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Background The Geriatric Surgery Verification Program (GSV) was developed to address perioperative care for patients ≥75 years, with a goal of improving outcomes and functional abilities after surgery. We sought to evaluate preoperative factors that place patients at risk for inability to return home (ie, discharge to a facility).Methods Retrospective review of patients ≥75 years old who underwent inpatient surgery from January 2018 to December 2022 at a referral Veterans Administration Medical Center enrolled in the GSV program. Preoperative factors included fall history, mobility aids, housing status, function, cognition, and nutritional status. Postoperative outcomes were discharge designations as home and home with services compared to a facility (skilled nursing facility and acute rehab). Exclusion criteria included preoperative facility residence, cardiac surgery, hospital transfer, postoperative complications, hospice discharge, or in-hospital mortality.Results 605 patients met inclusion criteria and 173 (29%) excluded as above. Of the remaining 432 patients, mean age was 79 ± 5 and the majority were male, 426 (99%). The majority of patients were discharged home, 388 (90%), compared to a facility, 44 (10%). Patients with a fall history (OR: 2.95, 95% CI: 1.56, 5.57), utilizing a mobility aid (OR: 6.0, 95% CI: 2.8, 12.83), were partial or totally dependent (OR: 4.83, 95% CI: 2.29, 10.17), or who lived alone (OR: 2.57, 95% CI: 1.08, 6.07) had higher rates of discharge to a facility.Discussion Preoperative mobility compromise and functional dependence are associated with higher rates of discharge to a facility. These preoperative factors are possibly modifiable with multidisciplinary care teams to decrease risks of facility placement.

Background: The ability to ambulate is an important indicator for wellness and quality of life. A major health event, such as a surgery, can derail this ability, and return to preoperative walking ability is a marker for recovery. Self-reported walking measurements by patients are subject to bias, thus wearable technology such as activity monitors have risen in popularity. We evaluated postoperative ambulation using an accelerometer in outpatient general surgery procedures with the hypothesis that those patients with less postoperative ambulation were at risk for adverse outcomes. Methods: A retrospective review of patients undergoing outpatient abdominal surgeries from November 2016 to July 2019 at a Veteran Affairs Medical Center. Patients wore an accelerometer preoperatively and postoperatively to measure their ambulation (steps/day). Outcome measures were 30-day readmissions and Emergency Department (ED) utilization. Postoperative ambulation was defined as daily percentages of their preoperative baseline. Patients without preoperative baseline data, > 3 missing days or any missing days prior to reaching baseline were excluded. Results: One-hundred-six patients underwent outpatient abdominal surgery. Twenty-two patients were excluded. Patients stratified into adult (18–64 years, 44 patients, 52%) and geriatric (≥ 65 years, 40 patients, 48%) cohorts. Geriatric patients were less likely to meet their preoperative baseline by postoperative day 7, 35% vs 61%, p= 0.016. Adult patients who failed to meet their preoperative baseline in first postoperative week had higher ED utilization; 4 (24%) vs 1 (4%), p= 0.04. Geriatric patients who failed to meet their baseline trended toward increased ED utilization; 5 (19%) vs. 1 (7%), p= 0.31. Conclusion: Patients aged < 65 who fail to return to their preoperative daily step count within one week of outpatient abdominal surgery are 6× more likely to be seen in the ED. Postoperative ambulation may be able to predict ED utilization and recovery after outpatient surgery.

Background: Stray energy transfer from monopolar instruments during laparoscopic surgery is a recognized cause of potentially catastrophic complications. There are limited data on stray energy injuries in robotic surgery. We sought to characterize stray energy injury in the form of superficial burns to the skin surrounding laparoscopic and robotic trocar sites. Our hypothesis was that stray energy burns will occur at all laparoscopic and robotic port sites. Methods: We conducted a prospective, randomized controlled trial of patients undergoing elective unilateral inguinal hernia repair at a VAMC over a 4-year period. Surgery was performed via transabdominal preperitoneal approach either laparoscopic-assisted (TAPP) or robotic-assisted (rTAPP). A monopolar scissor was used to deliver energy at 30W coagulation for all cases. At completion of the procedure, skin biopsies were taken from all the port sites. A picro-Sirius red stain was utilized to identify thermal injury by a blinded pathologist. Results: Over half (54%, 59/108) of all samples demonstrated thermal injury to the skin. In the laparoscopic group, 49% (25/51) samples showed thermal injury vs. 60% (34/57) in the robotic group (p= 0.548). The camera port was the most frequently involved with 68% (13/19) rTAPP samples showing injury vs. 47% (8/17) in the TAPP group (p= 0.503). There was no difference in the rate of injury at the working port site (rTAPP 53%, 10/19 vs. TAPP 47%, 8/17; p= 0.991) or the assistant port site (rTAPP 58%, 11/19 vs. TAPP 53%, 9/17; p= 0.873). Conclusions: Stray energy causes thermal injury to the skin at port sites in the majority robotic laparoscopic TAPP inguinal hernia repairs. There is no difference in stray energy transfer between the laparoscopic and robotic platform. This is the first study to confirm in-vivo transfer of stray energy during robotic surgical procedures. More study is needed to determine the clinical significance of these thermal injuries.

