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Plasma facing components are usually qualified to a given heat load density applied at the top face of the armour tiles with normal incidence angle. When employed in tokamak fusion machines, heat loading on the tile sides is possible due to optimised shaping, that doesn't provide edge shadowing for all design situations. An edge heat load may occur both at the tile and component scales. The edge load needs to be controlled and quantified. The adequate control of edge heat loads is especially critical for water cooled components that uses armour tiles which are bonded to the heat sink, for ensuring the long-term integrity of the tile bonding. An edge heat load allowance criterion of 10% of the top heat load is proposed. The 10% criterion is supported by experimental heat flux tests.

Background: The combination of oral pentoxifylline (Ptx) and vitamin E (VitE) has been used to treat radiation-induced fibrosis and soft tissue injury. Here, we review outcomes and perform a radiomic analysis of treatment effects in patients prescribed Ptx + VitE at our institution for the treatment of radiation necrosis (RN). Methods: A total of 48 patients treated with stereotactic radiosurgery (SRS) had evidence of RN and had MRI before and after starting Ptx + VitE. The radiation oncologist’s impression of the imaging in the electronic medical record was used to score response to treatment. Support Vector Machine (SVM) was used to train a model of radiomics features derived from radiation necrosis on pre- and 1st post-treatment T1 post-contrast MRIs that can classify the ultimate response to treatment with Ptx + VitE. Results: A total of 43.8% of patients showed evidence of improvement, 18.8% showed no change, and 25% showed worsening RN upon imaging after starting Ptx + VitE. The median time-to-response assessment was 3.17 months. Nine patients progressed significantly and required Bevacizumab, hyperbaric oxygen therapy, or surgery. Patients who had multiple lesions treated with SRS were less likely to show improvement (p = 0.037). A total of 34 patients were also prescribed dexamethasone, either before (7), with (16), or after starting (11) treatment. The use of dexamethasone was not associated with an improved response to Ptx + VitE (p = 0.471). Three patients stopped treatment due to side effects. Finally, we were able to develop a machine learning (SVM) model of radiomic features derived from pre- and 1st post-treatment MRIs that was able to predict the ultimate treatment response to Ptx + VitE with receiver operating characteristic (ROC) area under curve (AUC) of 0.69. Conclusions: Ptx + VitE appears safe for the treatment of RN, but randomized data are needed to assess efficacy and validate radiomic models, which may assist with prognostication.

The COVID-19 pandemic has negatively impacted numerous people?s mental health and created new barriers to services. To address the unknown effects of the pandemic on accessibility and equality issues in mental health care, this study aimed to investigate gender and racial/ethnic disparities in mental health and treatment use in undergraduate and graduate students amid the COVID-19 pandemic. The study was conducted based on a largescale online survey (N = 1,415) administered during the weeks following a pandemic-related university-wide campus closure in March 2020. We focused on the gender and racial disparities in current internalizing symptomatology and treatment use. Our results showed that in the initial period of the pandemic, students identified as cis women (p < 0.001), non-binary/genderqueer (p < .001), or Hispanic/Latinx (p = 0.002) reported higher internalizing problem severity (aggregated from depression, generalized anxiety, intolerance of uncertainty, and COVID-19-related stress symptoms) compared to their privileged counterparts. Additionally, Asian (p < 0.001) and multiracial students (p = 0.002) reported less treatment use than White students while controlling for internalizing problem severity. Further, internalizing problem severity was associated with increased treatment use only in cisgender, non-Hispanic/Latinx White students (pcis man = 0.040, pcis woman < 0.001). However, this relationship was negative in cis-gender Asian students (pcis man = 0.025, pcis woman = 0.016) and nonsignificant in other marginalized demographic groups. The findings revealed unique mental health challenges faced by different demographic groups and served as a call that specific actions to enhance mental health equity, such as continued mental health support for students with marginalized gender identities, additional COVID-related mental and practical support for Hispanic/Latinx students and promotion of mental health awareness, access, and trust in non-White, especially Asian, students are desperately needed.

Primary meningeal melanomatosis is an extremely rare tumor with very few documented responses to treatment. A 3-year-old male with a complex past medical history, including prematurity and shunted hydrocephalus, was diagnosed with primary meningeal melanomatosis with peritoneal implants. Molecular testing revealed an NRAS Q61R mutation. The patient received proton craniospinal radiation followed by immunotherapy with nivolumab (1 mg/kg) and ipilimumab (3 mg/kg) IV every 3 weeks and, upon progression, he was switched to a higher dose of nivolumab (3 mg/kg IV every 2 weeks) and binimetinib (24 mg/m2/dose, twice a day). The patient had significant improvement of CNS disease with radiation therapy and initial immunotherapy but progression of extracranial metastatic peritoneal and abdominal disease. Radiation was not administered to the whole abdomen. After two cycles of nivolumab and treatment with the MEK inhibitor binimetinib, he had radiographic and clinical improvement in abdominal metastasis and ascitis. He ultimately died from RSV infection, Klebsiella sepsis, and subdural hemorrhage without evidence of tumor progression. This is the first report of a child with primary meningeal melanomatosis with extracranial metastatic disease with response to a combination of radiation, immunotherapy and MEK inhibitor therapy.

Radiation therapy (RT) is a critical part of definitive therapy for pediatric high-grade glioma (pHGG). RT is designed to treat residual tumor defined on conventional MRI (cMRI), though pHGG lesions may be ill-characterized on standard imaging. Spectroscopic MRI (sMRI) measures endogenous metabolite concentrations in the brain, and Choline (Cho)/N-acetylaspartate (NAA) ratio is a highly sensitive biomarker for metabolically active tumor. We provide a preliminary report of our study introducing a novel treatment approach of whole brain sMRI-guided proton therapy for pHGG. An observational cohort (c1 = 10 patients) receives standard of care RT; a therapeutic cohort (c2 = 15 patients) receives sMRI-guided proton RT. All patients undergo cMRI and sMRI, a high-resolution 3D whole-brain echo-planar spectroscopic imaging (EPSI) sequence (interpolated resolution of 12 µL) prior to RT and at several follow-up timepoints integrated into diagnostic scans. Treatment volumes are defined by cMRI for c1 and by cMRI and Cho/NAA ≥ 2x for c2. A longitudinal imaging database is used to quantify changes in lesion and metabolite volumes. Four subjects have been enrolled (c1 = 1/c2 = 3) with sMRI imaging follow-up of 4–18 months. Preliminary data suggest sMRI improves identification of pHGG infiltration based on abnormal metabolic activity, and using proton therapy to target sMRI-defined high-risk regions is safe and feasible.

