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There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. A survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. IV. • What is currently known about this topic? • At neonatal ECMO decannulation cervical vessels can be managed with ligation or repair.Ligation may alter cerebral blood flow with potential for hemorrhagic or ischemic events.Repaired vasculature may become stenotic, aneurysmal, and a risk for stroke.Currently, no guidelines exist for optimizing management of cervical vessels at ECMO decannulation. • What new information is contained in this article? • This manuscript presents practice patterns from pediatric and cardiothoracic surgeons at high-volume neonatal ECMO centers regarding surgical management of cervical vessels at ECMO decannulation, including post repair anticoagulation and imaging practices. It includes suggested elements of a protocol for management of these patients. [ABSTRACT FROM AUTHOR]

• Pure or well differentiated fetal histology has the best outcomes out of all hepatoblastoma histologies. • Well differentiated fetal tumor surgically removed at diagnosis are curable without adjuvant chemotherapy. • HB completely resected at diagnosis with 100% well differentiated fetal histology is curable with surgery and no adjuvant chemotherapy. • Evidence-based surgical guidelines utilizing internationally constructed criteria are crucial for identifying appropriate patients for resection at diagnosis. Hepatoblastoma (HB) requires surgical resection for cure, but only 20–30% of patients have resectable disease at diagnosis. Patients who undergo partial hepatectomy at diagnosis have historically received 4–6 cycles of adjuvant chemotherapy; however, those with 100% well-differentiated fetal histology (WDF) have been observed to have excellent outcomes when treated with surgery alone. Patients on the Children's Oncology Group non randomized, multicenter phase III study, AHEP0731, were stratified based on Evan's stage, tumor histology, and serum alpha-fetoprotein level at diagnosis. Patients were eligible for the very low risk stratum of surgery and observation if they had a complete resection at diagnosis and rapid central histologic review demonstrated HB with 100% WDF histology. A total of 8 eligible patients were enrolled on study between September 14, 2009 and May 28, 2014. Outcome current to 06/30/2020 was used in this analysis. The median age at enrollment was 22.5 months (range: 8–84 months) and the median AFP at enrollment was 714 ng/ml (range: 18–77,747 ng/mL). With a median follow-up of 6.6 years (range: 3.6–9.8 years), the 5-year event-free (EFS) and overall survival (OS) were both 100%. This report supports that HB with 100% WDF histology completely resected at diagnosis is curable with surgery only. The development of evidence-based surgical guidelines utilizing criteria based on PRETEXT group, vascular involvement (annotation factors), tumor-specific histology and corresponding biology will be crucial for optimizing which patients are candidates for resection at diagnosis followed by observation. Prognosis study, Level I evidence. [ABSTRACT FROM AUTHOR]

Adhesives that rely on a curing mechanism struggle to function in underwater environments due to detrimental interactions with water. One strategy to overcome this involves protecting sensitive components in mechanically responsive microcapsules. In this way, a two-part adhesive can be achieved via a single mixture, applied as one would apply a pressure sensitive adhesive. This work focused on improving polyurea microcapsule shell integrity, specifically focusing on the effect of additional thermal processing. The improved microcapsule shells displayed limited payload leakage with only an 8 % loss in pot life compared to the base isocyanate resin alone. A mixture of optimized microcapsules and isocyanate resin was evaluated against a wide range of substrates and conditions, including dry and wet environments. When microcapsules were intentionally ruptured to release the catalyst and crosslinker payload, the microcapsule-isocyanate mixture had improved adhesive strength (506 %) compared to the base isocyanate resin without microcapsules. [Display omitted] [ABSTRACT FROM AUTHOR]

Noninvasive biomarkers that predict surgical treatment response would inform personalized treatments and provide insight into potential biologic pathways underlying endometriosis-associated pain and symptom progression. To use plasma proteins in relation to the persistence of pelvic pain following laparoscopic surgery in predominantly adolescents and young adults with endometriosis using a multiplex aptamer-based proteomics biomarker discovery platform. We conducted a prospective analysis including 142 participants with laparoscopically-confirmed endometriosis from the Women's Health Study: From Adolescence to Adulthood observational longitudinal cohort with study enrollment from 2012–2018. Biologic samples and patient data were collected with modified World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project tools. In blood collected before laparoscopic ablation or excision of endometriosis, we simultaneously measured 1305 plasma protein levels, including markers for immunity, angiogenesis, and inflammation, using SomaScan. Worsening or persistent postsurgical pelvic pain was defined as having newly developed, persistent (ie, stable), or worsening severity, frequency, or persistent life interference of dysmenorrhea or acyclic pelvic pain at 1-year postsurgery compared with presurgery. We calculated odds ratios and 95% confidence intervals using logistic regression adjusted for age, body mass index, fasting status, and hormone use at blood draw. We applied Ingenuity Pathway Analysis and STRING analysis to identify pathophysiologic pathways and protein interactions. The median age at blood draw was 17 years (interquartile range, 15–19 years), and most participants were White (90%). All had superficial peritoneal lesions only and were treated by excision or ablation. One-year postsurgery, pelvic pain worsened or persisted for 76 (54%) of these participants with endometriosis, whereas pelvic pain improved for 66 (46%). We identified 83 proteins associated with worsening or persistent pelvic pain 1-year postsurgery (nominal P <.05). Compared with those with improved pelvic pain 1-year postsurgery, those with worsening or persistent pelvic pain had higher plasma levels of CD63 antigen (odds ratio, 2.98 [95% confidence interval, 1.44–6.19]) and CD47 (odds ratio, 2.68 [95% confidence interval, 1.28–5.61]), but lower levels of Sonic Hedgehog protein (odds ratio, 0.55 [95% confidence interval, 0.36–0.84]) in presurgical blood. Pathways related to cell migration were up-regulated, and pathways related to angiogenesis were down-regulated in those with worsening or persistent postsurgical pelvic pain compared with those with improved pain. When we examined the change in protein levels from presurgery to postsurgery and its subsequent risk of worsening or persistent postsurgical pain at 1-year follow-up, we observed increasing levels of Sonic Hedgehog protein from presurgery to postsurgery was associated with a 4-fold increase in the risk of postsurgical pain (odds ratio [quartile 4 vs 1], 3.86 [1.04–14.33]). Using an aptamer-based proteomics platform, we identified plasma proteins and pathways associated with worsening or persistent pelvic pain postsurgical treatment of endometriosis among adolescents and young adults that may aid in risk stratification of individuals with endometriosis. [ABSTRACT FROM AUTHOR]

