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There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital.All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs.The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model).Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research.

Two strains of Gram-negative, anaerobic, rod-shaped bacteria, from an abundant but uncharacterized rumen bacterial group of the order ‘Christensenellales’, were phylogenetically and phenotypically characterized. These strains, designated R-7T and WTE2008T, shared 98.6–99.0 % sequence identity between their 16S rRNA gene sequences. R-7T and WTE2008T clustered together on a distinct branch from other Christensenellaceae strains and had Luoshenia tenuis NSJ-44T. The genome sequences of R-7T and WTE2008T had 83.6 % average nucleotide identity to each other, and taxonomic assignment using the Genome Taxonomy Database indicates these are separate species within a novel family of the order ‘Christensenellales’. Cells of R-7T and WTE2008T lacked any obvious appendages and their cell wall ultra-structures were characteristic of Gram-negative bacteria. The five most abundant cellular fatty acids of both strains were C16 : 0, C16 : 0 iso, C17 : 0 anteiso, C18 : 0 and C15 : 0 anteiso. The strains used a wide range of the 23 soluble carbon sources tested, and grew best on cellobiose, but not on sugar-alcohols. Xylan and pectin were fermented by both strains, but not cellulose. Acetate, hydrogen, ethanol and lactate were the major fermentation end products. R-7T produced considerably more hydrogen than WTE2008T, which produced more lactate. Based on these analyses, Aristaeellaceae fam. nov. and Aristaeella gen. nov., with type species Aristaeella hokkaidonensis sp. nov., are proposed. Strains R-7T (=DSM 112795T=JCM 34733T) and WTE2008T (=DSM 112788T=JCM 34734T) are the proposed type strains for Aristaeella hokkaidonensis sp. nov. and Aristaeella lactis sp. nov., respectively.

Introduction Although treatment outcome expectancies (TOEs) may influence clinical outcomes, TOEs are rarely reported in the smoking cessation literature, in part because of the lack of validated measures. Therefore, we conducted a psychometric evaluation of TOEs scores with the Stanford Expectations of Treatment Scale (SETS) in the context of a smoking cessation clinical trial. Methods Participants were 320 adults enrolled in a randomized controlled trial of extended versus standard pre-quit varenicline treatment for smoking cessation (clinicaltrials.gov ID: NCT03262662). Across an 8-week treatment period, we examined the nature and stability of the factor structure using confirmatory factor analysis (CFA), evaluated discriminant validity by examining correlations with abstinence self-efficacy and positive/negative affect (PA/NA), and assessed internal consistency and test–retest reliability of SETS scores. Results CFAs supported a 2-factor structure that was stable (ie, invariant) across weeks. Positive and negative TOEs were each reflected in three-item subscales that exhibited acceptable to excellent internal consistency (Cronbach’s alphas ≥ .77). Positive and negative TOEs were modestly correlated with PA and NA (all |rs| Conclusions SETS scores generally reflect a valid and reliable assessment of positive and negative TOEs in a sample of adults enrolled in a smoking cessation trial. The SETS appears to be a reasonable option for assessing TOEs in future smoking treatment studies. Implications Assessments of treatment outcome expectancies are rarely reported in the smoking cessation literature. The present results support the validity and reliability of the SETS scores among adults seeking treatment for their smoking behavior.

“Managing up” for the radiologist means developing and cultivating work relationships to benefit high-level stakeholders and the institution at large, and to maximize one’s own effectiveness. Today’s breast radiologists are responsible for more than image interpretation and image-guided interventions. Radiologists’ roles and responsibilities have evolved to include clinical initiatives, staff development, quality improvement, and administrative tasks where management skills are needed. To be successful in these roles, developing skills to manage up will allow radiologists to be more effective team members. In this article, we discuss tactics to start developing strategies for managing up, including how to understand practice leaders and create meaningful relationships; explain various work style personalities and how to navigate them; describe how to understand oneself, including strengths and weaknesses; and, finally, provide tips on how to begin to cultivate managing up skills.

