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The common femoral artery (CFA) typically gives rise to its superficial and deep branches, with the deep femoral artery (DFA) being the largest and most substantial of these branches. This case study presents a rare variation of the DFA characterized by an unusual branching pattern and its specific relationship with the femoral vein within the subinguinal region. In nutshell, the DFA and the medial femoral circumflex artery shared a common origin from the medial aspect of the CFA. The DFA assumed an unusual course, initially passing anterior to the femoral vein above the saphenofemoral junction, followed by a spiraling trajectory around the medial aspect of the femoral vein before running posteriorly. The embryological origins and clinical implications of this anatomical variation are thoroughly examined. This unusual vascular relationship in the subinguinal region may potentially result in arterial injury during femoral vein cannulation or formation of arteriovenous fistula after the procedure.

Coral reefs are experiencing unprecedented loss in coral cover due to increased incidence of disease and bleaching events. Thus, understanding mechanisms of disease susceptibility and resilience, which vary by species, is important. In this regard, untargeted metabolomics serves as an important hypothesis-building tool enabling the delineation of molecular factors underlying disease susceptibility or resilience. In this study, we characterize metabolomes of four species of visually healthy stony corals, including Meandrina meandrites , Orbicella faveolata , Colpophyllia natans , and Montastraea cavernosa , collected at least a year before stony coral tissue loss disease reached the Dry Tortugas, Florida, and demonstrate that both symbiont and host-derived biochemical pathways vary by species. Metabolomes of Meandrina meandrites displayed minimal intraspecies variability and the highest biological activity against coral pathogens when compared to other species in this study. The application of advanced metabolite annotation methods enabled the delineation of several pathways underlying interspecies variability. Specifically, endosymbiont-derived vitamin E family compounds, betaine lipids, and host-derived acylcarnitines were among the top predictors of interspecies variability. Since several metabolite features that contributed to inter- and intraspecies variation are synthesized by the endosymbiotic Symbiodiniaceae, which could be a major source of these compounds in corals, our data will guide further investigations into these Symbiodiniaceae-derived pathways., Importance: Previous research profiling gene expression, proteins, and metabolites produced during thermal stress have reported the importance of endosymbiont-derived pathways in coral bleaching resistance. However, our understanding of interspecies variation in these pathways among healthy corals and their role in diseases is limited. We surveyed the metabolomes of four species of healthy corals with differing susceptibilities to the devastating stony coral tissue loss disease and applied advanced annotation approaches in untargeted metabolomics to determine the interspecies variation in host and endosymbiont-derived pathways. Using this approach, we propose the survey of immune markers such as vitamin E family compounds, acylcarnitines, and other metabolites to infer their role in resilience to coral diseases. As time-resolved multi-omics datasets are generated for disease-impacted corals, our approach and findings will be valuable in providing insight into the mechanisms of disease resistance., Competing Interests: The authors declare no conflict of interest.

Background: Revision total joint arthroplasty (rTJA) is a resource-intensive procedure addressing failed primary total joint hip (total hip arthroplasty [THA]) and knee arthroplasty (total knee arthroplasty [TKA]). Despite predictions of increased demand, reimbursement for rTJA has not kept pace with increasing costs and may be insufficient compared with primary procedures. The study aimed to highlight the diminishing surgeon reimbursement between primary and revision THA (rTHA) and TKA., Methods: This study is a retrospective analysis of billing data for primary and rTHA and TKA procedures from a single institution between 2019 and 2022. Insurance claims and charges data were provided by a local affiliate of a major national carrier which includes Medicare Advantage (MA) and commercial patients. Using insurance data, the study evaluates the total surgery costs for primary and rTHA and TKA and the individual charges that make up the total surgery cost., Results: Nine hundred five patients insured by the same carrier, who underwent a primary or rTJA, were identified. Irrespective of MA or commercial insurance, the average surgery cost for a primary THA was $26,043, compared with $53,456 for rTHA. Surgeon reimbursement for primary THA was 20% ($5,323) of the total surgery cost. Despite the doubled surgery cost for rTHA, surgeon reimbursement was 10% ($5,257) of the total surgery cost. Primary TKA surgery costs were $24,489, while revision costs were $43,074. Surgeon reimbursement for primary TKA was 20% ($4,918) of the total surgery cost, while reimbursement for revision TKA was 13% ($5,560). MA reimbursement was markedly lower than commercial reimbursement for primary and revision cases., Conclusion: Despite the higher total costs for rTJA, surgeon reimbursement is disproportionately diminished. The findings highlight the lack of incentive for revision cases. Surgeon reimbursement from MA and commercially insured patients for rTJA remains inadequate. This may limit patient access-to-care, leading to suboptimal outcomes and increased healthcare utilization., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Radiation therapy targets tumor tissue and requires children to lay still, often necessitating sedation. Historically anesthesiologists provided procedural sedation, but pediatric critical care physicians now regularly administer sedation outside the operating room. Procedural sedation for radiation poses unique challenges. The objective was to evaluate the success and assess complications of repeated sedations for radiation performed by pediatric critical care physicians. We performed a single-center, retrospective case series of children who received procedural sedation for radiation therapy by PICU physicians. The primary outcome was success, defined as completion of radiation treatment. Secondary outcomes included type of medication, dosing, tolerance, and complications requiring intervention. In our sample, 55 patients underwent 1174 sedation instances (mean 19.8 per patient). Patients had a mean age of 4.7 years (SD3.4), and weight of 20.2 kg (SD11.9). All patients had an ASA of 2 or 3. All patients had either a brain tumor or a non-mediastinal solid tumor. The success rate was 99.8%. The mean duration of sedation was 30.7 min (SD12.4). All sedations included propofol as a first agent with a mean bolus 3.3 mg/kg (SD1.4) and drip rate 148.7 mcg/kg/min (SD39.7). 4.4% of sedations required a second agent medication. There was no significant effect of repeated sedation with regards to the medication amount received ( p  = 0.97). Laryngospasm occurred during 0.2% of sedations. No patients required bag-mask ventilation, intubation, or chest compressions; no patients died during sedation. Pediatric critical care physicians can perform procedural sedation for radiation therapy successfully.