Abstract Stony coral tissue loss disease (SCTLD) has been causing significant whole colony mortality on reefs in Florida and the Caribbean. The cause of SCTLD remains unknown, with the limited concurrence of SCTLD-associated bacteria among studies. We conducted a meta-analysis of 16S ribosomal RNA gene datasets generated by 16 field and laboratory SCTLD studies to find consistent bacteria associated with SCTLD across disease zones (vulnerable, endemic, and epidemic), coral species, coral compartments (mucus, tissue, and skeleton), and colony health states (apparently healthy colony tissue (AH), and unaffected (DU) and lesion (DL) tissue from diseased colonies). We also evaluated bacteria in seawater and sediment, which may be sources of SCTLD transmission. Although AH colonies in endemic and epidemic zones harbor bacteria associated with SCTLD lesions, and aquaria and field samples had distinct microbial compositions, there were still clear differences in the microbial composition among AH, DU, and DL in the combined dataset. Alpha-diversity between AH and DL was not different; however, DU showed increased alpha-diversity compared to AH, indicating that, prior to lesion formation, corals may undergo a disturbance to the microbiome. This disturbance may be driven by Flavobacteriales, which were especially enriched in DU. In DL, Rhodobacterales and Peptostreptococcales–Tissierellales were prominent in structuring microbial interactions. We also predict an enrichment of an alpha-toxin in DL samples which is typically found in Clostridia. We provide a consensus of SCTLD-associated bacteria prior to and during lesion formation and identify how these taxa vary across studies, coral species, coral compartments, seawater, and sediment.

Purpose: The physical properties of protons lower doses to surrounding normal tissues compared with photons, potentially reducing acute and long-term adverse effects, including subsequent cancers. The magnitude of benefit is uncertain, however, and currently based largely on modeling studies. Despite the paucity of directly comparative data, the number of proton centers and patients are expanding exponentially. Direct studies of the potential risks and benefits are needed in children, who have the highest risk of radiation-related subsequent cancers. The Pediatric Proton and Photon Therapy Comparison Cohort aims to meet this need. Methods and Materials: We are developing a record-linkage cohort of 10,000 proton and 10,000 photon therapy patients treated from 2007 to 2022 in the United States and Canada for pediatric central nervous system tumors, sarcomas, Hodgkin lymphoma, or neuroblastoma, the pediatric tumors most frequently treated with protons. Exposure assessment will be based on state-of-the-art dosimetry facilitated by collection of electronic radiation records for all eligible patients. Subsequent cancers and mortality will be ascertained by linkage to state and provincial cancer registries in the United States and Canada, respectively. The primary analysis will examine subsequent cancer risk after proton therapy compared with photon therapy, adjusting for potential confounders and accounting for competing risks. Results: For the primary aim comparing overall subsequent cancer rates between proton and photon therapy, we estimated that with 10,000 patients in each treatment group there would be 80% power to detect a relative risk of 0.8 assuming a cumulative incidence of subsequent cancers of 2.5% by 15 years after diagnosis. To date, 9 institutions have joined the cohort and initiated data collection; additional centers will be added in the coming year(s). Conclusions: Our findings will affect clinical practice for pediatric patients with cancer by providing the first large-scale systematic comparison of the risk of subsequent cancers from proton compared with photon therapy.

Abstract An experiment evaluated the ability of 30 younger and older adults to visually judge object size under three conditions: (1) full cue, (2) in the dark, with linear perspective, and (3) in complete darkness. Each observer made repeated judgments for the same square stimuli (the task was to adjust a separation until it matched the perceived size of the squares), enabling an evaluation of precision as well as accuracy. The judgments were just as accurate in the dark with linear perspective condition as in the full cue condition, indicating that linear perspective serves as an important source of optical information to support the perception of object size). In contrast, in complete darkness (where linear perspective information was unavailable), the accuracy of the observers’ judgments was poor. Finally, there was no difference in either the accuracy or the precision of the observers’ judgments between the two age groups, despite the fact that the older adults were more than 50 years older than the younger adults (mean age of the younger and older adults was 22.3 and 74.1 years, respectively). The ability to visually perceive object size is well maintained with increasing age, unlike a number of other important visual abilities.

Purpose: Proton vertebral body sparing craniospinal irradiation (CSI) treats the thecal sac while avoiding the anterior vertebral bodies in an effort to reduce myelosuppression and growth inhibition. However, robust treatment planning needs to compensate for proton range uncertainty, which contributes unwanted doses within the vertebral bodies. This work aimed to develop an early in vivo radiation damage quantification method using longitudinal magnetic resonance (MR) scans to quantify the dose effect during fractionated CSI. Methods and Materials: Ten pediatric patients were enrolled in a prospective clinical trial of proton vertebral body sparing CSI, in which they received 23.4 to 36 Gy. Monte Carlo robust planning was used, with spinal clinical target volumes defined as the thecal sac and neural foramina. T1/T2-weighted MR scans were acquired before, during, and after treatments to detect a transition from hematopoietic to less metabolically active fatty marrow. MR signal intensity histograms at each time point were analyzed and fitted by multi-Gaussian models to quantify radiation damage. Results: Fatty marrow filtration was observed in MR images as early as the fifth fraction of treatment. Maximum radiation-induced marrow damage occurred 40 to 50 days from the treatment start, followed by marrow regeneration. The mean damage ratios were 0.23, 0.41, 0.59, and 0.54, corresponding to 10, 20, 40, and 60 days from the treatment start. Conclusions: We demonstrated a noninvasive method for identifying early vertebral marrow damage based on radiation-induced fatty marrow replacement. The proposed method can be potentially used to quantify the quality of CSI vertebral sparing and preserve metabolically active hematopoietic bone marrow.