Up to now, there was no way to observe and track the affective impacts of the massive amount of complex visual stimuli that people encounter “in the wild” during their many hours of digital life. In this paper, we propose and illustrate how recent advances in AI—trained ensembles of deep neural networks—can be deployed on new data streams that are long sequences of screenshots of study participants’ smartphones obtained unobtrusively during everyday life. We obtained affective valence and arousal ratings of hundreds of images drawn from existing picture repositories often used in psychological studies, and a new screenshot repository chronicling individuals’ everyday digital life from both N= 832 adults and an affect computation model (Parry & Vuong, 2021). Results and analysis suggest that (a) our sample rates images similarly to other samples used in psychological studies, (b) the affect computation model is able to assign valence and arousal ratings similarly to humans, and (c) the resulting computational pipeline can be deployed at scale to obtain detailed maps of the affective space individuals travel through on their smartphones. Leveraging innovative methods for tracking the emotional content individuals encounter on their smartphones, we open the possibility for large-scale studies of how the affective dynamics of everyday digital life shape individuals’ moment-to-moment experiences and well-being.

The photophysics associated with the self-assembly of π-peptide molecules into 1-D nanostructures has been well-established, thus revealing the creation of nanoscale electronic conduits in aqueous media. Such materials have therapeutic potential in many biomedical applications. In this work, we report the in vivo deployment of these π-peptide nanostructures in brain tissue using photothrombotic stroke as a model application. A test peptide was used for brain injections, and the nanostructures formed were visualized with electron microscopy. A new peptide bearing a low-energy fluorescence dye was prepared to facilitate direct visualization of π-peptide localization in the brain cavity by way of fluorescence microscopy. This work demonstrates feasibility for in vivo application of π-peptide nanostructures toward pressing biomedical challenges.

Predicting the redox behavior of magnetite in reducing soils and sediments is challenging because there is neither agreement among measured potentials nor consensus on which Fe(III) | Fe(II) equilibria are most relevant. Here, we measured open-circuit potentials of stoichiometric magnetite equilibrated over a range of solution conditions. Notably, electron transfer mediators were not necessary to reach equilibrium. For conditions where ferrous hydroxide precipitation was limited, Nernstian behavior was observed with an EHvs pH slope of −179 ± 4 mV and an EHvs Fe(II)aqslope of −54 ± 4 mV. Our estimated EHoof 857 ± 8 mV closely matches a maghemite|aqueous Fe(II) EHoof 855 mV, suggesting that it plays a dominant role in poising the solution potential and that it’s theoretical Nernst equation of EH[mV] = 855 – 177 pH – 59 log [Fe2+] may be useful in predicting magnetite redox behavior under these conditions. At higher pH values and without added Fe(II), a distinct shift in potentials was observed, indicating that the dominant Fe(III)|Fe(II) couple(s) poising the potential changed. Our findings, coupled with previous Mössbauer spectroscopy and kinetic data, provide compelling evidence that the maghemite/Fe(II)aqcouple accurately predicts the redox behavior of stoichiometric magnetite suspensions in the presence of aqueous Fe(II) between pH values of 6.5 and 8.5.

Accurate data on type 1 diabetes prevalence, incidence, associated mortality and life expectancy are crucial to inform public health policy, but these data are scarce. We therefore developed a model based on available data to estimate these values for 201 countries for the year 2021 and estimate the projected prevalent cases in 2040.

Background: The Fundamental Use of Surgical Energy (FUSE) program was developed by The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to promote the safe use of surgical energy. A curriculum that could be used in hospital educational programs was needed to expand access. The goal of this project was to develop a short, inexpensive, online module that emphasizes key FUSE learning objectives. The accompanying survey assessed perceived relevancy. Methods: The SAGES FUSE Committee developed the Hospital Compliance Module. The target audience included all OR personnel. The Module was piloted at Beth Israel Deaconess Medical Center. The data were analyzed using Chi-square with Yates’ correction two-tailed test. Results: Three-hundred-eighty individuals completed the survey: 198 (52%) surgeons, 139 (37%) nurses, 28 (7%) surgical technicians, and 15 (4%) house staff. For “…the Module taught me valuable information” 155 (41%) responded extremely and 350 (92%) responded at least somewhat. For “As a result of [the Module] how likely are you to change how you set up or use energy devices…?” 103 (27%) responded extremely and 305 (80%) responded at least somewhat. For “How likely are you to recommend this compliance module…?” 143 (38%) responded extremely and 333 (88%) responded at least somewhat. Conclusion: The FUSE Hospital Compliance Module is effective and efficient. It should be considered for widespread distribution by hospitals to enhance staff education.