First responders face greater exposure to potentially traumatic events compared with the general public, which can lead to an increased likelihood of developing mental health concerns. The challenges of disaster relief take a physical and mental toll on first responders. Critical incident stress debriefing (CISD), the widely accepted gold-standard treatment for psychological debriefing, is often applied to offset this toll among first responders. CISD is a manualized seven-stage group intervention that was developed to provide support and aid in coping and to allow individuals who respond to emergencies and disasters to continue working. Substantial evidence has been found for its effectiveness. However, there is a general dearth of evidence about the field of prolonged disaster response, and research is hampered by the difficulties of executing a controlled study in the context of an emergency scenario., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Adolescent suicide crises usually require mental health services (inpatient and/or outpatient) to address their needs. Navigating the health care system, especially around suicide crises, is difficult and parents of adolescents usually manage their treatment access and engagement. Little research has examined how parents take on this care management role, vital to maintaining safety and improving adolescent menta health, and the barriers and facilitators they experience in these processes., Aims: To explore parents' experiences around adolescent suicide crises, with a focus on care management and barriers/facilitators to this role., Methods: Interviews were conducted with 18 parents of adolescents in the United States who had suicide crises in the previous 3 years. Using a family-systems lens and thematic analysis, researchers identified three themes and three subthemes., Results: Relevant themes and subthemes were Care Manager Role Transition (subtheme: Home Safety) ; Barriers after Barriers (subthemes: Logistical and System Barriers; Poor Communication ); and Facilitating Engagement . Parents had a sudden transition to the role of care manager during the adolescent's suicide crisis. They experienced difficulty in managing safety and navigating health care systems. Parents of adolescents with eating disorders had more difficulty in navigating systems and managing safety., Conclusions: Policies and clinical practice must recognize the role and value of parents as care managers of adolescent's mental health services, especially around transitions out of acute care settings. Psychiatric nurses are well positioned to assist parents with this role transition so that parents can better support adolescents during and after suicide crises., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Examine self-reported substance use of cisgender and trans-spectrum students., Design: Observational Study, cross-sectional design., Setting: Arkansas post-secondary institutions., Subjects: Active students enrolled in 2021, sample responses n = 3659., Measures: 9 Demographics, 13 recent substance use outcomes, 1 weekly alcohol use outcome, and 1 COVID-related substance use outcome., Analysis: Demographic and geospatial descriptives; t test/Cohen's d effect size; X2 Test for Independence/Cramer's V effect size; OLS Regression/Standardized Beta coefficients/Adjusted R2 effect sizes; level of significance = .05., Results: Trans-spectrum students are 1.8% of the sampled responses (n = 3315) with geographical variation. Weekly alcohol consumption is greater with trans-spectrum (MD = 0.74, d = .102), along with frequency of recent use of marijuana (V = .113), cocaine (V = .097), sedatives (V = .098), hallucinogens (V = .127), designer drugs (V = .087), and meth (V = .151). Suicidal thoughts (V = .112) and attempted suicide (V = .118) are greater and COVID increased use of substances (29.3% for trans-spectrum v 13.7% for cisgender, V = .073). Gender (B = .099), family history (B = .092), and campus policies (B = .084) impact weekly alcohol consumption ( P < .001, R2 = .024)., Discussion/conclusions: Trans-spectrum students report higher usage rates, suicidal thoughts, and COVID impacts on usage. Family history and campus policies also show impact on weekly alcohol use. Future postsecondary substance use assessments should include trans-spectrum demographic categories., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To inform program development, the AACP Graduate Education Special Interest Group Colleagues in Training Committee (CITC) investigated professional development needs of graduate students and post-doctoral fellows at schools/colleges of pharmacy., Methods: A cross-sectional pilot survey examined preferred programming topics, mentoring needs, and career goals. A survey invitation was posted on AACP Connect and emailed to Graduate Program Officers and Assistant/Associate Deans for Research at US pharmacy schools/colleges for distribution to trainees. Eligible respondents were trainees in Master's, PhD, or post-doctoral programs at US schools/colleges of pharmacy., Results: A total of 108 responses were analyzed. Most respondents were White (51%) or Asian (34%), 4% African-American or Black, and 3% Hispanic/Latino(a). Most were female (58%), with mean age 30 years (SD=6.05 years). Fifty-five percent were domestic and 41% international. The majority were PhD students (84%) in Basic Sciences (60%) or Economic, Social, and Administrative Sciences (ESAS, 24%). Preferred programming topics included: overview of career options (72%), how to get a job in pharmaceutical/biotech companies (67%), and resume/CV development (65%). There were significant differences in preferred programming topics between international and domestic trainees. Only 17% had a written mentorship contract with their major advisor. Forty-four percent planned careers in pharmaceutical/biotech companies, 27% academia, and 10% government agencies., Conclusions: Future programming may prioritize strategies for graduate students/post-doctoral fellows to decide what career is the right fit and developing job application materials. Results are relevant for AACP programming and graduate school curricula, as well as implementing individualized development programs targeting essential soft skills training., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: This study aimed to investigate, characterize, and provide quantitative reference data on tissue dielectric constant (TDC) values of female breasts when measurements were made to 5 mm depths and determine the utility of these measurements to differentiate between benign and malignant breast tumors. Methods and Results: Breast TDC was measured bilaterally in 82 women just prior to an ultrasound-guided diagnostic biopsy of one tumor in one breast. TDC was measured in triplicate over the tumor and the contralateral healthy breast. Considering all paired breasts, the average TDC (mean ± SD) for healthy breasts was less than for tumor-bearing breasts (26.7 ± 4.5 vs. 29.9 ± 8.5, p = 0.0003). Conclusions: Breast TDC values measured to 5 mm in 82 healthy nonedematous breasts provide a two-SD threshold reference value of 35.7. This represents a TDC value above which the presence of breast edema/lymphedema may be indicated based on the two-SD threshold criterion. For unilateral cases, an interbreast TDC ratio exceeding 1.275 may be considered a breast edema/lymphedema indicator also based on the two SD criteria used. These thresholds may have utility for early detection and to track breast edema/lymphedema changes. A comparison of these TDC values obtained from benign versus malignant tumors indicates no statistically significant difference between them. However, interbreast TDC ratios were statistically higher for breasts with malignant versus benign tumors. However, the large overlap of the ratio values renders this method of discrimination between benign vs. malignant tumors inadequate based on the present findings.

Introduction: Sagittal synostosis (SS) is the most prevalent form of craniosynostosis. It is the premature fusion of the sagittal suture, resulting in a "boat like" skull shape. Early surgical intervention is crucial to prevent complications, yet no standard procedure exists for patients over 12 months old. This study introduces the "Scarab technique", a novel surgical approach for late-presenting SS cases diagnosed after 1 year of age., Methods: A single-center, board-approved retrospective review was conducted from May 2017 to June 2020. The Scarab technique was used exclusively for delayed SS diagnosed after 1 year old. A 4 cm craniectomy was outlined around the sagittal suture, and vascularized scarab bone flaps attached to the parietal bone vasculature were created. These extension flaps were then lifted for further biparietal and bitemporal expansion, followed by an occipital-type advancement and fixation with resorbable plates and screws., Results: A total of 7 patients with delayed sagittal synostosis diagnosis underwent scarab technique surgery. The majority were male (71%) and Caucasian (43%). Mean surgery age was 2.6 years (SD=1.3), with 3.43-hour average operation time (SD=0.86), 101.4 mL estimated blood loss (SD=54.5), 3.85 days in the PICU (SD=0.69), and only 1 patient with a resolved postoperative infection., Conclusions: The Scarab technique is an effective alternative for treating delayed sagittal craniosynostosis, yielding statistically significant improvements in head shape and overall development post-surgery. Further long-term analysis and multicenter comparative studies with alternative techniques are warranted to fully assess its efficacy and outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Thyroidectomy has been post-operatively managed by hormone replacement therapy in order to satisfy the reference ranges of thyroid stimulating hormone (TSH) and thyroxine (T4) levels. While medication and standardized reference ranges have proven to be effective, many patients continue to report unintentional weight gain despite adequate amounts of treatment and levels of TSH and T4. Physicians, over the years, have become complacent to these "normal" ranges, and have ignored the metabolic consequences that are affecting thyroidectomy patients. This paper aims to redefine the approach to post-thyroidectomy clinical care by challenging the current standardized hormonal range values, exploring the gaps in thyroid hormone conversion, investigating the metabolic pathways of T3, considering the influence of inflammatory markers, and proposing the future for patient-centered management.

