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CASE A new patient office visit A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and [...]

The 2022-2023 Term of the Supreme Court illustrates how important the Court has become to health-related matters, including decisions regarding the selection and training of new professionals, the daily practice [...]

With up to 75% of ObGyns reporting 'some form of professional burnout,' how can health care institutions be held liable, to clinicians and patients? These authors tackle the legal considerations, [...]

Although the use is off label, a progestin IUD can provide contraception not only in the reproductive years but also through perimenopause to treat HMB and allow for endometrial protection [...]

Telemedicine (or telehealth) originated in the early 1900s, when radios were used to communicate medical advice to clinics aboard ships. (1) According to the American Telemedicine Association, telemedicine is namely [...]

Operational art is a fundamental concept in contemporary U.S. military planning, but there are shortfalls when applying operational art doctrine in an environment with increasing interstate competition. Those shortfalls demonstrate [...]

Introduction Leiomyomas, most often referred to as uterine fibroids, are the most common benign pelvic tumors. It appears they originate from clonal expansion of a single myometrial cell. (1) They [...]

Study recaps and expert perspectives on SERMs and bone effects, the microbiome's role in bone metabolism, the added risks of frailty, and therapeutic possibilities for denosumab I recently heard a [...]

Surgeon tells patient, 'I have done a few' robotic hysterectomies before performing robotic-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What's the verdict after complications ensue? The approach to hysterectomy has [...]

Medical professionals were held criminally liable in 2 widely publicized cases. This analysis enhances understanding of the legal implications for practice. IN THIS ARTICLE Essential elements of a crime this [...]

The fighting that occurred around Burnside Bridge at the Battle of Antietam remains one of the most controversial subjects of the engagement. It was in the vicinity of the bridge, [...]

The 2021-2022 US Supreme Court Term was a blockbuster medical Term. The bookends of the Term were COVID-19 vaccinations and abortion rights. Between the bookends were Medicare reimbursement, criminal liability [...]

As virtually all health care providers are aware, symptoms of vulvovaginal candidiasis (VVC) are commonly reported among many of our patients. Consider the following statistics: * 75% of all women [...]

Although it is common to read about patients suing their hospitals, there has been increasing public and political attention given to hospitals suing their patients to collect unpaid hospital bills. [...]

Uterine closure technique is emerging as a significant factor in cesarean scar niche formation and its associated long-term complications. The authors recommend an endometrium-free closure technique and a high-volume surgeon [...]

While most clinicians are very familiar with older SERMS like tamoxifen and raloxifene, newer agents such as ospemifene and bazedoxifene offer other beneficial properties that can--and should--encourage their more widespread [...]

Coupled-cluster singles and doubles calculations with perturbative triples [CCSD(T)] offer high accuracy with significant cost. The standard way to reduce the cost of a CCSD(T) calculation is by excluding molecular orbitals from the correlated calculation. While this speeds up the calculation, it also throws away the contribution from the inactive orbitals to the correlation energy. Here, we propose extending the standard CCSD(T) method to account for the effects of these inactive orbitals. This approach is based on a perturbation expansion of the similarity-transformed Hamiltonian, and the final method includes external singles and doubles corrections along with a semi-internal triples term. Compared to all-electron CCSD(T) calculations with the cc-pCVTZ basis set for a set of small molecules, we recovered, on average, 98% of the total correlation energy while using only 30% of the molecular orbitals. Using 72% of the molecular orbitals gave 99.5% of the correlation energy.

