65 %, 68 %, and 99 % for radiologists' manual entry, LCS specialists' entry, and NLP algorithm, respectively. Accuracy, recall, and precision were high across all extraction methods (>94 %), though the NLP-based approach was consistently higher than both manual entries in all metrics., Discussion: An NLP-based method of LCS score determination is an efficient and more accurate means of extracting Lung-RADS scores than manual review and data entry. NLP-based methods should be considered best practice for extracting structured Lung-RADS scores from free-text radiology reports., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflicts of interest related to the submission of this manuscript. Dr. Bade is a site PI on industry-sponsored trials for Nucleix, Delfi Diagnostics, and Biodesix., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Lacking biomarkers in psychiatry calls for a valid and reliable assessment of psychopathology across mental disorders that is easy to use, bridges research and clinical care, and that can capture clinician and patient perspectives. Herein we propose, a novel, brief, transdiagnostic tool to assess and visualize symptom severity in different psychiatric disorders. The Transdiagnostic Global Impression - Psychopathology scale (TGI-P) is based on the Clinical Global Impression - Severity scale (CGI-S), which was originally designed to measure global illness severity in one score. The TGI-P covers 10 transdiagnostic symptom domains and similar to the CGI-S, it is rated on a 7-point Likert-scale from 1 (normal) to 7 (extreme). These ten domains include positive symptoms, negative symptoms, manic symptoms, depressive symptoms, addiction symptoms, cognitive symptoms, anxiety symptoms, sleep symptoms, hostility symptoms, and self-harm symptoms. The results are visually presented, thus simplifying the monitoring of symptoms, and facilitating discussion with patients and caregivers. As part of the development process, the TGI-P was surveyed among 36 psychiatrists from 3 countries. Importantly, over 80 % of them was "very positive" or "positive" about the concept of the tool, and most of them (70 %) reported willingness to use it in their everyday practice. Further psychometric development and testing of the TGI-P is underway alongside future TGI scales covering adverse events, functioning and satisfaction., Competing Interests: Declaration of competing interest Zs.B.D., Á.B., Gy.N., and T.B. are employees of Gedeon Richter Plc. C.U.C has been a consultant and/or advisor to or has received honoraria from: AbbVie, Acadia, Adock Ingram, Alkermes, Allergan, Angelini, Aristo, Biogen, Boehringer-Ingelheim, Bristol-Meyers Squibb, Cardio Diagnostics, Cerevel, CNX Therapeutics, Compass Pathways, Darnitsa, Delpor, Denovo, Gedeon Richter, Hikma, Holmusk, IntraCellular Therapies, Jamjoom Pharma, Janssen/J&J, Karuna, LB Pharma, Lundbeck, MedInCell, Merck, Mindpax, Mitsubishi Tanabe Pharma, Maplight, Mylan, Neumora Therapeutics, Neurocrine, Neurelis, Newron, Noven, Novo Nordisk, Otsuka, PPD Biotech, Recordati, Relmada, Reviva, Rovi, Sage, Saladax, Seqirus, SK Life Science, Sumitomo Pharma America, Sunovion, Sun Pharma, Supernus, Tabuk, Takeda, Teva, Tolmar, Vertex, Viatris and Xenon Pharmaceuticals. He provided expert testimony for Janssen, Lundbeck and Otsuka. He served on a Data Safety Monitoring Board for Compass Pathways, Denovo, Lundbeck, Relmada, Reviva, Rovi, Supernus, and Teva. He has received grant support from Janssen and Takeda. He received royalties from UpToDate and is also a stock option holder of Cardio Diagnostics, Kuleon Biosciences, LB Pharma, Medlink, Mindpax, and Quantic. R.S.M. has received research grant support from CIHR/GACD/National Natural Science Foundation of China (NSFC)and the Milken Institute; speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics,Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Neurawell,Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals,Viatris, AbbVie, and Atai Life Sciences. Dr. S. Roger McIntyre is a CEO of Braxia Scientific Corp., (Copyright © 2024. Published by Elsevier B.V.)