Objective: To determine if women with endometriosis experience lower urinary tract symptoms (LUTSs) more often than those without.Design: Cross-sectional analysis at enrollment in a longitudinal cohort.Setting: Enrollment at 2 academic hospitals and from the local community.Patient(s): This analysis included 1,161 women with (n = 520) and without (n = 641) surgically confirmed endometriosis who were enrolled in the Women's Health Study: from Adolescence to Adulthood between 2012 and 2018.Intervention(s): Not applicable.Main Outcome Measure(s): Prevalence of LUTSs, including stress incontinence, urgency and frequency, straining with urination, incomplete bladder emptying, hematuria, dysuria, and bladder pain using standardized questionnaires.Result(s): The primary outcomes were that women with endometriosis reported the following more often than those without: difficulty passing urine (7.9% vs. 2%; crude odds ratio [OR], 4.14 [95% confidence interval {CI}, 2.19-7.80]; adjusted OR [aOR], 4.31 [95% CI, 2.07-8.95]); still feeling full after urination (18.8% vs. 4.7%; crude OR, 4.73 [95% CI, 3.08-7.25]; aOR, 4.67 [95% CI, 2.88-7.56]); having to urinate again within minutes of urinating (33.1% vs. 17.0%; crude OR, 2.41 [95% CI, 1.83-3.18]; aOR, 2.49 [95% CI, 1.81-3.43]), dysuria (11.7% vs. 4.9%; crude OR, 2.55 [95% CI, 1.62-4.01]; aOR, 2.38 [95% CI, 1.40-4.02]); and pain when the bladder is full (23.0% vs. 4.9%; crude OR, 5.79 [95% CI, 3.82-8.78]; aOR, 6.04 [95% CI, 3.74-9.76]). For the secondary outcomes, among female participants with endometriosis, we observed that the odds of LUTS did not differ by the revised American Society for Reproductive Medicine stage (I/II vs. III/IV) or duration of endometriosis-associated symptoms.Conclusion(s): Women with surgically confirmed endometriosis were more likely to report LUTS than those without. [ABSTRACT FROM AUTHOR]

1. Utilizing a case-based approach, participants will be able to describe the unique roles embodied by in-person medical interpreters in the context of pediatric serious illness and summarize the personal, patient/encounter-level, and hospital-level challenges experienced by interpreters in the context of pediatric serious illness and pediatric palliative care. 2. Participants will be able to list five strategies that they can incorporate into their daily clinical practice to enhance partnership with and support for medical interpreters in the care of families of children with serious illness. Medical interpreters mitigate structural inequity in healthcare by serving as cultural mediators, health literacy guardians, and advocates. Their work is emotionally challenging and undervalued. Enhancing partnership with and support for interpreters can improve the quality of care palliative care teams provide to families who prefer a language other than English. Families of children with serious illness who prefer a language other than English experience structural racism and health inequity. Access to professional, in-person medical interpreters is fundamental to achieving equitable, high-quality healthcare. For many families, in-person medical interpreters become essential and trusted members of the care team. Unfortunately, the unique capabilities of medical interpreters are often underrecognized and underappreciated. Additionally, despite the emotional burden interpreters carry as the individuals delivering difficult news to families in their spoken language, they are often not acknowledged as members of the medical team and their distress goes unsupported. Through a case-based approach, we will illuminate the multi-dimensional roles embodied by medical interpreters in the care of children with serious illness. We will highlight a medical interpreter's unique ability to identify and meet a family's needs, provide continuity of care by holding patient and family stories, and build trust with the medical team. We will share the insights from two professional pediatric medical interpreters (one Spanish-speaking and one Portuguese- and Cape Verdean Creole-speaking) through pre-recorded video interviews. These videos underscore the challenges experienced by interpreters at three levels: (1) the interpreter's personal experience, (2) dynamics of the patient/family encounter, and (3) the hospital system. We present five strategies that clinicians caring for seriously ill patients can incorporate into their daily clinical practice to enhance collaboration with medical interpreters: (1) recognizing and enabling the unique capabilities of interpreters, (2) huddling at the bedside before encounters, (3) seeking specific feedback on communication, (4) acknowledging the emotional burden of the work and providing opportunities for debriefing, and (5) modeling inclusivity and respect. Palliative care clinicians must model regular, effective integration of medical interpreters into interdisciplinary care teams, and find ways to provide support for the emotionally challenging work medical interpreters do. Diversity, Equity, Inclusion, Belonging, Justice / Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]

When leaving initial professional librarian positions to join new organizations, the authors considered several common factors: salaries and benefits, livability of potential cities, and new colleagues. However, thriving early- and mid-career librarians taking the step into different roles must be able to navigate one less commonly discussed aspect of a workplace transition: differing expectations of original research among institutions and according to job classification. When moving from one tenure track position to another, librarians are likely to encounter different formal tenure requirements and support mechanisms at a new institution. Small universities might weigh the successful completion of day-to-day duties more heavily, with less emphasis on research output. Often larger research institutions are the inverse, with a much heavier emphasis on what research is published or presented, and where. Since expectations can be informally relayed and not expressly stated in job postings or during interviews, understanding an employer's idea of what constitutes significant scholarship is often developed over the course of the first year at an organization. This column will discuss the two main characteristics that typically inform expected research output: the type of institution for which the librarian works and the classification of the individual's position. The authors draw on recent experiences assessing different research expectations when changing employers, as well as current research on the topic. Expectations can also change moving from non-research-intensive positions into tenure-track or continuing-status-eligible positions at the same institution, and librarians in these situations often will have to deal with differing expectations around output metrics or impact factors in their research. Successful librarians changing roles will recognize that research expectations are a continuum, and will be able to assess where their current job falls on the library research spectrum. Once readers determine whether their new position requires a low, medium, or high level of scholarship and service, they can then strategize to adapt their existing agenda to meet expectations. Lastly, the column will help early- and mid-career librarians identify and assess the resources and support available to assist them in continuing their research agendas, regardless of positional research and scholarship expectations. Formal mentors, peer researchers in one's professional network, and new colleagues can all help with the stated and informal expectations of research. [ABSTRACT FROM AUTHOR]

There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. Retrospective comparative study. Level III. [ABSTRACT FROM AUTHOR]

