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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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