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Competing Interests: Conflicts of interest None to declare.

Background: A diagnosis of breast cancer has a significant impact on a patient's physical and emotional health. Breast reconstruction improves quality of life and self-esteem following mastectomy. However, many patients undergo additional elective revision procedures after reconstruction., Objectives: The aim of this study was to assess the relationship between perioperative emotional well-being and elective revisions in breast reconstruction., Methods: A retrospective review was performed of patients who underwent breast reconstruction with a single surgeon between January 2007 and December 2017. Revision procedures were defined as additional operations that fall outside the index reconstructive plan. Medical records were reviewed for a history of generalized anxiety disorder (GAD) and/or major depressive disorder. Multivariate analysis was performed to identify factors associated with revision., Results: A total of 775 patients undergoing breast reconstruction were included, of whom 121 (15.6%) underwent elective revision. Overall, a history of any psychiatric history (P < .001), depression alone (P = .001%), and GAD and depression together (P = .003) were significantly associated with revision surgery. On multivariate logistic regression controlling for comorbidities and reconstruction modality, depression alone, and GAD and depression together were significantly associated with an increased likelihood of revision surgery (odds ratio, 3.20, P < .001; odds ratio, 2.63, P < .001)., Conclusions: Perioperative emotional well-being and reconstruction modality impact the rate of secondary revision surgery. An understanding of the surgical and patient-related risk factors for revision can provide more informed patient-decision making and improve surgical planning., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic 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.)

Objective: This study analyzes gender disparities between men and women otolaryngology faculty in the top 20 otolaryngology departments ranked by research output and discusses the implications of these disparities., Methods: This was a cross-sectional study of all articles published by faculty from January 2020 to December 2021 at the top 20 otolaryngology departments as ranked by Doximity's 2022 research output report. Integrated data from Web of Science, faculty directories, and NIH RePORT were used to collect data on faculty. Social network analysis was performed using ORA-LITE. Student's and Welch's t-tests and Pearson chi-squared tests were used to evaluate gender differences in academic metrics., Results: The findings revealed significant gender disparities, with men holding higher academic positions (men = 3.16, women = 2.69, p < 0.0001), higher H-indices (22.4, 13.8, p < 0.0001), more NIH grants (0.15, 0.07, p = 0.0032), and greater total degree centrality (3.98E-4, 2.4E-4, p < 0.0001) and betweenness centrality (4.47E-3, 3.00E-3, p = 0.0021). Men also had more publications (9.8, 6.8, p < 0.0001) with more distinct co-authors, both within (4, 3.1, p = 0.0074) and across (38.1, 25.8, p < 0.0001) institutions. Disparities persisted after accounting for career length. Notably, total degree centrality differences between men and women were statistically significant from 1991 to 2017 (p < 0.0001), but not from 2018 to 2022 (p = 0.83)., Conclusions: This study highlights gender inequities in otolaryngology, encouraging mentors to foster new collaborations with female peers. Importantly, it identifies a trend toward narrowing the gender gap within the specialty, particularly over the past 5 years, emphasizing the need to sustain these positive changes for enhanced gender equity., Level of Evidence: NA Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Two-dimensional (2D) semiconducting transition-metal dichalcogenides (TMDCs) are an exciting platform for excitonic physics and next-generation electronics, creating a strong demand to understand their growth, doping, and heterostructures. Despite significant progress in solid-source (SS-) and metal-organic chemical vapor deposition (MOCVD), further optimization is necessary to grow highly crystalline 2D TMDCs with controlled doping. Here, we report a hybrid MOCVD growth method that combines liquid-phase metal precursor deposition and vapor-phase organo-chalcogen delivery to leverage the advantages of both MOCVD and SS-CVD. Using our hybrid approach, we demonstrate WS 2 growth with tunable morphologies─from separated single-crystal domains to continuous monolayer films─on a variety of substrates, including sapphire, SiO 2 , and Au. These WS 2 films exhibit narrow neutral exciton photoluminescence line widths down to 27-28 meV and room-temperature mobility up to 34-36 cm 2 V -1 s -1 . Through simple modifications to the liquid precursor composition, we demonstrate the growth of V-doped WS 2 , Mo x W 1- x S 2 alloys, and in-plane WS 2 -MoS 2 heterostructures. This work presents an efficient approach for addressing a variety of TMDC synthesis needs on a laboratory scale.

