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Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries. [ABSTRACT FROM AUTHOR]

[Display omitted] • Microstructure evolution was studied in-situ during tension of Mg-Y-Zn-Al alloy. • Most dislocations were of non-basal 〈a〉 and pyramidal 〈c + a〉 types. • Dislocation-induced hardening was lower below the strain of 3% than above that. • This was caused by the interaction between prismatic dislocations and LPSO plates. • The effect of annealing on the deformation behavior during tension was also studied. Mg-Y-Zn-Al alloys processed by rapidly solidified ribbon consolidation (RSRC) technique exhibit an exceptional mechanical performance indicating promising application potential. This material has a bimodal microstructure consisting of fine recrystallized and coarse non-recrystallized grains with solute-rich stacking faults forming cluster arranged layers (CALs) and nanoplates (CANaPs), or complete long period stacking ordered (LPSO) phase. In order to reveal the deformation mechanisms, in-situ synchrotron X-ray diffraction line profile analysis was employed for a detailed study of the dislocation arrangement created during tension in Mg - 0.9% Zn - 2.05% Y - 0.15% Al (at%) alloy. For uncovering the effect of the initial microstructure on the mechanical performance, additional samples were obtained by annealing of the as-consolidated specimen at 300 and 400 °C for 2 h. The heat treatment at 300 °C had no significant effect on the initial microstructure, its evolution during tension and, thus, the overall deformation behavior under tensile loading. On the other hand, annealing at 400 °C resulted in a significant increase of the recrystallized grains fraction and a decrease of the dislocation density, leading to only minor degradation of the mechanical strength. The maximum dislocation density at the failure of the samples corresponding to the plastic strain of 10–25% was estimated to be about 16–20 × 1014 m−2. The diffraction profile analysis indicated that most dislocations formed during tension were of non-basal 〈a〉 and pyramidal 〈 c + a 〉 types, what was also in agreement with the Schmid factor values revealed independently from orientation maps. It was also shown that the dislocation-induced Taylor hardening was much lower below the plastic strain of 3% than above this value, which was explained by a model of the interaction between prismatic dislocations and CANaPs/LPSO plates. [ABSTRACT FROM AUTHOR]

T2-weighted imaging in at least two orthogonal planes is recommended for assessment of the uterus. To determine whether a convolutional neural network-based algorithm could be used for the re-constructions of uterus axes derived from a 3D SPACE with iterative denoising. 50 patients aged 18–81 (mean: 42) years who underwent an MRI examination of the uterus participated voluntarily in this prospective study after informed consent. In addition to a standard MRI pelvis protocol, a 3D SPACE research application sequence was acquired in sagittal orientation. Reconstructions for both the cervix and the cavum in the short and long axes were performed by a research trainee (T), an experienced radiologist (E), and the prototype software (P). In the next step, the reconstructions were evaluated anonymously by two experienced readers according to 5-point-Likert-Scales. In addition, the length of the cervical canal, the length of the cavum and the distance between the tube angles were measured on all reconstructions. Interobserver agreement was assessed for all ratings. For all axes, significant differences were found between the scores of the reconstructions by research T, E and P. P received higher scores and was preferred significantly more often with the exception of the comparison of the reconstruction Cervix short of E (Cervix short: P vs. T: p = 0.02; P vs. E: p = 0.26; Cervix long: P vs. T: p = 0.01; P vs. E: p < 0.01; Cavum short: P vs. T: p = 0.01; P vs. E: p = 0.02; Cavum long: P vs. T: p < 0.01; P vs. E: p < 0.01). Regarding the measured diameters, (length of cervical canal/cavum/distance between tube angles) significantly larger diameters were recorded for P compared to E and T (Cervix long (mm): T: 25.43; E: 25.65; P: 26.65; Cavum short (mm): T: 26.24; E: 25.04; P: 27.33; Cavum long (mm): T: 31.98; E: 32.91; P: 34.41; P vs. T: p < 0.01); P vs. E: p = 0.04). Moderate to substantial agreement was found between Reader 1 and Reader 2 (range: 0.39–0.67). P was able to reconstruct the axes at least as well as or better than E and T. P could thereby lead to workflow facilitation and enable more efficient reporting of uterine MRI. [ABSTRACT FROM AUTHOR]