The recent decline of coral health and substantial loss of coral cover along Florida’s Coral Reef (FCR) results from local stressors such as degraded water quality and disease outbreaks in addition to anthropogenically driven global stressors including ocean warming and acidification. Intervention strategies intended for the restoration of degraded reef habitats need a better understanding of the influence of ocean warming and acidification on coral health to target coral species and individual genotypes that may be more resistant or resilient to such stressors. Here, we examined a suite of physiological traits (coral host and algal symbiont) in response to experimentally elevated water temperatures and pCO2 levels, both separately and in concert, using threatened reef-building corals Pseudodiploria clivosa and Orbicella faveolata reared within a land-based coral nursery. After two months of exposure, responses differed by coral species, where P. clivosa showed declined physiology in response to combined ocean warming and acidification stress and ocean warming alone, whereas O. faveolata showed a positive response under ocean acidification. Responses to temperature could be associated with the algal symbionts harbored, as P. clivosa was dominated by the thermally sensitive Breviolum, and O. faveolata was dominated by the thermally tolerant Durusdinium. Additionally, corals were raised in well-sourced seawater that was naturally high in pCO2, which could have led to corals acclimating to acidified conditions. Of the three P. clivosa genets tested, we determined a top-performing genotype under the combined warming and acidification treatment. O. faveolata, however, displayed high genet variation by treatment and phenotypic trait, making genotype performance rankings challenging to discern. The evidence provided in this study demonstrates that high phenotypic variation in nursery-reared corals contributes to variable warming-acidification responses, suggesting that high-standing genetic variation in nursery-reared corals could support diverse coral restoration population outcomes along FCR.

Abstract Premise The degree of gametophyte dependence on the sporophyte life stage is a major feature that differentiates the life cycles of land plants, yet the evolutionary consequences of this difference remain poorly understood. Most evolutionary models assume organisms are either haploid or diploid for their entire lifespan, which is not appropriate for simulating plant life cycles. Here, we introduce shadie (Simulating Haploid–Diploid Evolution), a new, simple Python program for implementing simulations with biphasic life cycles and analyzing their results, using SLiM 3 as a simulation back end. Methods We implemented evolutionary simulations under three realistic plant life cycle models supported in shadie, using either standardized or biologically realistic parameter settings to test how variation in plant life cycles and sexual systems affects patterns of genome diversity. Results The dynamics of single beneficial mutation fixation did not vary dramatically between different models, but the patterns of spatial variation did differ, demonstrating that different life histories and model parameters affect both genetic diversity and linkage disequilibrium. The rate of linkage disequilibrium decay away from selected sites varied depending on model parameters such as cloning and selfing rates, through their impact on effective population sizes. Discussion Evolutionary simulations are an exciting, underutilized approach in evolutionary research and education. shadie can aid plant researchers in developing null hypotheses, examining theory, and designing empirical studies, in order to investigate the role of the gametophyte life stage, and the effects of variation in plant life cycles, on plant genome evolution.

Infectious disease outbreaks are a primary contributor to coral reef decline worldwide. A particularly lethal disease, black band disease (BBD), was one of the first coral diseases reported and has since been documented on reefs worldwide. BBD is described as a microbial consortium of photosynthetic cyanobacteria, sulfate-reducing and sulfide-oxidizing bacteria, and heterotrophic bacteria and archaea. The disease is visually identified by a characteristic dark band that moves across apparently healthy coral tissue leaving behind bare skeleton. Despite its virulence, attempts to effectively treat corals with BBD in the field have been limited. Here, we developed and tested several different therapeutic agents on Pseudodiploria spp. corals with signs of active BBD at Buck Island Reef National Monument in St. Croix, USVI. A variety of therapies were tested, including hydrogen peroxide-based treatments, ointment containing antibiotics, and antiviral/antimicrobial-based ointments (referred to as CoralCure). The CoralCure ointments, created by Ocean Alchemists LLC, focused on the dosing regimen and delivery mechanisms of the different active ingredients. Active ingredients included carbamide peroxide, Lugol's iodine solution, along with several proprietary essential oil and natural product blends. Additionally, the active ingredients had different release times based on treatment: CoralCure A-C had a release time of 24 hours, CoralCure D-F had a release time of 72 hours. The ointments were applied directly to the BBD lesion. Also, jute rope was saturated with a subset of these CoralCure ointment formulations to assist with adhesion. These ropes were then applied to the leading edge of the BBD lesion for one week to ensure sufficient exposure. Corals were revisited approximately three to five months after treatment application to assess disease progression rates and the presence/absence of lesions-the metrics used to quantify the efficacy of each treatment. Although most of the treatments were unsuccessful, two CoralCure rope formulations-CoralCure D rope and CoralCure E rope, eliminated the appearance of BBD in 100% of the corals treated. As such, these treatments significantly reduced the likelihood of BBD occurrence compared to the untreated controls. Additionally, lesions treated with these formulations lost significantly less tissue compared with controls. These results provide the mechanisms for an easily employable method to effectively treat a worldwide coral disease.

Hawaiian Melicope are one of the major adaptive radiations of the Hawaiian Islands comprising 54 endemic species. The lineage is monophyletic with an estimated crown age predating the rise of the current high islands. Phylogenetic inference based on Sanger sequencing has not been sufficient to resolve species or deeper level relationships. Here, we apply restriction site-associated DNA sequencing (RAD-seq) to the lineage to infer phylogenetic relationships. We employ Quartet Sampling to assess information content and statistical support, and to quantify discordance as well as partitioned ABBA-BABA tests to uncover evidence of introgression. Our new results drastically improved resolution of relationships within Hawaiian Melicope. The lineage is divided into five fully supported main clades, two of which correspond to morphologically circumscribed infrageneric groups. We provide evidence for both ancestral and current hybridization events. We confirm the necessity for a taxonomic revision of the Melicope section Pelea, as well as a re-evaluation of several species complexes by combining genomic and morphological data.