Objective(s): To investigate the effectiveness of ciprofloxacin/dexamethasone in reducing granulation tissue post-tracheostomy in pediatric patients., Methods: This cohort study examined pediatric patients with a tracheostomy at a single academic institution from 2016 to 2020. Exclusion criteria included: deceased within 1 year (n = 38), >16 years of age (n = 21), decannulated within 1 year (n = 15), lost to follow-up within 1 year (n = 6), and revision tracheostomy (n = 2). Logistic regression or Wilcoxon rank-sum (α = 0.05) were used to compare demographic and clinical characteristics between patients who did and did not receive ciprofloxacin/dexamethasone within 1 year of their tracheostomy., Results: In this cohort, (n = 126, median age 5.2 months, 54.0 % male), 62.7 % received ciprofloxacin/dexamethasone within 1 year, with 27.8 % taking the nebulized form. Granulation tissue occurred in 81.0 % of cases, predominantly peristomal (69.8 %) and suprastomal (34.9 %). Notable complications included accidental decannulation (13.6 %), suprastomal collapse (11.2 %), and bleeding (7.2 %). Although granulation tissue was more common in ciprofloxacin/dexamethasone users (92.4 %) versus non-users (61.7 %) (OR: 7.55, 95 % CI: 2.73-20.9, p < 0.001), patients exhibited less frequent granulation tissue events after initiation (z = 3.88, p < 0.001). No significant differences in antibiotic resistance (p = 1.0) or endocrinology complications (p = 0.1) were found between those with and without ciprofloxacin/dexamethasone., Conclusions: We found a statistically significant reduction of granulation tissue incidence with ciprofloxacin/dexamethasone use and no significant differences in antibiotic resistance or endocrinology complications were noted. Future investigation is warranted to explore timing of ciprofloxacin/dexamethasone administration for granulation tissue and its role in managing and preventing tracheostomy complications., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

IgG4-related disease is a fibroinflammatory condition characterized by dense lymphoplasmacytic infiltrates rich in IgG4-positive plasma cells affecting multiple organs. Though the most common renal manifestation of IgG4-related disease is tubulointerstitial nephritis, it can rarely present as secondary membranous nephropathy. We present a case of a 75-year-old male with phospholipase A2 receptor-negative membranous nephropathy as an atypical manifestation of IgG4-related disease. The patient presented with nephrotic syndrome and was found to have elevated serum IgG4 levels and IgG4-positive plasma cells in the kidney biopsy. He was successfully treated with corticosteroids and rituximab, resulting in significant improvement in proteinuria and normalization of IgG4 levels. This case highlights the importance of considering IgG4-related disease in patients with phospholipase A2 receptor-negative membranous nephropathy, especially in those with a history of other organ involvement. Early recognition and treatment of IgG4-related disease are crucial to prevent progressive kidney damage and improve patient outcomes., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Since we rely entirely on plastics or their products in our daily lives, plastics are the invention of the hour. Polyester plastics, such as Polyethylene Terephthalate (PET), are among the most often used types of plastics. PET plastics have a high ratio of aromatic components, which makes them very resistant to microbial attack and highly persistent. As a result, massive amounts of plastic trash accumulate in the environment, where they eventually transform into microplastic (<5 mm). Rather than macroplastics, microplastics are starting to pose a serious hazard to the environment. It is imperative that these polymer microplastics be broken down. Through the use of enrichment culture, the PET microplastic-degrading bacterium was isolated from solid waste management yards. Bacterial strain was identified as Gordonia sp. CN2K by 16 S rDNA sequence analysis and biochemical characterization. It is able to use polyethylene terephthalate as its only energy and carbon source. In 45 days, 40.43 % of the PET microplastic was degraded. By using mass spectral analysis and HPLC to characterize the metabolites produced during PET breakdown, the degradation of PET is verified. The metabolites identified in the spent medium included dimer compound, bis (2-hydroxyethyl) terephthalate (BHET), mono (2-hydroxyethyl) terephthalate (MHET), and terephthalate. Furthermore, the PET sheet exposed to the culture showed considerable surface alterations in the scanning electron microscope images. This illustrates how new the current work is., 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 The Authors. Published by Elsevier Inc. All rights reserved.)

The COVID-19 pandemic has resulted in substantial lifestyle changes with significant implications for nutritional health. Factors such as movement restrictions and disruptions in food supply chains led to the restricted availability of primary sources of essential micronutrients. To highlight this, we present the case of an elderly woman with an underlying subclinical cobalamin deficiency who developed symptomatic megaloblastic anemia, requiring hospital admission under lockdown conditions. This exemplifies how changes in diet during the COVID-19 lockdown have hastened the onset of B12 deficiency symptoms. Adverse outcomes can be avoided by identifying people at high risk of poor nutritional status and implementing policy initiatives that enhance their nutritional condition. This case report showed how important the B12 shortage was during the COVID-19 lockdown, especially for older people. They are more likely to be malnourished during COVID-19 for several reasons., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Reddy et al.)