BackgroundTranslating repetitive transcranial magnetic stimulation (rTMS) into evidence-based clinical applications relies on research volunteers with different perspectives on the burden of study participation. Additionally, clinical applications of rTMS require multiple visits over weeks or months, the impact of research burden is an important component for these studies and translation of these findings to clinical practice. High frequency rTMS has significant potential to be developed as an evidence-based treatment for smoking cessation, however, the optimal rTMS dosing strategies have yet to be determined. Participant burden is an important component of determining optimal dosing strategy for rTMS as a treatment for long-term smoking cessation.MethodsIn this double-blinded, sham-controlled, randomized design, the effects of treatment duration, intensity, and active/sham assignment of rTMS on research burden were examined.ResultsOverall level of perceived research burden was low. Experienced burden (M = 26.50) was significantly lower than anticipated burden (M = 34.12). Research burden did not vary by race or income.ConclusionsOverall research burden was relatively low. Contrary to our hypotheses, we found little evidence of added significant burden for increasing the duration or intensity of rTMS, and we found little evidence for differences in research burden by race or income.Clinical Trial Registrationidentifier NCT03865472.

Rationale and Objectives The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists. Materials and Methods In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed. Results Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC ‘always’ or ‘most of the time’. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003). Conclusion Radiologists’ reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

ImportanceEven with varenicline, the leading monotherapy for tobacco dependence, smoking abstinence rates remain low. Preliminary evidence suggests that extending the duration of varenicline treatment before quitting may increase abstinence.ObjectiveTo test the hypotheses that, compared with standard run-in varenicline treatment (1 week before quitting), extended run-in varenicline treatment (4 weeks before quitting) reduces smoking exposure before the target quit date (TQD) and enhances abstinence, particularly among women.Design, Setting, and ParticipantsThis double-blind, randomized, placebo-controlled clinical trial enrolled participants from October 2, 2017, to December 9, 2020, at a single-site research clinic in Buffalo, New York. Of 1385 people screened, 320 adults reporting smoking 5 or more cigarettes per day (CPD) were randomized and followed up for 28 weeks. Data were analyzed from August 2021 to June 2022.InterventionsIn the pre-TQD period (weeks 1-4), the extended run-in group received 4 weeks of varenicline; the standard run-in group received 3 weeks of placebo followed by 1 week of varenicline. Both groups received open-label varenicline during weeks 5 to 15 and brief quit counseling at 6 clinic visits.Main Outcomes and MeasuresThe primary outcome consisted of cotinine-verified (at end of treatment [EOT]) self-reported continuous abstinence from smoking (in CPD) during the last 4 weeks of treatment. Secondary outcomes included bioverified self-report of continuous abstinence at the 6-month follow-up and percentage of reduction in self-reported smoking rate during the prequit period (week 1 vs week 4).ResultsA total of 320 participants were randomized, including 179 women (55.9%) and 141 men (44.1%), with a mean (SD) age of 53.7 (10.1) years. Continuous abstinence during the final 4 weeks of treatment (weeks 12-15; EOT) was not greater in the extended run-in group (64 of 163 [39.3%]) compared with the standard run-in group (57 of 157 [36.3%]; odds ratio [OR], 1.13 [95% CI, 0.72-1.78]), nor was the hypothesized group × sex interaction significant (OR, 0.52 [95% CI, 0.21-1.28]). Similar nonsignificant results were obtained for continuous abstinence at the 6-month follow-up. The mean (SE) decrease in self-reported smoking rate during the prequit period was greater in the extended run-in group (−38.8% [2.8%]) compared with the standard run-in group (−17.5% [2.7%]).Conclusions and RelevanceAmong adult daily smokers, extending the duration of prequit varenicline treatment beyond the standard 1-week run-in period reduced prequit smoking exposure but, more importantly, did not significantly improve continuous abstinence rates.Trial RegistrationClinicalTrials.gov Identifier: NCT03262662

Communication technologies, including cell phones, social media, and location tracking services, can be used to perpetrate abuse against current or former intimate partners. A growing literature examines these behaviors in adolescent and college samples, yet very little research has investigated cyber abuse prevalence and risk factors in broader samples of adults. The present study examines whether in-person forms of intimate partner aggression (IPA) and important IPA risk factors are associated with cyber psychological abuse (CPA) in a sample of adults (N = 243; Mean age = 33.49, SD = 11.31) who reported being in a romantic relationship within the last 12 months and were recruited through Amazon’s Mechanical Turk. Participants completed assessments of CPA, physical assault, emotional abuse, maltreatment history, attachment insecurity, jealousy, emotion dysregulation, substance abuse, and relationship functioning. The Cyber Psychological Abuse scales significantly and positively correlated with physical assault and emotional abuse. Multivariate risk factor analyses accounted for 40% and 30% of the variance in CPA perpetration and victimization, respectively. Behavioral jealousy, relationship discord, and extent of daily cell phone use had significant unique associations with both CPA perpetration and victimization. The results indicate that CPA is highly prevalent among adults, strongly associated with other forms of IPA, and correlated with both IPA risk factors and extent of technology use. Findings support the further development of efforts to prevent CPA, to educate potential CPA victims, and to assess and address CPA among adults who engage in or experience in-person forms of partner abuse.