Background: Recovery of preoperative ambulation levels 1 month after surgery represents an important patient-centered outcome. The objective of this study is to identify clinical factors associated with the inability to regain baseline preoperative ambulation levels 28 days postoperatively. Methods: This is a prospective cohort study enrolling patients scheduled for elective inpatient abdominal operations. Daily ambulation (steps/day) was measured with a wristband accelerometer. Preoperative steps were recorded for at least 3 full calendar days before surgery. Postoperatively, daily steps were recorded for at least 28 days. The primary outcome was delayed recovery of ambulation, defined as inability to achieve 50% of preoperative baseline steps at 28 days postoperatively. Results: A total of 108 patients were included. Delayed recovery (< 50% of baseline preoperative steps/day) occurred in 32 (30%) patients. Clinical factors associated with delayed recovery after multivariable logistic regression included longer operative time (OR 1.37, 95% CI 1.05–1.79), open operative approach (OR 4.87, 95% CI 1.64–14.48) and percent recovery on POD3 (OR 0.73, 95% CI 0.56–0.96). In addition, patients with delayed ambulation recovery had increased rates of postoperative complications (16% vs 1%, p< 0.01) and readmission (28% vs 5%, p< 0.01). Conclusion: After elective inpatient abdominal operations, nearly one in three patients do not recover 50% of their baseline preoperative steps 28 days postoperatively. Factors that can be used to identify these patients include longer operations, open operations and low ambulation levels on postoperative day #3. These data can be used to target rehabilitation efforts aimed at patients at greatest risk for poor ambulatory recovery.

•DNP enables the implementation of 13C-195Pt J-HMQC experiments on surface-supported Pt sites at natural isotopic abundance.•This methodology can detect as low as 0.015 wt% Pt.•Key NMR parameters of Pt sites, δ(13C), δ(195Pt) and 1J(13C-195Pt), are measured.•These NMR parameters directly report on the coordination sphere of surface Pt sites.•This study confirms that the surface Pt complexes have a well-defined structure.

Introduction: Stray energy from surgical energy instruments can cause unintended thermal injuries. There are no published data regarding electrosurgical generators and their influence on stray energy transfer during robotic surgery. There are two approved generators for the DaVinci Xi robotic platform: a constant-voltage regulating generator (cVRG) and a constant-power regulating generator (cPRG). The purpose of this study was to quantify and compare stray energy transfer in the robotic Xi platform using a cVRG versus a cPRG. Methods: An ex vivo bovine model was used to simulate a standard multiport robotic surgery. The DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) robotic platform was attached to a trainer box using robotic ports. A 5 s, open-air activation of the monopolar scissors was done with commonly used electrosurgical settings using a cPRG (ForceTriad, Covidien-Medtronic, Boulder, CO) or cVRG (ERBE VIO 300 dV 2.0, ERBE USA, Marietta, GA). Stray energy transfer was quantified as the change in tissue temperature (°C) nearest the tip of the assistance grasper (which was not in direct contact with the active monopolar scissors). Results: Stray energy transfer occurred with both generators. Utilizing common, comparable settings for standard coagulation, significantly less stray energy was transferred with the cVRG versus cPRG (4.4 ± 1.6 °C vs. 41.1 ± 13.0 °C, p< 0.001). Similarly, less stray energy was transferred using cut modes with the cVRG compared to the cPRG (5.61 ± 1.79 °C vs. 33.9 ± 18.4 °C, p< 0.001). Conclusion: Stray energy transfer increases tissue temperatures more than 45C in the DaVinci Xi robotic platform. Low voltage modalities, such as cut or blend; as well as a cVRG generator, significantly reduces stray energy. Robotic surgeons can minimize the risk of stray energy injuries by using these low risk modes and/or generator.