The in-hospital survival of patients suffering from acute pancreatitis (AP) is 95% to 98%. However, there is growing evidence that patients discharged after AP may be at risk of serious morbidity and mortality. Here, we aimed to investigate the risk, causes, and predictors of the most severe consequence of the post-AP period: mortality. A total of 2613 well-characterized patients from 25 centers were included and followed by the Hungarian Pancreatic Study Group between 2012 and 2021. A general and a hospital-based population was used as the control group. After an AP episode, patients have an approximately threefold higher incidence rate of mortality than the general population (0.0404 vs 0.0130 person-years). First-year mortality after discharge was almost double than in-hospital mortality (5.5% vs 3.5%), with 3.0% occurring in the first 90-day period. Age, comorbidities, and severity were the most significant independent risk factors for death following AP. Furthermore, multivariate analysis identified creatinine, glucose, and pleural fluid on admission as independent risk factors associated with post-discharge mortality. In the first 90-day period, cardiac failure and AP-related sepsis were among the main causes of death following discharge, and cancer-related cachexia and non–AP-related infection were the key causes in the later phase. Almost as many patients in our cohort died in the first 90-day period after discharge as during their hospital stay. Evaluation of cardiovascular status, follow-up of local complications, and cachexia-preventing oncological care should be an essential part of post-AP patient care. Future study protocols in AP must include at least a 90-day follow-up period after discharge. [Display omitted] Post-discharge mortality in acute pancreatitis is as important as in-hospital mortality. A follow-up plan and a screening program are recommended for patients with acute pancreatitis. [ABSTRACT FROM AUTHOR]

Sustainable communities require emerging innovations to fulfill the energy needs of urban societies. Renewable energy systems are the most significant trend in net-zero energy buildings (NZEBs) that serve sustainable development. Due to their consistent power generation, standalone hybrid solar photovoltaic/thermal (PV/T) systems are currently in reasonable demand in the building sector. This study adopted a special design of the hybrid solar collector utilising a combination of water and air simultaneously as a working fluid (combi-PV/T), considering the waste heat generated from classical polycrystalline photovoltaic (PV) modules that negatively affect the building's sustainability. The main comparison parameters considered between the examined combi-PV/T and PV modules are the waste heat, solar cell surface temperature, exergy efficiency, and sustainability index. The experimental result confirmed the effectiveness of the combi-PV/T compared to the classical PV module. The results showed that the waste heat generated by the combi-PV/T module was lowered by 77.6 %. Besides, the average solar cell surface temperature of the PV module decreased by 30.6 % in the combi-PV/T module from 53.6 °C to 36.4 °C. Exergy efficiencies for combi-PV/T and PV ranged from 12.6 to 35.3 % and 4.4–6.8 %, respectively. Moreover, the sustainability index values were in the range of 1.15–1.8 and 1.03–1.06, respectively. Obtained findings indicated that the combination of hybrid solar PV/T systems has an efficient sustainability contribution and the potential to subsidise sustainable building construction towards NZEBs. [Display omitted] • A configuration of a water-air-based PV/T unit has been experimentally analyzed. • Wasted heat transferred by PV and PV/T modules has been calculated and compared. • The study configuration of the PV/T increases the sustainability contribution. • Overall exergy efficiency was obtained between 12.6 and 35.3 %. • Sustainability index comparison between the PV/T and PV modules. [ABSTRACT FROM AUTHOR]

Although efficacy of ustekinumab (UST) has been demonstrated through randomized trials, data from real-life prospective cohorts are still limited. Our aim was to evaluate clinical efficacy, drug sustainability, dose intensification and results from therapeutic drug monitoring in UST treated patients with Crohn's disease (CD) using a prospective, nationwide, multicenter cohort. Patients from 10 Inflammatory Bowel Disease centers were enrolled between 2019 January and 2020 May. Patient demographics, disease phenotype, treatment history, clinical disease activity (Crohn's Disease Activity Index(CDAI), Harvey Bradshaw Index(HBI)), biomarkers, and serum drug levels were obtained. Evaluations were performed at week8 (post-induction), w16–20, w32–36, and w52–56 follow-up visits. A total of 142 patients were included [57.4% female; complex disease behavior (B2/B3):48%, previous anti-TNF exposition:97%]. Clinical response and remission rates after induction(w8) were 78.1% and 57.7% using CDAI, and 82.5% and 51.8% based on HBI scores. The one-year clinical remission rate was 58%/57.3%(CDAI/HBI). Composite clinical and biomarker remission (CDAI<150 and C-reactive protein<10 mg/L) rates were 35.4%; 33.3%; 38.6% and 36.6% at w8/w16–20/w32–36 and w52–56. Drug sustainability was 81.9%(standard deviation(SD): 3.4) at 1 year(1y). Probability of dose intensification was high and introduced early, 42.2%(SD:4.2) at ~w32 and 51.9%(SD:4.4%) at 1y. Ustekinumab showed favorable drug sustainability and clinical efficacy in a patient population with severe disease phenotype and previous anti-tumor necrosis factor (anti-TNF) failure, however frequent dose intensification was required. [ABSTRACT FROM AUTHOR]