Bulk PbSnSe has a two-phase region, or miscibility gap, as the crystal changes from a van der Waals-bonded orthorhombic 2D layered structure in SnSe-rich compositions to the related 3D-bonded rocksalt structure in PbSe-rich compositions. This structural transition drives a large contrast in the electrical, optical, and thermal properties. We realize low temperature direct growth of epitaxial PbSnSe thin films on GaAs via molecular beam epitaxy using an in situ PbSe surface treatment and show a significantly reduced two-phase region by stabilizing the Pnma layered structure out to Pb 0.45 Sn 0.55 Se, beyond the bulk limit around Pb 0.25 Sn 0.75 Se at low temperatures. Pushing further, we directly access metastable two-phase films of layered and rocksalt grains that are nearly identical in composition around Pb 0.50 Sn 0.50 Se and entirely circumvent the miscibility gap. We present microstructural and compositional evidence for an incomplete displacive transformation from a rocksalt to layered structure in these films, which we speculate occurs during the sample cooling to room temperature after synthesis. In situ temperature-cycling experiments on a Pb 0.58 Sn 0.42 Se rocksalt film reproduce characteristic attributes of a displacive transition and show a modulation in electronic properties. We find well-defined orientation relationships between the phases formed and reveal unconventional strain relief mechanisms involved in the crystal structure transformation using transmission electron microscopy. Overall, our work adds a scalable thin film integration route to harness the dramatic contrast in material properties in PbSnSe across a potentially ultrafast crystalline-crystalline structural transition.

Background: There is a paucity of data examining the psychosocial factors relevant to depigmentation therapy, an irreversible treatment for vitiligo. This study explores patients' perspective and experience while undergoing depigmentation therapy and quality-of-life effects of such therapy., Methods: An online instrument assessing the impact of depigmentation therapy on various psychosocial variables and including the validated Dermatology Life Quality Index (DLQI) were administered to two groups of participants with vitiligo: (1) those who are currently undergoing or have completed depigmentation therapy and (2) those with vitiligo who have not undergone depigmentation therapy but had considered it. Data were collected on psychosocial factors such as length of time until depigmentation therapy was offered, duration, financial burden, level of satisfaction, impact on life activities, and challenges faced during and after depigmentation therapy. DLQI scores were also measured., Results: Thirty-five vitiligo patients who did not undergo depigmentation and 42 patients who did undergo depigmentation therapy were included in the study. Baseline characteristics were comparable between groups. Mean DLQI was higher for patients who did not undergo depigmentation than for those who underwent depigmentation (10.2 versus 5.3, p = 0.002), indicating worse quality-of-life in those not depigmenting. Patients who underwent depigmentation reported significantly less discomfort in various social situations after undergoing depigmentation therapy compared to how they felt before undergoing therapy and reported significantly less discomfort in these situations than patients who did not undergo depigmentation therapy., Conclusions: Despite potential challenges, depigmentation therapy appears to augment quality-of-life across various domains in individuals with vitiligo., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type., Materials and Methods: This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics., Results: A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm., Conclusion: Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

In the field of antiferromagnetic (AFM) spintronics, there is a substantial effort present to make AFMs viable active components for efficient and fast devices. Typically, this is done by manipulating the AFM Néel vector. Here, we establish a method of enabling AFM active components by directly controlling the magnetic order. We show that magneto-ionic gating of hydrogen enables dynamic control of the Ruderman-Kittel-Kasuya-Yosida (RKKY) interaction in solid-state synthetic AFM multilayer devices. Using a gate voltage, we tune the RKKY interaction to drive continuous transitions from AFM to FM and vice versa. The switching is submillisecond at room temperature and fully reversible. We validate the utility of this method by demonstrating that magneto-ionic gating of the RKKY interaction allows for 180° field-free deterministic switching. This dynamic method of controlling a fundamental exchange interaction can engender the manipulation of a broader array of spin textures, e.g., chiral domain walls and skyrmions.

We use a rich set of transaction data from a large retailer in India and a dataset on bribe payments to train random forest and XGBoost models using empirical measures guided by Benford's Law, a commonly used tool in forensic analytics. We evaluate the performance around the 2016 Indian Demonetization, which affects the distribution of legal tender notes in India, and find that models using only pre-2016 data or post-2016 data for both training and testing data had F1 score ranges around 90%, suggesting that these models and Benford's law criteria contain meaningful information for detecting bribe payments. However, the performance for models trained in one regime and tested in another falls dramatically to less than 10%, highlighting the role of the institutional setting when using financial data analytics in an environment subject to regime shifts., Competing Interests: The authors have declared that no competing interests exist.