A subset (35%) of triple-negative breast cancers (TNBCs) expresses androgen receptor (AR) activity. However, clinical trials with antiandrogen drugs have shown limited efficacy, with about a 19% clinical benefit rate. We investigated the therapeutic enhancement of antiandrogens as radiosensitizers in combination with (18)F-FDG in TNBC. Methods: We screened 5 candidate drugs to evaluate shared toxicity when combined with either (18)F-FDG, x-rays, or ultraviolet radiation, at doses below their respective half-maximal inhibitory concentrations. Cytotoxic enhancement of antiandrogen in combination with (18)F-FDG was evaluated using cell proliferation and DNA damage assays. Finally, the therapeutic efficacy of the combination treatment was evaluated in mouse tumor models of TNBC and prostate cancer. Results: Bicalutamide, an antiandrogen drug, was found to share similar toxicity in combination with either (18)F-FDG or x-rays, indicating its sensitivity as a radiosensitizer to (18)F-FDG. Cell proliferation assays demonstrated selective toxicity of combination bicalutamide-(18)F-FDG in AR-positive 22RV1 and MDA-MB-231 cells in comparison to AR-negative PC3 cells. Quantitative DNA damage and cell cycle arrest assays further confirmed radiation-induced damage to cells, suggesting the role of bicalutamide as a radiosensitizer to (18)F-FDG–mediated radiation damage. Animal studies in MDA-MB-231, 22RV1, and PC3 mouse tumor models demonstrated significant attenuation of tumor growth through combination of bicalutamide and (18)F-FDG in the AR-positive model in comparison to the AR-negative model. Histopathologic examination corroborated the in vitro and in vivo data and confirmed the absence of off-target toxicity to vital organs. Conclusion: These data provide evidence that (18)F-FDG in conjunction with antiandrogens serving as radiosensitizers has utility as a radiotherapeutic agent in the ablation of AR-positive cancers.

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient’s upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Severe acute respiratory syndrome coronavirus 2 has spread across the world since December 2019, infecting 100 million and killing millions. The impact on health care institutions during the coronavirus disease 2019 pandemic has been considerable, with exhaustion of institutional and personal protective equipment resources during local outbreaks and crushing financial consequences for many institutions. Establishing adaptive principles of leadership is necessary during crises, fostering quick decision-making and workflow modifications, while a rapid review of data must determine necessary course corrections. This report describes concepts of crisis leadership teams that can help maximize their effectiveness during the current and future pandemics. © RSNA, 2021

The Protecting Access to Medicare Act (PAMA) mandates clinical decision support mechanism (CDSM) consultation for all advanced imaging. There are a growing number of studies examining the association of CDSM use with imaging appropriateness, but a paucity of multicenter data. This observational study evaluates the association between changes in advanced imaging appropriateness scores with increasing provider exposure to CDSM. Each provider’s first 200 consecutive anonymized requisitions for advanced imaging (CT, MRI, ultrasound, nuclear medicine) using a single CDSM (CareSelect, Change Healthcare) between January 1, 2017 and December 31, 2019 were collected from 288 US institutions. Changes in imaging requisition proportions among four appropriateness categories (“usually appropriate” [green], “may be appropriate” [yellow], “usually not appropriate” [red], and unmapped [gray]) were evaluated in relation to the chronological order of the requisition for each provider and total provider exposure to CDSM using logistic regression fits and Wald tests. The number of providers and requisitions included was 244,158 and 7,345,437, respectively. For 10,123 providers with ≥ 200 requisitions (2,024,600 total requisitions), the fraction of green, yellow, and red requisitions among the last 10 requisitions changed by +3.0% (95% confidence interval +2.6% to +3.4%), −0.8% (95% CI −0.5% to −1.1%), and −3.0% (95% CI 3.3% to −2.7%) in comparison with the first 10, respectively. Providers with > 190 requisitions had 8.5% (95% CI 6.3% to 10.7%) more green requisitions, 2.3% (0.7% to 3.9%) fewer yellow requisitions, and 0.5% (95% CI −1.0% to 2.0%) fewer red (not statistically significant) requisitions relative to providers with ≤ 10 requisitions. Increasing provider exposure to CDSM is associated with improved appropriateness scores for advanced imaging requisitions.