Background: The COVID-19 pandemic has brought many challenges including barriers to delivering high-quality surgical care and follow-up while minimizing the risk of infection. Telehealth has been increasingly utilized for post-operative visits, yet little data exists to guide surgeons in its use. We sought to determine safety and efficacy of telehealth follow-up in patients undergoing cholecystectomy during the global pandemic at a VA Medical Center (VAMC). Methods: This was a retrospective review of patients undergoing cholecystectomy at a level 1A VAMC over a 2-year period from August 2019 to August 2021. Baseline demographics, post-operative complications, readmissions, emergency department (ED) visits and need for additional procedures were reviewed. Patients who experienced a complication prior to discharge, underwent a concomitant procedure, had non-absorbable skin closure, had new diagnosis of malignancy or were discharged home with drain(s) were ineligible for telehealth follow-up and excluded. Results: Over the study period, 179 patients underwent cholecystectomy; 30 (17%) were excluded as above. 20 (13%) missed their follow-up, 52 (35%) were seen via telehealth and 77 (52%) followed-up in person. There was no difference between the two groups regarding baseline demographics or intra-operative variables. There was no significant difference in post-operative complications [4 (8%) vs 6 (8%), p> 0.99], ED utilization [5 (10%) vs 7 (9%), p= 0.78], 30-day readmission [3 (6%) vs 6 (8%), p = 0.74] or need for additional procedures [2 (4%) vs 4 (5%), p= 0.41] between telehealth and in-person follow-up. Conclusion: Telehealth follow-up after cholecystectomy is safe and effective in Veterans. There were no differences in outcomes between patients that followed up in-person vs those that were seen via phone or video. Routine telehealth follow-up after uncomplicated cholecystectomy should be considered for all patients.

Introduction: Enteral access is required for a variety of reasons from neuromuscular disorders to dysphagia. Gastrostomy tubes (GTs) can be placed endoscopically, surgically, or radiographically and complications include infection, bleeding, leakage and unintentional removal. Routine post-procedural follow-up is limited by inconsistent guidelines and management by different specialty teams. We established a dedicated GT clinic to provide continuity of care and prophylactic GT exchange. We hypothesized that patients followed in the GT clinic would have reduced Emergency Department (ED) utilization. Methods: A retrospective review of patients who underwent GT placement from January 2010 to January 2020 was conducted. Baseline demographics, indications for GT placement, number and reason for ED visits and utilization of a multidisciplinary GT clinic were studied. Results: A total of 97 patients were included. The most common indication for placement was dysphagia (88, 91%) and the most common primary diagnosis was head and neck malignancy (51, 51%). The GT clinic is a multidisciplinary clinic staffed by surgeons and residents, dieticians, and wound care specialists and cared for 16 patients in this study. Three patients (19%) in the GT clinic group required ED visits compared to 44 (54%) in the standard of care (SOC) group (p< 0.05). There was an average of 0.9 ED visits per patient (range 0–7) in the GT clinic group vs 1.6 ED visits per patient (range 0–20) in the SOC group (p= 0.34). Feeding tubes were prophylactically exchanged an average of 7 times per patient in the GT clinic group vs 3 times per patient in the SOC group (p< 0.05). Conclusion: A multidisciplinary clinic dedicated to GT care limits ED visits for associated complications by more than 50%. Follow-up in a dedicated clinic with prophylactic tube exchange decreases ED visits and should be considered at facilities that care for patients with GTs.

AbstractFirms in the USA rely on highly skilled immigrants, particularly in the science and engineering sectors. Yet, the recent politics of immigration marks a substantial change to US immigration policy. We implement a conjoint experiment that isolates the causal effect of nativist, anti-immigrant, pronouncements on where skilled potential-migrants choose to immigrate to. While these policies have a significantly negative effect on the destination choices of Chilean and UK student subjects, they have little effect on the choices of Indian and Chinese student subjects. These results are confirmed through an unobtrusive test of subjects’ general immigration destination preferences. Moreover, there is some evidence that the negative effect of these nativist policies are particularly salient for those who self-identify with the Left.

Introduction: More than 3 million patients have a cardiac implanted electronic device (CIED) such as a pacemaker or implanted cardioverter-defibrillator in the USA. These devices are susceptible to electromagnetic interference (EMI) leading to malfunction and injury. Radiofrequency energy, the most common modality for obtaining hemostasis during endoscopy, is the most common source of EMI. Few studies have evaluated the effect of endoscopic radiofrequency energy on CIEDs. We aim to characterize CIED dysfunction related to endoscopic procedures. We hypothesize that EMI from endoscopic energy can result in patient injury. Methods: We queried the Manufacturer and User Facility Device Experience (MAUDE) database for CIED dysfunction related to electrosurgical devices over a 10-year period (2009–2019). CIED dysfunction events were identified using seven problem codes (malfunction, electromagnetic interference, ambient noise, pacing problem, over-sensing, inappropriate shock, defibrillation). These were cross-referenced for the terms “cautery, electrocautery, endoscopy, esophagus, colonoscopy, colon, esophagoscopy, and esophagogastroduodenoscopy.” Reports were individually reviewed to confirm and characterize CIED malfunction due to an endoscopic procedure. Results: A search for CIED dysfunction resulted in 43,759 reports. Three hundred and eleven reports (0.7%) were associated with electrocautery, and of these, 45 reports (14.5%) included endoscopy. Ten reports involving endoscopy (22%) specified upper (3, 7%) or lower (7, 16%) endoscopy while the remainder were non-specific. Twenty-six of reports involving endoscopy (58%) suffered injury because of CIED dysfunction: Of these, 17 (65%) received inappropriate shocks, 5 (19%) had pacing inhibition with bradycardia or asystole, 3 (12%) had CIED damage requiring explant and replacement, and 1 (4%) patient suffered ventricular tachycardia requiring hospital admission. Conclusion: The use of energy during endoscopy can cause dysfunction of CIEDs. This most commonly results in inappropriate defibrillation, symptomatic bradycardia, and asystole. Patients with CIEDs undergoing endoscopy should undergo pre- and post-procedure device interrogation and re-programming to avoid patient injury.