The purpose of this study is to quantify the prevalence of dyspareunia and its impact on quality of life (QOL) in adolescent and young adult women (AYA) diagnosed with endometriosis. Eligible participants from the Women's Health Study: From Adolescence to Adulthood, a longitudinal cohort study, were AYA 18–25 years who reported having had sexual intercourse. We included n = 151 AYA with a surgical diagnosis of endometriosis and n = 287 without known endometriosis. Participants completed a questionnaire including the Short Form-36 (SF-36) QOL survey, on which lower scores indicate impairment. Dyspareunia was defined as answering "yes" to having had pain during/within 24 hours following sexual intercourse. Normative-based scores for SF-36 subscales were calculated and compared between groups using linear regression adjusted for age, body mass index, educational level, and race. Participants with endometriosis experienced dyspareunia twice as often (79%) than AYA without endometriosis (40%, p <.0001). In participants with and without endometriosis, all SF-36 subscale scores were significantly lower in AYA with dyspareunia than without. For six subscales, the negative impact was significantly stronger in AYA with endometriosis than those without, and mean scores were all less than the normative score, indicating impairment. More than three quarters of AYA with endometriosis and two thirds without experience dyspareunia that negatively impacts both physical and mental health QOL scores. This impairment is stronger in those with endometriosis. Given the importance of relationships and peer engagement for identity formation during adolescence, dyspareunia could be particularly impactful. Clinicians should ask patients not only about contraception and prevention of sexually transmitted infections, but inquire about how dyspareunia may impact mental and physical well-being. [ABSTRACT FROM AUTHOR]

Background Adolescents with endometriosis are a particularly underserved population who struggle with chronic pain. Despite widespread use, there are no published trials examining the individual effects of vitamin D and omega-3 (n–3) fatty acid supplementation on endometriosis-associated pain in adolescents. Objectives We aimed to determine whether supplementation with vitamin D or ω-3 fatty acids remediates pain, changes frequency of pain medication usage, or affects quality of life in young women with endometriosis. Methods Women (aged 12–25 y) with surgically confirmed endometriosis and pelvic pain enrolled in a double-blind, randomized, placebo-controlled trial. The primary outcome was pain measured by the visual analog scale (VAS). Secondary outcomes were quality of life, pain catastrophizing, and pain medication usage. Participants were randomly assigned to receive 2000 IU vitamin D3, 1000 mg fish oil, or placebo daily for 6 mo. Results A total of 147 women were screened and 69 were randomly assigned as follows: 27 to vitamin D3; 20 to fish oil; and 22 to placebo. Participants in the vitamin D arm experienced significant improvement in VAS pain [mean (95% CI) worst pain in the past month, from baseline to 6 mo: 7.0 (6.2, 7.8) to 5.5 (4.2, 6.8), P  = 0.02]; however, an improvement of nearly identical magnitude was observed in the placebo arm [6.0 (5.1, 6.9) to 4.4 (3.0, 5.8), P  = 0.07]. A more modest improvement was observed in the fish oil arm [5.9 (4.8, 7.0) to 5.2 (3.7, 6.8), P  = 0.39]. Neither of the intervention arms were statistically different from placebo. Conclusions In young women with endometriosis, supplementation with vitamin D led to significant changes in pelvic pain; however, these were similar in magnitude to placebo. Supplementation with fish oil resulted in about half of the VAS pain reduction of the other 2 arms. Studies are needed to better define the physiology underlying the observed reduction in pain score in the placebo arm that persisted across 6 mo. This trial was registered at clinicaltrials.gov as NCT02387931. [ABSTRACT FROM AUTHOR]

Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement. The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation. We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p < 0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5–36) to 5.5 days (1–19), p = 0.0002) decreased. A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes. Prognosis study. Level II. [ABSTRACT FROM AUTHOR]

Study Objective: To compare symptom persistence in women with adenomyosis based on retention or removal of the cervix at the time of hysterectomy.Design: Retrospective cohort study and follow-up survey (Canadian Task Force classification xx).Setting: Tertiary care academic hospital in Boston, Massachusetts.Patients: Women (n = 1580) who underwent laparoscopic hysterectomy for benign indications between 2008 and 2012 at Brigham and Women's Faulkner Hospital and Brigham and Women's Hospital.Intervention: Retrospective chart review and follow-up survey.Measurements and Main Results: Among the 1580 women contacted, 762 (48%) responded to the postoperative symptom resolution survey. Of these 762 women, 623 agreed to participate in the study. Menopausal women or those who had undergone bilateral salpingo-oophorectomy were excluded. Adenomyosis was identified on histopathologic evaluation of the uterus in 171 of the remaining 443 women (39%). Compared with women without adenomyosis, those with adenomyosis were older on average (mean age, 46.6 ± 6.8 years vs 45.0 ± 5.5 years; p = .009) and more likely to report that abnormal bleeding and pain led to their hysterectomy (87.7% vs 79.8%; p = .03 and 64.9% vs 51.4%; p = .009, respectively). The rates of total and supracervical hysterectomies were similar in the 2 groups. Following surgery, women with adenomyosis were less likely than those without adenomyosis to report persistent pain (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.20-0.93; p = .03). Persistent bleeding was similar in the 2 groups (aOR, 0.97; 95% CI, 0.49-1.93; p = .94). Among women with adenomyosis, multivariable logistic regression showed no difference in persistence of symptoms with cervical removal or retention at the time of hysterectomy.Conclusion: Compared with women without adenomyosis, those with histopathologically proven adenomyosis were less likely to report persistent pain following hysterectomy. Retention of the cervix does not appear to increase the risk of symptom persistence or postprocedure patient satisfaction. [ABSTRACT FROM AUTHOR]

Abstract Background/purpose We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO). Methods Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared. Results Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42. Conclusions Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost. Type of study Retrospective comparative study. Level of evidence Level III. [ABSTRACT FROM AUTHOR]

This study evaluated the effect of the alpha-2A-adrenoceptor agonist guanfacine on prefrontally mediated cognitive functions, as well as quality of life and global function in healthy older participants. One hundred twenty-three participants aged 75 years and older were randomly assigned to guanfacine 0.5 mg, 0.1 mg, or placebo daily for 12 weeks. The primary outcome measure was the change in z -score for 6 prefrontal executive function tasks over 12 weeks (PEF6). Neither dose of guanfacine improved PEF6 z -score relative to placebo. The rate of mean change (95% confidence interval) in PEF6 z -score over 12 weeks was 0.270 (0.159, 0.380) for placebo, compared with 0.121 (0.011, 0.232) for guanfacine 0.1 mg ( p = 0.06, compared to placebo) and 0.213 (0.101, 0.324) for 0.5 mg ( p = 0.47). Neither dose of guanfacine improved the quality of life or global function relative to placebo. Among common adverse events, only dry mouth was significantly more frequent on guanfacine compared to placebo. Guanfacine failed to ameliorate prefrontal cognitive function in older individuals, who were cognitively normal for age. [ABSTRACT FROM AUTHOR]

Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus. [ABSTRACT FROM AUTHOR]

Background Determining the efficacy of human vaccines that induce antigen-specific protective CD4 T cell responses against pathogens can be particularly challenging to evaluate. Surface expression of CD11a and CD49d has been shown to identify antigen-specific CD4 T cells against viral pathogens in mice. We hypothesized that CD11a and CD49d would also serve as markers of human antigen-specific T cells responding to vaccination. Methods A phase I vaccine trial enabled us to evaluate a novel gating strategy based on surface expression of CD11a and CD49d as a means of detecting antigen-specific, cytokine producing CD4 and CD8 T cells induced after vaccination of naïve individuals against leishmaniasis. Three study groups received LEISH-F3 recombinant protein combined with either squalene oil-in-water emulsion (SE) alone, SE with the synthetic TLR-4 ligand glucopyranosyl lipid adjuvant (GLA-SE), or SE with Salmonella minnesota- derived monophosphoryl lipid A (MPL-SE). Individuals were given 3 vaccine doses, on days 0, 28 and 168. Results Starting after the first vaccine dose, the frequency of both CD11a hi CD49d + CD4 and CD11a hi CD49d + CD8 T cells significantly increased over time throughout the 24-week trial. To confirm the role of CD11a hi CD49d + expression in the identification of the antigen-specific T cells, cytokine production was measured following LEISH-F3 stimulation. All of the IFN-γ, TNF-α, and IL-2 producing cells were found within the CD11a hi CD49d + population. Conclusions Our results suggest that the change in the frequency of CD11a hi CD49d + T cells can be used to track antigen-specific CD4 and CD8 T cell responses following T cell-targeted vaccination. [ABSTRACT FROM AUTHOR]

Study Objective: To compare perioperative outcomes associated with the use of 3 techniques for tissue removal at the time of laparoscopic hysterectomy and myomectomy.Design: A retrospective cohort study (Canadian Task Force classification II-2).Setting: An academic hospital in Boston, MA.Patients: Women who underwent a laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy involving tissue morcellation in 2014.Interventions: One of 3 morcellation techniques: electronic power morcellation (PM), manual vaginal morcellation via the vagina (VM), or manual morcellation via minilaparotomy (ML).Measurements and Main Results: Of the 297 cases included in this study (137 myomectomies, 62 total laparoscopic hysterectomies, and 98 laparoscopic supracervical hysterectomies), 96% of the cases were performed by fellowship-trained surgeons using conventional laparoscopy. Containment bags were used at the time of tissue extraction in 77% of the cases. Baseline characteristics and perioperative outcomes were similar in all groups. In hysterectomy cases, the average specimen size was largest in the ML group (591 ± 419 g in the ML group compared with 368 ± 293 g in the PM group and 449 ± 175 g in the VM group, p = .0009). After multivariate regression, no significant difference was found in blood loss, length of stay, or complications. The operative time was shorter in the PM group compared with the ML group by 16 minutes (mean = 140 minutes [95% confidence interval, 130-149 minutes] compared with 156 [95% confidence interval, 146-167], p = .02); this association remained significant once additionally adjusting for the use or nonuse of containment bags (p = .05).Conclusion: We did not detect a significant difference between the 3 morcellation techniques when comparing the perioperative complications although the longest operative times were noted for the minilaparotomy approach. All 3 morcellation techniques represent viable options for tissue extraction at the time of minimally invasive surgery. [ABSTRACT FROM AUTHOR]

The present study aimed to further validate the Loss of Control Over Eating Scale (LOCES) for use with undergraduate men and women with and without eating disorder (ED) symptoms. A total of 261 participants completed the LOCES and the Eating Disorder Examination - Questionnaire (EDE-Q) and were identified as non-clinical or having probable ED symptomatology based on previously used EDE-Q cutoff scores. Results indicated that the LOCES and its subscales were significantly associated with and a significant predictor of global ED pathology and binge episode frequency. The LOCES behavioral subscale appeared to be a stronger predictor of episode frequency compared to other subscales. The ED pathology groups reported significantly higher LOCES scores compared to the non-ED pathology groups. Binary logistic regression analyses revealed that the LOCES was able to accurately distinguish between those with ED pathology and those without ED pathology in the majority of cases. Findings from the present study suggest that the LOCES is highly predictive of ED pathology, strongly associated with ED cognitions and behaviors, and an accurate index for global eating disorder pathology. Future directions for research are discussed. [ABSTRACT FROM AUTHOR]

A urogenital sinus (US) and an anorectal malformation (ARM) are a rare constellation of anomalies, and the optimal surgical approach is unclear. Open and laparoscopic approaches have been described for US and ARM, but no data exist to support robotic assistance in children. A 20-month-old Amish female presented to the study center with fever and abdominal pain. Abdominal ultrasound showed a large fluid-filled vagina, urinalysis was positive, and she was admitted for antibiotic therapy. Magnetic resonance imaging (MRI) confirmed hydrocolpos. An examination under anesthesia including cystoscopy demonstrated a short perineal body, an anteriorly displaced anus by muscle stimulation, and no vaginal opening. An ultrasound-guided, percutaneous vaginostomy tube was placed, and 650 cc of pus was drained. Vaginal and urine cultures grew similar strains of Escherichias coli. After a course of antibiotics, she underwent a robot-assisted mobilization of the intra-abdominal vagina and uterus, posterior sagittal anorectoplasty, vaginal pull-through, and a diverting colostomy. There were no intra-operative complications. Her Foley catheter was removed on post-operative day #3, and she voided spontaneously and was discharged in good condition. She remained in the hospital for ostomy teaching, but pain control and diet were not barriers to discharge after 12 h. Robotic mobilization of the intra-abdominal vagina in a pediatric patient with US and ARM is technically feasible and can be accomplished safely. Further comparative studies to other approaches are lacking. In this case, the robot allowed for good visualization, intra-operative collaboration between multiple specialties for complex patients with aberrant anatomy, and easy dissection in a narrow pre-pubertal pelvis and would be an approach that the study group uses in future cases. [ABSTRACT FROM AUTHOR]