Background/aims: Suboptimal bowel cleansing is common in children and can impact diagnostic and therapeutic outcomes. We aimed to identify risk factors for suboptimal bowel preparation for colonoscopy in pediatric patients., Methods: This was a retrospective study of all patients ages 0 to 21 years who underwent colonoscopy at a children's hospital from 2015 to 2019 in the United States. Demographics and clinical information were obtained from the electronic health record. The primary outcome was suboptimal bowel preparation measured by the endoscopist on a dichotomized Aronchik Scale. Univariate and multivariate regression modeling were used to determine independent predictors of suboptimal preparation., Results: Nine hundred and eight patients (mean age 12.17 years [±5.14], boys 465 (51.2%), were included in the analysis. Suboptimal preparation was noted in 242 (26.7%). On univariate analysis, suboptimal preparation was more common in those of younger age (38.6%), Medicaid (32.1%), Spanish as primary language (35.7%), and failure to thrive (FTT) (45.9%). Suboptimal preparations were less common in patients with inflammatory bowel disease (IBD) (11.6%). After adjustment for other covariates, IBD and FTT maintained their statistical associations, IBD (odds ratio [OR] 0.27 95% confidence interval [CI] 0.095-0.75, P =  0.01), FTT (OR 1.98 95% CI 1.28-3.06, P =  <0.01)., Conclusions: To our knowledge, this is the first investigation of pediatric patients to identify independent risk factors for suboptimal bowel preparation. We confirm Medicaid status and English as a second language as risk factors as well as highlight distinct associations from those reported in the adult literature including FTT and younger age. IBD was associated with optimal cleansing. Future research to understand the mechanisms of inferred risk or potential protection is required., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Objectives: Monitoring of public social media posts is an underutilized method to understand patients' perspectives regarding their condition and treatment. We investigated information shared by Instagram users of oral and topical antibiotics for treatment of acne vulgaris., Material and Methods: We performed a retrospective observational study of public Instagram posts assigned common hashtags to denote the use of antibiotics therapy for acne over nearly eight years., Results: Dissatisfaction was more prevalent among users of oral antibiotics (25.6%) compared to users of topical antibiotics (9.8%), and negative tone among this group was most commonly due to lack of improvement in skin appearance. Reported side effects paralleled known side effects for oral and topical antibiotics., Conclusions: Instagram may have utility in elucidating patient behavior and attitudes. Dermatologists should increase their social media presence in order to disqualify any incorrect information endorsed in 'popular' or commonly viewed posts.

Newborns are at high risk for identification errors due to their inability to speak and indistinguishable features. To reduce this risk, The Joint Commission requires hospitals to use a distinct identification method for newborns. Most hospitals create medical records for newborns at birth using temporary naming conventions, resulting in patients with similar identifiers. Typically, multiple-birth infants are distinguished from their siblings by a single character (1, 2, or A, B), placing them at higher risk for identification errors, which can delay care and compromise patient safety., Methods: We present 2 unrelated cases involving naming errors in sets of infant twins receiving care in a healthcare system using Joint Commission compliant distinct temporary naming convention., Results: In the 2 cases, system failures contributed to naming errors in 2 sets of infant twins, which resulted in delayed care. In the first case, twins were inadvertently assigned the same temporary name. In the second case, an infant's blood specimen label did not include a single character, which distinguishes a multiple-birth infant from their sibling. Further safeguards are needed to reduce this risk. These cases illustrated the potential for misidentification related to newborn naming conventions during the registration process, especially between siblings of multiple-birth infants., Conclusions: Further research is needed to determine strategies to prevent newborn identification errors. Potential strategies to reduce this risk and protect newborns include improving the design of newborn identifiers, systems-level interventions such as verification alerts, and improved registration processes., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Social media is an underutilized method for the surveillance of the patient perspective regarding their pharmacologic therapies. The purpose of this study was to investigate the nature of content posted on the social media platform Instagram with respect to the systemic acne medication isotretinoin. The search term "#accutane" was queried into Instagram to generate all public posts using this hashtag between February 1 and May 31, 2018. Four independent investigators then scrutinized posts for eligibility. Our inclusion criteria were posts written in English, accessible by URL, primarily focused on isotretinoin, and posted by users of the medication. Data regarding multiple variables (tone of post, reason for positive or negative elements, posting of a face or other body part, mention of side effects, etc.) from each individual post was then entered into a Microsoft Excel template. Of 7,661 posts, 3,082 were eligible. Among posts that contained negative tone (n=1312), this element was more commonly due to the presence of side effects (65%) than lack of improvement in skin appearance (33%). Overall, 1,263 posters (41%) mentioned adverse effects of oral isotretinoin, most commonly dry facial skin (17%), dry/cracked lips (16%), or arthralgias/myalgias (8%). Neuropsychiatric side effects were also documented, with users reporting fatigue (4%), mood changes (3%), and headache (2%). In conclusion, reported side effects of oral isotretinoin on Instagram closely tracked its known side effects in frequency. Social media may be a valuable tool to surveil the general pattern and burden of adverse effects for patients undergoing treatment of dermatologic conditions., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Alex et al.)