Background Recurrent laryngeal nerve (RLN) injury is a serious complication of thyroidectomy. The purpose of this study is to determine the predictors and consequences of RLN injury during thyroidectomy. Methods A retrospective analysis was conducted using the ACS-NSQIP 2016–2017 main and thyroidectomy targeted procedure databases. Data was analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of RLN injury and morbidity/mortality. Results Age ≥65, black race, neoplastic indication, total or subtotal thyroidectomy, concurrent neck surgery, operation time > median, hypoalbuminemia, and anemia were associated with RLN injury. Use of intraoperative nerve monitoring was associated with decreased RLN injuries. RLN injury is a risk factor for overall morbidity, hypocalcemia, hematoma, pulmonary morbidity, readmission, reoperation, and length of stay > median. Conclusion Several predictors of RLN injury during thyroidectomy are identified, while use of intraoperative nerve monitoring was associated with a decreased risk of RLN injury. RLN injury is associated increased postoperative complications.

The transition from trainee to newly minted breast radiologist is exciting and daunting in equal measure. The early years in practice are pivotal to long-term success in breast imaging whether entering academic or nonacademic practice. Yet a paucity of literature exists to guide junior radiologists in their early career transition. New breast radiologists can successfully navigate the start of a prosperous and enriching career by implementing strategies adapted from the business world and collective wisdom from the radiology world. This article provides an outline of tips and habits for new radiologists to incorporate in their work lives as attendings to ensure that they will thrive in breast imaging for years to come.

RATIONALE: Varenicline, a partial nicotinic agonist, is theorized to attenuate pre-quit smoking reinforcement and post-quit withdrawal and craving. However, the mechanisms of action have not been fully characterized, as most studies employ only retrospective self-report measures, hypothetical indices of reinforcing value, and/or non-treatment seeking samples. OBJECTIVES: The current research examined the impact of pre-quit varenicline (vs. placebo) on laboratory measures of smoking and food (v. water) reinforcement and craving. METHODS: Participants were 162 treatment-seeking smokers enrolled in a randomized controlled trial of smoking cessation (clinicaltrials.gov ID: NCT03262662). Participants completed two laboratory sessions: a pre-treatment session, ~1 week prior to beginning varenicline or placebo, and an active treatment session, after ~3 weeks of treatment. At each session, participants completed a laboratory choice procedure; on each of 36 trials, a lit cigarette, food item, or cup of water was randomly presented. Participants reported level of craving and spent $0.01-$0.25 to have a corresponding 5%-95% chance to sample the cue. RESULTS: As predicted, spending was significantly higher on cigarette trials than water trials, and varenicline resulted in a greater between-session decline in spending on cigarette trials (but not water) than did placebo. Cigarette craving was enhanced in the presence of smoking cues compared to water, but neither average (tonic) cigarette craving nor cue-specific cigarette craving was significantly influenced by varenicline. Food spending and craving were generally unaffected by varenicline treatment. CONCLUSIONS: These laboratory data from treatment-seeking smokers provide the strongest evidence to date that varenicline selectively attenuates smoking reinforcement prior to quitting.

Objective To determine the diagnostic accuracy of MRI textural analysis (TA) to differentiate malignant from benign axillary lymph nodes in patients with breast cancer. Methods This was an institutional review board–approved retrospective study of axillary lymph nodes in women with breast cancer that underwent ultrasound-guided biopsy and contrast-enhanced (CE) breast MRI from January 2015 to December 2018. TA of axillary lymph nodes was performed on 3D dynamic CE T1-weighted fat-suppressed, 3D delayed CE T1-weighted fat-suppressed, and T2-weighted fat-suppressed MRI sequences. Quantitative parameters used to measure TA were compared with pathologic diagnoses. Areas under the curve (AUC) were calculated using receiver operating characteristic curve analysis to distinguish between malignant and benign lymph nodes. Results Twenty-three biopsy-proven malignant lymph nodes and 24 benign lymph nodes were analyzed. The delayed CE T1-weighted fat-suppressed sequence had the greatest ability to differentiate malignant from benign outcome at all spatial scaling factors, with the highest AUC (0.84–0.93), sensitivity (0.78 [18/23] to 0.87 [20/23]), and specificity (0.76 [18/24] to 0.88 [21/24]). Kurtosis on the 3D delayed CE T1-weighted fat-suppressed sequence was the most prominent TA parameter differentiating malignant from benign lymph nodes (P < 0.0001). Conclusion This study suggests that MRI TA could be helpful in distinguishing malignant from benign axillary lymph nodes. Kurtosis has the greatest potential on 3D delayed CE T1-weighted fat-suppressed sequences to distinguish malignant and benign lymph nodes.