Study Objective: Although the selection of an approach to minimally invasive hysterectomy is relatively straightforward in an ideal patient scenario, it is more difficult in patients who pose operative challenges such as high body mass index (BMI) and enlarged uteri. The objective of this study was to explore the association between surgical approach and operative morbidity after minimally invasive hysterectomy and examine whether the association varies based on patient BMI and uterine size.Design: Retrospective cohort (Canadian Task Force classification II-2).Setting: Data abstracted from the American College of Surgeons National Safety and Quality Improvement Project registry.Patients: Thirty-six thousand seven hundred fifty-seven women undergoing vaginal, laparoscopic-assisted vaginal, or total laparoscopic hysterectomy for benign indications between January 2005 and December 2012.Interventions: Associations between surgical approach, BMI, and operative morbidity were examined, stratifying by uterine size (< or >250 g) and adjusting for covariates. Adjusted means, rate ratios, or odds ratios with 95% confidence intervals (CI) were calculated using linear, Poisson, or logistic regression.Measurements and Main Results: Operative times were shortest in women undergoing vaginal hysterectomy regardless of BMI or uterine size (all p < .02). Although operative time increased with BMI, the association varied with uterine size in women undergoing vaginal hysterectomy; increasing BMI had a minimal impact on operative time with small uteri <250 g but lengthened operative time in uteri >250 g. Compared with vaginal hysterectomy, total laparoscopic hysterectomy had lower odds of blood transfusion (all p < .02) and shorter hospitalizations (all p < .03) regardless of uterine size or BMI. Stratifying by uterine size, the association was strongest in morbidly obese women with small uteri; women with uteri <250 g and BMI >40 kg/m2 had 76% lower odds of blood transfusion (95% CI, 0.10-0.54) and 18% shorter hospitalization (95% CI, 0.75-0.90) after laparoscopic hysterectomy compared with vaginal hysterectomy.Conclusion: Major operative morbidity after minimally invasive hysterectomy is rare regardless of the surgical approach. A vaginal approach to hysterectomy is associated with the shortest operative times, but increasing BMI results in a rapid escalation of operative time in women with large uteri. Total laparoscopic hysterectomy is associated with shorter hospitalizations and lower odds of blood transfusion across the BMI spectrum, particularly in women with small uteri. Laparoscopic-assisted vaginal hysterectomy appears to confer no specific advantage over the vaginal or laparoscopic approaches. [ABSTRACT FROM AUTHOR]

Objective Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of immunosuppression with little consensus on its evaluation and management. The purpose of this contemporary review is to describe a pediatric patient with PTLD of the airway and review the literature to provide multidisciplinary recommendations regarding management. Data Sources Retrospective chart and literature review. Review Methods A pediatric patient with PTLD of the airway is described. An extensive literature search to review the existing data on pediatric PTLD of the upper airway was also performed. Results A pediatric patient with mixed fetal/embryonal hepatoblastoma developed laryngo-tracheal PTLD following liver transplantation. Diagnostic positron emission tomography (PET) scan demonstrated multiple sites of abnormal fluorodeoxyglucose (FDG) uptake within the larynx, distal esophagus, cervical lymph nodes, and abdomen concerning for PTLD. Laryngeal biopsy demonstrated Epstein–Barr virus (EBV) positive cells confirming the diagnosis. Rituximab therapy and reduction of immunosuppression resulted in resolution of his laryngeal disease in 3 months. An extensive literature search to review the existing data on pediatric PTLD of the larynx and trachea revealed 14 reported cases. Conclusions PTLD of the pediatric airway is an EBV-associated disease that requires a high index of suspicion as patients can often present with non-specific signs and symptoms but progress to have significant airway compromise. Evaluation consists of peripheral blood polymerase chain reaction (PCR) assays, biopsy, and PET/CT imaging. Management options include reduction of immunosuppression and/or systemic therapies. [ABSTRACT FROM AUTHOR]

Background Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. Methods A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Results A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9–50.2%) and 97.7% (95% CI, 96.9–98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. Conclusion This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component. [ABSTRACT FROM AUTHOR]

Vocal emissions in non-human mammals can be used as non-invasive indicators of animal emotion and welfare. Therefore, we aimed to validate the use of acoustic parameters as indicators of affective states and welfare in farmed spotted paca (Cuniculus paca). We recorded the vocalizations of 36 pacas, living in 12 groups (two females and one male/group), during four distinct experiences that were assumed to generate different affective states (negative, positive, ambiguous, and highly positive). Spotted pacas emitted more snorts, either as single elements or phrases, when experiencing a negative affective state. Four acoustic parameters of snorts, roars, and barks, which were recorded during all experiences, differed according to the affective valence assumed to be experienced by the spotted pacas. During the negative condition – morning cleaning routine spotted pacas emitted many more snort calls, which are characterized by a shift in the mean amplitude towards a higher level of intensity and as well as by a shift in the energy distribution (Q75) towards a higher frequency than those emitted in the positive condition compared to those emitted in the assumed positive valence condition – feeding time with the regular diet. These call-characteristics, along with the increase in the mean amplitude of snort calls from the lowest to the highest arousal levels, may thus reflect negative affective state and arousal in spotted paca. Therefore, the increase in the overall emission of snorts together with changes in their acoustic parameters may be valuable as indicators of negative emotions of C. paca , and thus have potential as an automated and non-invasive tool for welfare assessment in this species. [Display omitted] • C. paca vocalizes more in a situation assumed to induce negative affective valence. • C. paca emits calls with characteristics that reflect a negative affective state. • Vocalizations reflect spotted paca' affective valence. • Vocalizations can thus be used as a non-invasive tool to evaluate their welfare. [ABSTRACT FROM AUTHOR]

The formation of chemoattractant plumes around benthic invertebrate eggs in steady and unsteady shear flows is investigated for a range of shear rates, and the ability of sperm to navigate within these plumes is assessed using several chemotactic strategies. Although many of the details of sperm taxis remain uncertain, we investigate the role of basic processes using a toy model in two dimensions. Search strategies in 2D are intrinsically less complex than 3D, but many of the basic components are similar, and the simplified geometry permits an understanding and identification of the key factors of navigation tactics. Numerical simulations are used to model the advection and diffusion of the chemoattractant within the different flows, using three different sperm swimming behaviors. A Monte-Carlo approach is then used to determine the probability of a sperm reaching an egg for a range of flow conditions, initial conditions, and swimming behaviors. The spatial structure of chemoattractant plumes at the scale of the gametes is also investigated. Success rates for locating an egg decrease monotonically with increasing shear rates, and a definitive hierarchical ordering of the tested swimming strategies is identified. A conceptual framework to study and identify important aspects of this fundamental process to support further studies is provided. [ABSTRACT FROM AUTHOR]