Magnetic nanomaterials in magnetic fields can serve as versatile transducers for remote interrogation of cell functions. In this study, we leveraged the transition from vortex to in-plane magnetization in iron oxide nanodiscs to modulate the activity of mechanosensory cells. When a vortex configuration of spins is present in magnetic nanomaterials, it enables rapid control over their magnetization direction and magnitude. The vortex configuration manifests in near zero net magnetic moment in the absence of a magnetic field, affording greater colloidal stability of magnetic nanomaterials in suspensions. Together, these properties invite the application of magnetic vortex particles as transducers of externally applied minimally invasive magnetic stimuli in biological systems. Using magnetic modeling and electron holography, we predict and experimentally demonstrate magnetic vortex states in an array of colloidally synthesized magnetite nanodiscs 98-226 nm in diameter. The magnetic nanodiscs applied as transducers of torque for remote control of mechanosensory neurons demonstrated the ability to trigger Ca 2+ influx in weak (≤28 mT), slowly varying (≤5 Hz) magnetic fields. The extent of cellular response was determined by the magnetic nanodisc volume and magnetic field conditions. Magnetomechanical activation of a mechanosensitive cation channel TRPV4 (transient receptor potential vanilloid family member 4) exogenously expressed in the nonmechanosensitive HEK293 cells corroborated that the stimulation is mediated by mechanosensitive ion channels. With their large magnetic torques and colloidal stability, magnetic vortex particles may facilitate basic studies of mechanoreception and its applications to control electroactive cells with remote magnetic stimuli.

The Dzyaloshinskii-Moriya interaction (DMI) is responsible for exotic chiral and topological magnetic states such as spin spirals and skyrmions. DMI manifests at metallic ferromagnet/heavy-metal interfaces, owing to inversion symmetry breaking and spin-orbit coupling by a heavy metal such as Pt. Moreover, in centrosymmetric magnetic oxides interfaced by Pt, DMI-driven topological spin textures and fast current-driven dynamics have been reported, though the origin of this DMI is unclear. While in metallic systems, spin-orbit coupling arises from a proximate heavy metal, we show that in perpendicularly-magnetized iron garnets, rare-earth orbital magnetism gives rise to an intrinsic spin-orbit coupling generating interfacial DMI at mirror symmetry-breaking interfaces. We show that rare-earth ion substitution and strain engineering can significantly alter the DMI. These results provide critical insights into the origins of chiral magnetism in low-damping magnetic oxides and identify paths toward engineering chiral and topological states in centrosymmetric oxides through rare-earth ion substitution.

Biomaterials-based nanovaccines, such as those made of poly(lactic-co-glycolic acid) (PLGA), can induce stronger immunity than soluble antigens in healthy wild-type mouse models. However, whether metabolic syndrome can influence the immunological responses of nanovaccines remains poorly understood. Here, we first show that alteration in the sensing of the gut microbiome through Toll-like receptor 5 (TLR5) and the resulting metabolic syndrome in TLR5 -/- mice diminish the germinal center immune response induced by PLGA nanovaccines. The PLGA nanovaccines, unexpectedly, further changed gut microbiota. By chronically treating mice with antibiotics, we show that disrupting gut microbiome leads to poor vaccine response in an obesity-independent manner. We next demonstrate that the low immune response can be rescued by an immunomodulatory Pyr-pHEMA nanogel vaccine, which functions through TLR2 stimulation, enhanced trafficking, and induced stronger germinal center response than alum-supplemented PLGA nanovaccines. The study highlights the potential for immunomodulation under gut-mediated metabolic syndrome conditions using advanced nanomaterials.

Background: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions., Design/methods: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved., Results: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers., Conclusions: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.

