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Sepsis is a life-threatening immune response to infection in the body, eventually resulting in fatal organ failure. Current methods utilize blood cultures and quick-Sequential-Organ-Failure-Assessment (qSOFA), but there is a need for more accurate and time-sensitive diagnostic methods to improve survival rates. We present a 3D-printed microfluidic chip that bioconjugates antibodies CD69, CD64, and CD25 to channel surfaces to capture sepsis cells in blood samples and validate it with clinical samples (n = 125 septic, n = 10 healthy). Other variables were taken such as healthy volunteer blood samples and patient demographics to validate and confirm our device's diagnostic ability. Statistical differences were found between healthy volunteer and sepsis patient antigen cell counts (CD69 p-value < 0.001, CD64 p-value < 0.004, CD25 p-value < 0.0009), and were confirmed using principal component analysis. Demographics such as length of stay, age, culture results, and need for surgery also factored into sepsis detection on a smaller scale than the antigen cell counts. The receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.989, 0.988, and 0.992 for CD69, CD64, and CD25, respectively, and a combined biomarker panel of 0.997. Overall, the device performed within a shorter time frame of 4 h compared to standard blood culture tests and was validated for use in detecting sepsis in patients., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D Pappas reports financial support was provided by National Institutes of Health. D Pappas reports a relationship with NaMi Diagnostics that includes: non-financial support. D Pappas has patent #10,761,093 licensed to NaMi Diagnostics. Dr. Pappas’s patent on this technology is licensed through NaMi Diagnostics, who have no competing interest in this work. Dr. Pappas has no financial position in NaMi Diagnostics. If there are other authors, they 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 B.V. All rights reserved.)

Young adults thrust into the role of caregiving for parents with young-onset dementia (YOD) face unique challenges during their formative years. While existing research acknowledges the crucial role of young adult caregivers, a gap persists in understanding how this group experiences and redefines their identity amidst these circumstances, along with the psychological and societal challenges encountered. This knowledge deficit hinders the identification of suitable social support, adversely affecting the personal growth and well-being of these young adult caregivers. In this single-case study, we used a combination of a semi-structured interview and photovoice to explore the journey of a 19-year-old caregiver, Alice, whose mother had been diagnosed with dementia in the preceding 3 years. Through this unique perspective, we aimed to illuminate how caregiving for a mother with YOD may profoundly redefine familial roles and relationships. Over 3 months, Alice captured significant life moments through photography, selecting meaningful images for bi-weekly meetings. These images served as pivotal themes, triggering in-depth conversations during subsequent interviews to provide nuanced insights into her life experiences. Findings reveal four major themes faced by a young caregiver: (1) challenges adapting to an unexpected role, (2) navigating the complex emotional terrain of losing a loved one to YOD, (3) prioritizing the well-being of the healthy parent, and (4) expressing a profound desire for both informal and formal support. These results underscore the intricate identity and emotional challenges faced by young adult caregivers, emphasizing the urgency of addressing their unique needs through family-centered systemic support services., 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.

Introduction: Emergency clinical research has played an important role in improving outcomes for acutely ill patients. This is due in part to regulatory measures that allow Exception From Informed Consent (EFIC) trials. The Food and Drug Administration (FDA) requires sponsor-investigators to engage in community consultation and public disclosure activities prior to initiating an Exception From Informed Consent trial. Various approaches to community consultation and public disclosure have been described and adapted to local contexts and Institutional Review Board (IRB) interpretations. The COVID-19 pandemic has precluded the ability to engage local communities through direct, in-person public venues, requiring research teams to find alternative ways to inform communities about emergency research., Methods: The PreVent and PreVent 2 studies were two Exception From Informed Consent trials of emergency endotracheal intubation, conducted in one geographic location for the PreVent Study and in two geographic locations for the PreVent 2 Study. During the period of the two studies, there was a substantial shift in the methodological approach spanning across the periods before and after the pandemic from telephone, to in-person, to virtual settings., Results: During the 10 years of implementation of Exception From Informed Consent activities for the two PreVent trials, there was overall favorable public support for the concept of Exception From Informed Consent trials and for the importance of emergency clinical research. Community concerns were few and also did not differ much by method of contact. Attendance was higher with the implementation of virtual technology to reach members of the community, and overall feedback was more positive compared with telephone contacts or in-person events. However, the proportion of survey responses received after completion of the remote, live event was substantially lower, with a greater proportion of respondents having higher education levels. This suggests less active engagement after completion of the synchronous activity and potentially higher selection bias among respondents. Importantly, we found that engagement with local community leaders was a key component to develop appropriate plans to connect with the public., Conclusion: The PreVent experience illustrated operational advantages and disadvantages to community consultation conducted primarily by telephone, in-person events, or online activities. Approaches to enhance community acceptance included partnering with community leaders to optimize the communication strategies and trust building with the involvement of Institutional Review Board representatives during community meetings. Researchers might need to pivot from in-person planning to virtual techniques while maintaining the ability to engage with the public with two-way communication approaches. Due to less active engagement, and potential for selection bias in the responders, further research is needed to address the costs and benefits of virtual community consultation and public disclosure activities compared to in-person events., 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.

This case report presents the story of Mr. S, a professional orchestral musician with declining musical sight-reading ability, followed by progressive visuospatial and language deficits. Our novel musical assessment battery revealed deficits in music-reading (musical alexia) and music-writing (musical agraphia), with spared auditory perception and expression. Taken with neuropsychological testing, clinical history, and imaging, we conclude that his symptoms evolved from musical alexia to a multidomain, neurodegenerative process centered in the dominant inferior parietal lobe and temporoparietal junction. We suspect a primary TDP-opathy with comorbid preclinical Alzheimer's disease. Mr. S's case highlights musical symptoms as meaningful, early indicators of neurodegeneration.