The current study examined onset and maintenance insomnia as mediators of the bidirectional relation between anxiety and depressive symptoms over a three-year period. The sample included 3,415 US community-dwelling Medicare beneficiaries aged 66-103. Participants completed measures of types of insomnia, anxiety symptoms, and depressive symptoms at four time points. Analyses included two double mediation models adjusted for baseline depressive or anxiety symptoms, chronic health problem burden, use of sleep medications, age, and sex. Both covariate-adjusted models showed significant direct relations between anxiety and depressive symptoms, and these relations were modestly partially mediated by onset and maintenance insomnia. In older adults, onset and maintenance insomnia are distinct outcomes of both anxiety and depressive symptoms and also predictors of each symptom cluster. Further research testing these models is warranted and, if supported, may support prevention and treatment studies focused on primary and secondary prevention of these problems in older adults., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To develop and validate a patient-reported outcome measure (PROM) to evaluate the quality of life (QoL) among patients with obstructive sleep apnea (OSA)., Study Design: A prospective cohort study., Settings: Tertiary referral center., Methods: We developed a 15-item English questionnaire that was administered to 176 adults with OSA and 22 adult controls without symptoms of OSA in a tertiary sleep surgery clinic between June 2021 and December 2021. The internal consistency and test-retest reliability were measured using the Cronbach's α and the intraclass correlation coefficient, respectively. The 2-sample Wilcoxon rank-sum (Mann-Whitney) test was applied to compare the 2 groups. Convergent validity of the test scores of the questionnaire was compared to previously validated outcome measures and objective sleep study outcomes using the Spearman correlation coefficient., Results: Of the 198 respondents (176 cases and 22 controls); 71% were men and 29% were women. The internal consistency was excellent with the α of .92 (lower 95% confidence limit of 0.90). All the test-retest correlations were positive, significant, and strong ranging from 0.50 to 0.90. The differences between cases and controls were statistically significant for all the items and for the total score. The total score of the questionnaire with the Epworth Sleepiness Scale and objective OSA measures was moderate to strong., Conclusions and Relevance: The new tool provides a validated PROM to evaluate the QoL among OSA patients specifically, with excellent internal consistency, reasonable test-retest reliability, discriminant validity, and construct validity., Level of Evidence: Level 4., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background and Context: Unplanned readmission within 30 days following elective spine surgery is a key indicator of quality of care, as readmissions often signal early complications or poor recovery. The Hospital Readmission Reduction Program (HRRP) and the Centers for Medicare and Medicaid Services (CMS) utilizes this metric to assess hospital and surgeon performance., Purpose: Here we aim to delineate quality of care metrics for full-endoscopic spine surgery (FESS) compared to traditional spine surgery., Design: The study was a retrospective multicenter analysis comparing outcomes of propensity matched cohorts., Patient Sample: The study included 908 FESS patients operated between 2014 and 2023 and a matched cohort of 73,906 non-FESS patients., Outcome Measures: Our primary outcome measures were postoperative 30-day hospital readmissions and revision surgery. Furthermore, demographic data, hospitalization, surgical details and comorbidities were included., Methods: Data were collected from 6 participating institutions. Patients older than 18 years undergoing non-instrumented FESS spine surgeries for degenerative lumbar spinal pathologies from 2016-2023 were included. A matched non-FESS cohort was identified in the ACS-NSQIP database (2015-2019). Propensity-score matching was used to compare the cohorts., Results: Before matching, the 30-day readmission rate was significantly lower in the FESS cohort (1.1% vs. 4.4%, p < 0.001), which remained consistent after matching (1.1% vs. 4.5%, p < 0.001). The rate of 30-day surgical revisions was similar between cohorts (1.0% vs. 1.1%, p = 0.63). Multivariate analysis indicated a significant correlation between FESS and reduced 30-day readmissions (odds ratio [OR] 0.28, 95% CI 0.14 to 0.57, p < 0.001)., Conclusion: This study is the first to compare 30-day hospital readmissions between FESS and non-endoscopic surgeries in a large, matched multicenter cohort. FESS significantly reduces both the length of postoperative hospital stay and 30-day readmission rates compared to non-endoscopic approaches, underscoring the safety and effectiveness of outpatient FESS. Future studies are needed to define the role of FESS in more complex spine procedures., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Chest trauma is a common injury in civilian and military polytrauma patients and is a leading cause of death and chronic disabilities. Evolving surgical techniques and advancements in chest wall reconstruction have improved clinical outcomes, reduced operative complications, and decreased mortality. In this case report, a 23-year-old male U.S. Army soldier sustained a left chest wall and shoulder blast injury with significant soft tissue damage, volumetric pectoralis major muscle loss, mild sensory nerve damage, and third-degree burns from a flashbang grenade. The initial treatment involved wound debridement, IV antibiotics, and pain management. This was followed by surgical reconstruction using a local advancement flap to prevent infection, address tissue loss, and restore chest wall integrity. Postoperative care included pain management and physical therapy, leading to a successful recovery with restored mobility and chest wall stability. This case highlights the challenges of treating severe chest wall trauma with burns, emphasizing the importance of timely surgical intervention and a multidisciplinary approach., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Patel et al.)