Background: Accurate individualized assessment of preeclampsia risk enables the identification of patients most likely to benefit from initiation of low-dose aspirin at 12 to 16 weeks of gestation when there is evidence for its effectiveness, and enables the guidance of appropriate pregnancy care pathways and surveillance., Objective: The primary objective of this study was to evaluate the performance of artificial neural network models for the prediction of preterm preeclampsia (<37 weeks' gestation) using patient characteristics available at the first antenatal visit and data from prenatal cell-free DNA screening. Secondary outcomes were prediction of early-onset preeclampsia (<34 weeks' gestation) and term preeclampsia (≥37 weeks' gestation)., Methods: This secondary analysis of a prospective, multicenter, observational prenatal cell-free DNA screening study (SMART) included singleton pregnancies with known pregnancy outcomes. Thirteen patient characteristics that are routinely collected at the first prenatal visit and 2 characteristics of cell-free DNA (total cell-free DNA and fetal fraction) were used to develop predictive models for early-onset (<34 weeks), preterm (<37 weeks), and term (≥37 weeks) preeclampsia. For the models, the "reference" classifier was a shallow logistic regression model. We also explored several feedforward (nonlinear) neural network architectures with ≥1 hidden layers, and compared their performance with the logistic regression model. We selected a simple neural network model built with 1 hidden layer and made up of 15 units., Results: Of the 17,520 participants included in the final analysis, 72 (0.4%) developed early-onset, 251 (1.4%) preterm, and 420 (2.4%) term preeclampsia. Median gestational age at cell-free DNA measurement was 12.6 weeks, and 2155 (12.3%) had their cell-free DNA measurement at ≥16 weeks' gestation. Preeclampsia was associated with higher total cell-free DNA (median, 362.3 vs 339.0 copies/mL cell-free DNA; P<.001) and lower fetal fraction (median, 7.5% vs 9.4%; P<.001). The expected, cross-validated area under the curve scores for early-onset, preterm, and term preeclampsia were 0.782, 0.801, and 0.712, respectively, for the logistic regression model, and 0.797, 0.800, and 0.713, respectively, for the neural network model. At a screen-positive rate of 15%, sensitivity for preterm preeclampsia was 58.4% (95% confidence interval, 0.569-0.599) for the logistic regression model and 59.3% (95% confidence interval, 0.578-0.608) for the neural network model. The contribution of both total cell-free DNA and fetal fraction to the prediction of term and preterm preeclampsia was negligible. For early-onset preeclampsia, removal of the total cell-free DNA and fetal fraction features from the neural network model was associated with a 6.9% decrease in sensitivity at a 15% screen-positive rate, from 54.9% (95% confidence interval, 52.9-56.9) to 48.0% (95% confidence interval, 45.0-51.0)., Conclusion: Routinely available patient characteristics and cell-free DNA markers can be used to predict preeclampsia with performance comparable to that of other patient characteristic models for the prediction of preterm preeclampsia. Logistic regression and neural network models showed similar performance., (Copyright © 2024. Published by Elsevier Inc.)