Species with large geographic distributions often exhibit complex patterns of diversity that can be further complicated by human activities. Cutthroat trout (Oncorhynchus clarkii) are one of the most widely distributed freshwater fish species in western North America exhibiting substantial phenotypic and genetic variability; however, fish stocking practices have translocated populations outside of their native range and may have obscured intraspecific boundaries. This study focuses on cutthroat trout populations representing three distinct evolutionary clades that are found intermixed within a contact zone between the Bonneville and upper Snake River watersheds in the western United States. We used mitochondrial and microsatellite genetic data, as well as historical stocking records, to evaluate whether populations of cutthroat trout in the contact zone are native or are introduced. We found significant genetic differentiation and fine-scale genetic population structure that was organized primarily by watershed boundaries. While we detected increased genetic diversity in some areas in close proximity to the greatest number of stocking events, the highly organized population structure both within and between areas of the contact zone indicates that the populations are native to the watersheds. Intermixing of distinct evolutionary lineages of cutthroat trout appears to be the result of historical connections between paleodrainages. Our analyses provide a context for understanding how genetic data can be used to assess the status of populations as native or introduced.

The ability to pattern surfaces down to the nanoscale is of increasing importance in nanoscience research. The use of supramolecular chemistry to drive the formation of self-assembled networks allows for a bottom-up approach to achieve nanopatterned surfaces. This short review highlights some of the recent breakthroughs in achieving long-range order in such molecular based systems, complemented with examples from our own work. The tuning of molecular architectures can exert control on the emergent properties and function of molecules at interfaces. In particular the formation of porous honeycomb networks allows the rational design of highly ordered patterned surface domains and the investigation of molecular dynamics, chirality and templating effects on surfaces.

A detailed scanning tunneling microscopy (STM) study of two variants of oligo(phenylene ethynylene) (OPE) molecules is presented. These molecules might serve as molecular wires up to ≈ 5 nm in length. Self-assembled arrangements as well as single molecules on a Au(111) surface were analyzed. The molecular orbitals were directly imaged and are compared to density functional theory calculations. Sub-molecular resolution images of both molecules directly display the chemical structure. One of the OPE variants was lifted off the surface by the STM tip to measure the single-molecule conductance in order to explain previously reported low conduction values. Furthermore, we present a detailed analysis of a tip-induced conformational switching of the hexyl side groups from all-trans to a nonlinear conformation, which was observed for both variants.

Controlling metal nanoparticle sizeis one of the principle challengesin developing new supported catalysts. Typical methods where a metalsalt is deposited and reduced can result in a polydisperse mixtureof metal nanoparticles, especially at higher loading. Polydispersitycan exacerbate the already significant challenge of controlling sinteringat high temperatures, which decreases catalytic surface area. Here,we demonstrate the size-selective photoreduction of Ag nanoparticleson TiO2whose surface has been partially masked with athin SiO2layer. To synthesize this layered oxide material,TiO2particles are grafted with tert-butylcalix[4]arenemolecular templates (∼2 nm in diameter) at surface densitiesof 0.05–0.17 templates.nm–2, overcoated with∼2 nm of SiO2through repeated condensation cyclesof limiting amounts of tetraethoxysilane (TEOS), and the templatesare removed oxidatively. Ag photodeposition results in uniform nanoparticlediameters ≤ 3.5 nm (by transmission electron microscopy (TEM))on the partially masked TiO2, whereas Ag nanoparticlesdeposited on the unmodified TiO2are larger and more polydisperse(4.7 ± 2.7 nm by TEM). Furthermore, Ag nanoparticles on the partiallymasked TiO2do not sinter after heating at 450 °Cfor 3 h, while nanoparticles on the control surfaces sinter and growby at least 30%, as is typical. Overall, this new synthesis approachcontrols metal nanoparticle dispersion and enhances thermal stability,and this facile synthesis procedure is generalizable to other TiO2-supported nanoparticles and sizes and may find use in thesynthesis of new catalytic materials. [ABSTRACT FROM AUTHOR]

Based on the use of neural networks for representation of the dynamics of faults, an active fault accommodation control law is proposed that guarantees the closed-loop stability for a class of nonlinear systems with faults. An example of using the control design proposed demonstrates the efficiency of this law for a typical nonlinear system. [ABSTRACT FROM AUTHOR]

Between 65 and 175 K, nitroxyl radicals with spirocyclohexyl groups at the 2- and 6-positions of the piperidine ring exhibit spin echo dephasing rates that are slower than for nitroxyl radicals with 2,5-gem-dimethyl or 2,6-gem-dimethyl substituents that are currently used as spin labels, and are slow enough to permit DEER measurements at temperatures up to about 125 K for spin labels with analogous ring structures. [ABSTRACT FROM AUTHOR]

Abstract Eighteen younger and older adults (mean ages were 20.4 and 72.8 years, respectively) participated in a tactile speed matching task. On any given trial, the participants felt the surfaces of rotating standard and test wheels with their index fingertip and were required to adjust the test wheel until its speed appeared to match that of the standard wheel. Three different standard speeds were utilized (30, 50, and 70 cm/s). The results indicated that while the accuracy of the participants’ judgments was similar for younger and older adults, the precision (i.e., reliability across repeated trials) of the older participants’ judgments deteriorated significantly relative to that exhibited by the younger adults. While adverse effects of age were obtained with regards to both the precision of tactile speed judgments and the participants’ tactile acuity, there was nevertheless no significant correlation between the older adults’ tactile acuities and the precision of their tactile speed judgments.