The acute respiratory distress syndrome (ARDS) is a common complication of severe COVID-19 (coronavirus disease 2019) caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection. Knowledge of molecular mechanisms driving host responses to SARS-CoV-2 is limited by the lack of reliable preclinical models of COVID-19 that recapitulate human illness. Further, existing COVID-19 animal models are not characterized as models of experimental acute lung injury (ALI) or ARDS. Acknowledging differences in experimental lung injury in animal models and human ARDS, here we systematically evaluate a model of experimental acute lung injury as a result of SARS-CoV-2 infection in Syrian golden hamsters. Following intranasal inoculation, hamsters demonstrate acute SARS-CoV-2 infection, viral pneumonia, and systemic illness but survive infection with clearance of virus. Hamsters exposed to SARS-CoV-2 exhibited key features of experimental ALI, including histologic evidence of lung injury, increased pulmonary permeability, acute inflammation, and hypoxemia. RNA sequencing of lungs indicated upregulation of inflammatory mediators that persisted after infection clearance. Lipidomic analysis demonstrated significant differences in hamster phospholipidome with SARS-CoV-2 infection. Lungs infected with SARS-CoV-2 showed increased apoptosis and ferroptosis. Thus, SARS-CoV-2 infected hamsters exhibit key features of experimental lung injury supporting their use as a preclinical model of COVID-19 ARDS. [ABSTRACT FROM AUTHOR]

To evaluate the intraoperative visual effect of treatment with GnRH-analogues and Dienogest in endometriosis. Retrospective observational study. Every laparoscopy from all the different disciplines in our hospital is documented on video and stored in a database. The study was approved by the local ethics committee. A total of 193 patients with histological proven endometriosis from 2007 to 2021 were included, who underwent 2-step surgical procedure. Indications were endometrioma before CO2-Laser therapy, missing consent because of emergencies or other surgeries from other disciplines, or high active and extended disease. When endometriosis was suspected in a surgery conducted by other disciplines, a gynecological surgeon was called during the surgery. Data and intraoperative videos were reviewed by 2 independent reviewers at one referral center. Only cases with available video of first and second look laparoscopy were included. We excluded patient who had prior hormonal treatment in the last 6 months. Lesions were classified according to the description of Khan et al. Statistical analysis was performed using SPSS (Version 27.0, IBM). Mann-Whitney U test (nonparametric analysis) and χ2 tests were applied. Percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. Significance level was set to p <.05. Seventy-seven received GnRH-analogues and 116 Dienogest for preoperative hormone down-regulation. The median duration of down-regulation with GnRH-analogues or Dienogest was 3 months. The mean age was 32.3 (SD 6.3) years for GnRH-analogues and 32.6 (SD 6.3) years for Dienogest, p =.619 respectively. The visible intraoperative effect will be demonstrated in the video. The effect of a hormonal treatment can be observed macroscopically in endometriosis. This can help to understand the in vivo response to the administrated treatment. This video is showing our past experience, as performing second-look laparoscopy is not state of the art anymore. [Display omitted] [ABSTRACT FROM AUTHOR]

Law enforcement officer (LEO) administered naloxone is an effective intervention for treating prehospital opioid overdoses. Our objective is to determine the rate and factors associated with adverse behavioral effects and efficacy following LEO naloxone administration. This is a retrospective cohort study of patients treated with naloxone law enforcement over 5 years in one county EMS system. Law enforcement officers utilized intranasal 4 mg/0.1 mL for suspected opioid overdose. Data were acquired from forms completed by LEO following administration of naloxone. We performed descriptive statistics. Univariate regression analysis with a primary outcome of improved neurological status and a secondary outcome of patient irritability/combativeness post-naloxone. A total of 597 cases of LEO administered naloxone were reported. Naloxone was felt to be effective by the LEO in 370 (62%) of these cases with 6 (1%) exhibiting combativeness and 57 (10%) having the composite outcome of irritability or combativeness. The perceived rate of efficacy was higher when an opioid, rather than a non-opioid agent was suspected (239/346 [67%] vs. 83/165 [50%], OR 2.21, 95% CI 1.51–3.23), and for heroin and fentanyl specifically. Suspected fentanyl exposure was the only variable associated with our secondary outcome of irritability or combativeness (7/22 [32%] vs. 45/489 [9%], OR 4.60, 95% CI 1.78–11.8). LEO administered naloxone remains an effective intervention for overdose victims, with higher perceived efficacy when opioids are specifically implicated. Combativeness is rare following LEO naloxone administration. Further research is needed to understand a relationship between suspected fentanyl intoxication and post-naloxone behavioral disturbances. • Law enforcement officers administered naloxone for 597 patients with possible opioid overdose. • In 370 (62%) of cases, naloxone was effective. • In 6 cases (1%), patients exhibited combativeness, and in 57 cases (10%), they were irritable or combative. • Cases where fentanyl was the suspected intoxicant were associated with irritability following naloxone reversal, but the causality of this relationship is unknown. [ABSTRACT FROM AUTHOR]