Discordance in perception of disease activity between adolescent patients with lupus and their providers may influence disease outcomes. We found that patients endorsed higher perceptions of disease activity than providers. Discordance was present at all levels of disease activity, particularly in patients with high activity, nephritis, and/or taking corticosteroids or mycophenolate mofetil., Competing Interests: Declaration of Competing Interest K.K.R., K.R., and S.B. are the recipients of grant funding (#2019-10021) from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR). T.B.R. is supported by the Childhood Arthritis and Rheumatology Research Alliance/Arthritis Foundation Career Development Award and the National Institute of Arthritis and Musculoskeletal Skin Diseases (NIAMS) (K23AR080803). The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To explore associations between maternal characteristics and recall of obstetric provider actions in promoting antepartum tetanus-diphtheria-acellular-pertussis (Tdap) vaccination. Methods: A convenience sample of 1,682 postpartum women was surveyed in this cross-sectional study. Maternal characteristics and recall of four obstetric provider actions (recommending antepartum Tdap vaccine, offering it in clinic, providing written information, and referring patients elsewhere for vaccination) were collected. Univariate and multivariable logistic regression analyses were performed to characterize the association between maternal characteristics and each provider action. Results: Among 1,604 surveys (95% of total collected), maternal recall of an obstetric provider recommending Tdap vaccination, offering it in clinic, providing written information, or referring patients elsewhere was 68%, 59%, 53%, and 15%, respectively. Multivariable analysis revealed specific maternal characteristics that increased odds of recalling at least one obstetric provider action promoting Tdap vaccination, including receipt of first trimester prenatal care (adjusted odds ratio [aOR] 1.77, 95% confidence interval [CI] = 1.06-2.97), primiparity (aOR 1.35, 95% CI = 1.05-1.75), private health insurance (aOR 1.56, 95% CI = 1.16-2.04), higher household income (aOR ranging from 1.71 to 2.10 for ≥$150,000 for two actions), and non-White, non-Hispanic race/ethnicity (aOR ranging from 1.49 to 1.74 for Asian non-Hispanic for two actions and aOR 1.71 for Black non-Hispanic). Conclusion: Prenatal care, parity, insurance type, household income, and race/ethnicity are associated with recall of obstetric provider activities that impact antepartum Tdap vaccine promotion. Obstetric providers should recommend this potentially life-saving vaccine with each pregnancy, irrespective of differences in maternal characteristics, and policymakers should work to combat systemic factors that may cause disparities in uptake.

Introduction: In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial (LA) drainage for left heart decompression in this population., Methods: Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ 18 years with myocarditis or DCM on ECMO who underwent LA decompression. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes., Results: 369 pediatric ECMO runs were identified. 52% myocarditis, 48% DCM, overall survival 74%. 65% underwent BAS and 35% LA drainage. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar. 89% in the BAS group were peripherally cannulated onto ECMO, versus 3% in the LA drainage group ( p < .001). On multivariable analysis, LA drainage (OR 3.96; 95% CI, 1.47-10.711; p = .007), renal complication (OR 2.37; 95% CI, 1.41-4.01; p = .001), cardiac complication (OR 3.14; 95% CI, 1.70-5.82; p < .001), and non-white race/ethnicity (OR 1.75; 95% CI, 1.04-2.94; p = .035) were associated with greater odds of mortality. There was a trend toward more episodes of pulmonary hemorrhage in BAS ( n = 17) versus LA drainage group ( n = 3), p = .08. Comparing only those with central cannulation, LA drainage group was more likely to be discontinued from ECMO due to recovery (72%) versus the BAS group (48%), p = .032., Conclusions: In children with myocarditis or DCM, there was a three times greater likelihood for mortality with LA drainage versus BAS for LA decompression. When adjusted for central cannulation groups only, there was better recovery in the LA drainage group and no difference in mortality. Further prospective evaluation is warranted., Competing Interests: Declaration of conflicting interestsDavid LS Morales is a consultant for Abbott, Berlin Heart, CorMatrix/Azyio, Medtronic, and SynCardia Systems. Ravi R. Thiagarajan is supported by a grant from US Department of Defense Clinical Trial Award #W81XWH2210301, Callaghan Family Chair in Cardiac Critical Care. Farhan Zafar is employed as Procurement Surgeon for TransMedics, Inc.