Objective To harmonize the collection of nonsurgical clinical and epidemiologic data relevant to endometriosis research, allowing large-scale collaboration. Design An international collaboration involving 34 clinical/academic centers and three industry collaborators from 16 countries on five continents. Setting In 2013, two workshops followed by global consultation, bringing together 54 leaders in endometriosis research. Patients None. Intervention(s) Development of a self-administered endometriosis patient questionnaire (EPQ), based on [1] systematic comparison of questionnaires from eight centers that collect data from endometriosis cases (and controls/comparison women) on a medium to large scale (publication on >100 cases); [2] literature evidence; and [3] several global consultation rounds. Main Outcome Measure(s) Standard recommended and minimum required questionnaires to capture detailed clinical and covariate data. Result(s) The standard recommended (EPHect EPQ-S) and minimum required (EPHect EPQ-M) questionnaires contain questions on pelvic pain, subfertility and menstrual/reproductive history, hormone/medication use, medical history, and personal information. Conclusion(s) The EPQ captures the basic set of patient characteristics and exposures considered by the WERF EPHect Working Group to be most critical for the advancement of endometriosis research, but is also relevant to other female conditions with similar risk factors and/or symptomatology. The instruments will be reviewed based on feedback from investigators, and—after a first review after 1 year—triannually through systematic follow-up surveys. Updated versions will be made available through http://endometriosisfoundation.org/ephect . [ABSTRACT FROM AUTHOR]

Regulatory T cells (Tregs) play a critical role in maintaining tissue homeostasis and preventing the development of immunopathology. Depletion of REGulatory T cell (DEREG) mice express a diphtheria toxin receptor (DTR)-eGFP transgene under the control of the Foxp3 promoter allowing for Treg depletion following diphtheria toxin (DT) administration. DEREG mice have been utilized to investigate the role of Tregs in a wide range of disease settings. Administration of DT to naïve DEREG mice resulted in the rapid depletion of Foxp3+ Tregs from the peripheral blood. However, by day 4 post-DT administration, a GFP− Foxp3+ Treg population emerged that lacked expression of the DTR transgene and was resistant to further depletion by additional DT treatment. We further evaluated the impact of Treg depletion during both acute and chronic viral infections. Similar to naïve mice, Treg numbers rapidly rebounded during an inflammatory setting following an acute viral infection. DT treatment of both wild-type (WT) and DEREG mice following both acute and chronic viral infections induced exacerbated disease as compared to PBS-treated controls. Furthermore, following a chronic systemic viral infection, DT treatment resulted in nearly 100% mortality in both WT and DEREG mice while the PBS-treated controls survived. Our results demonstrate that Treg depletion in DEREG mice is transient and that DT administration can have adverse effects during virus-induced inflammation and highlights the critical need to include DT-treated WT mice when using DTR models to control for DT-mediated toxicity. [ABSTRACT FROM AUTHOR]

Background: Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure. Methods: The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity. Results: Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries. Conclusion: The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda. [Copyright &y& Elsevier]

Aims: To conduct a systematic review and critically evaluate the literature on the effectiveness of multidisciplinary interventions to improve quality of life for people with Parkinson's disease. Methods: An electronic search of the following publication databases was performed for records from 1995 to 2011: CINAHL PLUS (EBSCO), Joanna Briggs Institute, Pubmed, Web of Science (ISI), psycINFO, Scopus and Cochrane library. The keywords used were Parkinson's disease, nursing, allied health, doctor, intervention, quality of life, rehabilita- tion, multidisciplinary team and their various combinations. Key terms were matched to MeSH subject headings and exploded where relevant to include all subheadings and related terms to each key term used. 1808 articles were initially identified based on our selection criteria and the reference list of these articles was hand searched. Nine studies were included after this sifting process and critiqued by two reviewers. Results: Three randomised controlled trials and 6 non-randomised cohort studies were included. For these studies the level of evidence ranged from the Scottish Intercollegiate Network (SIGN) level of 1- to 2-. The outcome measures assessed were heterogeneous, including measures of disability of disease, stage of disease and various quality of life measures. Conclusion: The evidence quantifying positive and sustained effects of multidisciplinary interventions to improve quality of life for people with Parkinson's disease is inconclusive. There has been relative lack of controlled experimentation to quantify therapy outcomes. The studies reviewed were varied and lacked long-term follow-up to quantify retention of the intervention. It is recommended that interventions to improve quality of life are tested in randomised controlled trials using standardised outcome measures, adequately powered samples and longer follow-up periods to assess intervention sustainability. [ABSTRACT FROM AUTHOR]

This study provides the longest follow-up yet for comprehensive behavioral (ComB) treatment of trichotillomania (TTM) (M = 24.59 months after pre-treatment and 15.92 months after the last follow-up point in a recent clinical trial (Carlson et al., 2021), which had shown ComB to be significantly more efficacious than minimal attention at post-treatment). This study also examined changes in TTM severity from before to during the COVID-19 pandemic. Participants (N = 23) completed a survey assessing current TTM symptoms, the impact of the pandemic on their coping with TTM, and their experience with ComB treatment. Self-reported symptom severity at this follow-up evaluation fell between the scores obtained at the clinical trial's pre-treatment assessment and at its last follow-up before the pandemic and did not significantly differ from either time point. Most participants (73%) reported some change in their TTM management since onset of the pandemic, with changes to their environment/routine (61%) and in anxiety (32%) being the most common. Pandemic-related changes were associated with variable outcomes, improving symptoms and management for some while worsening them for others. Use of strategies from ComB had declined since the most recent follow-up, but more than half (55%) of participants reported that strategies from ComB remained useful. • Extended follow-up of an RCT of comprehensive behavioral treatment (ComB) of trichotillomania (TTM) was conducted. • Long-term follow-up TTM symptoms fell between pre-treatment and short-term follow-up, nonsignificantly different from either. • Participants reported varied responses to the COVID-19 pandemic. • Changes in routine and anxiety were perceived as having the most impact on pulling. [ABSTRACT FROM AUTHOR]