Clinical data on the efficacy and safety of non-medical switch between adalimumab(ADA) biosimilars are limited. The aim of this study was to evaluate medium-term clinical efficacy, drug sustainability and safety comparing non-medical switches from the originator to biosimilar ADA, and between ADA biosimilars. 276 consecutive patients on maintenance ADA therapy (n = 205 Crohn's disease, n = 71 ulcerative colitis) were included. Data on clinical efficacy, biomarkers and adverse events were collected at four time points: 8–12 weeks prior switch, at baseline/switch, 8–12 weeks and 20–24 weeks after switch. Drug survival was evaluated after a median 40(IQR:35–42) weeks follow-up. A total 174 patients underwent a non-medical switch from the originator to a biosimilar, and 102 patients had a biosimilar-to-biosimilar switch. No significant difference was found in clinical remission rates at any time point in patients switching from originator to biosimilar(87.3%/88.5%/86.5%/85.7%) or biosimilar to biosimilar(74.5%/78.4%/85.3%/79.8%). Mean C-reactive protein levels remained unchanged in both cohorts(p = 0.856 and p = 0.525). Drug survival was similar between the two cohorts with a probability of 91.6%(SE: 2.2) and 87.0%(SE:3.4) to stay on drug after 40 weeks(log-rank:0.96; p = 0.327). Five cases of injection related adverse events were reported. Clinical benefit was sustained following non-medical switch from originator to biosimilar, or between biosimilars in adalimumab treated IBD patients. [ABSTRACT FROM AUTHOR]

Hereditary angioedema (HAE) is a genetic disorder that manifests as recurrent angioedema attacks, most frequently due to absent or reduced C1 inhibitor (C1INH) activity. C1INH is a crucial regulator of enzymatic cascades in the complement, fibrinolytic, and contact systems. Inter-α-trypsin inhibitor heavy chain 4 (ITIH4) is an abundant plasma protease inhibitor that can inhibit enzymes in the proteolytic pathways associated with HAE. Nothing is known about its role in HAE. We investigated ITIH4 activation in HAE, establishing it as a potential biomarker, and explored its involvement in HAE-associated proteolytic pathways. Specific immunoassays for noncleaved ITIH4 (intact ITIH4) and an assay detecting both intact and cleaved ITIH4 (total ITIH4) were developed. We initially tested serum samples from HAE patients (n = 20), angiotensin-converting enzyme inhibitor–induced edema patients (ACEI) (n = 20), and patients with HAE of unknown cause (HAE-UNK) (n = 20). Validation involved an extended cohort of 80 HAE patients (60 with HAE-C1INH type 1, 20 with HAE-C1INH type 2), including samples taken during attack and quiescent disease periods, as well as samples from 100 healthy controls. In 63% of HAE patients, intact ITIH4 assay showed lower signals than total ITIH4 assay. This difference was not observed in ACEI and HAE-UNK patients. Western blot analysis confirmed cleaved ITIH4 with low intact ITIH4 samples. In serum samples lacking intact endogenous ITIH4, we observed immediate cleavage of added recombinant ITIH4, suggesting continuous enzymatic activity in the serum. Confirmatory HAE cohort analysis revealed significantly lower intact ITIH4 levels in both type 1 and type 2 HAE patients compared to controls, with consistently low intact/total ITIH4 ratios during clinical HAE attacks. The disease-specific low intact ITIH4 levels highlight its unique nature in HAE. ITIH4 may exhibit compensatory mechanisms in HAE, suggesting its utility as a diagnostic and prognostic biomarker. The variations during quiescent and active disease periods raise intriguing questions about the dynamics of proteolytic pathways in HAE. [ABSTRACT FROM AUTHOR]