Orthopaedic researchers need new strategies for engaging underrepresented minority (URM) students. Our field has demonstrated noticeable gaps in racial, ethnic, and gender diversity, which inhibit our ability to innovate and combat the severe socioeconomic burden of musculoskeletal disorders. Towards this goal, we designed, implemented, and evaluated Learning on a Limb (LoaL), an orthopaedic research outreach module to teach URM high school students about orthopaedic research. During the 4-h module, students completed hands-on activities to learn how biomechanical testing, microcomputed tomography, cell culture, and histology are used in orthopaedic research. Over 3 years, we recruited 32 high school students from the Greater Philadelphia Area to participate in LoaL. Most participants identified as racial/ethnic or gender minorities in orthopaedic research. Using pre/post-tests, we found that students experienced significant learning gains of 51 percentage points from completing LoaL. In addition to teaching students about orthopaedic research, post-survey data demonstrated that participating in LoaL strongly influenced students' interest in orthopaedic research and scientific confidence. Several students acted on this interest by completing summer research experiences in the McKay Orthopaedic Research Laboratory at the University of Pennsylvania. LoaL instructors also benefited by having the opportunity to "pay it forward" to the next generation of students and build community within their department. Empowering institutions to host modules like LoaL would synergistically inspire URM high school students and strengthen community within orthopaedic departments to ultimately enhance orthopaedic research innovations., (© 2024 The Author(s). Journal of Orthopaedic Research ® published by Wiley Periodicals LLC on behalf of Orthopaedic Research Society.)

Rodenticides are a key component of rodent management strategies, but birds of prey are susceptible to non-target exposure. New rules on sale and use of rodenticide products were introduced across the UK in 2016 in an industry-led stewardship scheme, with the aim of reducing this risk. To determine if this intervention has achieved its aim, exposure to second generation anticoagulant rodenticides (SGARs) was measured in buzzards. Liver samples from 790 buzzards collected between 2005 and 2022 (excluding 2016 and 2017 samples) were analyzed and the percentage presence and concentrations of SGARs from pre-stewardship and post-stewardship samples were compared. There was no statistically significant decrease in the percentage of buzzards exposed to bromadiolone, difenacoum or combined SGAR residues after the introduction of stewardship. The percentage of buzzards exposed to brodifacoum increased significantly post-stewardship, from 8 % to 27 %. There were no significant decreases in the concentrations of individual SGARs post-stewardship but concentration of combined SGARs increased significantly post-stewardship. Individual buzzards were significantly more likely to be exposed to multiple SGARs post-stewardship. Rodenticide poisoning was recorded as the cause of death for 5 % of pre- and post-stewardship buzzards with detectable levels of SGARs, and 90 % of these had combined SGAR residues >0.1 mg/kg. These findings suggest that the industry-led stewardship scheme has not yet had the intended impact of reducing SGAR exposure in non-target wildlife. The study highlights a substantial increase in exposure of buzzards to brodifacoum and to multiple SGARs post-stewardship, indicating that further changes to the stewardship scheme may be necessary., 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. Published by Elsevier B.V.)

Orthopaedic researchers need new strategies for engaging diverse students. Our field has demonstrated noticeable gaps in racial, ethnic, and gender diversity, which inhibit our ability to innovate and combat the severe socioeconomic burden of musculoskeletal disorders. Towards this goal, we designed, implemented, and evaluated Learning on a Limb, an orthopaedic research outreach module to teach diverse high school students about orthopaedic research. During the 4-hr module, students completed hands-on activities to learn how biomechanical testing, microcomputed tomography, cell culture, and histology are used in orthopaedic research. Over three years, we recruited 32 high school students from the Greater Philadelphia Area to participate in Learning on a Limb. Most participants identified as racial/ethnic or gender minorities in orthopaedic research. Using pre/post-tests, we found that students experienced significant learning gains of 51 percentage points from completing Learning on a Limb. In addition to teaching students about orthopaedic research, post-survey data demonstrated that participating in Learning on a Limb strongly influenced students' interest in orthopaedic research. Several students acted on this interest by completing summer research experiences in the McKay Orthopaedic Research Laboratory at the University of Pennsylvania. Learning on a Limb instructors also benefited by having the opportunity to "pay it forward" to the next generation of students and build community within their department. Empowering institutions to host modules like Learning on a Limb would synergistically inspire diverse high school students and strengthen community within orthopaedic departments to ultimately enhance orthopaedic research innovations.

Introduction: Negative psychological factors such as depression and other common mental disorders have been found to be associated with voice problems in teachers. However, there is little research with teachers that investigates the relationship between positive psychological factors such as wellbeing and voice problems. Although negative and positive mental states are on a continuum of psychological health, research suggests negative and positive effects are not necessarily inversely correlated and therefore need to be investigated separately., Objective/hypothesis: To explore the relationship between voice symptoms and wellbeing in teachers working in primary and secondary schools in England. We hypothesise that as wellbeing increases voice symptoms will decrease., Design: Cross sectional study using a self-administered web-based questionnaire conducted with primary and secondary school teachers in England., Methods: The study included 1205 teachers from 608 primary and secondary schools, including state and fee paying, and mainstream and special schools. Voice symptoms were measured using The Voice Symptom Scale and wellbeing was measured using the Warwick Edinburgh Mental Wellbeing Scale. Information was also obtained on health, lifestyle, sociodemographic and environmental factors. Analysis was conducted using a linear multi-level regression model., Results: A statistically significant relationship between voice symptoms and wellbeing was identified (-0.31 95% CI -0.41, -0.20 P =< 0.001). Other factors found to be statistically significantly associated with voice symptoms were age, sex, gastroesophageal reflux, class size, background noise, speaking louder than normal and respiratory infection. Hours teaching per week, deprivation of school, voice training, teaching subject, smoking status and asthma were not associated with voice symptoms., Conclusions: This study suggests that there is an association between vocal symptoms and wellbeing. Teachers with higher wellbeing had fewer voice symptoms., Competing Interests: Conflict of Interest None., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Industrial facilities are not located uniformly across communities in the United States, but how the burden of exposure to carcinogenic air emissions may vary across population characteristics is unclear. We evaluated differences in carcinogenic industrial pollution among major sociodemographic groups in the United States and Puerto Rico., Methods: We evaluated cross-sectional associations of population characteristics including race and ethnicity, educational attainment, and poverty at the census tract level with point-source industrial emissions of 21 known human carcinogens using regulatory data from the US Environmental Protection Agency. Odds ratios and 95% confidence intervals comparing the highest emissions (tertile or quintile) to the referent group (zero emissions [ie, nonexposed]) for all sociodemographic characteristics were estimated using multinomial, population density-adjusted logistic regression models., Results: In 2018, approximately 7.4 million people lived in census tracts with nearly 12 million pounds of carcinogenic air releases. The odds of tracts having the greatest burden of benzene, 1,3-butadiene, ethylene oxide, formaldehyde, trichloroethylene, and nickel emissions compared with nonexposed were 10%-20% higher for African American populations, whereas White populations were up to 18% less likely to live in tracts with the highest emissions. Among Hispanic and Latino populations, odds were 16%-21% higher for benzene, 1,3-butadiene, and ethylene oxide. Populations experiencing poverty or with less than high school education were associated with up to 51% higher burden, irrespective of race and ethnicity., Conclusions: Carcinogenic industrial emissions disproportionately impact African American and Hispanic and Latino populations and people with limited education or experiencing poverty thus representing a source of pollution that may contribute to observed cancer disparities., (Published by Oxford University Press 2024.)