Introduction: Stray energy transfer from surgical monopolar radiofrequency energy instruments can cause unintended thermal injuries during laparoscopic surgery. Single-incision laparoscopic surgery transfers more stray energy than traditional laparoscopic surgery. There is paucity of published data concerning stray energy during single-incision roboticsurgery. The purpose of this study was to quantify stray energy transfer during traditional, multiport robotic surgery (TRS) compared to single-incision robotic surgery (SIRS). Methods: An in vivo porcine model was used to simulate a multiport or single-incision robotic cholecystectomy (DaVinci Si, Intuitive Surgical, Sunnyvale, CA). A 5 s, open air activation of the monopolar scissors was done on 30 W and 60 W coag mode (ForceTriad, Covidien-Medtronic, Boulder, CO) and Swift Coag effect 3, max power 180 W (VIO 300D, ERBE USA, Marietta, GA). Temperature of the tissue (°C) adjacent to the tip of the assistant grasper or the camera was measured with a thermal camera (E95, FLIR Systems, Wilsonville, OR) to quantify stray energy transfer. Results: Stray energy transfer was greater in the SIRS setup compared to TRS setup at the assistant grasper (11.6 ± 3.3 °C vs. 8.4 ± 1.6 °C, p= 0.013). Reducing power from 60 to 30 W significantly reduced stray energy transfer in SIRS (15.3 ± 3.4 °C vs. 11.6 ± 3.3 °C, p= 0.023), but not significantly for TRS (9.4 ± 2.5 °C vs. 8.4 ± 1.6 °C, p= 0.278). The use of a constant voltage regulating generator also minimized stray energy transfer for both SIRS (0.7 ± 0.4 °C, p< 0.001) and TRS (0.7 ± 0.4 °C, p< 0.001). Conclusions: More stray energy transfer occurs during single-incision robotic surgery than multiport robotic surgery. Utilizing a constant voltage regulating generator minimized stray energy transfer for both setups. These data can be used to guide robotic surgeons in their use of safe, surgical energy.

Introduction: Stray energy transfer from monopolar radiofrequency energy during laparoscopy can be potentially catastrophic. Robotic surgery is increasing in popularity; however, the risk of stray energy transfer during robotic surgery is unknown. The purpose of this study was to (1) quantify stray energy transfer using robotic instrumentation, (2) determine strategies to minimize the transfer of energy, and (3) compare robotic stray energy transfer to laparoscopy. Methods: In a laparoscopic trainer, a monopolar instrument (L-hook) was activated with DaVinci Si (Intuitive, Sunnyvale, CA) robotic instruments. A camera and assistant grasper were inserted to mimic a minimally invasive cholecystectomy. During activation of the L-hook, the non-electric tips of the camera and grasper were placed adjacent to simulated tissue (saline-soaked sponge). The primary outcome was change in temperature from baseline (°C) measured nearest the tip of the non-electric instrument. Results: Simulated tissue nearest the robotic grasper increased an average of 18.3 ± 5.8 °C; p< 0.001 from baseline. Tissue nearest the robotic camera tip increased (9.0 ± 2.1 °C; p< 0.001). Decreasing the power from 30 to 15 W (18.3 ± 5.8 vs. 2.6 ± 2.7 °C, p< 0.001) or using low-voltage cut mode (18.3 ± 5.8 vs. 3.1 ± 2.1 °C, p< 0.001) reduced stray energy transfer to the robotic grasper. Desiccating tissue, in contrast to open air activation, also significantly reduced stray energy transfer for the grasper (18.3 ± 5.8 vs. 0.15 ± 0.21 °C, p< 0.001) and camera (9.0 ± 2.1 vs. 0.24 ± 0.34 °C, p< 0.001). Conclusions: Stray energy transfer occurs during robotic surgery. The assistant grasper carries the highest risk for thermal injury. Similar to laparoscopy, stray energy transfer can be reduced by lowering the power setting, utilizing a low-voltage cut mode instead of coagulation mode and avoiding open air activation. These practical findings can aid surgeons performing robotic surgery to reduce injuries from stray energy.

IMPORTANCE: Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications. OBJECTIVES: To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019. EXPOSURES: Adults 80 years or older who underwent an inpatient surgical procedure. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient’s ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location. RESULTS: Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure. CONCLUSIONS AND RELEVANCE: In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.

Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2–5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations.

Objective:To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2–5 years of age.Methods:Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2–5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs.Results:Included were 51 studies evaluating 58 interventions (N= 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g= 0.10, 95% CI = 0.02–0.18; k= 55) and at the last follow-up (g= 0.17, 95% CI = 0.04–0.30; k= 14; range = 18–143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers.Conclusions:Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Introduction: The SAGES Fundamental Use of Surgical Energy (FUSE) program accompanied by a bench-top simulation has shown to improve knowledge of the safe use of energy devices. However, there are significant barriers and costs associated with delivering an effective structured simulation curriculum to a widespread international audience. The purpose of this study was to evaluate if bench-top simulation FUSE curriculum through telementoring is as effective as a live-in house proctor for electrosurgical training. Methods: A two-armed multi-institutional randomized controlled trial was designed, including a 1-h didactic electrosurgery course (FUSE curriculum), followed by a structured 1-h bench-top simulation training session. For the simulation, participants were randomized to either a live proctor who delivered the course on-site (LIVE group), or a proctor from a remote location using videoconferencing platform (TELEM group). Pre- and post-curriculum (immediate and 6 months) knowledge and self-perceived comfort and competence were assessed. Data are expressed as median [interquartile range], *p< 0.05. Results: Sixty-five (35 LIVE; 30 TELEM) surgical trainees from three institutions participated. Baseline characteristics were similar. Total score on the exam improved from 47% [40–54] to 78% [71–84]* amongst all participants, with similar immediate post-curriculum scores in the LIVE group compared to the TELEM group (77% [69–83] vs 80% [75–85]). At 6 months, performance on the exam declined significantly for both groups, but remained similar between the two (LIVE: 59% [51–71] vs TELEM: 71% [57–77]). Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 6 months) compared to baseline, with no difference between the two groups. Conclusion: A bench-top simulation FUSE course delivered via a telementoring platform seems to improve surgical trainees’ knowledge and comfort in the safe use of electrosurgical devices as effectively as when it is delivered by a live proctor, despite long-term decay for both methods.

In this study we use a combination of ionic- and photo-cross-linking to develop a fabrication method for producing biocompatible microstructures using a methacrylated gellan gum (a polyanion) and chitosan (a polycation) in addition to lithium phenyl-2,4,6-trimethylbenzoylphosphinate (LAP) as the photoinitiator. This work involves the development of a low-cost, portable 3D bioprinter and a customized extrusion mechanism for controlled introduction of the materials through a 3D printed microfluidic nozzle, before being cross-linked in situ to form robust microstructure bundles. The formed microstructures yielded a diameter of less than 1 μm and a tensile strength range of ∼1 MPa. This study is the first to explore and achieve GGMA:CHT microstructure fabrication by means of controlled in-line compaction and photo-cross-linking through 3D printed microfluidic channels.

Introduction: Surgical fires are a rare event that still occur at a significant rate and can result in severe injury and death. Surgical fires are fueled by vapor from alcohol-based skin preparations in the presence of increased oxygen concentration and a spark from an energy device. Carbon dioxide (CO2) is used to extinguish electrical fires, and we sought to evaluate its effect on fire creation in the operating room. We hypothesize that CO2delivered by the energy device will decrease the frequency of surgical fires fueled by alcohol-based skin preparations. Methods: An ex vivo model with 15 × 15 cm section of clipped, porcine skin was used. A commercially available electrosurgical pencil with a smoke evacuation tip was connected to a laparoscopic CO2insufflation system. The electrosurgical pencil was activated for 2 s at 30 watts coagulation mode immediately after application of alcohol-based surgical skin preparations: 70% isopropyl alcohol with 2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol with 0.7% iodine povacrylex (Iodine-IPA). CO2was infused via the smoke evacuation pencil at flow rates from 0 to 8 L/min. The presence of a flame was determined visually and confirmed with a thermal camera (FLIR Systems, Boston, MA). Results: Carbon dioxide eliminated fire formation at a flow rate of 1 L/min with CHG-IPA skin prep (0% vs. 60% with no CO2, p< 0.0001). Carbon dioxide reduced fire formation at 1 L/min (25% vs. 47% with no CO2, p= 0.1) with Iodine-IPA skin prep and fires were eliminated at 2 L/min of flow with Iodine-IPA skin prep (p< 0.0001). Conclusion: Carbon dioxide can eliminate surgical fires caused by energy devices in the presence of alcohol-based skin preps. Future studies should determine the optimal technique and flow rate of carbon dioxide in these settings.