[Display omitted] Angioedema (AE) manifests with intermittent, localized, self-limiting swelling of the subcutaneous and/or submucosal tissue. AE is heterogeneous, can be hereditary or acquired, may occur only once or be recurrent, may exhibit wheals or not, and may be due to mast cell mediators, bradykinin, or other mechanisms. Several different taxonomic systems are currently used, making it difficult to compare the results of studies, develop multicenter collaboration, and harmonize AE treatment. We developed a consensus on the definition, acronyms, nomenclature, and classification of AE (DANCE). The initiative involved 91 experts from 35 countries and was endorsed by 53 scientific and medical societies, and patient organizations. A consensus was reached by online discussion and voting using the Delphi process over a period of 16 months (June 2021 to November 2022). The DANCE initiative resulted in an international consensus on the definition, classification, and terminology of AE. The new consensus classification features 5 types and endotypes of AE and a harmonized vocabulary of abbreviations/acronyms. The DANCE classification complements current clinical guidelines and expert consensus recommendations on the diagnostic assessment and treatment of AE. DANCE does not replace current clinical guidelines, and expert consensus algorithms and should not be misconstrued in a way that affects reimbursement of medicines prescribed by physicians using sound clinical judgment. We anticipate that this new AE taxonomy and nomenclature will harmonize and facilitate AE research and clinical studies, thereby improving patient care. [ABSTRACT FROM AUTHOR]

The occurring and projected changes in climate patterns and associated demographic, socio-economic, and environmental factors make Central European cities vulnerable to heatwaves. However, urban areas in the Carpathian Basin, located just a few hundred kilometers apart, exhibit diverse geographical and microclimatic conditions contributing to distinct local-specific features. This paper aims to analyze the vulnerability of Hungarian county seats and Slovak regional seats to heatwaves by integrating statistical indicators, remote-sensing data, and qualitative information on urban climate strategies. By comparing less-studied urban areas, this paper fills a gap in the current literature and provides an easily adaptable assessment methodology incorporating quantitative and qualitative methods, which were rarely combined in previous research. The results highlight significant differences in sensitivity and adaptive capacity factors among the selected cities while also revealing country-specific aspects of policy-making strengths and weaknesses. • Synthetizing quantitative vulnerability analysis and policy assessment. • Quantitative analysis uses demographic, socio-economic, health, remote sensing data. • Qualitative research comprises a content analysis of local climate plans. • Results show lower vulnerability of Slovak cities to heatwaves. • Strategies usually fail to consider the most vulnerable groups to heatwaves. [ABSTRACT FROM AUTHOR]

• Pediatric patients on immunosuppressive drugs had mild COVID-19. • Risk of flare related to SARS CoV-2 exposure in rheumatic disease patients was similar to baseline. • Seroprevalence survey identified high asymptomatic infection rate. [ABSTRACT FROM AUTHOR]

Use of minimally invasive approaches to acute abdominal surgical emergencies has increased in recent decades. Uptake has been slower than for elective surgery, however, with concerns regarding inadvertent injury and operative time being most frequently cited. Laparoscopy for abdominal pain has shown to be safe and is a useful diagnostic procedure in the context of unexplained abdominal pain. Minimally invasive surgery has also been shown to be the approach of choice in appendicitis and cholecystitis. Laparoscopy has shown to be useful in trauma patients and may obviate the need for laparotomy. Management of perforated peptic ulcers has shown to be feasible and safe, with some uncertainty as to the superiority over an open approach. The management of perforated diverticulitis has been the subject of much debate, with significant risk possibly associated with minimally invasive lavage. Small bowel obstruction may also be managed using laparoscopy but the potential for inadvertent injury remains. While useful and certainly yielding benefits in terms of postoperative recovery when performed without incident, the decision to proceed minimally invasively in many acute abdominal emergencies must be taken by clinicians and surgical teams with suitable experience and expertise. [ABSTRACT FROM AUTHOR]

Multifunctional laser technology integrates different laser processes in one manufacturing cell to meet the demand for agile production technology. A processing head was developed and put into operation mastering cutting, joining and additive manufacturing steps without tool change. Parallel development of a digital twin of the entire system aims at the acceleration and optimization of the engineering of the robot cell up to its virtual commissioning. This approach enabled the first realization of a multifunctional laser robot cell and its digital twin. Virtual commissioning accelerated the design and optimization of mechanics and control as well as the programming of the production cell. The multifunctional approach saves numerous single production steps and, hence, leads to a significant shortening of manufacturing lines utilizing the full flexibility of the tool laser beam. Virtualization enables accelerated commissioning of the entire system, significantly reduced susceptibility to errors in production preparation and more efficient production planning. [ABSTRACT FROM AUTHOR]