Background: Much research has explored how raising a child with a neurodevelopmental disability influences parents' well-being. However, little research has focused on the unique experiences of parenting multiple children with neurodevelopmental disabilities. We explored the unique experiences of parenting multiple children with neurodevelopmental disabilities with a focus on mothers' well-being and social participation., Methods: Ten mothers who parent multiple children with neurodevelopmental disabilities participated in semi-structured interviews. Interviews were analyzed using a reflexive thematic approach., Results: Three themes were identified: 'Knowledge is power' described positive influences of enhanced disability knowledge and advocacy with each child who experienced disability. 'Shifts in wellbeing' acknowledged these mothers' exhaustion, decreased time for self-care, and invisible work, yet also increased feelings of empowerment, purpose and empathy for others. '(Dis)Connection and engagement with others' reflected struggles of balancing responsibilities, social and community participation, and experiences with isolation. Yet, mothers' also experienced enhanced disability community and family connections, and a sense of meaning and purpose., Conclusions and Implications: Findings highlighted challenges, and many rewarding and unique experiences of parenting multiple children with neurodevelopmental disabilities. Health, education and social service practitioners are encouraged to acknowledge parent's challenges, but also celebrate and draw on families' strengths and knowledge., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Sepsis is a serious medical condition that arises from a runaway response to an infection, which triggers the immune system to release chemicals into the bloodstream. This immune response can result in widespread inflammation throughout the body, which may cause harm to vital organs and, in more severe cases, lead to organ failure and death. Timely and accurate diagnosis of sepsis remains a challenge in analytical diagnostics. In this work, we have developed and validated a sepsis detection device, utilizing 3D printing technology, which incorporates multiple affinity separation zones. Our device requires minimal operator intervention and utilizes CD64, CD69, and CD25 as the biomarker targets for detecting sepsis in liquid biopsies. We assessed the effectiveness of our 3D-printed multizone cell separation device by testing it on clinical samples obtained from both septic patients ( n = 35) and healthy volunteers ( n = 8) and validated its performance accordingly. Unlike previous devices using poly(dimethyl siloxane), the 3D-printed device had reduced nonspecific binding for anti-CD25 capture, allowing this biomarker to be assayed for the first time in cell separations. Our results showed a statistically significant difference in cell capture between septic and healthy samples (with p values of 0.0001 for CD64, CD69, and CD25), suggesting that 3D-printed multizone cell capture is a reliable method for distinguishing sepsis. A receiver operator characteristic (ROC) analysis was performed to determine the accuracy of the captured cell counts for each antigen in detecting sepsis. The ROC area under the curve (AUC) values for on-chip detection of CD64+, CD69+, and CD25+ leukocytes were 0.96, 0.92, and 0.88, respectively, indicating our diagnostic test matches clinical outcomes. When combined for sepsis diagnosis, the AUC value for CD64, CD69, and CD25 was 0.99, indicating an improved diagnostic performance due to the use of multiple biomarkers.

Introduction: There is limited evidence on educational needs and preferences of pediatric health care professionals regarding transition from pediatric to adult health care., Methods: We distributed an anonymous online survey to physicians and advanced practice providers at a large, free-standing children's hospital and associated primary care network to assess attitudes, practices, and educational preferences about transition. We analyzed data with descriptive statistics, chi-square, and logistic regression., Results: A total of 178 providers responded (20% response rate) across 31 specialties (66% attending physicians, 19% fellows, and 15% advanced practice providers). Less than half (43%) were comfortable in their knowledge of transition, with fellows reporting significantly lower comfort than attendings ( P < .05). In total, 47% reported annually discussing transition with their patients (fellows: 17% vs. attendings: 50%, P < .05). Educational topics of greatest interest included legal (71%) and financial concerns (69%), whereas preferred educational formats included Grand Rounds/lectures (68%) and webinars (63%). Facilitators to transition included lists of local adult providers for transition (89%), parent/family educational resources (88%), and a medical summary template in the electronic health record (85%)., Discussion: Major gaps exist in attitudes and practices related to transition. Identified educational strategies may serve as targets to improve the transition process through educational interventions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

We present the detailed metrology of a superconducting Transition-Edge Sensor (TES) absorber-coupled bolometer array bonded to a variable-delay backshort to form an integral field unit. The backshort is shaped as a wedge to continuously vary the electrical phase delay of the bolometer absorber reflective termination across the array. This resonant absorber termination structure is used to define a spectral response over a 4:1 bandwidth in the far-infrared, from ∼30 to 120 μm. The metrology of the backshort-bolometer array hybrid was achieved with a laser confocal microscope and a compact cryogenic system that provides a well-defined thermal (radiative and conductive) environment for the hybrid when cooled to ∼10 K. The results show the backshort free-space delays do not change with cooling. The estimated backshort slope is 1.58 milli-radians and within 0.3% of the targeted value. The sources of error in the free-space delay of the hybrid and optical cryogenic metrology implementations are discussed in detail. We also present measurements of the bolometer's single-crystal silicon membrane topography. The membranes deform and deflect out-of-plane under both warm and cold conditions. Intriguingly, the optically active area of the membranes tends to flatten when cold and repeatably achieve the same mechanical state over many thermal cycles; hence, no evidence for thermally-induced mechanical instability is observed. Most of the cold deformation is sourced from thermally-induced stress in the metallic layers comprising the TES element of the bolometer pixels. These results provide important considerations for the design of ultra-low-noise TES bolometers., (© 2023 Public Domain.)