The evolutionary history and taxonomy of the Leopardus tigrinusspecies complex have been studied based on several approaches, mostly employing genetic and morphological data, leading to distinct classification schemes. We approached this problem from an ecological perspective, with 2 main goals: (i) to evaluate ecological niche differences among regional L. tigrinuspopulations to determine the extent of ecological divergence among them; and (ii) to identify environmental barriers to historical dispersal that could have driven differentiation among the proposed groups. We modeled the ecological niche of all taxonomic/geographic groups proposed so far to comprise the L. tigrinuscomplex using the Maximum Entropy algorithm, and evaluated geographic and ecological niche differences among them. Furthermore, we investigated possible environmental barriers to historical dispersal that could have driven differentiation among regional groups. We evaluated 4 hypothetical barriers across 3 time periods to assess their potential historical effect. We found high ecological divergence between northeastern tigrina populations and the northern Andean and Central American tigrinas. Other groups within the L. tigrinuscomplex are less divergent. In addition, the Guiana Shield tigrina, where the type locality of the species is located, seems to be ecologically similar to populations from northeastern Brazil while also showing some overlap with Andean populations. The Panama center, the Llanos of Colombia and Venezuela, and the Amazon region were identified as historical barriers for tigrina dispersal across all time periods. The inferred historical barriers and ecological divergence observed in this study contribute to the inference of evolutionary differentiation among geographic groups comprising the L. tigrinuscomplex, revealing areas of consistently low habitat suitability that have likely contributed to divergence among regional populations.The study characterizes ecological niche differences among regional L. tigrinuspopulations and discovers 3 historical environmental barriers (Panama center, the Llanos of Colombia/Venezuela, and the Amazon region) that may have promoted differentiation among these groups.

IMPORTANCE: Exception From Informed Consent (EFIC) research requires community consultation (CC) and public disclosure (PD). Traditional methods of conducting CC and PD are slow, expensive, and labor intensive. OBJECTIVE: To describe the feasibility and reach of a novel interactive, media-based approach to CC and PD and to identify the similarities and differences between trial sites in website views, survey responses, online community forum attendance, and opt-out requests. DESIGN, SETTING, AND PARTICIPANTS: This survey study analyzed the CC and PD campaigns conducted for the TAP trial (Evaluation of BE1116 in Patients With Traumatic Injury and Acute Major Bleeding to Improve Survival), an EFIC trial of the early administration of prothrombin complex concentrate in patients with trauma. The CC and PD campaigns consisted of social media advertisements, linked websites, community surveys, and online community forums. These activities were coordinated from a central site and approved by a central institutional review board. This study focused on the first 52 of 91 TAP trial sites (level I trauma centers) in the US to have completed their CC and PD campaigns. Community members in the catchment areas of the participating trauma centers were targeted. Data analysis was conducted between October 2023 and February 2024. EXPOSURE: Social media advertisements, surveys, and online community meetings conducted as part of the CC and PD campaign for the TAP trial. MAIN OUTCOMES AND MEASURES: Social media campaign reach and engagement, web page views, survey results, online community forum attendance, and opt-out requests. RESULTS: Fifty-two trial sites were approved for participant enrollment. Social media advertisements were displayed 92 million times, reaching 11.8 million individuals. The median (IQR) number of people reached in each location was 210 317 (172 068-276 968). Site-specific websites were viewed 144 197 times (median [IQR] viewings per site, 2984 [1267-4038]). A total of 17 206 fully or partly completed surveys were received, and survey respondents had a median (IQR) age of 40.1 (15-65) years and included 10 444 females (60.7%). Overall, 60.6% survey respondents said they would want to be entered into the trial even if they could not give consent, 87.7% agreed that emergency care research was necessary, and 88.0% agreed that the TAP trial should be conducted in their community. Online community forums were attended by a median (IQR) number of 38 (20-63) people. Four opt-out requests were received. CONCLUSIONS AND RELEVANCE: The interactive media-based approach to CC and PD for the ongoing TAP trial showed the feasibility and benefits of executing an efficient, coordinated, centrally run series of locally branded and geographically targeted CC and PD campaigns for a large EFIC study.

Current guidelines for the treatment of obesity recommend dietary restriction to create a caloric deficit, and caloric reductions of 16% to 68% have been achieved in adults with overweight or obesity engaging in intentional weight loss programs.