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCV ref = 4.67 (LEOPEN) and SCV/SCV ref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons. [ABSTRACT FROM AUTHOR]

Several studies have investigated the association between diverticular disease (DD) and colorectal cancer. However, whether there is an association between DD and malignancies other than those in the colorectum remains uncertain. For the 1978–2019 period, we conducted a nationwide, population-based cohort study using national Danish health care data. We followed patients with DD for up to 20 years, beginning 1 year after the date of DD diagnosis until the first occurrence of incident cancer, emigration, death, 20 years of follow-up, or December 31, 2019. We calculated cumulative incidence proportions of cancer and standardized incidence ratios (SIRs) comparing cancer incidence among patients with DD with that in the general population. We identified 200,639 patients with DD, of whom 20,498 were diagnosed with cancer during the 1–20 years after their DD diagnosis. The SIRs were increased for most cancer sites except for those in the colorectum (SIR, 0.75; 95% confidence interval, 0.72–0.78). The highest SIRs were observed for cancers of the lung, bronchi, and trachea (SIR, 1.20; 95% confidence interval, 1.15–1.24) and kidney (SIR, 1.27; 95% confidence interval, 1.16–1.39). Our findings show an increased long-term relative risk of cancer following a diagnosis of DD. These findings are likely caused by prevalence of numerous risk factors in patients with DD that confer an increased risk of cancer. The decreased relative risk of colorectal cancer might be explained by an increased likelihood of patients with DD undergoing colonoscopy with polypectomy. [ABSTRACT FROM AUTHOR]

The prolonged COVID-19 pandemic and the Russia-Ukraine War (multiple crises or catastrophes) affected the logistics sector in the world, especially in developing countries. Collaborative logistics is a strategy to mitigate the negative impacts of multiple crises. Thus, this study aims to uncover the impact of multiple crises on logistics collaboration in developing countries in the case of Indonesia and to disclose the collaboration patterns among logistics companies in the country. Data were collected through a questionnaire survey of 183 logistics professionals working in logistics companies in Indonesia from June to November 2023. Of the 183 respondents, 148 observations were used in the statistical analysis using the Partial-Least Square–Structural Equation Model (PLS-SEM) with Rstudio. This study had the following findings: First, the early days of the COVID-19 pandemic (2020–2021) promoted domestic and international collaborations. Second, the latter days of the COVID-19 pandemic (2022–2023) promote less intensive collaboration at domestic and international levels due to the termination of some restrictions to contain the COVID-19 spread and the relative resiliency of the logistics sector. Third, the negative impact of the Russia-Ukraine War drove logistics companies to collaborate intensively at the domestic and international levels. Fourth, companies' responses to multiple crises demonstrate a fluctuating collaboration pattern, depending on the severity of the crisis. Thus, it is suggested that maintaining intensive logistics collaboration is a strategy to gain resilience from unintended events that negatively affect the supply chain. This study has an academic contribution to the logistics and supply chain field, emphasising collaboration during crises in developing countries. [ABSTRACT FROM AUTHOR]

Observing reactions and responses to climate change worldwide, we think climate policies cannot exert their impact sufficiently. Consequently, studying the climate policy paradigms (CPPs) shaped by the dominant environmental ideas and climate objectives is essential. This paper analyses the CPPs in the Visegrad Countries (Czech Republic, Hungary, Poland, Slovakia) (V4). We investigated the strategic background and implementation related to climate policies by studying the CPPs' different levels. Our research comprises two components: 1. Analysis of national climate strategies and plans (n = 9) to reveal documented policy goals. 2. In-depth interviews (n = 58) to explore the implementation of policy goals and strategic principles. According to our results, the V4's climate strategy documents (CSDs) align with global climate policy efforts and follow EU standards. However, we have found contradictions between the policy goals and their implementation. Our findings show that CSDs are only partial indicators of the CPPs, and all four countries have gaps between ideas and the realization of climate actions. One of the main reasons is that V4 prioritizes national economic interest and energy security. Consequently, the climate policy paradigm takes a back seat. The other inhibiting factors are the lack of social will and the shortcomings of climate governance. [Display omitted] • The V4 has taken significant steps in climate policy over the past decade. • Policy implementation does not fully match climate policy goals. • Obstacles are economic interest, lack of social will, and institutional failures. • Poland's coal reliance drives pronounced policy gaps. • Climate strategies serve as superficial indicators of climate policy paradigms. [ABSTRACT FROM AUTHOR]