Design thinking is an innovative, human-centered approach to problem-solving. In design thinking, teams step away from immediate and reactionary approaches to complex problems in favor of novel, broader approaches. The key tenets of empathy and user-centered insights are emphasized. The primary objective in this holistic approach is to keep the needs, desires, and behaviors of all stakeholders involved in the ecosystem at the center of the design process. This approach creates more extensive, more diverse, and more productive teams in which each member is invested in the changes being designed and proposed. This review highlights the methodology, outcome metrics, advantages, and challenges of human-centered design in health care and radiology.

BackgroundRepetitive transcranial magnetic stimulation (rTMS) is a novel treatment for smoking cessation and delay discounting rate is novel therapeutic target. Research to determine optimal therapeutic targets and dosing parameters for long-term smoking cessation is needed. Due to potential biases and confounds introduced by the COVID-19 pandemic, we report preliminary results from an ongoing study among participants who reached study end prior to the pandemic.MethodsIn a 3 × 2 randomized factorial design, participants (n = 23) received 900 pulses of 20 Hz rTMS to the left dorsolateral prefrontal cortex (PFC) in one of three Durations (8, 12, or 16 days of stimulation) and two Intensities (1 or 2 sessions per day). We examined direction and magnitude of the effect sizes on latency to relapse, 6-month point-prevalence abstinence rates, research burden, and delay discounting rates.ResultsA large effect size was found for Duration and a medium for Intensity for latency to relapse. Increasing Duration increased the odds of abstinence 7–8-fold while increasing Intensity doubled the odds of abstinence. A large effect size was found for Duration, a small for Intensity for delay discounting rate. Increasing Duration and Intensity had a small effect on participant burden.ConclusionFindings provide preliminary support for delay discounting as a therapeutic target and for increasing Duration and Intensity to achieve larger effect sizes for long-term smoking cessation and will provide a pre-pandemic comparison for data collected during the pandemic.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT03865472].

Single-cell proteomics (SCP) has great potential to advance biomedical research and personalized medicine. The sensitivity of such measurements increases with low-flow separations (

Background: Prior studies have not clearly established risk of cardiovascular disease (CVD) among smokers who switch to exclusive use of electronic nicotine delivery systems (ENDS). We compared cardiovascular disease incidence in combustible-tobacco users, those who transitioned to ENDS use, and those who quit tobacco with never tobacco users. Methods: This prospective cohort study analyzes five waves of Population Assessment of Tobacco and Health (PATH) Study data, Wave 1 (2013–2014) through Wave 5 (2018–2019). Cardiovascular disease (CVD) incidence was captured over three intervals (Waves 1 to 3, Waves 2 to 4, and Waves 3 to 5). Participants were adults (40+ years old) without a history of CVD for the first two waves of any interval. Change in tobacco use status, from exclusive past 30 day use of any combustible-tobacco product to either exclusive past 30 day ENDS use, dual past 30 day use of ENDS and combustible-tobacco, or no past 30 day use of any tobacco, between the first two waves of an interval was used to predict onset of CVD between the second and third waves in the interval. CVD incidence was defined as a new self-report of being told by a health professional that they had congestive heart failure, stroke, or a myocardial infarction. Generalized estimating equation (GEE) analyses combined 10,548 observations across intervals from 7820 eligible respondents. Results: Overall, there were 191 observations of CVD among 10,548 total observations (1.7%, standard error (SE) = 0.2), with 40 among 3014 never users of tobacco (1.5%, SE = 0.3). In multivariable models, CVD incidence was not significantly different for any tobacco user groups compared to never users. There were 126 observations of CVD among 6263 continuing exclusive combustible-tobacco users (adjusted odds ratio [AOR] = 1.44; 95% confidence interval (CI) 0.87–2.39), 15 observations of CVD among 565 who transitioned to dual use (AOR = 1.85; 0.78–4.37), and 10 observations of CVD among 654 who quit using tobacco (AOR = 1.18; 0.33–4.26). There were no observations of CVD among 53 who transitioned to exclusive ENDS use. Conclusions: This study found no difference in CVD incidence by tobacco status over three 3 year intervals, even for tobacco quitters. It is possible that additional waves of PATH Study data, combined with information from other large longitudinal cohorts with careful tracking of ENDS use patterns may help to further clarify this relationship.