Despite the rising incidence of childhood obesity, international data from Eurostat show that the prevalence of obesity among those aged 15–19 years remains under 5%, which offers an important opportunity for preventing subsequent adult obesity. Young people engage poorly, even obstructively, with conventional health initiatives and are often considered ‘hard to reach’. However, when approached in the language of youth, via IT, they express great concern, and unwanted weight gain in young people can be prevented by age-appropriate, independent, online guidance. Additionally, when shown online how ‘added value’ by industry can generate consumer harms as free market ‘externalities’, and how obesogenic ‘Big Food’ production and distribution incur environmental and ethical costs, young people make lasting behavioural changes that attenuate weight gain. This evidence offers a novel approach to obesity prevention, handing the initiative to young people themselves and supporting them with evidence-based methods to develop, propagate and ‘own’ social movements that can simultaneously address the geopolitical concerns of youth and obesity prevention.

To understand how people use digital media, researchers need to move beyond screen time and capture everything we do and see on our screens.

Surgical smoke evacuators may reduce the concentration of alcohol vapors from skin preparations at the site of electrosurgical device activation, decreasing operating room fire risk. Our aim was to compare the incidence of flames with and without smoke evacuation in a porcine ex vivo model. A monopolar device was activated after application of either 70% isopropyl alcohol/2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol/0.7% iodine povacrylex (iodine-IPA) skin preparations. No suction was compared with standard wall suction and 2 monopolar devices with built-in smoke evacuators. Flames were generated in 60% of CHG-IPA and 47% of iodine-IPA tests without suction. Wall suction did not significantly reduce fires (CHG-IPA 43% vs. 60%, P=0.30; iodine-IPA 57% vs. 47%, P=0.61). Use of both smoke evacuation devices reduced fires for CHG-IPA (17% vs. 60%, P=0.001 and 20% vs. 60%, P=0.004) but not for iodine-IPA. Smoke evacuation devices reduce fire risk when used with a chlorhexidine-alcohol skin preparation.

Gustilo type III open fractures involve extensive soft tissue damage and wound contamination that pose significant infection risks. The historical standard for antibiotic prophylaxis has been cefazolin and gentamicin. We conducted a retrospective cohort study of lower extremity type III open fractures treated with ceftriaxone alone for prophylaxis. Eighty-six patients were identified. Nearly all (98%) were managed with appropriate antibiotics, but only 55 (64%) received prophylaxis within 1 hour. Overall, there were 12 infections. This infection rate was not statistically different than the reported literature (14% vs 19%, P= .20). The infection rate between those who received antibiotics within 1 hour was not statistically different from those who got it beyond 1 hour (15% vs 13%, P= .98). In conclusion, the use of ceftriaxone as monotherapy for antibiotic prophylaxis in lower extremity type III open fractures is not statistically different than the use of historic prophylactic regimens.

Inadvertent medication reconciliation discrepancies are common among trauma patient populations. We conducted a prospective study at a level 1 trauma center to assess incidence of inadvertent medication reconciliation discrepancies following decreased reliance on short-term nursing staff. Patients and independent sources were interviewed for home medication lists and compared to admission medication reconciliation (AMR) lists. Of the 108 patients included, 37 patients (34%) never received an AMR. Of the 71 patients that had a completed AMR, 42 patients (59%) had one or more errors, with total 154 errors across all patients, for a rate of 3.7 per patient with any discrepancy. Patients taking ≥ 5 medications were significantly more likely to have an incomplete or inaccurate AMR than those taking <5 medications (89% vs 41%, P< .0001). Decreased reliance on short-term nursing staff did not decrease inadvertent admission medication reconciliation discrepancies. Additional interventions to decrease risk of medication administration errors are needed.

This work develops a type of local analysis that can prove concurrent systems deadlock free. As opposed to examining the overall behaviour of a system, local analysis consists of examining the behaviour of small parts of the system to yield a given property. We analyse pairs of interacting components to approximate system reachability and propose a new sound but incomplete/approximate framework that checks deadlock and local-deadlock freedom. By replacing exact reachability by this approximation, it looks for deadlock (or local-deadlock) candidates, namely, blocked (locally-blocked) system states that lie within our approximation. This characterisation improves on the precision of current approximate techniques. In particular, it can tackle non-hereditary deadlock-free systems, namely, deadlock-free systems that have a deadlocking subsystem. These are neglected by most approximate techniques. Furthermore, we demonstrate how SAT checkers can be used to efficiently implement our framework, which, typically, scales better than current techniques for deadlock-freedom analysis. This is demonstrated by a series of practical experiments.