Background: Soil underpins most terrestrial systems; hence, its degradation should concern everyone. In 2021, Soilsafe Aotearoa surveyed the adult population of New Zealand about how they value soil, particularly values related to how they care about and are concerned about soil. Pursuant to this study, Soilsafe Kids (the outreach branch of Soilsafe Aotearoa) developed a combined research and outreach program to collect a supplemental data set of children's soil values, so both adults' and children's voices can be considered when understanding the implications of different practices and how to care for presently "uncared for" or neglected soils in the future., Objective: The program not only asks primary school students about their soil values but also aims to teach them about soil from many disciplinary perspectives to enhance their understanding and awareness of soil, and, more broadly, for knowledge production., Methods: Here we describe the research protocol used in this Soilsafe Kids program. This program uses surveys (in the form of worksheets), focus groups (introduced as group discussions), and art projects to learn what children think about soil in Tāmaki Makaurau Auckland. We have received ethics approval from the University of Auckland's Human Participants Ethics Committee (reference number 23556) on March 25, 2022, for 3 years., Results: We have begun recruiting participants and delivering the Soilsafe Kids program in schools across Tāmaki Makaurau Auckland. Our data collection is ongoing with final student engagement in the first quarter of 2023. We expect to analyze data at the start of 2023 and to disseminate results later this year., Conclusions: Once this study is complete, we will disseminate the final results to the research community, stakeholders, and the local community through conference presentations, journal articles, hui (meetings), on our website, and in art exhibits. We note that although Tāmaki Makaurau Auckland is home to the majority of people living in Aotearoa New Zealand, the Auckland region only represents a small portion of Aotearoa New Zealand's land, and findings are not generalizable to Aotearoa New Zealand as a whole., International Registered Report Identifier (irrid): DERR1-10.2196/43390., (©Sophia Tsang, Victoria Egli, Bridget Crawshaw-Mclean, Lianne Edwards-Maas, Melanie Kah, Emma Sharp. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.03.2023.)

The contamination of the environment by some veterinary medicines and their impact on wild animals is of increasing concern. However, there is a lack of information about their residues in wildlife. The sentinel animals most commonly used for monitoring the level of environmental contamination are birds of prey, and information on other carnivores and scavengers scarce. This study examined the livers from 118 foxes for residues of a range of 18 veterinary medicines (16 anthelmintic agents and 2 metabolites) used on farm livestock. The samples were collected from foxes, primarily in Scotland, shot during legal pest control activities conducted between 2014 and 2019. Closantel residues were detected in 18 samples, and the concentrations found ranged from 6.5 µgkg -1 to 1383 µgkg -1 . No other compounds were found in significant quantities. The results show a surprising frequency and level of closantel contamination, raising concerns about both the route of contamination and the potential impacts on wild animals and the environment, such as the potential for significant wildlife contamination to contribute to the development of closantel-resistant parasites. The results also suggest that red fox (Vulpes vulpes) could be a useful sentinel species for detecting and monitoring some veterinary medicine residues in the environment., 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., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Introduction: There is a stage migration for detection of kidney cancer, thus we aim to evaluate the distribution of metastatic renal cell carcinoma by presenting clinical T stage over time., Materials and Methods: The National Cancer Database was evaluated for patients with metastatic kidney cancer from 2010 to 2016. The primary outcome was the temporal trend of presenting clinical T stage over time. The secondary outcome was overall survival. Kaplan-Meier and Cox regression analyses were performed., Results: The incidence of metastatic kidney cancer has increased, from 3426 new cases in 2010 to 4510 in 2016. While diagnosis of metastasis has increased for all tumor stages over time, there has been a more rapid increase in metastasis of localized renal masses (cT1-T2) as compared to locally advanced disease (cT3-T4). In 2010, 46% of the new metastatic cases diagnosed were cT3-T4, while in 2016 this proportion decreased to 38.2%. Conversely, metastatic cases with cT1-T2 tumors increased from 54% in 2010 to 61.9% in 2016. Cox regression noted an increased risk of death correlating with higher clinical T stage. On Kaplan Meier analysis, the 2-year survival was 29.3%, 30.3%, 28.3%, and 16.0% for cT1, cT2, cT3, and cT4, respectively (logrank P < .001)., Conclusion: Metastatic kidney cancer is increasingly diagnosed at a lower presenting cT stage. Survival outcomes worsen with increasing cT stage in the setting of metastasis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Trauma is the leading cause of death among people aged 1-45 in the United States with the abdomen being the third most commonly injured anatomic region. The incidence of gallbladder trauma in the setting of abdominal injury ranges between 0.5 and 2.1 %. While gallbladder injuries secondary to penetrating abdominal wounds are found intra-operatively owing to the likely progression towards laparotomy, due to the paradigm shift of non-operative management of blunt liver injuries, the diagnosis of blunt gallbladder injuries are commonly delayed upwards of 1 to 6 weeks. 4 We present a case of a pre-emptive cholecystectomy less than 36 h after sustaining a grade V liver injury status post blunt abdominal trauma in effort emphasize the importance of critical review of diagnostic images, and support the utilization of diagnostic laparoscopy to definitively diagnose and manage traumatic blunt gallbladder injuries. When operative intervention is not performed, the nonspecific findings suggestive of gallbladder injuries can lead to delayed diagnosis and subsequent increased morbidity and mortality. Due to the lack of previous guidelines we propose a diagnostic algorithm for the approach of traumatic blunt gallbladder injuries.