Background: Progranulin (PGRN), also identified as Precursor cell-derived growth factor (PCDGF), is a glycoprotein that is expressed and released ubiquitously. PGRN is plays a crucial role in regulating cell proliferation, differentiation, and pathological pathways. PGRN overexpression has been noted in many cancers and plays an important role in wound healing. Surgery's impact on PGRN levels is unknown. The aim of this study was to assess the levels of plasma PGRN before during the first month after minimally invasive colorectal resection (MICR) for colorectal cancer (CRC) resection., Methods: CRC patients who were enrolled in a data/plasma bank approved by an Institutional Review Board and underwent MICR for whom adequate plasma samples were available were studied. Blood samples were obtained before surgery and at different time intervals after the operation and late samples were grouped into 7-day blocks and considered as single time points. PGRN levels (pg/mL) were determined in duplicate via ELISA and reported as median and 95% confidence interval (95% CI) values. The paired t -test was used for statistical analysis., Results: Preoperative and 1 or more late postoperative plasma sample were available for 93 MICR CRC patients. The distribution of cancer stages in the final analysis was: stage I accounted for 37% of cases, stage II for 27%, stage III for 32%, and stage IV for 4%. The median preoperative PGRN level was 50.69 pg/mL, 95% CI: 47.71-56.30, n=93. When compared to preoperative levels, significantly elevated (P<0.001) median levels (pg/mL) were noted on postoperative day (POD) 1 (64.78, 95% CI: 60.86-68.83, n=92), POD 3 (69.15, 95% CI: 66.43-74.32, n=85), POD 7-13 (63.93, 95% CI: 59.62-68.35, n=68), and POD 14-20 (68.19, 95% CI: 60.12-73.37, n=26), POD 21-27 (67.38, 95% CI: 60.30-76.65, n=20) and on POD 28-41 (75.13, 95% CI: 54.02-83.16, n=22; P<0.01)., Conclusions: Following surgery for CRC, plasma PGRN levels showed a significant increase compared to baseline levels, persisting for a duration of one month. This initial surge post-operation could potentially be attributed to the transient acute inflammatory response. The elevation observed in weeks 2 and 4 could potentially be attributed to the process of wound healing, as PGRN has been shown to enhance the accumulation of fibroblasts and facilitate angiogenesis within wounds. Additional investigation is warranted., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-24-114/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

BACKGROUND Trastuzumab (Herceptin) is a recombinant DNA-derived humanized monoclonal antibody that the US Food and Drug Administration (FDA) approved in 1998 for metastatic human epidermal growth factor receptor 2 (HER2)-positive breast cancer therapy. It selectively binds to the extracellular domain of HER2 and mediates an antibody-dependent cellular toxicity in various tissues. Trastuzumab use alone does not typically cause aggressive ocular complications. However, herein is a case report of a patient presenting with corneal ulceration in both eyes and perforation in the left eye after 2 months of trastuzumab therapy. CASE REPORT A 59-year-old woman with a history of metastatic breast cancer receiving chemotherapy was consulted for ophthalmic evaluation. She denied any history of ocular conditions and complained of eyelid crusting and sandy sensation in both eyes for 2 weeks. She had been using antibiotic eyedrops for presumed eye infection before her vision deteriorated 3-4 days prior to presentation. A thorough workup for autoimmune and infectious diseases was unyielding. Ophthalmologic examination revealed multiple epithelial defects with ulceration in the right eye and a corneal ulcer with perforation in the left eye. Corneal cultures were negative. Orbital imaging revealed metastases with optic nerve compression. In conjunction with the oncology team, further trastuzumab treatment was deferred. Therapeutic keratoplasty along with ocular surface therapy eventually stabilized both eyes. CONCLUSIONS Ocular adverse effects such as corneal epithelial changes and melts have been reported with trastuzumab. We recommend ophthalmology consultation for any ocular symptoms in patients on trastuzumab treatment.