•More time spent in accelerometry-measured (i.e., ActiGraph) and self-reported moderate-to-vigorous physical activity was associated with significantly higher skeletal muscle energetics (i.e., ATPmaxand maxOXPHOS).•More time spent in ActiGraph, but not self-reported daily sedentary behavior, was associated with lower skeletal muscle energetics.•Higher activPAL step count, but not time spent in sedentary behavior, was associated with higher ATPmaxand maxOXPHOS.•Older age was associated with lower muscle energetics for men but not women; adjustment for ActiGraph moderate-to-vigorous physical activity attenuated the age association with ATPmaxby 58%, indicating that higher intensity physical activity may offset age-related decline in ATPmax.

The growing complexity of biopharmaceutical sponsored trials has adverse impacts on increased burdens on participants, clinical sites, and sponsors, including greater difficulty recruiting and retaining participants, difficulty engaging sites to participate in trials, excessive cost of trials, and increased cycle times. The schedule of assessments (SoAs) is the origin of and blueprint for complexity that is often generated by copying and pasting from previous SoAs. We developed an approach, termed Lean Design, for redesigning the assessments in SoAs that generate data, the ‘Data SoA.’ It starts with a simple “ground zero” SoA. Any addition is challenged using several principles of trial design. We employed a system, the Faro Trial Designer Tool, to quantify the impacts of changes in an SoA to provide real-time feedback to the team and sponsor. We applied the approach in workshops with teams for six clinical trials in various stages of design and implementation. The approach resulted in recommendation for substantial potential savings in participant and site staff time, costs, and complexity of the trials. Application of this approach to very early stages of protocol design has the potential to reduce the complexity of biopharmaceutical sponsored trials and its consequences.

CASE Embryo mix-up with 2 couples A lawsuit was recently filed in California by a couple after the woman carried and gave birth to 'the wrong child.' This was the [...]

There is now great interest in the Supreme Court's handling of cases that involve a woman's ability to have an abortion. Recent decisions, and those planned in the next few [...]

How muscle mass, strength, and performance are playing a recognized role in bone health, plus when to measure BMD in premenopausal women Recently, the National Osteoporosis Foundation (NOF) changed its [...]

For much of the general public, in-home care from a physician is akin to the rotary telephone: a feature of a bygone age, long since replaced by vastly different systems. [...]

Negative sentiment override (NSO), or messages and experiences interpreted in an increasingly negative manner, is one way to explain dissatisfaction in romantic relationships. In addition, psychological factors, like anxiety, have been shown to increase levels of dissatisfaction. In the current study, we examined the extent that significant anxiety, determined by responses to the Symptom Checklist--90, influenced the endorsement of items on Gottman's NSO scale. We examined the item characteristic curves (ICCs) of the individual items on Gottman's NSO scale and then tested for differential item functioning between those with significant anxiety and those without significant anxiety for a sample of 262 individuals seeking counseling. Our results demonstrate different ICC patterns between those with anxiety and those without. More specifically, individuals with anxiety reported elevated NSO compared to individuals without anxiety. Implications of these findings are discussed., Reviews of divorce rate hover around 50% for individuals in the United States (Afifi et al,, 2013; Bradford et al., 2014). Reasons cited for dissatisfaction and/or divorce include communication issues, [...]

Historians frequently state that Maj. Gen. George B. McClellan suffered from a messianic complex and that he alone believed he had been called by God to save the Union. McClellan's [...]

Ultrasonography truly has revolutionized the practice of obstetrics and gynecology. Initially, transabdominal ultrasonography was mainly a tool of the obstetrician. Early Unear array, real-time equipment had barely enough resolution to [...]