The Indiana State Museum's Fix: Heartbreak and Hope: Inside Our Opioid Crisis is the first large-scale exhibit dedicated to the opioid epidemic. It involves diverse groups of visitors in learning about the history and science of opioid use disorder, making decisions that will help resolve the opioid crisis, and practicing techniques that for many people are essential to long-term recovery. By reviewing the different components of the exhibit, I show how the exhibit can serve as a basic model for advancing health promotion in museums. The exhibit illuminates the ways interactive health exhibits can engage adult visitors, reduce stigma, provide knowledge that visitors can use to exercise control over their health, and expand awareness of the need for evidence-based approaches to public health crises.

Iatrogenic nerve injury during surgery is a major source of concern for both patients and surgeons. This study aimed to identify the nerves most commonly injured during surgery, along with the commonly associated operative procedures. A literature search was conducted using the PubMed database to identify nerves commonly injured during surgery, along with the surgical procedure associated with the injury. The following 11 nerves, ranked in order with their associated surgical procedures, were found to be the most commonly injured: (a) intercostobrachial nerve in axillary lymph node dissections and transaxillary breast augmentations, (b) vestibulocochlear nerve in cerebellopontine tumor resections and vestibular schwannoma removals, c) facial nerve in surgeries of the inner ear and cheek region, (d) long thoracic nerve in axillary lymph node dissections, (e) spinal accessory nerve in surgeries of the posterior triangle of the neck and cervical lymph node biopsies, (f) recurrent laryngeal nerve in thyroid surgeries, (g) genitofemoral nerve in inguinal hernia and varicocele surgeries, (h) sciatic nerve in acetabular fracture repairs and osteotomies, (i) median nerve in carpal tunnel release surgeries, (j) common fibular nerve in varicose vein and short saphenous vein surgeries, and (k) ulnar nerve in supracondylar fracture surgeries. Although the root cause of iatrogenic nerve injury differs for each nerve, there are four unifying factors that could potentially decrease this risk for all peripheral nerves. These four influencing factors include knowledge of potential anatomical variations, visual identification of at-risk nerves during the procedure, intraoperative nerve monitoring, and expertise of the surgeon., (© 2020 American Association of Clinical Anatomists.)

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has had innumerable profound impacts, many of which have resulted in irrevocable changes to both the practice of medicine and the teaching of medicine. Medical educators have adapted to the need for social distancing by providing virtual educational opportunities for their learners, often without training or experience in online teaching. Because these educators require both professional development and technical support for their online teaching to be sustainable and effective, departments need to provide immediate help and support. These twelve tips are designed for those in leadership roles who have recognized the need for investment in online education and are interested in strategies to ensure the success of their educational programs., (Copyright: © 2020 Norman M et al.)

Background: Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective., Objectives: To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments., Design: This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out., Setting: The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018., Participants: Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology., Interventions: The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy., Main Outcome Measures: The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important., Results: The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p  = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p  = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p  = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release, n  = 8; manipulation under anaesthesia, n  = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST., Limitations: Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial., Conclusions: None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs., Future Work: Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence., Trial Registration: Current Controlled Trials ISRCTN48804508., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

Background: Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection., Methods: In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508., Findings: Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release)., Interpretation: All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective., Funding: The National Institute for Health Research Health Technology Assessment programme., (Copyright © 2020 The Author(s). Publishedx by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Hyperglycemia is a complication of induction chemotherapy in 10%-50% of pediatric patients with acute lymphoblastic leukemia (ALL). Though hyperglycemia in ALL patients is usually transient, it may be associated with adverse health outcomes. However, the risk factors for and consequences of hyperglycemia are poorly understood. We hypothesized that hyperglycemia significant enough to require insulin therapy during induction chemotherapy would be associated with increased morbidity and mortality in pediatric ALL patients during induction chemotherapy and in subsequent care., Methods: We abstracted clinical and resource utilization data from the Pediatric Health Information System (PHIS) database utilizing ICD-9 codes and medication charges. We used logistic regression analysis to predict the development of hyperglycemia. The effects of hyperglycemia on binary and count adverse outcomes following induction chemotherapy were modeled using mixed-effect regression models., Results: An increased risk of hyperglycemia requiring insulin was associated with older age, female sex, higher risk group and trisomy 21. Patients on insulin for hyperglycemia had increased mortality following induction chemotherapy. These patients were more likely to have subsequent infectious complications, need for bone marrow transplant, and risk of disease relapse. They also had greater length of inpatient stay, higher cost of care, and were more likely to require intensive care unit admission during induction chemotherapy., Conclusions: Hyperglycemia requiring insulin during induction chemotherapy in pediatric ALL is associated with an increased risk of short-term and long-term complications. Prospective studies are needed to analyze formal screening, preventive measures, and optimal management practices for hyperglycemia during ALL induction chemotherapy., (© 2020 Wiley Periodicals LLC.)