Introduction Negative reinforcement models posit that relapse to cigarette smoking is driven in part by changes in affect and craving during the quit attempt. Varenicline may aid cessation by attenuating these changes; however, this mediational pathway has not been formally evaluated in placebo-controlled trials. Thus, trajectories of negative affect (NA), positive affect (PA), and craving were tested as mediators of the effect of varenicline on smoking cessation. Aims and Methods Secondary data analysis was conducted on 828 adults assigned to either varenicline or placebo in a randomized controlled trial for smoking cessation (NCT01314001). Self-reported NA, PA, and craving were assessed 1-week pre-quit, on the target quit day (TQD), and 1 and 4 weeks post-TQD. Results Across time, NA peaked 1-week post-quit, PA did not change, and craving declined. Less steep rises in NA (indirect effect 95% CI: .01 to .30) and lower mean craving at 1-week post-quit (CI: .06 to .50) were mediators of the relationship between varenicline and higher cessation rates at the end of treatment. PA was associated with cessation but was not a significant mediator. Conclusions These results partially support the hypothesis that varenicline improves smoking cessation rates by attenuating changes in specific psychological processes and supported NA and craving as plausible treatment mechanisms of varenicline. Implications The present research provides the first evidence from a placebo-controlled randomized clinical trial that varenicline’s efficacy is due, in part, to post-quit attenuation of NA and craving. Reducing NA across the quit attempt and craving early into the attempt may be important treatment mechanisms for effective interventions. Furthermore, post-quit NA, PA, and craving were all associated with relapse and represent treatment targets for future intervention development.

Ventilator sharing has been proposed as a method of increasing ventilator capacity during instances of critical shortage. We sought to assess the ability of a regulated, shared ventilator system, the multisplit ventilator system, to individualize support to multiple simulated patients using one ventilator. We employed simulated patients of varying size, compliance, minute ventilation requirement, and positive end-expiratory pressure (PEEP) requirement. Performance tests were performed to assess the ability of the system, versus control, to achieve individualized respiratory goals to clinically disparate patients sharing a single ventilator following ARDSNet guidelines (Acute Respiratory Distress Syndrome). Resilience tests measured the effects of simulated adverse events occurring to one patient on another patient sharing a single ventilator. The multisplit ventilator system met individual oxygenation and ventilation requirements for multiple simulated patients with a tolerance similar to that of a single ventilator. Abrupt endotracheal tube occlusion or extubation occurring to one patient resulted in modest, clinically tolerable changes in ventilation parameters for the remaining patients. The proof-of-concept ventilator system presented in this paper is a regulated, shared ventilator system capable of individualizing ventilatory support to clinically dissimilar simulated patients. It is resilient to common adverse events and represents a feasible option to ventilate multiple patients during a severe ventilator shortage.

Most adults who regularly use e-cigarettes or Electronic Nicotine Delivery Systems (ENDS) desire to discontinue use. ENDS use can result symptoms of nicotine withdrawal and dependence which can make it more difficult to discontinue use. Brief, valid assessment of nicotine dependence among adults who use ENDS is needed to guide treatment for nicotine dependence in this group. We sought to develop a brief, valid instrument to measure nicotine dependence among adults seeking to discontinue ENDS in a busy Quitline.In this cross-sectional design, we examined content, construct, and concurrent validity of the Roswell ENDS Nicotine Dependence Scale (Roswell eND Scale) and the Penn State E-Cigarette Dependence Index (Penn State eCDI). Participants who called the New York Quitline from November 2019 to June 2020 seeking to discontinue ENDS use were invited to participate. Construct validity was examined with exploratory and confirmatory factor analyses. Instrument and factor scores were then correlated with cotinine, a biomarker of nicotine exposure.All participants (n = 209) were highly dependent and co-used combustible cigarettes to varying degrees. Both instruments demonstrated content validity and construct validity, however only the 5-item Roswell eND Scale demonstrated criterion-related validity by showing a significant positive correlation with salivary cotinine levels.The 5-item Roswell eND Scale can briefly and effectively assess nicotine dependence among treatment-seeking adults who co-use ENDS and cigarettes. These preliminary psychometric findings have the potential to be generalizable to other adults seeking to discontinue ENDS use, many of whom currently or formerly smoked cigarettes.