Background: Percutaneous dilational tracheostomy (PDT) is commonly performed by a broad spectrum of practitioners. Aside from relative contraindications such as morbid obesity, coagulopathy, and complex airway anatomy, it is preferred over surgical tracheostomy in the critically ill. Rigid bronchoscopy-guided (RBG) PDT provides a secure airway, allows for unobstructed ventilation, protects the posterior membrane from puncture, and increases suction capacity., Methods: This is a retrospective case series of patients who underwent RBG-PDT from 2008 to 2023 at Beth Israel Deaconess Medical Center. Electronic medical records were reviewed for preprocedural demographic data, procedural events, and postprocedural outcomes., Results: A total of 104 patients underwent RBG-PDT over a 15-year period. Median patient age was 61.95 (95% CI: 59.00-64.90), median BMI was 30.25 kg/m2 (IQR, 23.6 to 37.2) with 41.9% (32.5% to 51.3%) of patients included having a BMI over 30 kg/m2. PDT placement occurred in a mean of 13.7 days after intubation, with 70% due to prolonged mechanical ventilation resulting from ongoing respiratory failure. In all, 51.0% of patients had at least one increased bleeding risk factor, with an increased aPTT >36 seconds being the most common (36.5%). In all, 26.9% of patients underwent tracheostomy with ongoing therapeutic anticoagulation with heparin. In total, 60.6% of patients received concomitant percutaneous endoscopic gastrostomy (PEG) tube placement. No cases of pneumothorax or loss of the airway at the time of exchange of the endotracheal tube for rigid tracheoscopy were reported., Conclusion: RBG-PDT is a safe and effective procedure extending the patient population appropriate for PDT when performed by an experienced Interventional Pulmonology team., Competing Interests: Disclosures: M.P.: Educational consultant for Intuitive Surgical. A.M.: Educational consultant for Cook Medical. The remaining authors declare no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Informed consent is a cornerstone of ethical medical practice, particularly in obstetrics where procedures like labor induction carry significant risks and require clear patient understanding. Despite legal mandates for patient materials to be accessible, many consent forms remain too complex, resulting in patient confusion and dissatisfaction. This study explores the use of Generative Artificial Intelligence (GAI) to simplify informed consent for labor induction with oxytocin, ensuring content is both medically accurate and comprehensible at an 8th-grade readability level. GAI-generated consent forms streamline the process, automatically tailoring content to meet readability standards while retaining essential details such as the procedure's nature, risks, benefits, and alternatives. Through iterative prompts and expert refinement, the AI produces clear, patient-friendly language that bridges the gap between medical jargon and patient comprehension. Flesch Reading Ease scores show improved readability, meeting recommended levels for health literacy. GAI has the potential to revolutionize healthcare communication by enhancing patient understanding, promoting shared decision-making, and improving satisfaction with the consent process. However, human oversight remains critical to ensure that AI-generated content adheres to legal and ethical standards. This case study demonstrates that GAI can be an effective tool in creating accessible, standardized, yet personalized consent documents, contributing to better-informed patients and potentially reducing malpractice claims., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Phthalates are chemical risk factors of chronic kidney disease (CKD); however, little is known about temporal trends of phthalate exposure and associated health risks among CKD patients. Such information is even scarce for alternative plasticizers. CKD patients were recruited from 2011 to 2020 in Korea ( n = 200) and assessed for the temporal changes of both traditional and alternative plasticizer exposure. Their associations with kidney dysfunction were also investigated. In CKD patients, urinary levels of DEP, BBzP, and DEHP metabolites declined significantly during this period, while those of the DEHTP metabolite increased. The level of DEHP metabolites showed a negative association with the estimated glomerular filtration rate (eGFR) in multiple association models, but additional eGFR subgroup analysis failed to show consistent results. Associations between phthalate exposure and eGFR were influenced by the severity of kidney dysfunction: DEHP and BBzP exposure showed negative associations with eGFR only among the patients with moderate kidney dysfunction (eGFR 30-59 mL/min/1.73 m 2 ). Changing associations by CKD severity may be explained by negative correlations between eGFR and both urinary creatinine concentration and specific gravity. Our observations show that DEHTP has rapidly replaced DEHP and exposure to several phthalates adversely influences kidney function even among CKD patients.