Background: Mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL) is a rare lymphoma localized in the skin. Due to its indolent nature and similarity to other skin conditions, diagnosis is often delayed or incorrect. Consequently, accurate calculations of incidence and prevalence are difficult to make. The treatment pathway taken by MF-CTCL patients can differ depending upon local healthcare systems, clinical policies and guidelines., Aims: This study aims to (1) provide an estimate for the prevalence of treated MF-CTCL patients in Spain, (2) describe the Spanish patient treatment pathways for MF-CTCL, including quantification of the distribution of patients between primary, secondary and tertiary care institutions, and (3) investigate and quantify the treatment preferences of physicians., Methodology: This study employed primary market research methodologies to facilitate the collection of patient numbers and treatment practices from healthcare professionals (HCPs) and patients., Limitations: Poor diagnosis of MF-CTCL may mean that actual prevalence levels in the broader population are higher than those estimated by this analysis of treated patients. This study was reliant upon accurate reporting by HCPs of patient numbers and their personal treatment practices. The rarity of the condition means the patient sample size is relatively small and limits possible accuracy of the quantitative analyses of patient-derived data, although this is supplemented by HCP-derived data in the analysis., Findings: Around 75% of MF-CTCL patients in Spain report that the initial diagnosis by their general practitioner is incorrect. This is usually due to underestimation of severity or type of skin disease. Once they have been correctly diagnosed (usually by a dermatologist) in secondary care, the management of MF-CTCL is led by dermatologists. In 39% of patients, shared care teams are also involved in patient management. Following diagnosis, the majority of patient management is conducted by secondary or tertiary care centers., Conclusions: Incidence rates have increased in recent years, and possible reasons for this include improving levels of diagnosis. Survival in MF-CTCL has also increased over the last few decades. This trend appears to be reflected in the prevalence reported in this study, which is higher than suggested by some other estimates. However, it is still likely that there are further undiagnosed MF-CTCL patients in Spain due to the challenges of diagnosis at the primary care level., Competing Interests: Disclosure and potential conflicts of interest: Paolo D’Agostino and Marco Turini were both employees of Helsinn Healthcare SA at the time of the study. Fabian Schmidt was an employee of Recordati Rare Diseases SARL at the time of the study. Eric Sharp and Alan Kent are both directors of Polestar Insights Limited. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2020/07/dic.2020-4-8-COI.pdf, (Copyright © 2020 D’Agostino P, Kent A, Sharp E, Schmidt F, Turini M.)

The Primordial Inflation Polarization Explorer (PIPER) is a balloon-borne telescope mission to search for inflationary gravitational waves from the early universe. PIPER employs two 32 × 40 arrays of superconducting transition-edge sensors, which operate at 100 mK. An open bucket Dewar of liquid helium maintains the receiver and telescope optics at 1.7 K. We describe the thermal design of the receiver and sub-Kelvin cooling with a continuous adiabatic demagnetization refrigerator (CADR). The CADR operates between 70 and 130 mK and provides ≈10 μW cooling power at 100 mK, nearly five times the loading of the two detector assemblies. We describe electronics and software to robustly control the CADR, overall CADR performance in flightlike integrated receiver testing, and practical considerations for implementation in the balloon float environment.

This short communication describes the clinical and morphological findings, diagnosis and treatment of a case of Mycobacterium avium infection in a golden retriever that presented with a progressive nasal swelling and lymphadenopathy. Although well documented in cats, where cutaneous lesions are frequently recognised, canine M avium infection is less commonly reported, and cutaneous lesions are rare. To the authors' knowledge this is the first documented case of canine M avium infection that presented with a cutaneous lesion but no systemic clinical signs. It occurred in a dog with no previously reported breed predisposition and highlights that in cases of cutaneous histiocytic infiltrate in dogs mycobacterial infection should remain a differential diagnosis, even in the absence of suggestive organisms on histopathological examination., Competing Interests: Competing interests: CO’H is in receipt of a grant from Biotechnology and Biological Sciences Research Council., (© British Veterinary Association 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose The purpose of this paper is to explore the attitudes and beliefs of doctors towards medication error reporting following 15 years of a national patient safety agenda. Design/methodology/approach This is a qualitative descriptive study utilising semi-structured interviews. A group of ten doctors of different disciplines shared their attitudes and beliefs about medication error reporting. Using thematic content analysis, findings were reflected upon those collected by the same author of a similar study 13 years before (2002). Findings Five key themes were identified: lack of incident feedback, non-user-friendly incident reporting systems, supportive cultures, electronic prescribing and time pressures. Despite more positive responses to the benefits of medication error reporting in 2015 compared to 2002, doctors at both times expressed a reluctance to use the hospital's incident reporting system, labelling it time consuming and non-user-friendly. A more supportive environment, however, where error had been made was thought to exist compared to 2002. The role of the pharmacist was highlighted as critical in reducing medication error with the introduction of electronic prescribing being pivotal in 2015. Originality/value To the authors' knowledge, this is the first study to compare doctors' attitudes on medication errors following a period of time of increased patient safety awareness. The results suggest that error reporting today is largely more positive and organisations are more supportive than in 2002. Despite a change from paper to electronic methods, there is a continuing need to improve the efficacy of incident reporting systems and ensure an open, supportive environment for clinicians.

Background: Frozen shoulder (also known as adhesive capsulitis) occurs when the capsule, or the soft tissue envelope around the ball and socket shoulder joint, becomes scarred and contracted, making the shoulder tight, painful and stiff. It affects around 1 in 12 men and 1 in 10 women of working age. Although this condition can settle with time (typically taking 1 to 3 years), for some people it causes severe symptoms and needs referral to hospital. Our aim is to evaluate the clinical and cost-effectiveness of two invasive and costly surgical interventions that are commonly used in secondary care in the National Health Service (NHS) compared with a non-surgical comparator of Early Structured Physiotherapy., Methods: We will conduct a randomised controlled trial (RCT) of 500 adult patients with a clinical diagnosis of frozen shoulder, and who have radiographs that exclude other pathology. Early Structured Physiotherapy with an intra-articular steroid injection will be compared with manipulation under anaesthesia with a steroid injection or arthroscopic (keyhole) capsular release followed by manipulation. Both surgical interventions will be followed with a programme of post-procedural physiotherapy. These treatments will be undertaken in NHS hospitals across the United Kingdom. The primary outcome and endpoint will be the Oxford Shoulder Score (a patient self-reported assessment of shoulder function) at 12 months. This will also be measured at baseline, 3 and 6 months after randomisation; and on the day that treatment starts and 6 months later. Secondary outcomes include the Disabilities of Arm Shoulder and Hand (QuickDASH) score, the EQ-5D-5 L score, pain, extent of recovery and complications. We will explore the acceptability of the different treatments to patients and health care professionals using qualitative methods., Discussion: The three treatments being compared are the most frequently used in secondary care in the NHS, but there is uncertainty about which one works best and at what cost. UK FROST is a rigorously designed and adequately powered study to inform clinical decisions for the treatment of this common condition in adults., Trial Registration: International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508 . Registered on 25 July 2014.