Although known from more than 180 sites in North America, sites with records of multiple Megalonyx elements and individuals are rare. The Tarkio site in southwestern Iowa is unique with three contemporaneous individuals at different stages of development. Among these is one of the largest (ca. 1286 kg) and most complete adult Megalonyx jeffersonii skeletons (ca. 50%, NISP, 123) known. An intermingled sub-adult (ca. 25%, NISP, 63) represents a comparatively complete skeleton for this ontogenetic stage. A third individual, an infant known only from both scapulae (NISP 2), is commingled with sub-adult remains. Scapula sizes indicate that the two juveniles were 50 and 30% of the adult’s size. Differential bone preservation and pattern of scatter shows that the adult decomposed lying on its left side and the remains were partially scavenged. Multiple taphonomic proxies demonstrate that the skeletons were subaerially exposed for a limited period, but fluvial transport was not a factor. These individuals, preserved in the same low-energy microstratigraphic unit, apparently died concurrently and probably represent a Megalonyx social unit. Using mammal body size to estimate life history, the estimated average lifespan for M. jeffersonii was around 19 years; gestation time was about 14 months; the interbirth interval was approximately 3 years; and sexual maturation occurred at around 6.5 years. OSL analysis indicates that the sloths were deposited about 106,000 years ago (MIS substage 5ec). Paleoenvironmental proxies suggest an interglacial environment of open woodland along a stream with marshes, like the environment in southwest Iowa today.

During newborn lung injury, excessive activity of lysyl oxidases (LOXs) disrupts extracellular matrix (ECM) formation. Previous studies indicate that TGFβ activation in the O2-injured mouse pup lung increases lysyl oxidase (LOX) expression. But how TGFβ regulates this, and whether the LOXs generate excess pulmonary aldehydes are unknown. First, we determined that O2-mediated lung injury increases LOX protein expression in TGFβ-stimulated pup lung interstitial fibroblasts. This regulation appeared to be direct; this is because TGFβ treatment also increased LOX protein expression in isolated pup lung fibroblasts. Then using a fibroblast cell line, we determined that TGFβ stimulates LOX expression at a transcriptional level via Smad2/3-dependent signaling. LOX is translated as a pro-protein that requires secretion and extracellular cleavage before assuming amine oxidase activity and, in some cells, reuptake with nuclear localization. We found that pro-LOX is processed in the newborn mouse pup lung. Also, O2-mediated injury was determined to increase pro-LOX secretion and nuclear LOX immunoreactivity particularly in areas populated with interstitial fibroblasts and exhibiting malformed ECM. Then, using molecular probes, we detected increased aldehyde levels in vivo in O2-injured pup lungs, which mapped to areas of increased pro-LOX secretion in lung sections. Increased activity of LOXs plays a critical role in the aldehyde generation; an inhibitor of LOXs prevented the elevation of aldehydes in the O2-injured pup lung. These results reveal new mechanisms of TGFβ and LOX in newborn lung disease and suggest that aldehyde-reactive probes might have utility in sensing the activation of LOXs in vivo during lung injury.

Biliary disease is a common surgical problem. A unique case of a 53-year-old male with an enormous gallstone precluding safe laparoscopic cholecystectomy is presented. The patient was a 53-year-old male who presented to the emergency department with a 1-day history of abdominal pain for which clinical findings were consistent with acute cholecystitis. A laparoscopic cholecystectomy was attempted, but could not be safely completed due to an enormous gallstone prohibiting attainment of the critical view of safety. The stone measured 12.2 cm × 5.2 cm × 5.2 cm. Although biliary disease is very common and its management well documented, it is rare to uncover stones larger than 5 centimeters in diameter. Clinicians should be aware that enormous gallstones require prompt surgical intervention if discovered in the elective setting to minimize future morbidity should cholecystitis develop; early elective cholecystectomy should be considered upon discovery of large gallstones to prevent encountering a gallbladder with decreased mobilization in the setting of inflamed tissues.