Background: Approximately 15% of general surgeons practicing in the United States face a medical malpractice lawsuit each year. This study aimed to determine the reasons for litigation for breast cancer care during the past 17 years by reviewing a public legal database., Methods: The LexisNexis legal database was queried using a comprehensive list of terms related to breast cancer, identifying all cases from 2000 to 2017. Data were abstracted, and descriptive analyses were performed., Results: The study identified 264 cases of litigation pertaining to breast cancer care. Delay in breast cancer diagnosis was the most common reason for litigation (n = 156, 59.1%), followed by improperly performed procedures (n = 26, 9.8%). The medical specialties most frequently named in lawsuits as primary defendants were radiology (n = 76, 28.8%), general surgery (n = 74, 28%), and primary care (n = 52, 19.7%). The verdict favored the defendant in 145 cases (54.9%) and the plantiff in 60 cases (22.7%). In 59 cases (22.3%), a settlement was reached out of court. The median plaintiff verdict payouts ($1,485,000) were greater than the settlement payouts ($862,500) (p = 0.04)., Conclusion: Failure to diagnose breast cancer in a timely manner was the most common reason for litigation related to breast cancer care in the United States. General surgery was the second most common specialty named in the malpractice cases studied. Most cases were decided in favor of the defendant, but when the plaintiff received a payout, the amount often was substantial. Identifying the most common reasons for litigation may help decrease this rate and improve the patient experience.

Background: The 9th edition of Advanced Trauma Life Support recommends up to three crystalloid boluses in pediatric trauma patients with consideration of transfusion after the second bolus; however, this approach is debated. We aimed to determine if requirement of more than one fluid bolus predicts the need for transfusion., Methods: The 2010 to 2016 highest tier activation patients younger than 15 years from two ACS Level I pediatric trauma centers were identified from prospectively maintained trauma databases. Those with a shock index (heart rate/systolic blood pressure) greater than 0.9 were included. Crystalloid boluses (20 ± 10 mL/kg) and transfusions administered prehospital and within 12 hours of hospital arrival were determined. Univariate and multivariable analyses were conducted to determine association between crystalloid volume and transfusion., Results: Among 208 patients, the mean age was 5 ± 4 years (60% male), 91% sustained blunt injuries, and median (interquartile range) Injury Severity Score was 11 (6,25). Twenty-nine percent received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) red blood cells was 23 (0-89) mL/kg, plasma 8 (0-69), and platelets 1 (0-18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring 2 or more boluses (Fig. 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (Area under the Receiver Operating Characteristic, 0.84). Shock index was also strongly associated with transfusion., Conclusion: Almost half of pediatric trauma patients with elevated shock index require transfusion following two crystalloid boluses and the odds of requiring a transfusion plateau at this point in resuscitation. This supports consideration of blood with the second bolus in conjunction with shock index though prospective studies are needed to confirm this and its impact on outcomes., Level of Evidence: Therapeutic study, level IV.

The present investigation was to study the effect of different non-ionic surfactants (Tween-80, Tween-60, Tween-40, Tween-20, Triton X-100) and a rhamnolipid biosurfactant on the degradation of fluorene by Paenibacillus sp. PRNK-6. An enhancement in the growth, as well as fluorene utilization by this strain were observed in the presence of biosurfactant and non-ionic surfactants except Tween-20 and Triton X-100. Triton X-100 and Tween-20 were toxic to this bacterium. The strain PRNK-6 utilized 75% of fluorene (280mg/L) in 24h in an unamended condition. On the other hand, the complete utilization of higher concentration fluorene (320mg/L) by this strain was noticed when the medium was amended with Tween-80 (1.5% v/v) within 24h of incubation. Whereas, 90.6%, 96.5% and 96.7% of fluorene (280mg/L) was utilized when amended with Tween-60 (3.5% v/v), Tween-40 (3% v/v) and biosurfactant (25mg/L) respectively. Biosurfactant promoted the fluorene degradation potential of PRNK-6 as 96.2% of 320mg/L fluorene was degraded within 24h. Further, the added tween series surfactants and a biosurfactant have increased the cell surface hydrophobicity of the PRNK-6. Thus correlating with the enhanced degradation of the fluorene., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods., Methods: Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems., Results: There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay., Conclusions: The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system., Level of Evidence: IV Study Type: Single institutional retrospective review.