During the last several decades, Florida’s Coral Reef (FCR) has been impacted by both global and local stressors that have devastated much of its living coral cover. Additionally, since 2014 FCR has experienced a lethal disease outbreak termed stony coral tissue loss disease (SCTLD). Here, we examined SCTLD spreading dynamics within and among fragmented coral colonies and quantified lesion progression rate of two intermediately susceptible species—Montastraea cavernosa and Orbicella faveolata—through induction experiments conducted in laboratory aquaria. M. cavernosa colonies showing subacute tissue loss were sequentially fragmented parallel to the lesion edge to determine whether isolated tissue that showed no tissue-loss signs, referred to as isolated apparently healthy (AH) donor fragments, would subsequently exhibit tissue loss. Additionally, AH M. cavernosa and O. faveolata fragments, referred to as recipient fragments, were placed in direct contact with the M. cavernosa donor fragments to assess incidence of new tissue-loss lesions. Finally, AH M. cavernosa donor fragments were placed in direct contact with recipient M. cavernosa and O. faveolata fragments to account for aggression from direct contact. Samples were collected for histopathology of the corals through time. Many isolated AH donor fragments developed tissue-loss lesions during the 60-day study, suggesting SCTLD may be systemic within small-sized colonies. Our results confirmed that physical contact between recipient fragments and subacute SCTLD-lesioned tissue often led to tissue loss in recipient fragments. None of the control recipient or donor fragments experienced tissue loss. Grossly, multifocal lesions started on or adjacent to the septal and costal basal body walls with tissue loss progressing across the polyp septa and coenenchyme, respectively, in both species. Histologically, initial tissue-loss lesions in both species exhibited characteristic lytic necrosis (LN) at the basal body wall of the gastrodermis. O. faveolata exhibited higher rates of lesion appearance and subsequent mortality compared to M. cavernosa, but once a lesion appeared, M. cavernosa lost tissue faster than O. faveolata. This work contributes to the growing knowledge of SCTLD dynamics and highlights the differences in lesion progression within susceptible species.

Background: To investigate the impact of proton radiotherapy (PBT) on overall survival (OS) and evaluate PBT usage trends for patients with gliomas in the National Cancer Data Base (NCDB).Methods: Patients with a diagnosis of World Health Organization (WHO) Grade I-IV glioma treated with definitive radiation therapy (RT) between the years of 2004–13 were identified. Patients were stratified based on WHO Grade and photon radiotherapy (XRT) vs. PBT. Univariate (UVA) and multivariable analysis (MVA) with OS were performed by Cox proportional hazards model and log-rank tests. Propensity score (PS) weighting was utilized to account for differences in patient characteristics and to minimize selection bias.Results: There were a total of 49,405 patients treated with XRT and 170 patients treated with PBT. Median follow-up time was 62.1 months. On MVA, the following factors were associated with receipt of PBT (all p < 0.05): WHO Grade I-II gliomas, treatment at an academic/research program, west geographic facility location, and surgical resection. After PS weighting, all patients treated with PBT were found to have superior median and 5 year survival than patients treated with XRT: 45.9 vs. 29.7 months (p = 0.009) and 46.1 vs. 35.5% (p = 0.0160), respectively.Conclusions: PBT is associated with improved OS compared to XRT for patients with gliomas. This finding warrants verification in the randomized trial setting in order to account for potential patient imbalances not adequately captured by the NCDB, such as tumor molecular characteristics and patient performance status.Importance of the Study: This is the first study that compares the outcomes of patients treated with photon based radiotherapy vs. proton based radiotherapy for patients with gliomas. In this retrospective analysis, the results demonstrate that proton therapy is associated with improved outcomes which support ongoing prospective, randomized clinical trials comparing the two modalities in patients with gliomas.

The challenges associated with sampling rare species or populations can limit our ability to make accurate and informed estimates of biodiversity for clades or ecosystems. This may be particularly true for tropical trees, which tend to be poorly sampled, and are thought to harbor extensive cryptic diversity. Here, we integrate genomics, morphology, and geography to estimate the number of species in a clade of dioecious tropical trees (Canarium L.; Burseraceae) endemic to Madagascar, for which previous taxonomic treatments have recognized between one and 33 species. By sampling genomic data from even a limited number of individuals per taxon, we were able to clearly reject both previous hypotheses, and support instead an intermediate number of taxa. We recognize at least six distinct clades based on genetic structure and species delimitation analyses that correspond clearly with geographic and discrete morphological differences. Two widespread clades co-occur broadly throughout eastern wet forests, one clade is endemic to western dry forests, and several slightly admixed clades are more narrowly distributed in mountainous regions in the north. Multiple previously described taxa were recovered as paraphyletic in our analyses, some of which were associated with admixed individuals, suggesting that hybridization contributes to taxonomic difficulties in Canarium. An improved understanding of Canarium species diversity has important implications for conservation efforts and understanding the origins of diversity in Madagascar. Our study shows that even limited genomic sampling, when combined with geography and morphology, can greatly improve estimates of species diversity for difficult tropical clades.

Radiation induced secondary malignancies are a significant, yet uncommon cause of morbidity and mortality among cancer survivors. Secondary malignancy risk is dependent upon multiple factors including patient age, the biological and genetic predisposition of the individual, the volume and location of tissue irradiated, and the dose of radiation received. Proton therapy is an advanced particle therapy with unique dosimetric properties resulting in reduced entrance dose and minimal to no exit dose when compared with standard photon radiation therapy. Multiple dosimetric studies in varying cancer subtypes have demonstrated that proton therapy enables the delivery of adequate target volume coverage with reduced integral dose delivered to surrounding tissues, and modeling studies taking into account dosimetry and radiation cell biology have estimated a significantly reduced risk of radiation induced secondary malignancy with proton therapy. Clinical data is emerging supporting the lower incidence of secondary malignancies after proton therapy compared with historical photon data, though longer follow-up in proton treated cohorts is awaited. This article reviews the current dosimetric and clinical literature evaluating the incidence of and risk factors associated with radiation induced secondary malignancy following proton therapy.