Background/aim: According to American Cancer Society's recent estimates, about 5,330 men and 3,950 women are diagnosed each year with chronic myeloid leukemia (CML). Roughly, 750 men and 530 women are predicted to die as a result of CML, establishing a dire need for advancements in CML treatment. Tyrosine kinase inhibitors (TKIs) imatinib and dasatinib have profound effects for prognosis and delaying survival from CML. The role of inecalcitol in the treatment and prevention of various cancers including leukemia has been established. The aim of this study was to analyze the putative synergistic treatment effects of inecalcitol in combination with imatinib or dasatinib on various cell lines including AR-230, LAMA-84-s, KCL-22, and U-937., Materials and Methods: Cells grown in plates were treated alone or with varying combinations of inecalcitol, imatinib, and dasatinib and incubated for 48 h at 37°C. Cell death was determined using MTT assay., Results: KCL-22 and U-937 were resistant to both combination treatments, whereas AR-230 exhibited a maximal antiproliferative effect (24%) with the combined treatment of imatinib (0.325 μM) and inecalcitol (15.8 μM) (p<0.001). With dasatinib (0.456 nM) and inecalcitol (15.8 μM), AR-230 exhibited a 34% antiproliferative effect (p<0.001). In drastic contrast, LAMA84-s exhibited a 45% antiproliferative effect (with the combined treatment of imatinib (0.325 μM) and inecalcitol (15.8 μM) (p<0.006). Notably, with dasatinib (0.456 nM) and inecalcitol (15.8 μM), LAMA84-s exhibited approximately 78% cell killing (p<0.007)., Conclusion: The study suggests that the synergistic effects of inecalcitol with imatinib on cell killing are more drastic in some cells than others. These varying effects may be due to differences in cell metabolism., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Antisemitism has been rising for decades and worsened following the events of Oct 7, 2023. Although anecdotal evidence suggests that these trends extend into the US medical community, quantitative data have been lacking. To address this gap, we quantitated publications about antisemitism, analyzed social media posts from the accounts of 220,405 healthcare professionals, and disseminated a survey to members of Jewish medical associations. Publications and social media posts about antisemitism rose > fivefold, while posts promoting antisemitic stereotypes increased 2-fourfold. Most Jewish-identifying medical students and professionals (75.4%) reported exposure to antisemitism. Together, our results suggest that antisemitism is escalating within the US healthcare community., Competing Interests: Declarations. Conflict of interest: Mr. Leiba is a full-time employee of the Foundation to Combat Antisemitism (Foxboro, MA). Dr. Wald is Commissioner, Lancet Commission on Medicine, Nazism, and the Holocaust. Dr. Roth is president of the Healthcare Council of the Coalition for Jewish Values (Baltimore, Maryland), and head of the Publications Committee of the American Jewish Medical Association (New York, NY). Dr. Schwartz, Dr. Spence, Dr. Oratz  and Dr. Feldman are members of the Publications Committee of the American Jewish Medical Association. The opinions expressed herein are those of the authors and not necessarily of their employers or of the Lancet Commission on medicine, Nazism, and the Holocaust. Ethical approval: This study utilized de-identified public social media data and an anonymous, voluntary survey of health professionals. All survey respondents were informed that their data would be used for research. The University of Illinois College of Medicine Institutional Review Board deemed this study “exempt.”, (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: We aim to explore and target factors contributing to disparities in trauma-care outcomes between urban vs rural trauma centers including EMS protocols, trauma centers' (TC) distribution, infrastructure, and hospital resources., Methods: A comprehensive literature review was conducted from January 1988 through April 1st, 2024, using Google Scholar, Embase, Cochrane, ProQuest, and PubMed. Included studies evaluated prehospital and in-hospital factors impacting trauma outcomes in urban and rural care settings. Key outcomes of interest were EMS transport times, TC access, inter-hospital transfers, trauma system utilization, and workforce infrastructure., Results: A review of 29 studies demonstrated prolonged EMS on-scene and transport times, higher undertriage rates, and lower geospatial access to TCs in rural compared to urban settings. Transferring from rural to urban TCs was associated with increased mortality and designating rural TCs as Level III TCs reduced mortality (32 % decrease, p < 0.0001). The unregulated expansion of TCs did not improve patient access or outcomes. Rural hospitals lacked specialized providers, had more hospitalizations (x̄ rural = 685.4 vs x̄ urban = 566.3; p = 0.005), ICU admissions (20.2% vs 11.6 %, p = 0.042), and ventilation requirements (37.8% vs 20.7 %, p = 0.001) among trauma patients., Conclusions: Rural trauma patients often experience worse outcomes than their urban counterparts, possibly due to longer prehospital times, reduced TC access, and less specialized care. The designation of targeted Level III TCs in rural areas has been associated with improved outcomes. In contrast, unregulated TC expansion has not necessarily enhanced access or outcomes for rural patients., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: Patients with refractory chronic pain may be considered for spinal cord stimulation (SCS) as an interventional therapy. Studies have shown that psychiatric disorders are associated with worse outcomes. However, this relationship may not be understood by all healthcare professionals. Despite psychologic clearance and proper indication, pain medicine physicians often find themselves questioning the appropriateness of some candidates. The authors conducted a scoping review to identify assessments ascertaining patients with pronounced psychiatric burden that may complicate optimal response, to identify any clearly defined psychiatric contraindications, and to review ways psychiatric comorbidities may be addressed in patients at risk for suboptimal long-term response., Materials and Methods: A scoping review was conducted at the Mayo Clinic using the Center for The Science of Health Care Delivery and the Plummer Library; 62 studies reporting clinical data related to psychiatric conditions and their use in assessing candidates for SCS implantation were deemed relevant. The extracted data underwent qualitative analysis., Results: Decreased depression and anxiety, increased life quality, and reduction in panic attacks, pain intensity during mania, and opioid use were reported after SCS. Antidepressant-medicated depression showed greater improvement. The exclusion criteria included substance use disorders, delirium, active psychosis, depression with suicidal ideation, significant somatization, and cognitive impairment/dementia. Benzodiazepine or antipsychotic use and presence of anxiety or mood disorders were associated with failed SCS. Numerous psychosocial risk factors and differences in cognitive appraisal, including pain catastrophizing and external locus of control, were associated with negative outcomes. Multiple psychologic interventions were identified, and a psychologic evaluation tool highly correlated to SCS implantation outcomes was developed., Conclusions: This review indicates a need for a standardized, evidence-based, algorithmic psychologic clearance protocol for SCS implantation. The authors designed such a protocol using multiple assessments targeted at establishing true contraindications and identifying barriers requiring further intervention to optimize outcomes, while ensuring individual accommodation., Competing Interests: Conflict of Interest Christine L. Hunt has received funding from Nevro in support of research unrelated to this work, paid to her institution. The remaining authors reported no conflict of interest., (Copyright © 2024 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Objective: Digital flexible ureteroscopes (DFUs) play a crucial role in endourological procedures, and scope breakages are often avoidable with proper measures in place. We aimed to evaluate the effect of mandatory training on DFU durability and to assess the influence of various factors on instrument damage. Materials and Methods: Mandatory training involving instructional videos on DFU care was introduced for all processing and operating room staff handling DFUs. Only certified personnel were allowed to handle DFUs, with meticulous usage documentation. The average annual usage of each DFU was compared pre and post program implementation. We examined factors such as patient demographics, procedure details, and operator experience impacting scope life using negative binomial regression. Results: The average usage of DFU increased by 21%, from 6.38 to 7.74 cases. We found that post-graduate year stood out as a significant predictive factor (estimate = 3.28, p = 0.04). Moreover, the streamlined model revealed that previous ureteral-stent use (estimate = 0.94, p < 0.001), struvite stones (estimate = 3.08, p = 0.01), and a higher number of stones (estimate = 0.11, p = 0.04) were associated with an increased number of procedures before DFU breakage, whreas in situ lithotripsy in the lower calyx was associated with a reduced number of procedures before DFU breakage (estimate = -1.11, p = 0.003). Conclusion: Implementing a mandatory training program showed an increase in DFU durability by 21%, suggesting a potential reduction in annual repair and replacement costs by the same percentage. Furthermore, outcomes were more favorable when experienced practitioners conducted treatments, especially in cases involving struvite stones.

Background: Green tea (GT) is a common component of supplements known as fat burners. It has gained popularity as an ergogenic aid for weight reduction to assist with obesity management. This systematic review and meta-analysis aim to explore the effect of green tea ingestion coupled with exercise training (EX) on body composition and lipid profile in overweight and obese individuals., Methods: Two independent researchers systematically searched the electronic databases of PubMed, Web of Science, and Scopus. Studies with a randomized-controlled design to compare the effect of green tea in conjunction with exercise training (EX+GT) versus exercise training alone (EX+P) in overweight or obese participants were included., Results: Of the 1,015 retrieved studies, 24 were identified to undergo full-text review, out of which 10 randomized trials met the inclusion criteria. EX+GT versus EX+P had a small and consistent effect on weight [Standardized mean difference (SMD) = -0.30, CI: -0.53 to -0.07], BMI [SMD = -0.33 CI: -0.64 to -0.02] and fat reduction [SMD = -0.29, CI: -0.57 to -0.01] and there was no evidence of heterogeneity across the trials. When compared to EX+P, EX+GT had no greater effect on lipid profile improvement [triglyceride: SMD = -0.92, CI: -1.30 to 0.49; LDL: SMD = -1.44, CI: -0.73 to 0.82; HDL: SMD = 0.56, CI -0.71 to 0.46; and total cholesterol SMD = -0.54, CI -0.85 to 0.13]., Conclusions: Current evidence suggests that green tea could have quite minimal additive benefit over exercise-induced weight loss. However, incorporation of green tea into exercise training does not seem to exert additional benefits on lipid profile and it warrants further investigations in the future.