Hereditary angioedema (HAE) is a rare, life-threatening genetic disorder characterized by recurrent episodes of subcutaneous or submucosal angioedema. The ultimate goals of treatment for HAE remain ill-defined. The aim of this Delphi process was to define the goals of HAE treatment and to examine which factors should be considered when assessing disease control and normalization of the patient's life. The Delphi panel comprised 23 participants who were selected based on involvement with scientific research on HAE or coauthorship of the most recent update and revision of the World Allergy Organization/European Academy of Allergy and Clinical Immunology guideline on HAE. The process comprised 3 rounds of voting. The final round aimed to aggregate the opinions of the expert panel and to achieve consensus. Two direct consensus questions were posed in round 2, based on the responses received in round 1, and the panel agreed that the goals of treatment are to achieve total control of the disease and to normalize the patient's life. For the third round of voting, 21 statements were considered, with the participants reaching consensus on 18. It is clear from the wide-ranging consensus statements that the burdens of disease and treatment should be considered when assessing disease control and normalization of patients' lives. The ultimate goal for HAE treatment is to achieve no angioedema attacks. The availability of improved treatments and disease management over the last decade now makes complete control of HAE a realistic possibility for most patients. [ABSTRACT FROM AUTHOR]

Hypophosphatemic rickets is a hereditary disease of childhood that affects bone metabolism. Patients with this disease can have poor bony healing at growth centers due to impaired mineralization of the cartilaginous bone plates. The orthopedic literature has shown appropriate long bone healing in patients with rickets who are undergoing concurrent medical management. However, there has never been a report of successful osteotomy or fracture of the maxillomandibular skeleton in a patient with rickets with documented radiographic and clinical resolution. This report describes a case of successful Le Fort I osteotomy with bilateral mandibular sagittal split osteotomies with concurrent medical management in an 18-year-old female with hypophosphatemic rickets. Before surgery the patient was consented and understood that because there has never been a documented case such as this, she might especially risk complications including non-union, malunion, or unfavorable osteotomy splits. The intraoperative quality of the patient's bone was of normal caliber and allowed routine osteotomy creation and internal fixation with no complications. She was followed for over 3 years and showed uneventful healing. While this disease is especially rare, practitioners should be aware that acceptable healing alongside appropriate medical management has been documented. [ABSTRACT FROM AUTHOR]

Introduction: There are concerns about pulmonary function tests (PFTs) being associated with aerosol generation and enhanced virus transmission. As a consequence, the number of PFTs was reduced significantly during the coronavirus disease 2019 pandemic. However, there are no robust data supporting this fear.Objectives: To perform real-life measurement of aerosol concentrations in a PFT laboratory to monitor the concentration of particles near the patient, and to model the associated potential viral load.Methods: Two optical particle counters were used to sample the background concentration and the concentration of particles near the patient's mouth in a whole-body plethysmography box. Statistical evaluation of the measured particle concentration time series was completed. The particle exhalation rate was assessed based on the measured particle concentration data by applying the near-field/far-field theory. The number of exhaled viruses by an infected patient during the test was compared with the emission of viruses during quiet breathing and speaking.Results: Twenty-five patients were included in the study. Eighteen patients showed a significant increase in aerosol concentration [mean 1910 (standard deviation 593) particles/L]. Submicron particles dominated the number size distribution of the generated particles, but large particles represented a higher volume fraction in the generated particles compared with background. An average gene exhalation rate of 0.2/min was estimated from this data. This is one order of magnitude higher than the release rate for the same infected person during quiet breathing, and of the same order of magnitude as the release rate during normal speaking.Conclusions: This study demonstrated that PFTs are aerosol-generating procedures. Based on these results, the moderate increase in viral load does not underpin stopping such examinations. [ABSTRACT FROM AUTHOR]

Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. The National Inpatient Sample (NIS) database was queried (1998–2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998–2009 and 2010–2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1–11.0; p < 0.0001) and decreased over time. The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes. [ABSTRACT FROM AUTHOR]