A high-efficiency fluoranthene-degrading bacterium Paenibacillus sp. PRNK-6 was isolated from PAH-contaminated soil. The strain degrades 96% (240 mg l -1 ) of fluoranthene in 48 h. Various metabolic intermediates of fluoranthene catabolism were identified by gas chromatography (GC) and gas chromatography-high resolution mass spectrometry (GC-HRMS). Metabolite characterization, metabolite-feeding experiments, and appropriate enzyme activities in the cell-free extracts suggest the existence of a bifurcated pathway down the phthalic acid for complete mineralization of fluoranthene in PRNK-6. In this strain, fluoranthene catabolism begins by the attack on the fused aromatic ring portion of fluoranthene. Two terminal aromatic metabolites protocatechuate and catechol undergo ring cleavage by protocatechuate 3,4-dioxygenase and catechol 1,2-dioxygenase, respectively, and enter the central metabolism.

Three bacterial strains; Pseudomonas sp. TRMK1, Stenotrophomonas sp. TRMK2 and Xanthomonas sp. TRMK3 were isolated from agro-industrial waste by enrichment culture technique that are capable of utilizing phenolic acids as sole source of carbon and energy. These strains were found to utilize p-coumaric, ferulic and caffeic acid. The individual strains utilized 5 mM of mixed phenolic acids within 20 h of incubation. The bacterial consortium composing these strains was prepared and studied the efficient degradation of phenolic compounds. The bacterial consortium showed the enhanced utilization of 30 mM individual and 25 mM mixed phenolic acids within 32 and 40 h of incubation, respectively. The degradation efficiency of these strains in all the above experiments was above 90%. The prepared bacterial consortium serves as a suitable method for the in situ application of sites contaminated with wide range of phenolic compounds.

A bacterium Pseudomonas sp. TRMK1 capable of utilizing various phenylpropanoids was isolated from agro-industrial waste by enrichment culture technique. It is gram-negative, motile, aerobic, and able to utilize three different phenolic acids such as p-coumaric, ferulic, and caffeic acids at concentrations of 5, 10, and 15 mM in 18 h of incubation. The residual concentration of phenolic acids was analyzed by HPLC. The catabolic pathway of p-coumaric, ferulic, and caffeic acids is suggested based on the characterization of metabolic intermediates by GC, GC-HRMS, and different enzymatic assays. Further, Pseudomonas sp. TRMK1 utilizes a wide range of mixture of phenolic acids present in the synthetic effluent.

Type 1 diabetes (T1D) that accounts for about 5-10 % of all diabetes cases results from the autoimmune destruction of the insulin-producing beta cells in the pancreas. It is characterized by severe inflammatory reaction mediated by pronounced T helper type-1 response. Parasitic infections having the ability to skew the host immune responses towards type-2 type as a part of their defense mechanism are able to induce protection against autoimmune diseases like T1D. Hence, the present study is undertaken to explore a recombinant abundant larval transcript protein of the human lymphatic filarial parasite Brugia malayi ( rBm ALT-2), a known anti-inflammatory molecule for its therapeutic effect on streptozotocin (STZ)-induced T1D in mice. The diabetic mice on treatment with r Bm ALT-2 showed a significant ( p  < 0.0005) decrease in their fasting blood glucose levels. By the end of the second week after the initiation of treatment with the r Bm ALT-2, 28 % of the diabetic mice became normal and none of them were diabetic by the end of 5th week. The anti-diabetic effect of r Bm ALT-2 significantly correlated with the concomitant redressal of the pancreatic histopathological damage caused by STZ assault (rho = 0.87; p  < 0.0005). The sera of r Bm ALT-2 treated diabetic mice had increased levels of IgG1 antibodies associated with decreased IgG2a antibodies against the principal autoantigen insulin. The splenocyte proliferative response and the cytokine release in the treated mice showed marked bias against inflammation skewing the immune response to Th-2 type. From this study, it can be envisaged that that filarial proteins like r Bm ALT-2 with effective immunomodulatory activity and anti-diabetic effect are promising alternative therapeutic agents for T1D., Competing Interests: All the authors have declared that they have no conflict of interest. Ethical Approval This study does not contain any studies with human participants performed by any of the authors. This study was approved by Institutional Animal Ethics Committee and national guidelines as per Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA) for the care and use of animals were followed.