Objectives: Behavioral factors of pain catastrophizing and perceived injustice are associated with pain intensity in chronic pain. Diminished heart rate variability (HRV) is also strongly associated with chronic pain. These factors have been less explored earlier in the pain experience and it is unclear whether they play a role in the transition from acute to chronic pain. The aim of this study was to determine the relationship between pain catastrophizing, perceived injustice, pain intensity, and HRV in naturally occurring acute pain., Materials and Methods: Ninety-seven patients were recruited from local outpatient physical therapy clinics. Seated HRV was captured on 94 patients via Polar chest strap while patients were taking a survey via iPad. In addition to sociodemographic data, the survey included the Pain Catastrophizing Scale (PCS), Injustice Experience Questionnaire (IEQ), and Numeric Pain Rating Scale (NPRS). The natural log of high-frequency power (lnHFP) HRV was used in the statistical analysis., Results: Multiple linear regression modeling revealed that lower pain catastrophizing, higher perceived injustice, and lower pain intensity were associated with lower HRV, and accounted for 11.4% of the variance in HRV., Discussion: While greater chronic pain intensity is associated with lower HRV, the relationship is reversed in the setting of acute pain. These findings highlight the need to better understand the unique factors that contribute to lower HRV in the acute phase., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Catfish are a highly diverse group of fish comprising more than 3500 species found in both freshwater and marine ecosystems. Upon handling, they can inflict a sting, with certain species capable of inducing significant pain and injury to the affected extremity. The prevalence of aquatic activities, such as fishing by line or manual capture ("noodling"), increases the likelihood of catfish stings, making prompt identification and treatment an important aspect of managing such encounters. A case of a presumed catfish spine injury during noodling in Tallahassee, Florida, is presented. The pectoral fin penetrated the volar aspect of the patient's right hand resulting in immediate pain and numbness. Over the course of 2 weeks, the patient developed distal ulnar neuropathy with conduction block at the wrist level. Surgical exploration revealed the ulnar nerve to be grossly intact, but the area surrounding the terminal division point of the ulnar nerve in the hand displayed infiltration by fibrous tissue that entrapped the nerve and its branches. Following surgical release of the ulnar nerve and its terminal branches from the fibrous tissue, complete resolution of distal ulnar neuropathy was achieved. In this patient's case, the absence of foreign bodies and the lack of visible nerve damage suggest that the injury to the patient's hand was largely attributable to toxin-mediated proinflammatory response and fibrosis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Position Statement: The International Society of Sports Nutrition (ISSN) provides an objective and critical review of the use of a ketogenic diet in healthy exercising adults, with a focus on exercise performance and body composition. However, this review does not address the use of exogenous ketone supplements. The following points summarize the position of the ISSN., 1. A ketogenic diet induces a state of nutritional ketosis, which is generally defined as serum ketone levels above 0.5 mM. While many factors can impact what amount of daily carbohydrate intake will result in these levels, a broad guideline is a daily dietary carbohydrate intake of less than 50 grams per day., 2. Nutritional ketosis achieved through carbohydrate restriction and a high dietary fat intake is not intrinsically harmful and should not be confused with ketoacidosis, a life-threatening condition most commonly seen in clinical populations and metabolic dysregulation., 3. A ketogenic diet has largely neutral or detrimental effects on athletic performance compared to a diet higher in carbohydrates and lower in fat, despite achieving significantly elevated levels of fat oxidation during exercise (~1.5 g/min)., 4. The endurance effects of a ketogenic diet may be influenced by both training status and duration of the dietary intervention, but further research is necessary to elucidate these possibilities. All studies involving elite athletes showed a performance decrement from a ketogenic diet, all lasting six weeks or less. Of the two studies lasting more than six weeks, only one reported a statistically significant benefit of a ketogenic diet., 5. A ketogenic diet tends to have similar effects on maximal strength or strength gains from a resistance training program compared to a diet higher in carbohydrates. However, a minority of studies show superior effects of non-ketogenic comparators., 6. When compared to a diet higher in carbohydrates and lower in fat, a ketogenic diet may cause greater losses in body weight, fat mass, and fat-free mass, but may also heighten losses of lean tissue. However, this is likely due to differences in calorie and protein intake, as well as shifts in fluid balance., 7. There is insufficient evidence to determine if a ketogenic diet affects males and females differently. However, there is a strong mechanistic basis for sex differences to exist in response to a ketogenic diet.

Previously, many studies have reported changes in the gut microbiota of patients with colorectal cancer (CRC). While CRC is a well-described disease, the relationship between its development and features of the intestinal microbiome is still being understood. Evidence linking Fusobacterium nucleatum enrichment in colorectal tumor tissue has prompted the elucidation of various molecular mechanisms and tumor-promoting attributes. In this review we highlight various aspects of our understanding of the relationship between the development of CRC and the alteration of intestinal microbiome, focusing specifically on the role of F . nucleatum . As the amount of F . nucleatum DNA in CRC tissue is associated with shorter survival, it may potentially serve as a prognostic biomarker, and most importantly may open the door for a role in CRC treatment., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Letters of recommendation (LOR) are considered by program directors (PDs) to be an integral part of the residency application. With the conversion of United States Medical Licensing Examination (USMLE) Step 1 to a binary pass/fail outcome, LORs will likely have higher important in the application process moving forward. However, their utility in securing an interview for a particular applicant remains undetermined. This study aims to identify the applicant and LOR characteristics associated with an interview invitation., Methods: Letter writer (n = 977) characteristics were abstracted from applications (n = 264) to an individual integrated vascular surgery residency program over 2 application cycles. A validated text analysis program, Linguistic Inquiry and Word Count, was used to characterize LOR content. Applicant, letter writer, and LOR characteristics associated with an interview invitation were determined using multivariable analysis., Results: Letter writers were 70.9% vascular surgeons (VS), 23.7% PDs, and 45.4% professors. Applicants offered an interview were more likely to come from a top 50 medical school (35.2% vs 25.8%, P = 0.013) and an institution with a home vascular program (45.5% vs 34.1%, P = 0.006). Alpha Omega Alpha membership was significantly associated with interview offer (28.4%, P < 0.001). A greater proportion of letters from VS was associated with an interview offer (P < 0.001) compared with letter writers of other specialties. One or more PD letters were significantly associated with an interview offer (79.55% vs 20.45%, P = 0.008), whereas number of letters from APDs was not significantly associated with interview offer. Letters written by away institution faculty were significantly associated with interview offer (75%, P < 0.001), whereas nonclinical letters were not. Presence of one or more letters from a chair (57.95% vs 42.05%, P = 0.015) or chief (67.05% vs 32.95%, P = 0.028) was significantly associated with interview offer. Letters for applicants offered an interview had more references to research and teaching, which were more common in letters written by versus Letters written by PDs were more likely to use assertive, advertising language in favor of applicants. There were no significant applicant, letter writer, or LOR characteristics associated with a top 20 rank., Conclusions: Successful applicants were more likely to have LORs written by VS, PDs, and those of higher academic rank with references to research and teaching., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Protein supplementation often refers to increasing the intake of this particular macronutrient through dietary supplements in the form of powders, ready-to-drink shakes, and bars. The primary purpose of protein supplementation is to augment dietary protein intake, aiding individuals in meeting their protein requirements, especially when it may be challenging to do so through regular food (i.e. chicken, beef, fish, pork, etc.) sources alone. A large body of evidence shows that protein has an important role in exercising and sedentary individuals. A PubMed search of "protein and exercise performance" reveals thousands of publications. Despite the considerable volume of evidence, it is somewhat surprising that several persistent questions and misconceptions about protein exist. The following are addressed: 1) Is protein harmful to your kidneys? 2) Does consuming "excess" protein increase fat mass? 3) Can dietary protein have a harmful effect on bone health? 4) Can vegans and vegetarians consume enough protein to support training adaptations? 5) Is cheese or peanut butter a good protein source? 6) Does consuming meat (i.e., animal protein) cause unfavorable health outcomes? 7) Do you need protein if you are not physically active? 8) Do you need to consume protein ≤ 1 hour following resistance training sessions to create an anabolic environment in skeletal muscle? 9) Do endurance athletes need additional protein? 10) Does one need protein supplements to meet the daily requirements of exercise-trained individuals? 11) Is there a limit to how much protein one can consume in a single meal? To address these questions, we have conducted a thorough scientific assessment of the literature concerning protein supplementation.