Abstract: Background: Individuals are adherent to approximately 50% of their prescribed medications, which decreases when multiple, chronic conditions are involved. Objective: To examine factors affecting adherence to multiple prescribed medications for consumers with co-existing diabetes and chronic kidney disease (diabetic kidney disease) from the time of prescription to the time they took their medications. Design: A descriptive exploratory design was used incorporating in-depth interviews and focus groups. Setting: The diabetes and nephrology departments of two metropolitan, public hospitals in Melbourne, Australia. Participants: A convenience sample of 23 consumers with diabetic kidney disease participated in an in-depth interview. Inclusion criteria involved English-speaking individuals, aged ≥18 years, with co-existing diabetes and chronic kidney disease, and who were mentally competent. Exclusion criteria included impending commencement on dialysis, pregnancy, an aggressive form of cancer, or a mental syndrome that was not stabilised with medication. Sixteen health professionals working in diabetes and nephrology departments in Melbourne, Australia also participated in one of two focus groups. Methods: In-depth structured interviews and focus groups were conducted and analysed according to a model of medication adherence. Results: Consumers were not convinced of the need, effectiveness and safety of all of their medications. Alternatively, health professionals focussed on the importance of consumers taking their medications as prescribed and believed that the risk of medication-related adverse effects was over-rated. Accessing prescribed medications and difficulties surrounding continuity of care contributed to consumers’ unintentional medication non-adherence. In particular, it was hard for consumers to persist taking their ongoing medication prescriptions. Healthcare system inadequacies were highlighted, which affected relationships between consumers with diabetic kidney disease and health professionals. Conclusions: Acknowledging the barriers as perceived by consumers with diabetic kidney disease can facilitate effective communication and partnerships with health professionals necessary for medication adherence and medication safety. [Copyright &y& Elsevier]

Abstract: This study investigated differences in psychosocial risk factors for eating disorders among university females (n =406) of diverse Hispanic background (Puerto Rican, Cuban, Central American/Mexican, Dominican, Venezuelan) and among White non-Hispanic (n =102) female students. Risk factors were assessed using the Psychosocial Risk Factor Questionnaire (PRFQ) which includes four subscales: Social Pressure for Thinness, Media Pressure for Thinness, Concern for Physical Appearance, and Perception of Physical Appearance. There were significant differences among the groups in total PRFQ score, F(7,499)=2.76, P <.008, and the subscale score for Concern, F(7,499)=2.99, P <.004, with Dominicans, Venezuelans and Columbians having higher scores than White non-Hispanics and Central Americans/Mexicans. In addition, there was a significant difference in BMI, F(7,499)=2.70, P <.009. Both Puerto Ricans (24.27+0.81) and Venezuelans (24.66+1.00) had higher BMIs than White non-Hispanics (21.87+0.37), Cubans (21.99+0.24) and Brazilians (21.46+0.96). There was also a significant, F(7,498)=2.70, P <.009, difference among the groups in Ideal Body Image score. Puerto Ricans had the highest score and Brazilians the lowest. Acknowledging that differences in psychosocial risk factors exist among Hispanic females of diverse background can assist us in creating more targeted approaches for the prevention of potential eating disorders in this population. [Copyright &y& Elsevier]

Fibrolamellar carcinoma (FLC) is a rare malignant entity arising from the liver and primarily affecting patients in late adolescence and young adulthood. FLC tumors are characterized by their unique histologic features and an only recently discovered genomic alteration: a chimeric fusion protein found in nearly all tumors. The rarity of these tumors coupled with the only recent acknowledgement of this genomic abnormality has likely led to disease under-recognition and de-prioritization of collaborative efforts aimed at establishing an evidence-guided standard of care. Surgical resection undoubtedly remains a mainstay of therapy and a necessity for cure but given the incidence of metastatic disease at diagnosis and high rates of distant relapse, systemic therapies remain a key component of disease control. There are few systemic therapies that have demonstrated proven benefit. Recent efforts have galvanized around single-institute or small consortia-based studies specifically focused on the enrollment of patients with FLC or use of agents with biologic rationale. This review will outline the current state of FLC epidemiology, histology, biology and trialed therapies derived from available published literature. [ABSTRACT FROM AUTHOR]

• Corticospinal tract integrity is an important biomarker of the motor system in stroke. • Diffusion imaging-based measures of integrity differed when extracted from standard versus native space. • Corticospinal tract integrity related to motor impairment regardless of extraction space. • Extraction space should be considered when comparing measures of corticospinal tract integrity across studies. Fractional anisotropy (FA) and mean diffusivity (MD) are measures derived from diffusion-weighted imaging that represent the integrity of the corticospinal tract (CST) after stroke. Some studies of the motor system after stroke extract FA and MD from native space while others extract from standard space making comparison across studies challenging. The purpose was to compare CST integrity measures extracted from standard versus native space in individuals with chronic stroke. Twenty-four individuals with stroke underwent diffusion-weighted imaging and motor impairment assessment. The spatial location of the CST was identified using four commonly utilized approaches; therefore, our results are applicable to a variety of approaches. FA extracted from standard space (FA std) was significantly different from FA extracted from native space (FA nat) for all four approaches; FA std was greater than FA nat for three approaches. The relationship between ipsilesional CST FA and UE FM was significant for all approaches and similar regardless of extraction space. MD std was significantly different from MD nat for most approaches, however, the directionality of the differences was not consistent. Our study shows that extraction space influences diffusion-based microstructural integrity values (FA and MD) of the CST in individuals with stroke, which is important when considering methods for aggregating CST integrity data across studies. The relationship between CST integrity and motor impairment appears to be robust to extraction space. The differences we identified are important for comparing FA and MD values across studies that use different extraction space. Our results provide context for future meta-analyses of diffusion-based metrics of CST integrity in individuals with stroke. [ABSTRACT FROM AUTHOR]