IMPORTANCE: Autism behavioral therapy is effective but expensive and difficult to access. While mobile technology–based therapy can alleviate wait-lists and scale for increasing demand, few clinical trials exist to support its use for autism spectrum disorder (ASD) care. OBJECTIVE: To evaluate the efficacy of Superpower Glass, an artificial intelligence–driven wearable behavioral intervention for improving social outcomes of children with ASD. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial in which participants received the Superpower Glass intervention plus standard of care applied behavioral analysis therapy and control participants received only applied behavioral analysis therapy. Assessments were completed at the Stanford University Medical School, and enrolled participants used the Superpower Glass intervention in their homes. Children aged 6 to 12 years with a formal ASD diagnosis who were currently receiving applied behavioral analysis therapy were included. Families were recruited between June 2016 and December 2017. The first participant was enrolled on November 1, 2016, and the last appointment was completed on April 11, 2018. Data analysis was conducted between April and October 2018. INTERVENTIONS: The Superpower Glass intervention, deployed via Google Glass (worn by the child) and a smartphone app, promotes facial engagement and emotion recognition by detecting facial expressions and providing reinforcing social cues. Families were asked to conduct 20-minute sessions at home 4 times per week for 6 weeks. MAIN OUTCOMES AND MEASURES: Four socialization measures were assessed using an intention-to-treat analysis with a Bonferroni test correction. RESULTS: Overall, 71 children (63 boys [89%]; mean [SD] age, 8.38 [2.46] years) diagnosed with ASD were enrolled (40 [56.3%] were randomized to treatment, and 31 (43.7%) were randomized to control). Children receiving the intervention showed significant improvements on the Vineland Adaptive Behaviors Scale socialization subscale compared with treatment as usual controls (mean [SD] treatment impact, 4.58 [1.62]; P = .005). Positive mean treatment effects were also found for the other 3 primary measures but not to a significance threshold of P = .0125. CONCLUSIONS AND RELEVANCE: The observed 4.58-point average gain on the Vineland Adaptive Behaviors Scale socialization subscale is comparable with gains observed with standard of care therapy. To our knowledge, this is the first randomized clinical trial to demonstrate efficacy of a wearable digital intervention to improve social behavior of children with ASD. The intervention reinforces facial engagement and emotion recognition, suggesting either or both could be a mechanism of action driving the observed improvement. This study underscores the potential of digital home therapy to augment the standard of care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03569176

The reaction of (S)-proline with two-dimensional Ni nanoclusters on Au(111) results in the formation of ordered structures constructed from two distinct types of nickel prolinate complex. Scanning tunnelling microscopy and density functional theory are combined to analyze the supramolecular arrangements produced as a function of annealing temperature. Octahedral Ni(Pro)3complexes are the fundamental building blocks of multiple phases identified by the formation of hexagonal pores of 1 nm diameter. Coexisting with the hexagonal porous phases is a honeycombphase constructed from Ni(Pro)2complexes. In contrast to the thermal stability of the hexagonal porous phases, the honeycombphase transforms on heating to a meshphase which is concluded to be constructed from a Pro-Pro dipeptide species coordinated to Ni ions. At even higher temperature, more extensive oligomerization occurs to produce an ordered rosephase whose structure is consistent with the formation of oligoproline species.

This paper reports the results of a scientific survey of the equity valuation practices of CFAInstitute members with equity analysis job responsibilities. Using an instrument designed to minimize biases in prior valuation surveys and sampling a larger group than in previous studies (13,500 investment professionals, resulting in 1,980 valid completed questionnaires), this paper documents professional practices in the selection of equity valuation approaches, including specific model variations and key input preferences. Important differences in practice were observed across geographies and employer firm types.

AbstractChildhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare–community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

Supplemental Digital Content is available in the text

Supplemental Digital Content is available in the text

Objective.Adult patients with psoriatic arthritis are at increased risk for obesity and metabolic syndrome, but data regarding adiposity in children with juvenile psoriatic arthritis (JPsA) are limited. Our study assessed adiposity in children with JPsA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry.Methods.Patients with JPsA in the CARRA registry were divided into nonoverweight and overweight groups using recommendations from the US Centers for Disease Control, and differences in demographic and clinical characteristics between groups at baseline and after 1-year followup were assessed using chi-square test, Fisher’s exact test, T test, or Mann-Whitney U test, as appropriate. The prevalence of overweight status in the JPsA registry patients was compared to rheumatoid factor–positive and −negative polyarticular juvenile idiopathic arthritis (RF+polyJIA; RF−polyJIA) registry cohorts and the US pediatric population, using a chi-square goodness-of-fit test.Results.Overweight children represented 36.3% of this JPsA cohort (n = 320). Compared to nonoverweight children, they were significantly older at symptom onset and rheumatologist’s first assessment, and scored significantly worse on patient/physician outcome measures. At 1-year followup, changes in body mass index were not associated with changes in clinical features or outcome measures. The prevalence of overweight and obesity in patients with JPsA was significantly higher than in RF+polyJIA patients, RF−polyJIA patients, and the US pediatric population.Conclusion.In this registry, almost 1 in 5 patients with JPsA were obese and more than one-third were overweight. This is significantly more than expected compared to the US pediatric population, and appropriate longterm followup of this JPsA subgroup is warranted.