Caffeine is a popular ergogenic aid that has a plethora of evidence highlighting its positive effects. A Google Scholar search using the keywords "caffeine" and "exercise" yields over 200,000 results, emphasizing the extensive research on this topic. However, despite the vast amount of available data, it is intriguing that uncertainties persist regarding the effectiveness and safety of caffeine. These include but are not limited to: 1. Does caffeine dehydrate you at rest? 2. Does caffeine dehydrate you during exercise? 3. Does caffeine promote the loss of body fat? 4. Does habitual caffeine consumption influence the performance response to acute caffeine supplementation? 5. Does caffeine affect upper vs. lower body performance/strength differently? 6. Is there a relationship between caffeine and depression? 7. Can too much caffeine kill you? 8. Are there sex differences regarding caffeine's effects? 9. Does caffeine work for everyone? 10. Does caffeine cause heart problems? 11. Does caffeine promote the loss of bone mineral? 12. Should pregnant women avoid caffeine? 13. Is caffeine addictive? 14. Does waiting 1.5-2.0 hours after waking to consume caffeine help you avoid the afternoon "crash?" To answer these questions, we performed an evidence-based scientific evaluation of the literature regarding caffeine supplementation.

Purpose: The purpose of this study was to examine Tear Film Imager (TFI, AdOM, Israel) generated parameters across controls and dry eye (DE) subgroups and examine the changes in TFI parameters with contact lens (CL) placement., Methods: The retrospective study (n = 48) was conducted at the Miami Veterans Hospital. Symptoms were assessed through validated questionnaires and signs of tear function by tear break-up time and Schirmer scores. Participants were grouped as 1) healthy, 2) evaporative, 3) aqueous deficient, and 4) mixed DE based on tear function. Seventeen individuals had a baseline scan and a repeat scan following CL placement. Descriptives were compared across groups and over time., Results: The median age was 27 years, 74% self-identified as White, 45% as male, and 51% as Hispanic. Subjects in the aqueous deficiency category had lower muco-aqueous layer thickness (MALT) (2672 vs. 3084 nm) but higher lipid layer thickness (47.5 vs. 38.3 nm), lipid break-up time (4.4 vs. 2 seconds), and interblink interval (13.9 vs. 5.4 seconds) compared with the evaporative group. Subjects in the evaporative group had the highest MALT values (3084 vs. 2988, 2672, 3053 nm) compared with healthy, aqueous-deficient, and mixed groups. Symptoms were not significantly correlated with TFI parameters. CL placement significantly decreased MALT values (2869 → 2175 nm, P = 0.001)., Conclusions: The TFI provides unique information regarding the dynamic function of the tear film not captured by clinical examination. TFI generated metrics demonstrate a thinner aqueous layer in individuals with aqueous deficiency but highlight a thicker aqueous layer in those with evaporative DE., Competing Interests: Professor Alon Harris would like to disclose that he received remuneration from AdOM, Qlaris, and Cipla for serving as a consultant, and he serves on the board of AdOM, Qlaris and SlitLed. Professor Alon Harris holds an ownership interest in AdOM, Oxymap, Qlaris, and SlitLed. All relationships listed above are pursuant to Icahn School of Medicine's policy on outside activities. If you have questions regarding paid relationships that your physician/researcher may have with industry, you are encouraged to talk with your physician/researcher, or check for industry relationships posted on individual faculty pages on our website at http://icahn.mssm.edu/ . The remaining authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Coronary atherosclerosis can lead to acute clinical events upon atherosclerotic plaque rupture (PR) or erosion and arterial thrombus formation. Identifying the effect of distinct plaque characteristics on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) is critical for clinical therapy. Our goal was to ascertain the correlation between clinical outcome, long-term prognosis, and morphological plaque characteristics in STEMI., Methods: The data used in this prospective cohort research came from a prior multicenter prospective cohort study (ChiCTR1800019923). One hundred and thirteen consecutive STEMI patients were involved in our cohort study. Patients with STEMI who received primary percutaneous coronary intervention (pPCI) within 24 hours of symptom onset were included in the study and divided into two groups according to plaque characteristics derived from intravascular ultrasound (IVUS): a PR group and a non-PR group. The primary outcome was the incidence of no reflow or slow flow, the secondary outcome was major adverse cardiac events (MACEs) at 1-year follow-up., Results: This study enrolled 113 consecutive patients with STEMI [mean age 56 (range, 49-65.5) years; males 90.27%]. Of the 113 patients, PR was found in 93 (82.3%), while non-PR was found in 20 (17.7%). The PR group had a higher rates of plaque eccentricity index (64.28%±22.69% vs . 60.08%±15.54%; P=0.045), higher rates of lipid pool-like images (62.37% vs . 30.00%; P=0.008), and higher rates of tissue prolapse (22.95% vs . 13.33%; P=0.01). Compared with that in the non-PR group, the incidence of no reflow or slow flow was higher in the PR group after pPCI (26.88% vs . 5.00%; P=0.04). Multivariable logistic regression showed that PR [odds ratio (OR) =8.188; 95% confidence interval (CI): 1.020-65.734; P=0.048] was an independent predictor of no reflow or slow flow. Survival analysis revealed no significant differences in MACE incidence between the two groups at 1-year follow-up (7.61% vs . 10.00%; P=0.66). Furthermore, 29 patients with PR were treated without stenting, most of them were free of MACEs (27/29). MACE between subgroups of stenting and non-stenting had no significant differences (7.94% vs . 6.90%; P=0.86) in the PR group., Conclusions: In comparison to patients with non-PR, PR were not associated with the risk of recurrent myocardial infarction (MI), revascularization, heart failure, or cardiac death at 1-year follow-up, while associated with an increased incidence of no reflow or slow flow during pPCI. This observation would be considered while risk stratification and dealing with patients who have STEMI. Most patients with PR who were treated without stenting were MACE free. Further research should be conducted to determine whether interventional treatment without stenting is feasible for patients with STEMI and PR., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1482/coif). S.T. reports research grants and consultancy from Pulse Medical. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Objective: The efficacy of middle meningeal artery (MMA) embolization in the management of chronic subdural hematoma (cSDH) has been increasingly supported by recent randomized controlled trials. However, long-term data on the natural history of cSDH post-treatment remain limited. This study aims to evaluate the natural history and outcomes of cSDH over a 12-month period following MMA embolization., Methods: We conducted a retrospective analysis of 61 MMA embolization for the treatment of cSDH in 49 consecutive patients at a single institution between October 2019 and December 2022. Patients underwent MMA embolization as the primary treatment of cSDH, concurrently with surgical evacuation, or after initial surgical evacuation and subsequent recurrence. Clinical data, including patient demographics, hematoma maximal thickness, midline shift size, procedural details, and outcomes, were collected and analyzed. The primary outcomes assessed were time to resolution of hematoma maximal thickness, midline shift reduction and clinical improvement. Secondary outcomes included occurrence of complications, recurrence rate and the characteristics of the group of patients who needed surgical rescue. Tables and Kaplan-Meier curves were created, broken down by the percentage of reduction in current hematoma maximal thickness. Results for the primary, concurrent and recurrent groups were compared., Results: The mean age of included patients was 73 ± 10.8 years. Among them, 33 patients (67.3%) reported a history of previous trauma, with falls being the main mechanism of injury (65.3%). The majority of patients (77.5%) were male. The most frequent neurological symptom was headache (61.2%). The mean hematoma thickness and midline shift were 15.9±7.1 and 5.6±2.6 mm, respectively. There was a significant improvement in clinical symptoms within 1 month following middle meningeal artery embolization. Kaplan-Meier curves were generated for resolution of hematoma size and midline shift. At one month post procedure, only 25% of patients had at least a 25% reduction in hematoma size. However, by three months, 75% had a decrease in hematoma size by 50%. 85% of patients had complete resolution of hematoma by 7 months and all patients had resolution of hematoma by 12 months. Four patients underwent surgical rescue hematoma evacuation and the mean timeframe between the embolization and the surgical rescue was 2 weeks. Hematoma size and midline shift resolved faster for patients who underwent concurrent or rescue surgical evacuation of the hematoma in addition to embolization. No difference in results between the liquid embolics n-BCA and Onyx-18 was found., Conclusion: This study demonstrated a favorable resolution of subdural hematoma within 7 months in 85% of patients and in all patients by 12 months. By 3 months, 50% of patients had a decrease in hematoma size by 50% or more. A complete resolution of midline shift within 7 months, and a significant improvement in clinical symptoms within 1 month following middle meningeal artery embolization. Hematoma size and midline shift resolved faster for patients who underwent embolization for recurrent hematoma or concurrent surgical evacuation of the hematoma in addition to embolization., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Cannabinoid-related emergency department (ED) visits are increasing, yet little has been published about how the route of cannabinoid use (inhaled versus oral) affects ED presentations. We sought to compare ED visits from inhaled versus oral cannabinoid use., Methods: We performed a retrospective cohort study using ED patients with a cannabinoid related diagnosis from January 1, 2020 and May 31, 2023 from a single hospital system in Florida. We performed manual chart review to categorize visits into "unlikely", "possibly", or "highly likely" to be due to acute cannabinoid use. For our primary analysis, we used the "highly likely" group to compare the presentations and outcomes of patients who had used oral cannabinoids versus inhaled. Our primary outcome was hospital admission., Results: We deemed 303 patient visits "highly likely" to be from acute cannabinoids: 59 (19.5%) inhaled and 244 (80.5%) oral. Zero patients in the inhaled group were admitted compared to 15 (6.2%) in the oral group, a difference of 6.2% (95% CI 3.1-9.2%), p = 0.05. Additionally, 65 (26.7%) of the oral group reported using cannabinoids unintentionally including 8 housekeepers who ate food products left by hotel guests. Comparatively, 4 (6.8%) of the inhaled group unintentionally used cannabinoids (difference 19.9% [95% CI 11.4-28.3])., Conclusions: Most patients who presented to the ED for the effects of acute cannabinoids had used them orally. Compared to patients who had inhaled cannabinoids, those who used them orally required more ED diagnostic resources and were more likely to be admitted to the hospital for additional evaluation or treatment. From a public health perspective, increased regulation of edible cannabinoid products may be needed., Competing Interests: Declarations. Conflict of interest: None. Previous Presentations: None., (© 2024. American College of Medical Toxicology.)