Previous phylogenetic studies in oaks (Quercus, Fagaceae) have failed to resolve the backbone topology of the genus with strong support. Here, we utilize next-generation sequencing of restriction-site associated DNA (RAD-Seq) to resolve a framework phylogeny of a predominantly American clade of oaks whose crown age is estimated at 23-33 million years old. Using a recently developed analytical pipeline for RAD-Seq phylogenetics, we created a concatenated matrix of 1.40 E06 aligned nucleotides, constituting 27,727 sequence clusters. RAD-Seq data were readily combined across runs, with no difference in phylogenetic placement between technical replicates, which overlapped by only 43-64% in locus coverage. 17% (4,715) of the loci we analyzed could be mapped with high confidence to one or more expressed sequence tags in NCBI Genbank. A concatenated matrix of the loci that BLAST to at least one EST sequence provides approximately half as many variable or parsimony-informative characters as equal-sized datasets from the non-EST loci. The EST-associated matrix is more complete (fewer missing loci) and has slightly lower homoplasy than non-EST subsampled matrices of the same size, but there is no difference in phylogenetic support or relative attribution of base substitutions to internal versus terminal branches of the phylogeny. We introduce a partitioned RAD visualization method (implemented in the R package RADami; http://cran.r-project.org/web/packages/RADami) to investigate the possibility that suboptimal topologies supported by large numbers of loci--due, for example, to reticulate evolution or lineage sorting--are masked by the globally optimal tree. We find no evidence for strongly-supported alternative topologies in our study, suggesting that the phylogeny we recover is a robust estimate of large-scale phylogenetic patterns in the American oak clade. Our study is one of the first to demonstrate the utility of RAD-Seq data for inferring phylogeny in a 23-33 million year-old clade.

Introduction: Lumbar degenerative spinal disease is a common, major cause of pain and disability. Titanium and polyetheretherketone (PEEK) are popular materials for interbody implants although evidence is mixed on which material is superior in terms of fusion and subsidence. The purpose of this study was to evaluate the clinical outcome of 3D printed titanium (3DPT) cages in patients undergoing TLIFs, as well as complication profiles based on widely used outcome metrics and reoperation events., Methods: A retrospective review was conducted for patients receiving 1- or 2-level TLIF at an academic medical center between January 2018 and May 2022. Patients were divided into two cohorts according to the material of interbody cage(s), either 3DPT banana or titanium-coated PEEK bullet. Radiographs, patient-reported outcome measures (PROMs), and complications were analyzed and compared. All included patients had radiographic and clinical follow-up of at least one year., Results: 200 patients with 277 interbody cage-implanted levels were included. Patients received either 3DPT (n = 140) or PEEK (n = 60) interbody cages with 202 and 75 instrumented vertebral levels per cohort, respectively. At one year, the 3DPT cohort demonstrated a higher fusion rate of 93.3 % compared to the PEEK cohort's fusion rate of 73.2 % (p < 0.0001). Subsidence rates were 6.0 % and 25.0 % for the 3DPT and PEEK groups, respectively (p < 0.0001)., Conclusion: While 3DPT and PEEK interbody cages demonstrated few adverse events at short- and long-term follow-up, 3DPT exhibited a higher rate of fusion and lower rate of subsidence at one year., 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 © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

The activity and connectivity of neurons in the primate brain underlying behavior cannot yet be completely specified, but neural networks provide complete models of the connectivity and activity that performs specific tasks and provide insight into the neural computations performed by the primate brain (Fetz and Shupe 2003). Studies of neurons in the monkey cortex have shown that short-term memory of sensory events may be mediated by sustained neural activity. Short-term memory tasks have been modeled with dynamic neural networks using a single continuous variable and a gate input to create a sample-and-hold (SAH) function (Zipser 1991; Maier 2003). Networks trained to perform these short-term memory tasks develop hidden unit activity which resembles that of cortical neurons in monkeys performing memory tasks. We here extend the investigation of single-input SAH networks to networks computing SAH for two continuous-variable inputs that have varying degrees of common mode signal. Results provide insights into computational mechanisms of associative short-term memory of sensory signals with common mode components, such as visual inputs to the two eyes, auditory inputs to the ears and proprioceptive input from multiple muscle spindle afferents. We also examined the attractor states that these SAH networks eventually reach after sufficiently long delay periods and found that these were determined by the shapes of the input-output functions of the hidden units rather than network architecture.

Alternatives assessment is a methodology used to identify, evaluate, and compare potential chemical and nonchemical solutions with a substance of concern. It is required in several chemicals management regulatory frameworks, with the objective of supporting the transition to safer chemistry and avoiding regrettable substitutions. Using expert input from symposium presentations and a discussion group hosted by the Association for the Advancement of Alternatives Assessment, four case examples of the use of alternatives assessment in regulatory frameworks were evaluated and compared: (1) the US Environmental Protection Agency Significant New Alternatives Policy (USEPA SNAP), (2) authorization provisions in the EU REACH (Registration, Evaluation, Authorisation, and Restriction of Chemicals) regulation, (3) the California (CA) Safer Consumer Products (SCP) Program, and (4) the Safer Products for Washington (WA) Program. Factors such as the purpose of the alternatives assessment, the timeline of actions, who completes the assessment, the role of stakeholder engagement, and the regulatory response options for each policy are outlined. Through these presentations and expert discussions, four lessons learned about the use of alternatives assessments in regulatory policy emerged: (1) the goal and purpose of the regulatory framework significantly affects its ability to result in safer substitution, (2) existing frameworks struggle with data access and insufficient stakeholder engagement, (3) some frameworks lack clear decision rules regarding what is a safer and feasible alternative, and (4) regulatory response options provide limited authority for enforcement and do not adequately address options where alternatives are unavailable or limited. Five recommendations address these lessons as well as how the application of alternatives assessment in regulatory settings could have greater impact in the future. This synthesis is not meant to be a comprehensive policy analysis, but rather an assessment based on the perspectives from experts in the field, which should be supplemented by formal policy analysis as policies are implemented over time. Integr Environ Assess Manag 2024;20:1035-1045. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC)., (© 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).)