Few studies have examined the use of prescription opioids in schools. The current study aimed to: (1) describe the context within which school nurses encounter student opioid prescriptions; (2) assess school nurses' preferences for training and student education; and (3) explore urban-rural differences in school nurses' experiences and training preferences. A convenience sample of school nurses (n = 633) from North Carolina and South Carolina participated in a brief, anonymous, online survey. Qualitative data were analyzed thematically and statistical tests (t-tests and Chi-square tests) were performed to investigate urban-rural differences. Many school nurses (40.3%) had encountered a student with an opioid prescription, but only 3.6% had naloxone available in case of an overdose. Most school nurses (69.9%), especially rural school nurses, believed students would benefit from opioid education (74.9 versus 66.6%, p = 0.03). The majority of school nurses (83.9%) were interested in opioid-related training. Many school nurses encounter students with prescription opioids and would like additional opioid-related training. The potential benefits of providing naloxone access to prevent opioid-related deaths at schools should be explored.

Anticoagulant rodenticides (ARs) are highly toxic compounds that are exclusively used for the control of rodent pests. Despite their defined use, they are nonetheless found in a large number of non-target species indicating widespread penetration of wildlife. Attempts to quantify the scale of problem are complicated by non-random sampling of individuals tested for AR contamination. The American mink (Neovison vison) is a wide ranging, non-native, generalist predator that is subject to wide scale control efforts in the UK. Exposure to eight ARs was determined in 99 mink trapped in NE Scotland, most of which were of known age. A high percentage (79%) of the animals had detectable residues of at least one AR, and more than 50% of the positive animals had two or more ARs. The most frequently detected compound was bromadiolone (75% of all animals tested), followed by difenacoum (53% of all mink), coumatetralyl (22%) and brodifacoum (9%). The probability of mink exposure to ARs increased by 4.5% per month of life, and was 1.7 times higher for mink caught in areas with a high, as opposed to a low, density of farms. The number of AR compounds acquired also increased with age and with farm density. No evidence was found for sexual differences in the concentration and number of ARs. The wide niche and dietary overlap of mink with several native carnivore species, and the fact that American mink are culled for conservation throughout Europe, suggest that this species may act as a sentinel species, and the application of these data to other native carnivores is discussed., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Identification of risk factors which are associated with severe clinical signs can assist in the management of disease outbreaks and indicate future research areas. Pregnancy loss during late gestation in the mare compromises welfare, reduces fecundity and has financial implications for horse owners. This retrospective study focussed on the identification of risk factors associated with pregnancy loss among 46 Thoroughbred mares on a single British stud farm, with some but not all losses involving equid herpesvirus-1 (EHV-1) infection. In a sub-group of 30 mares, association between pregnancy loss and the presence of five common Thoroughbred horse haplotypes of the equine Major Histocompatibility Complex (MHC) was assessed. This involved development of sequence specific, reverse transcriptase polymerase chain reactions and in several mares, measurement of cytotoxic T lymphocyte activity. Of the 46 mares, 10 suffered late gestation pregnancy loss or neonatal foal death, five of which were EHV-1 positive. Maternal factors including age, parity, number of EHV-1 specific vaccinations and the number of days between final vaccination and foaling or abortion were not significantly associated with pregnancy loss. In contrast, a statistically significant association between the presence of the MHC class I B2 allele and pregnancy loss was identified, regardless of the fetus/foal's EHV-1 status (p=0.002). In conclusion, this study demonstrated a significantly positive association between pregnancy loss in Thoroughbred mares and a specific MHC class I allele in the mother. This association requires independent validation and further investigation of the mechanism by which the mare's genetic background contributes to pregnancy outcome., (Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.)

Existing research on aggression tends to narrowly focus on peers; less is known about sibling aggression, most likely due to its historical acceptance. Aggression is characterized by its forms (i.e., physical vs. social or relational aggression) and its functions (i.e., the motivations behind the aggressive act and categorized as proactive vs. reactive aggression). We use data from a two-wave study of middle (n = 197; M age = 12.63 years at Wave 1) and older (n = 159; M age = 16.50 years at Wave 1) adolescents to assess the extent to which proactive and reactive functions of sibling aggression make unique or conditional contributions to adolescent adjustment (i.e., depression, delinquency, and substance use). We find that proactive sibling aggression increases risk for problem substance use and delinquent behavior, reactive sibling aggression increases risk for depressed mood and delinquent behavior, and such results are observed even with statistical adjustments for sociodemographic and family variables, stressful life events, and prior adjustment. Few conditional effects of proactive or reactive sibling aggression by sex or grade are observed; yet, for all three outcomes, the harmful effects of reactive sibling aggression are strongest among adolescents who report low levels of proactive sibling aggression. The results speak to the importance of understanding the proactive and reactive functions of sibling aggressive behaviors for adolescent adjustment., (© The Author(s) 2014.)

A 42-year-old female teetotaller presented via the accident and emergency department with a 2-day history of vomiting and upper abdominal pain. She was diagnosed with acute pancreatitis. The aetiology of the pancreatitis was identified as hypercalcaemia secondary to oral calcium supplementation. The hypercalcaemia was corrected by stopping calcium supplements and aggressive fluid resuscitation. A thorough literature search did not show any case reports in which the aetiology of pancreatitis was oral calcium supplement over-replacement.