Phosphate plays a critical role in chondrocyte maturation and skeletal mineralization. Studies examining the consequences of dietary phosphate restriction in growing mice demonstrated not only the development of rickets, but also a dramatic decrease in bone accompanied by increased marrow adipose tissue (MAT). Thus studies were undertaken to determine the effects of dietary phosphate restriction on bone formation and bone marrow stromal cell (BMSC) differentiation. Acute phosphate restriction of 28-day-old mice profoundly inhibited bone formation within 48 hours. It also resulted in increased mRNA expression of the early osteolineage markers Sox9 and Runt-related transcription factor 2 (Runx2), accompanied by decreased expression of the late osteolineage markers Osterix and Osteocalcin in BMSCs and osteoblasts, suggesting that phosphate restriction arrests osteoblast differentiation between Runx2 and Osterix. Increased expression of PPARγ and CEBPα, key regulators of adipogenic differentiation, was observed within 1 week of dietary phosphate restriction and was followed by a 13-fold increase in MAT at 3 weeks of phosphate restriction. In vitro phosphate restriction did not alter BMSC osteogenic or adipogenic colony formation, implicating aberrant paracrine or endocrine signaling in the in vivo phenotype. Because BMP signaling regulates the transition between Runx2 and Osterix, this pathway was interrogated. A dramatic decrease in pSmad1/5/9 immunoreactivity was observed in the osteoblasts of phosphate-restricted mice on day 31 (d31) and d35. This was accompanied by attenuated expression of the BMP target genes Id1, KLF10, and Foxc2, the latter of which promotes osteogenic and angiogenic differentiation while impairing adipogenesis. A decrease in expression of the Notch target gene Hey1, a BMP-regulated gene that governs angiogenesis, was also observed in phosphate-restricted mice, in association with decreased metaphyseal marrow vasculature. Whereas circulating phosphate levels are known to control growth plate maturation and skeletal mineralization, these studies reveal novel consequences of phosphate restriction in the regulation of bone formation and osteoblast differentiation. © 2016 American Society for Bone and Mineral Research., (© 2016 American Society for Bone and Mineral Research.)

Kidney transplant recipients may develop new-onset diabetes after transplantation (NODAT) and transplant-associated hyperglycemia (TAH) (NODAT or new-onset impaired glucose tolerance-IGT). We studied 251 consecutive renal transplant South Asian recipients for incidence of NODAT and its risk factors between June 2004 and January 2009. Pre-transplant glucose tolerance test (GTT) identified non-diabetics (n = 102, IGT-24, NGT-78) for analysis. Baseline immunosuppression along with either cyclosporine (CsA) (n = 70) or tacrolimus (Tac) (n = 32) was given. Patients underwent GTT 20 days (mean) post-transplant to identify NODAT, normal (N) or IGT. TAH was observed in 40.2% of the patients (40% in CsA and 40.6% in Tac) (P = 0.5). NODAT developed in 13.7% of the patients (12.9% in CsA and 15.6% in Tac) (P = 0.5). Overall, Hepatitis C (P = 0.007), human leukocyte antigen (HLA) B52 (P = 0.03) and lack of HLA A28 (A68/69) (P = 0.03) were associated with TAH. In the Tac group, higher Day 1 dosage (P <0.001), HLA A1 (P = 0.04), B13 (P = 0.03) and lack of DR2 (P = 0.004) increased the risk of TAH. In the CsA group, HLA A10 (P = 0.03), failure of triglyceride (P = 0.001) or low-density lipoprotein (LDL) (P = 0.03) to lower or high-density lipoprotein to rise (P = 0.001), and higher post-transplant LDL (P <0.001) and cholesterol levels (P = 0.02) were associated with NODAT or TAH. Post-transplant fasting plasma glucose on Day 1 had sensitivity-54.5%, specificity-50.1%, positive predictive value-18.1% and negative predictive value-84.8% for detecting NODAT. In conclusion, there is a genetic predisposition to NODAT and TAH in South Asia as seen by the HLA associations, and a predisposition exists to the individual diabetogenic effects of Tac and CsA based on HLA type. This could lead to more careful selection of calcineurin inhibitors based on HLA types in the South Asian population.

Jasminum grandiflorum belongs to the family Oleaceae and is known to have anti-inflammatory, antimicrobial, antioxidant, and antiulcer activities. The present study was undertaken to study its analgesic and anticonvulsant effects in rats and mice. The antinociceptive activity of the hydroalcoholic extract of J. grandiflorum leaves (HEJGL) was studied using tail flick and acetic acid - induced writhing method. Similarly, its anticonvulsant activity was observed by maximal electroshock (MES) method and pentylenetetrazol (PTZ) method. Statistical analysis was performed using one-way analysis of variance (ANOVA) followed by Dunnett's test. At doses of 50, 100, and 200 mg/kg, HEJGL showed significant analgesic and anticonvulsant effects in experimental animals. In view of its analgesic and anticonvulsant activity, the JGL extract can be used in painful conditions as well as in seizure disorders.