Background: There are various indications and approaches for hysterectomy; yet, the difference in long-term risk of subsequent prolapse after surgery is not well studied.Objective: To assess the risk of prolapse after abdominal, vaginal, and laparoscopic or robotic hysterectomy for up to 17 years from surgery.Study Design: A retrospective chart review study of women undergoing hysterectomy across all indications (benign and malignant) between 2001 and 2008 was conducted. An equivalent random sample of hysterectomy patients was selected each year. We compared demographic and other surgical characteristics data including age, race, parity, body mass index, indication and year of hysterectomy, blood loss, cervix removal, cuff suspension, and complications using chi-square, Kruskal-Wallis test, and Fisher's exact across the 3 groups. Presence and treatment of subsequent prolapse (based on patient symptoms, pelvic exam, International Classification of Diseases, Ninth Revision diagnosis, and current procedural terminology pessary or surgical codes) were compared with Kaplan-Meier survival analysis and Cox proportional hazards regression.Results: Of the 2158 patients, 1459, 375, and 324 underwent open, vaginal, and laparoscopic or robotic hysterectomy, respectively. The vaginal group (56) was older than the abdominal (52) or laparoscopic or robotic (49) groups, with a P value of <.05. Most patients were White with a mean body mass index of 30 kg/m2. The main indication was cancer for abdominal (33%) and laparoscopic or robotic hysterectomy (25%) and prolapse for vaginal hysterectomy (60%). Time to prolapse was shortest after vaginal surgery (27 months) and longest after laparoscopic or robotic surgery (71 months). After controlling for confounders, including surgery indication, the hazard ratio for subsequent prolapse was no different among vaginal (hazard ratio=1.36 [0.77-2.45]), laparoscopic or robotic (hazard ratio=1.47 [0.80-2.69]), or open (reference) hysterectomy. Prolapse grade was similar across the 3 groups. About 50% of women with recurrent prolapse received physical therapy, pessary, or surgical treatment.Conclusion: At the 17-year follow-up, the route of hysterectomy is not associated with a difference in recurrence, grade, or subsequent treatment of prolapse when the indication for hysterectomy is considered. Prolapse, as an indication for hysterectomy, increases risk for recurrence. Women planning a hysterectomy should be counseled appropriately about the risk of subsequent prolapse. [ABSTRACT FROM AUTHOR]

Gastroenterologic symptoms often are reported by adults with endometriosis, leading to unnecessary diagnostic tests or complicated treatment. We investigated associations between endometriosis and irritable bowel syndrome (IBS) in adolescents and whether concurrent pain disorders affect these. We collected data from within The Women's Health Study: Adolescence to Adulthood, which is a US longitudinal study of premenopausal females with and without endometriosis. Our study cohort included participants younger than 21 years enrolled from 2012 to 2018. Participants completed an extensive health questionnaire. Those with IBS based on a self-reported diagnosis or meeting Rome IV diagnostic criteria were considered cases and those without IBS were controls. Subjects without concurrent gastrointestinal disorders or missing pain data (n = 323) were included in the analyses. We calculated adjusted odds ratios using unconditional logistic regression. More adolescents with endometriosis (54 of 224; 24%) had comorbid IBS compared with adolescents without endometriosis (7 of 99; 7.1%). The odds of IBS was 5.26-fold higher among participants with endometriosis than without (95% CI, 2.13–13.0). In girls with severe acyclic pelvic pain, the odds of IBS was 35.7-fold higher in girls without endometriosis (95% CI, 4.67–272.6) and 12-fold higher in girls with endometriosis (95% CI, 4.2–36.3), compared with no/mild pain. For participants with endometriosis, each 1-point increase in acyclic pain severity increased the odds of IBS by 31% (adjusted odds ratio, 1.31; 95% CI, 1.18–1.47). In an analysis of data from a longitudinal study of girls and women with and without endometriosis, we found significant associations between endometriosis and IBS, and a linear relationship between acyclic pelvic pain severity and the odds of IBS. Increased provider awareness and screening for IBS and endometriosis will improve patient outcomes and increase our understanding of these complex disorders. [ABSTRACT FROM AUTHOR]

Objective: To identify metabolites in presurgical blood associated with risk of persistent postsurgical pelvic pain 1 year after endometriosis surgery in adolescent and young adult patients.Design: Prospective observational study within the Women's Health Study: From Adolescence to Adulthood, a US-based longitudinal cohort of adolescents and women enrolled from 2012-2018.Setting: Two tertiary care hospitals.Patient(s): Laparoscopically confirmed endometriosis patients (n = 180) with blood collected before their endometriosis surgery. Of these, 77 patients additionally provided blood samples 5 weeks to 6 months after their surgery. We measured plasma metabolites using liquid chromatography tandem mass spectrometry, and a total of 390 known metabolites were included in our analysis.Intervention(s): None.Main Outcome Measure(s): Persistent postsurgical pelvic pain, defined as severe, life-impacting pelvic pain 1 year after endometriosis surgery.Result(s): Most patients (>95%) were at stage I/II of the revised American Society for Reproductive Medicine classification. Their average age at diagnosis was 18.7 years, with 36% reporting persistent postsurgical pelvic pain. Of the 21 metabolites in presurgical blood that were associated with risk of persistent postsurgical pelvic pain, 19 metabolites, which were mainly lipid metabolites, were associated with increased risk. Only 2 metabolites-pregnenolone sulfate (odds ratio = 0.64, 95% confidence interval = 0.44-0.92) and fucose (odds ratio = 0.69, 95% confidence interval = 0.47-0.97)-were associated with decreased risk. Metabolite set enrichment analysis revealed that higher levels of lysophosphatidylethanolamines (false discovery rate = 0.01) and lysophosphatidylcholines (false discovery rate = 0.01) in presurgical blood were associated with increased risk of persistent postsurgical pelvic pain.Conclusion(s): Our results suggest that dysregulation of multiple groups of lipid metabolites may play a role in the persistence of pelvic pain postsurgery among young endometriosis patients. [ABSTRACT FROM AUTHOR]

We present the first reported case of heterotopic gastric mucosa (HGM) with pyloric type metaplasia obstructing the bile duct, with a literature review of bile duct obstruction from other types of HGM in children and adults. A 10-year old boy presented with severe, episodic, post-prandial, epigastric pain. An extensive work-up found a partially obstructing lesion of the common bile duct adjacent to the cystic duct. He underwent surgical resection of the lesion with restoration of the biliary drainage via choledocho-duodenostomy. Pathology revealed heterotopic gastric mucosa with pyloric metaplasia. Recovery was uneventful and he remains symptom-free 36 months later. Obstructing lesions of the biliary tree are exceedingly rare in children. In contrast with adults, there is minimal concern that such a lesion represents a malignancy. This may lead to prolonged diagnostic work-up as opposed to early surgical exploration. While it can be difficult to differentiate between benign and high-risk bile duct lesions in adults, malignant transformation of HGM of the bile duct has only been reported in an adult. In every pediatric and adult case reviewed, surgical exploration was required to establish the diagnosis. Our patient's pathology revealed pyloric type metaplasia as a component of HGM. This is the first report of pyloric type metaplasia in the literature. Previously reports have only shown HGM of fundic origin. We advocate early resection of these lesions for both diagnostic purposes, and due to the potential for malignant transformation. [ABSTRACT FROM AUTHOR]