Treatment of gunshot injuries to the maxillofacial region requires a multidisciplinary approach with specialist collaboration. The primary goals of treatment are to stabilize fractures, control bleeding, reconstruct the affected tissues, and restore function. This case report discusses a patient's treatment sequence resulting from a gunshot injury to the right posterior mandible. The initial stabilization and debridement, followed by mandibular augmentation, and finally prosthodontic restoration of lost teeth and the alveolar process are illustrated. Understanding the consequences of gunshot injuries to the maxillofacial region underscores the importance of coordinated quality care for a successful result., Competing Interests: Both authors declare no conflict of interest or financial interest in any part of this article.

Introduction: Iron is crucial for brain function, but excessive iron is neurotoxic. Abnormally high brain iron accumulation is one of the pathogenic factors in Alzheimer's disease (AD). Therefore, understanding the mechanistic basis of iron dyshomeostasis in AD is vital for disease mitigation. Calcium, another essential bioelement involved in cell signaling, also exhibits dysregulated homeostasis in AD. Calcium ion (Ca 2+ ) signaling can influence iron homeostasis through multiple effectors. Our previous studies identified Ca 2+ /calmodulin (CAM)-dependent protein kinase kinase 2 (CAMKK2) as a regulator of transferrin (TF)-bound iron trafficking through the TF receptor (TFRC). Given CAMKK2's high expression in brain cells, it was hypothesized that abnormal CAMKK2-TF/TFRC signaling may underlie excessive iron deposition in AD brains. This study aims to retrospectively investigate CAMKK2, TF, TFRC proteins, and iron content in temporal cortex tissues from AD patients and cognitively normal (CN) individuals, postmortem., Methods: Postmortem temporal cortex tissues from 74 AD patients, 27 Parkinson's disease (PD) patients, and 17 CN individuals were analyzed for CAMKK2, TF, and TFRC protein levels by Western blotting. Additionally, prefrontal/temporal cortex tissues from 30 CN individuals of various ages were examined for age-related effects. Iron content in cortical tissues was measured using a colorimetric assay., Results: CAMKK2, TF, and TFRC levels were significantly decreased in AD patients' temporal cortices compared to CN individuals, independent of age or postmortem interval-related changes. PD patients' also exhibited similar reductions in CAMKK2/TF/TFRC levels. The increased iron content in AD brains was significantly correlated with reduced TF/TFRC protein levels., Discussion: Building on the previous identification of CAMKK2 as a regulator of TF/TFRC trafficking and iron homeostasis, the findings from this study suggest that downregulation of CAMKK2 in AD cortices may disrupt TF/TFRC signaling and contribute to iron overloading and neurodegeneration through iron-induced toxicity. The decreased levels of TF/TFRC and increased iron in AD brains may result from enhanced clearance or post-trafficking degradation of TF/TFRC due to CAMKK2 downregulation. Restoring CAMKK2 levels in the AD brain could offer a novel therapeutic approach to reestablish iron homeostasis. Further studies are needed to explore the pathways linking CAMKK2 and iron dysregulation in AD and other neurodegenerative diseases., Competing Interests: Author MS was employed by Alzo Biosciences Inc. and is a cofounder of the company; however, the research work presented in this article has no conflict of interest related to the author’s past employment or association with Alzo Biosciences Inc., (Copyright © 2024 Sabbir.)

Introduction: Antimicrobial resistance (AMR) is largely driven by the inappropriate use of antibiotics. This has been attributed to the non-prescription sale of antibiotics in retail drug outlets. Despite the rising number of retail drug outlets in Malawi, the practice of drug dispensing in private pharmacies has not been evaluated. This study therefore assessed the prevalence of non-prescription sales of antibiotics in retail drug outlets in Lilongwe, Malawi., Methods: A community-based simulated client cross-sectional study was conducted in Lilongwe, Malawi from December 2023 to February 2024 using mystery shopping. Data were analyzed using IBM SPSS software version 29 using both descriptive and Analytical statistics. We computed simple proportions and conducted a hypotheses test using Chi-Square to test for Significance., Results: Antibiotic dispensing practices were surveyed in 51 retail drug outlets comprising 36 retail pharmacies and 15 drugstores. 35.3% (n=18) of the drug outlets had drug dispensing done by pharmacists, 13.7% (n=7) by pharmacy technicians, 21.5% (n=11) by pharmacy assistants and 25.5% (n=15) by drug dispensers who had no pharmacy-related training. The rate of non-prescription sales of antibiotics ranged between 53% for acute diarrhoea and 92% for upper respiratory tract infections. Amoxicillin was the most dispensed antibiotic across all case scenarios. Over 50% of dispensed antibiotics were done upon recommendation of the drug dispensers in the absence of a doctor's prescription. Furthermore, for all the dispensed antibiotics across all case scenarios, no advice was given for finishing a full course of the antibiotics., Conclusion: This study found high rates of over-the-counter dispensing of antibiotics, which call for urgent and comprehensive regulatory measures to control antibiotic consumption in an urban part of Malawi that risks increased AMR. These could range from enacting stringent antibiotic dispensing policies to deploying digital systems to monitor prescription practices and community education on rational antibiotic use., Competing Interests: The authors declare no conflicts of interest in this work., (© 2024 Lubanga et al.)