ABSTRACTMental fatigue shows consistent detrimental effects on physically-demanding tasks including running and muscular endurance tasks. Several strategies to mitigate these effects have been assessed; however, it is also important to explore factors that may combine with mental fatigue to amplify performance decrements. The present study investigated potential moderating effects of attentional focus on the mental fatigue – endurance performance relationship. Undergraduates (N = 78) completed two wall-sit tasks to volitional failure prior to, and following, a cognitive task. Using a 2 X 2 randomised factorial design, half the participants completed a mentally fatiguing cognitive task (incongruent Stroop; HF), while the other half performed a non-mentally fatiguing task (documentary viewing; LF). Prior to the second wall-sit task, half the participants in each of the HF and LF groups were given attentional focus instructions to focus internally (INT) and the other half to focus externally (EXT). Both the mental fatigue (p < .001) and attentional focus (p < .001) manipulations were found to be successful. Planned comparisons showed no significant effects of attentional focus or mental fatigue on wall-sit endurance performance. However, a large effect size was observed between the HF/INT group and the other three groups (d = −1.56). Overall, data indicate a potential moderating effect of attentional focus such that internal focus and high mental fatigue may combine to have detrimental effects on physical endurance performance.

It's a fragrant, soft fall day, not much light as the cloud base is low, adding to the wild feel of the woods. The willows are stunted and losing their [...]

CASE Mixed CP diagnosed at age 6 months After learning that the statute of limitations was to run out in the near future, the parents of a 17-year-old with cerebral [...]

Cases involving missed BRCA testing are increasing. Could you be exposing yourself to unnecessary risk if you don't counsel for and recommend genetic testing for a patient with red flags [...]

ABSTRACT:Native grasses are widely used in the Intermountain West for restoration and conservation of semi-arid rangelands negatively impacted by exotic weedy annuals and recurrent wildfire. Their utilization, however, is typically limited by low seed yields and poor establishment. To address this, Destination Germplasm Snake River wheatgrass (Elymus wawawaiensis J. Carlson & Barkworth [Poaceae]) was released by USDA ARS on 31 May 2023. Destination Germplasm was developed directly from 'Discovery', released in 2007, being selected for emergence from deep seeding in the greenhouse, which is a generally recognized technique to improve seedling vigor and spike numbers in the field. Establishment-year (2021) biomass of Destination Germplasm exceeded 'Secar' by 118.1% and Discovery by 51.3% at North Park Farm (Hyde Park, Utah). Across 2 seed-production years (2022–2023), Destination Germplasm biomass and seed yield exceeded Secar by 41.0% and 43.7%, respectively, and Discovery by 24.4% and 78.3%, respectively. Likewise, for seed mass, Destination Germplasm exceeded Secar by 25.5% and Discovery by 16.1%. When fall-seeded at Nephi, Utah, in 2022 on an equal seed-number basis, 2023 stand establishment was 65.8%, 34.0%, and 11.5% for Destination Germplasm, Discovery, and Secar, respectively. This calculates to a 93.5% and 66.6% increase in establishment for Destination Germplasm relative to Discovery when sown on an equal seed-number and an equal mass basis, respectively. A strong positive correlation (r2 = 0.958) was found between seed mass at North Park and establishment percentage at Nephi. Destination Germplasm will facilitate improved establishment and seed-production success relative to its predecessors, Secar and Discovery.

Background/Objectives: Type 1 diabetes (T1D) is associated with an increase in resting metabolic rate (RMR), but the impact of T1D on other components of 24-h energy expenditure (24-h EE) is not known. Also, there is a lack of equations to estimate 24-h EE in patients with T1D. The aims of this analysis were to compare 24-h EE and its components in young adults with T1D and healthy controls across the spectrum of body mass index (BMI) and derive T1D-specific equations from clinical variables. Subjects/Methods: Thirty-three young adults with T1D diagnosed ≥1 year prior and 33 healthy controls matched for sex, age and BMI were included in this analysis. We measured 24-h EE inside a whole room indirect calorimeter (WRIC) and body composition with dual x-ray absorptiometry. Results: Participants with T1D had significantly higher 24-h EE than healthy controls (T1D = 2047 ± 23 kcal/day vs control= 1908 ± 23 kcal/day; P&lt; 0.01). We derived equations to estimate 24-h EE with both body composition (fat free mass + fat mass) and anthropometric (weight + height) models, which provided high coefficients of determination (R2= 0.912 for both). A clinical model that did not incorporate spontaneous physical activity yielded high coefficients of determination as well (R2= 0.897 and R2= 0.880 for body composition and anthropometric models, respectively). Conclusion: These results confirm that young adults with established T1D have increased 24-h EE relative to controls without T1D. The derived equations from clinically available variables can assist clinicians with energy prescriptions for weight management in patients with T1D.