Rapid temperature and precipitation changes in High Arctic tundra ecosystems are altering the biogeochemical cycles of carbon (C) and nitrogen (N), but in ways that are difficult to predict. The challenge grows from the uncertainty of N cycle responses and the extent to which shifts in soil N are coupled with the C cycle and productivity of tundra systems. We used a long-term (since 2003) experiment of summer warming and supplemental summer water additions to a High Arctic ecosystem in NW Greenland, and applied a combination of discrete sampling and in situ soil core incubations to measure C and N pools and seasonal microbial processes that might control plant-available N. We hypothesized that elevated temperature and increased precipitation would stimulate microbial activity and net inorganic N mineralization, thereby increasing plant N-availability through the growing season. While we did find increased N mineralization rates under both global change scenarios, water addition also significantly increased net nitrification rates, loss of NO3 (-) -N via leaching, and lowered rates of labile organic N production. We also expected the chronic warming and watering would lead to long-term changes in soil N-cycling that would be reflected in soil δ(15) N values. We found that soil δ(15) N decreased under the different climate change scenarios. Our results suggest that temperature accelerates biological processes and existing C and N transformations, but moisture increases soil hydraulic connectivity and so alters the pathways, and changes the fate of the products of C and N transformations. In addition, our findings indicate that warmer, wetter High Arctic tundra will be cycling N and C in ways that may transform these landscapes in part leading to greater C sequestration, but simultaneously, N losses from the upper soil profile that may be transported to depth dissolved in water and or transported off site in lateral flow., (© 2013 John Wiley & Sons Ltd.)

Orthopaedic limb reconstruction patients often have wounds that are difficult to heal either due to the underlying problems, their surgery, underlying comorbidities or a combination of these factors. Negative pressure wound therapy (NPWT) is a useful tool with which to manage these wounds; however, many systems are not ideal for use in the patient's home, due in part to size and complexity. There are also staff training issues if transferring patients to an area which does not routinely use negative pressure systems. This paper reports the outcomes for some of the patients who were treated with a novel, single-use NPWT device in a orthopaedic trauma/limb reconstruction unit.

Despite the documented risk of secondary poisoning to non-target species by anticoagulant rodenticides there is no statutory post-approval monitoring of their use in the UK. This paper presents results from two Scottish monitoring schemes for the period 2000-2010; recording rodenticide use on arable farms and the presence of residues in raptor carcasses. More than three quarters of arable farms used anticoagulant rodenticides; predominately the second generation compounds difenacoum and bromadiolone. There was widespread exposure to anticoagulant rodenticides in liver tissues of the raptor species tested and the residues encountered generally reflected agricultural use patterns. As found in other studies, Red Kites (Milvus milvus) appeared to be particularly vulnerable to rodenticide exposure, 70 % of those sampled (n = 114) contained residues and 10 % died as a result of rodenticide ingestion. More unexpectedly, sparrowhawks (Accipiter nisus), which prey almost exclusively on birds, had similar exposure rates to species which prey on rodents. Although, with the exception of kites, confirmed mortality from rodenticides was low, the widespread exposure recorded is concerning. Particularly when coupled with a lack of data about the sub-lethal effects of these compounds. This raises questions regarding whether statutory monitoring of use is needed; both to address whether there are deficiencies in compliance with approval conditions or whether the recommended risk management procedures are themselves adequate to protect non-target wildlife.

Objectives: To identify risk factors for failure of outpatient antibiotic therapy (OPAT) in infective endocarditis (IE)., Patients and Methods: We identified IE cases managed at a single centre over 12 years from a prospectively maintained database. 'OPAT failure' was defined as unplanned readmission or antibiotic switch due to adverse drug reaction or antibiotic resistance. We analysed patient and disease-related risk factors for OPAT failure by univariate and multivariate logistic regression. We also retrospectively collected follow-up data on adverse disease outcome (defined as IE-related death or relapse) and performed Kaplan-Meier survival analysis up to 36 months following OPAT., Results: We identified 80 episodes of OPAT in IE. Failure occurred in 25/80 episodes (31.3%). On multivariate analysis, cardiac or renal failure [pooled OR 7.39 (95% CI 1.84-29.66), P=0.005] and teicoplanin therapy [OR 8.69 (95% CI 2.01-37.47), P=0.004] were independently associated with increased OPAT failure. OPAT failure with teicoplanin occurred despite therapeutic plasma levels. OPAT failure predicted adverse disease outcome up to 36 months (P=0.016 log-rank test)., Conclusions: These data caution against selecting patients with endocarditis for OPAT in the presence of cardiac or renal failure and suggest teicoplanin therapy may be associated with suboptimal OPAT outcomes. Alternative regimens to teicoplanin in the OPAT setting should be further investigated.

We report a 77-year-old woman, newly diagnosed with a malignant lung neoplasm of indeterminate nature who presented with profuse bilious vomiting without abdominal distension, pain or constipation. CT confirmed proximal small bowel obstruction. Laparotomy found a large area of intussusception from an intraluminal mass in the small bowel, which was resected and a primary anastomosis performed. Histology reported the mass as metastatic non-small-cell carcinoma and brought clarity to the primary tumour diagnosis. The patient made a good recovery from the operation, but unfortunately died a few months later from complications of her metastatic disease.

Coagulation in drinking water treatment has relied upon iron (Fe) and aluminium (Al) salts throughout the last century to provide the bulk removal of contaminants from source waters containing natural organic matter (NOM). However, there is now a need for improved treatment of these waters as their quality deteriorates and water quality standards become more difficult to achieve. Alternative coagulant chemicals offer a simple and inexpensive way of doing this. In this work a novel zirconium (Zr) coagulant was compared against traditional Fe and Al coagulants. The Zr coagulant was able to provide between 46 and 150% lower dissolved organic carbon (DOC) residual in comparison to the best traditional coagulant (Fe). In addition floc properties were significantly improved with larger and stronger flocs forming when the Zr coagulant was used with the median floc sizes being 930 μm for Zr; 710 μm for Fe and 450 μm for Al. In pilot scale experiments, a similar improved NOM and particle removal was observed. The results show that when optimised for combined DOC removal and low residual turbidity, the Zr coagulant out-performed the other coagulants tested at both bench and pilot scale., (Copyright © 2012 Elsevier Ltd. All rights reserved.)