We report an important role for microglia in regulating neuroplasticity within phrenic motor neurons. Brief episodes of low oxygen (acute intermittent hypoxia; AIH) elicit a form of respiratory motor plasticity known as phrenic long-term facilitation (pLTF) that is regulated by the balance of competing serotonin vs adenosine-initiated cellular mechanisms. Serotonin arises from brainstem raphe neurons, but the source of adenosine is unknown. We tested if hypoxic episodes initiate phrenic motor neuron to microglia fractalkine signaling that evokes extracellular adenosine formation using a well-defined neurophysiology preparation in male rats. With moderate AIH, phrenic motor neuron adenosine 2A receptor activation undermines serotonin-dominant pLTF whereas severe AIH induces pLTF by the adenosine-dependent mechanism. Consequently, phrenic motor neuron fractalkine knockdown, microglial fractalkine receptor inhibition, and microglial ablation enhance moderate AIH, but suppress severe AIH-induced pLTF. We conclude, microglia play important roles in healthy spinal cords, regulating plasticity in motor neurons responsible for breathing., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Sexual and gender minority youth (SGMY) are vulnerable to acquiring HIV and need HIV prevention and health services, but may have competing needs. A prior analysis found that PrEP use reports increased in a combination intervention study arm with coaching, peer support, and automated text-messages. This paper examines ancillary support and healthcare services utilization as secondary intervention objectives. SGMY (N = 895, 40% Black, 29% Latino) in Los Angeles and New Orleans were recruited from May, 2017 to August, 2019 and randomized to four intervention conditions: (a) automated text-messaging and monitoring intervention (AMMI), (b) AMMI plus peer support online (AMMI+PS), (c) AMMI plus strengths-based coaching by near-peer paraprofessionals (AMMI+C), or (d) all three (AMMI+PS+C). Intent-to-treat multivariate regression analyses evaluated the interventions' efficacy on past 4-month reports of ancillary support services use, having a regular healthcare provider, receiving care from doctor's office or clinic and mental health specialists, and participation in mental health support groups and HIV prevention programs. Ancillary services utilization reports declined from 40% of youth reporting an average of 4.4 services at baseline to 22.6% reporting 2.5 services by 24 months. Food, housing, transportation, and other basic services were utilized most frequently. Youth in the two coaching interventions maintained higher reports of services use over time compared to AMMI-only (both OR 1.23, 95%CI 1.12-1.35) and to AMMI+PS (both OR 1.20 95%CI 1.08-1.33). Our coaching intervention may support SGMY to stay engaged in support services. Results may be limited by self-report biases. It is unclear if these services are related to better long-term outcomes., Competing Interests: Declarations. Conflict of interest: Dr. Arnold was a consultant on project funded by Merck, Sharpe, and Dohme and has current funding from this entity. However, these projects are not related to the current study/manuscript. The other authors declare no competing interests, financial or non-financial. Ethical Approval: All study methods were approved by the IRB. The Institutional Review Board (IRB) of the University of California, Los Angeles served as the single IRB of Record for each collaborating university/agency partner (#16-001674-CR-00003), and the trial was registered at clinicaltrials.gov (#03134833). Consent to Participants: All participants provided informed consent per the IRB-approved process., (© 2024. The Author(s).)

We have observed two starkly contradictory notions regarding the sympathetic influence on the salivary outflow in discussions with our students. Most of them believe that sympathetic nerves decrease salivation and are antagonistic to parasympathetic nerves. Some students, however, show awareness of the cooperative stimulatory action of both types of autonomic fibers. We have found a similar dichotomy in the descriptions of the sympathetic effect on secretion of the main salivary glands and their inconsistent illustrations in Anatomy/Physiology textbooks. We have investigated the historical roots of this discrepancy. Ludwig discovered excitatory actions of both parasympathetic and sympathetic nerves on salivary flow by 1856. The next year, Czermak proposed the hypothesis of an inhibitory effect of sympathetic nerves, observing their interference with salivation induced by the chorda tympani (i.e., parasympathetic) stimulation. Bernard and Eckhard soon confirmed Ludwig's findings, but Czermak's notion persisted because sympathetically evoked salivation was unstable and potentially abatable by glandular vasoconstriction. The salivary secretory response to moderate sympathetic nerve electrostimulation was reaffirmed by Langley who also discovered salivation in response to adrenaline injection at the beginning of the 20th century. A few years later, Cannon, on a purely theoretical basis, attributed the sensation of dry mouth occasionally associated with fear to hyposalivation induced by elevated sympathetic discharge. Despite subsequent researchers' inability to find unequivocal evidence of salivary flow reduction by sympathetic activation, Cannon's assumption gained acceptance in some textbooks. Most Anatomy/Physiology textbook authors, however, recognized the excitatory action of sympathetic nerves on salivary glands established by Ludwig and Bernard.

Introduction: This study aims to assess various models of psychological debriefing, their benefits, and the impact of their implementation on medical trainees & healthcare professionals' stress management skills, mental well-being, and clinical performance., Methods: This review queried PubMed, ProQuest, Web of Science, and Google Scholar databases for articles regarding psychological debriefing in medical education published through May 2024. Included studies that assessed the utilization, implementation, and effectiveness of various psychological debriefing models in the hospital setting among nursing staff, medical trainees, and attending physicians. Outcomes evaluated were successful debriefing models, associated benefits, and attendees' attitudes toward implementation., Results: Sixteen studies were included. In all psychological debriefing models, attendees had improved coping skills following a challenging clinical scenario and supported the future use of these sessions. However, several barriers to the success of these sessions like untrained facilitators and insufficient time devoted have been noted., Conclusion: Psychological debriefing sessions assisted attendees cope with stressful situations, improved self-confidence, and advocate for themselves. Different models of psychological debriefing can be implemented depending on the resources of each facility., Competing Interests: Declaration of interest statement The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract: Polletta, J, Leung, K, Diaz, D, Branum, N, and Mokha, M. Influence of interlimb lean muscle mass asymmetry on countermovement jump neuromuscular performance qualities among American football players. J Strength Cond Res XX(X): 000-000, 2024-Body composition is a determinant of athletic performance. The purpose of this study was to determine the influence of lower limb lean muscle mass (LMM) asymmetry on countermovement jump (CMJ) performance and kinetic asymmetry during both eccentric and concentric CMJ phases. Seventy-four American football players (age, 23.0 ± 0.9 years; height, 1.86 ± 0.07 m; mass, 104.9 ± 21.6 kg; lean body mass, 88.7 ± 12.5 kg) training for the 2024 National Football League draft underwent body composition assessment using an InBody 270 bioelectrical impedance analyzer that yielded right and left leg LMM in kg. Subjects then performed 3 CMJs on dual uniaxial force plates that allowed for the calculation of jump height (JH), reactive strength index modified (RSImod), and interlimb percentage asymmetry of peak force and impulse for eccentric and concentric phases. A paired t-test and Pearson Product-moment Correlation Coefficients calculated the difference between left and right LMM and the associations between the symmetry variables, respectively, p ≤ 0.05. Right and left leg LMM were significantly different (t(73) = 3.772, p ≤ 0.001). However, no significant relationships were found between lower limb LMM asymmetry (0.67 ± 0.67%) and any asymmetry in CMJ eccentric peak force (4.77 ± 3.75%), r(72) = 0.001, p = 0.954; eccentric deceleration impulse (5.23 ± 4.36%), r(72) = 0.158, p = 0.180; concentric peak force (2.99 ± 2.54%), r(72) = -0.70, p = 0.553; concentric impulse (3.06 ± 2.97%), r(72) = 111, p = 0.347; JH (41.8 ± 7.3 cm), r(72) = -0.205, p = 0.08; or RSImod (0.53 ± 0.14 m·s-1), r(72) = -0.151, p = 0.199. The magnitude of LMM asymmetry did not influence CMJ performance or asymmetry magnitude. Reducing CMJ kinetic asymmetry may require targeted programming, especially for the eccentric loading phase., (Copyright © 2024 National Strength and Conditioning Association.)