Early identification of an acute respiratory infection is important for reducing transmission and enabling earlier therapeutic intervention. We aimed to prospectively evaluate the feasibility of home-based diagnostic self-testing of viral pathogens in individuals prompted to do so on the basis of self-reported symptoms or individual changes in physiological parameters detected via a wearable sensor.

IMPORTANCE: Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH. OBJECTIVE: To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines–Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021. EXPOSURES: Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke. MAIN OUTCOME MEASURES: sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages. RESULTS: Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P &lt; .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86). CONCLUSIONS AND RELEVANCE: Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.

Physical vapor deposited (PVD) molybdenum disulfide (nominal composition MoS2) is employed as a thin film solid lubricant for extreme environments where liquid lubricants are not viable. The tribological properties of MoS2are highly dependent on morphological attributes such as film thickness, orientation, crystallinity, film density, and stoichiometry. These structural characteristics are controlled by tuning the PVD process parameters, yet undesirable alterations in the structure often occur due to process variations between deposition runs. Nondestructive film diagnostics can enable improved yield and serve as a means of tuning a deposition process, thus enabling quality control and materials exploration. Grazing incidence X-ray diffraction (GIXRD) for MoS2film characterization provides valuable information about film density and grain orientation (texture). However, the determination of film stoichiometry can only be indirectly inferred via GIXRD. The combination of density and microstructure via GIXRD with chemical composition via grazing incidence X-ray fluorescence (GIXRF) enables the isolation and decoupling of film density, composition, and microstructure and their ultimate impact on film layer thickness, thereby improving coating thickness predictions via X-ray fluorescence. We have augmented an existing GIXRD instrument with an additional X-ray detector for the simultaneous measurement of energy-dispersive X-ray fluorescence spectra during the GIXRD analysis. This combined GIXRD/GIXRF analysis has proven synergetic for correlating chemical composition to the structural aspects of MoS2films provided by GIXRD. We present the usefulness of the combined diagnostic technique via exemplar MoS2film samples and provide a discussion regarding data extraction techniques of grazing angle series measurements.

IMPORTANCE: Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea. OBJECTIVE: To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice. EVIDENCE REVIEW: A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set. FINDINGS: The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting. CONCLUSIONS AND RELEVANCE: This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

The hardware utilized for rigid internal fixation of the craniofacial skeleton has evolved over time. Thus, the reasons for the unplanned removal of hardware continue to change. The purpose of this study is to compare past (1989–1995) and present (2000–2020) patient cohorts to establish trends related to unplanned removal of craniofacial hardware. A retrospective review study was designed. Data from our institution’s original publication describing the unplanned removal of craniofacial hardware (1989-1995) was obtained. Data related to patients who underwent unplanned removal of hardware from 2000 to 2020 was collected from the electronic medical record. A descriptive statistical analysis was performed to compare demographics, reasons for hardware placement, and reasons for unplanned hardware removal between cohorts. This study includes 55 patients treated from 1989 to 1995 and 184 patients treated from 2000 to 2020. The average age at hardware placement decreased from 32 years (1989–1995) to 28 years (2000–2020). The most common reason for hardware placement changed from motor vehicle accident (1989–1995) to congenital deformity (2000–2020). The length of time with hardware in situ increased from 13 months (1989–1995) to 25 months (2000–2020). The most common reason for hardware removal changed from prominent hardware (1989–1995) to hardware exposure (2000–2020). In summary, patients who underwent rigid internal fixation of the craniofacial skeleton from 2000 to 2020 retained their hardware 2 times longer than patients treated from 1989 to 1995. Factors potentially contributing to increased retention include improved surgical technique, decreased profile of hardware, and increased surgeon experience. Further studies are warranted to define preoperative risk factors for unplanned hardware removal.