Background: Humans are exposed to hazardous chemicals found in consumer products. In 2019, the Pollution Prevention for Healthy People and Puget Sound Act was passed in Washington State. This law is meant to reduce hazardous chemicals in consumer products and protect human health and the environment. The law directs the Washington State Department of Ecology to assess chemicals and chemical classes found in products, determine whether there are safer alternatives, and make regulatory determinations., Objectives: To implement the law, the Department of Ecology developed a hazard-based framework for identifying safer alternatives to classes of chemicals., Methods: We developed a hazard-based framework, termed the "Criteria for Safer," to set a transparent bar for determining whether new chemical alternatives are safer than existing classes of chemicals. Our "Criteria for Safer" is a framework that builds on existing hazard assessment methodologies and published approaches for assessing chemicals and chemical classes., Discussion: We describe implementation of our criteria using a case study on the phthalates chemical class in two categories of consumer products: vinyl flooring and fragrances used in personal care and beauty products. Additional context and considerations that guided our decision-making process are also discussed, as well as benefits and limitations of our approach. This paper gives insight into our development and implementation of a hazard-based framework to address classes of chemicals in consumer products and will aid others working to build and employ similar approaches. https://doi.org/10.1289/EHP13549.

Objective: A growing body of literature suggests that preoperative opioid exposure is an independent predictor of poor outcomes in surgical patients. No outcomes data exist on preoperative opioid use and craniotomies/craniectomies. The objective of this study was to determine the impact of preoperative opioid use on 90-day adverse events after craniotomy or craniectomy., Methods: A single-center retrospective cohort study of 2445 patients undergoing a craniotomy/craniectomy between January 1, 2013, and October 1, 2018, was conducted. Baseline demographics, pre- and postoperative opioid use (morphine milligram equivalents [MMEs]), and surgical metrics were recorded. Patients were categorized based on whether they took prescription opioids preoperatively, defined as within 1 month of surgery, or were opioid naive. The outcomes were mortality and adverse events 90 days after craniotomy/craniectomy., Results: Overall, 26.6% of patients composed the preoperative opioid group. The median daily MME intake among this group was 34.6 (IQR 14.1-90) MMEs. Lower employment rates (p < 0.001), uninsured status (p = 0.016), and intravenous drug use (p = 0.006) were associated with preoperative opioid use. Preoperative opioid use was associated with increased venous thromboembolism (p = 0.001), acute kidney injury (p = 0.002), acute respiratory failure (p < 0.001), myocardial infarction (p = 0.002), delirium (p < 0.001), and infection (p < 0.001). Preoperative opioid use was an independent predictor of overall 90-day adverse events (OR 1.643, 95% CI 1.289-2.095; p < 0.001) and 90-day mortality (OR 1.690, 95% CI 1.254-2.277; p < 0.001)., Conclusions: Preoperative opioid use was independently associated with 90-day postoperative adverse events and mortality. Opioid use increases vulnerability in craniotomy/craniectomy patients and necessitates close monitoring to improve outcomes.

Background: Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed., Objectives: The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF)., Methods: In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee., Results: Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups., Conclusions: Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT., Competing Interests: Funding Support and Author Disclosures Funding was provided by the Brigham Health Care Redesign Incubator and Startup Program, Brigham and Women’s Hospital, Mass General Brigham, Boston, Massachusetts. Dr Varshney has received consulting fees from Broadview Ventures. Dr Claggett has received consulting fees from Cardurion, Corvia, Cytokinetics, Intellia, and Novartis. Dr Eaton is employed at Brigham and Women’s hospital, but is also employed by Janssen Pharmaceuticals. Dr Cunningham has received consulting fees from Roche Diagnostics and Occlutech. Dr Choudhry has received research grant support to Brigham and Women‘s Hospital from Merck, Sanofi, AstraZeneca, CVS Health, and Medisafe. Dr Solomon has received research grants from Actelion, Alnylam, Amgen, AstraZeneca, Bellerophon, Bayer, Bristol Myers Squibb, Celladon, Cytokinetics, Eidos, Gilead, GlaxoSmithKline, Ionis, Lilly, Mesoblast, MyoKardia, National Institutes of Health/National Heart, Lung, and Blood Institute, Neurotronik, Novartis, NovoNordisk, Respicardia, Sanofi Pasteur, Theracos, and US2.AI; and has consulted for Abbott, Action, Akros, Alnylam, Amgen, Arena, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardior, Cardurion, Corvia, Cytokinetics, Daiichi Sankyo, GlaxoSmithKline, Lilly, Merck, Myokardia, Novartis, Roche, Theracos, Quantum Genomics, Cardurion, Janssen, Cardiac Dimensions, Tenaya, Sanofi-Pasteur, Dinaqor, Tremeau, CellProThera, Moderna, American Regent, and Sarepta. Dr Vaduganathan has received research grant support from, served on advisory boards for, or had speaker engagements with American Regent, Amgen, AstraZeneca, Bayer, Baxter Healthcare, Boehringer Ingelheim, Chiesi, Cytokinetics, Lexicon Pharmaceuticals, Novartis, Novo Nordisk, Pharmacosmos, Relypsa, Roche Diagnostics, Sanofi, and Tricog Health; and participates on clinical trial committees for studies sponsored by AstraZeneca, Galmed, Novartis, Bayer, Occlutech, and Impulse Dynamics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Dynamic contrast-enhanced CT (DCE-CT) and positron emission tomography/CT (PET/CT) have a high reported accuracy for the diagnosis of malignancy in solitary pulmonary nodules (SPNs). The aim of this study was to compare the accuracy and cost-effectiveness of these., Methods: In this prospective multicentre trial, 380 participants with an SPN (8-30 mm) and no recent history of malignancy underwent DCE-CT and PET/CT. All patients underwent either biopsy with histological diagnosis or completed CT follow-up. Primary outcome measures were sensitivity, specificity and overall diagnostic accuracy for PET/CT and DCE-CT. Costs and cost-effectiveness were estimated from a healthcare provider perspective using a decision-model., Results: 312 participants (47% female, 68.1±9.0 years) completed the study, with 61% rate of malignancy at 2 years. The sensitivity, specificity, positive predictive value and negative predictive values for DCE-CT were 95.3% (95% CI 91.3 to 97.5), 29.8% (95% CI 22.3 to 38.4), 68.2% (95% CI 62.4% to 73.5%) and 80.0% (95% CI 66.2 to 89.1), respectively, and for PET/CT were 79.1% (95% CI 72.7 to 84.2), 81.8% (95% CI 74.0 to 87.7), 87.3% (95% CI 81.5 to 91.5) and 71.2% (95% CI 63.2 to 78.1). The area under the receiver operator characteristic curve (AUROC) for DCE-CT and PET/CT was 0.62 (95% CI 0.58 to 0.67) and 0.80 (95% CI 0.76 to 0.85), respectively (p<0.001). Combined results significantly increased diagnostic accuracy over PET/CT alone (AUROC=0.90 (95% CI 0.86 to 0.93), p<0.001). DCE-CT was preferred when the willingness to pay per incremental cost per correctly treated malignancy was below £9000. Above £15 500 a combined approach was preferred., Conclusions: PET/CT has a superior diagnostic accuracy to DCE-CT for the diagnosis of SPNs. Combining both techniques improves the diagnostic accuracy over either test alone and could be cost-effective., Trial Registration Number: NCT02013063., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach., Objectives: To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies., Design: Multicentre comparative accuracy trial., Setting: Secondary or tertiary outpatient settings at 16 hospitals in the UK., Participants: Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included., Interventions: Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up., Main Outcome Measures: Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography., Results: A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51)., Limitations: The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening., Conclusions: Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider., Future Work: Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol., Study Registration: This study is registered as PROSPERO CRD42018112215 and CRD42019124299, and the trial is registered as ISRCTN30784948 and ClinicalTrials.gov NCT02013063., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 17. See the NIHR Journals Library website for further project information.

Study Design: This is a retrospective longitudinal study., Objectives: To explore the relative impact and contribution of using both the Spinal Cord Independence Measure III (SCIM) and Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) to assess rehabilitation outcome following an acute spinal cord injury (SCI)., Setting: The study was performed at National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK., Methods: A patient self-report SMS-NAC and clinician-rated SCIM were administered on admission and discharge from the NSIC as part of standardised care. This paper presents a retrospective analysis of the rehabilitation outcomes of 195 people with spinal cord injury (PwSCI) following their first admission., Results: In both measures, PwSCI improved from admission to discharge. Individuals with higher SCI obtained lower scores in both measures, at both admission and discharge. The SMS-NAC demonstrated the greatest increase in knowledge and skill for PwSCI who had higher and more complete injuries. On the SCIM, PwSCI who had lower and less complete injuries demonstrated the greatest increase in outcome., Conclusions: Overall, both measures demonstrated responsiveness to change during SCI rehabilitation and enable clinicians to systematically determine areas to focus rehabilitation effort. The relative strengths and contribution to delivering person-centred care for each are identified. The SMS-NAC enables clinicians to record, for people with higher injuries, their subjective self-report of skill and knowledge gains from rehabilitation that may be missed with other measures. Consequently, using both is encouraged in appreciation of the value of recording verbal (instructional) independence as well as functional (physical) independence., (© 2021. Crown.)

Objective: Mini C-arm fluoroscopes are widely used by orthopaedic surgeons for intraoperative image guidance without the need for radiographers. This puts the responsibility for radiation exposure firmly with the operating surgeon. In order to maintain safe and best practice under U.K. Ionising Radiation (Medical Exposure) Regulations, one must limit radiation exposure and audit performance using national diagnostic reference levels (DRLs). In the case of the mini C-arm, there are no national DRLs. IR(ME)R, therefore, require the establishment of local DRLs by each hospital to act as an alternative guideline for safe radiation use. The aim of our audit was to establish local DRLs based on our experience operating with the use of the mini C-arm over the last 7 years., Methods: This retrospective audit evaluates the end dose-area product (DAP) recorded for common trauma and orthopaedic procedures using the mini C-arm in a busy district general hospital.We present the quartile data and have set the cut-off point as the third quartile for formulating the local DRLs, consistent with the methodology for the conventional fluoroscope., Results: For our data set ( n = 1664), the third quartile DAP values were lowest for surgeries to the forearm (5.38 cGycm 2 ), hand (7.62 cGycm 2 ), and foot/ankle (8.56 cGycm 2 ), and highest for wrist (10.64 cGycm 2 ) and elbow (14.61 cGycm 2 ) procedures., Advances in Knowledge: To our knowledge, this is the largest data set used to establish local DRLs. Other centres may find our guidelines useful whilst they establish their own local DRLs.

Background: Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality., Results: We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer., Conclusions: Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The continuous increase of Coccidioidomycosis cases requires reliable detection methods of the causal agent, Coccidioides spp., in its natural environment. This has proven challenging because of our limited knowledge on the distribution of this soil-dwelling fungus. Knowing the pathogen's geographic distribution and its relationship with the environment is crucial to identify potential areas of risk and to prevent disease outbreaks. The maximum entropy (Maxent) algorithm, Geographic Information System (GIS) and bioclimatic variables were combined to obtain current and future potential distribution models (DMs) of Coccidioides and its putative rodent reservoirs for Arizona, California and Baja California. We revealed that Coccidioides DMs constructed with presence records from one state are not well suited to predict distribution in another state, supporting the existence of distinct phylogeographic populations of Coccidioides . A great correlation between Coccidioides DMs and United States counties with high Coccidioidomycosis incidence was found. Remarkably, under future scenarios of climate change and high concentration of greenhouse gases, the probability of habitat suitability for Coccidioides increased. Overlap analysis between the DMs of rodents and Coccidioides , identified Neotoma lepida as one of the predominant co-occurring species in all three states. Considering rodents DMs would allow to implement better surveillance programs to monitor disease spread.