This study compared pharmacokinetics, symptomatic and endoscopic efficacy, safety, and immunogenicity of a subcutaneous formulation of the infliximab biosimilar CT-P13 (CT-P13 SC) vs intravenous CT-P13 (CT-P13 IV) in patients with inflammatory bowel disease (IBD). This randomized, multicenter, open-label, parallel-group, phase 1 study enrolled tumor necrosis factor inhibitor–naïve patients with active ulcerative colitis (total Mayo score 6–12 points with endoscopic subscore ≥2) or Crohn's disease (Crohn's Disease Activity Index 220–450 points) at 50 centers. After CT-P13 IV induction at Week (W) 0/W2, patients were randomized (1:1) to receive CT-P13 SC every 2 weeks (q2w) from W6 to W54 or CT-P13 IV every 8 weeks from W6 to W22. At W30, all patients receiving CT-P13 IV switched to CT-P13 SC q2w until W54. The primary endpoint was noninferiority of CT-P13 SC to CT-P13 IV for observed predose CT-P13 concentration at W22 (C trough,W22), concluded if the lower bound of the 2-sided 90% confidence interval (CI) for the ratio of geometric least-squares means exceeded 80%. Overall, 66 and 65 patients were randomized to CT-P13 SC and CT-P13 IV, respectively. The primary endpoint of noninferiority was met with a geometric least-squares means ratio for C trough,W22 of 1154.17% (90% CI 786.37–1694.00; n = 59 [CT-P13 SC]; n = 57 [CT-P13 IV]). W30/W54 clinical remission rates were comparable between arms. Other efficacy, safety, and immunogenicity assessments were also broadly comparable between arms, including after switching. The pharmacokinetic noninferiority of CT-P13 SC to CT-P13 IV, and the comparable efficacy, safety, and immunogenicity profiles, support the potential suitability of CT-P13 SC treatment in IBD. ClinicalTrials.gov ID: NCT02883452. [Display omitted] [ABSTRACT FROM AUTHOR]

This study investigated how caregivers' mobile device use influenced the quality of their interactions with their children. The associations between quality of interactions and the type of activity (eg, typing/swiping, looking at screen), setting, caregiver-child proximity, and child behaviors were also examined. Researchers anonymously and systematically observed and coded the behavior of 98 caregiver-child dyads in public settings (eg, parks, food courts) during real-time, naturally occurring interactions using time sampling. Caregivers who used a mobile device for the entire observation engaged in less joint attention and were less responsive than caregivers who used the device some of the time. When looking at patterns within caregivers who used the device intermittently, the probability that they would engage in joint attention, initiate interactions with their child, talk, and display positive emotions was lower when they used a mobile device than when they did not. Child talking and positive affect were unrelated to caregiver device use. Activity type with the device, caregiver-child proximity and setting also related to interaction quality. Caregiver device use was negatively associated with adult behaviors that are key components of high-quality caregiver-child interactions. Additionally, setting, activity type, and caregiver-child proximity are factors that should be considered because they relate to the quality of caregiver-child interactions in the context of mobile screen technologies. [ABSTRACT FROM AUTHOR]

Human wastewater-derived pollution of the environment is an emerging health risk that increases the number of waterborne and foodborne illnesses globally. To better understand and mitigate such health risks, we investigated the prevalence of faecal indicator bacteria, Escherichia coli , and indicator virus (crAssphage) along with human and animal enteric viruses (adenoviruses, noroviruses, sapoviruses, hepatitis E virus) in shellfish and water samples collected from two shellfish harvesting areas in the UK. Human noroviruses were detected at higher detection rates in oyster and water samples compared to mussels with peaks during the autumn-winter seasons. Human enteric viruses were sporadically detected during the warmer months, suggesting potential introduction by tourists following the relaxation of COVID-19 lockdown measures. Our results suggest that viral indicators are more suitable for risk assessment and source tracking than E. coli. The detection of emerging hepatitis and sapoviruses, support the need for comprehensive viral monitoring in shellfish harvesting areas. • Domestic wastewater discharge to the aquatic environment is an emerging health risk. • Human norovirus, hepatitis E virus and sapovirus were detected in bivalve shellfish. • Viral indicators are more suited for risk assessment and source tracking than E. coli. • Better surveillance and risk management is needed for emerging waterborne pathogens. [ABSTRACT FROM AUTHOR]

UV (254 nm) and UV/VUV (254/185 nm) photolysis, ozonation, and O 3 /UV combination were investigated and compared for the transformation of two sulfonamide (SAs) antibiotics, sulfamethazine (SMT) and sulfamethoxypyridazine (SMP). Change in toxicity, the effect of bacteria growth inhibition of the treated solutions, and the cost-efficiency of the methods were studied. In UV/VUV radiated solutions, the formation of •OH results in the doubled transformation rate. The relative contribution of various ROS (•OH, 1O 2 , O 2 •−) to the transformations were also investigated in the case of UV and UV/VUV photolysis. Both SAs can be eliminated ten times faster during ozonation than UV photolysis; but conversion via ozonation is associated with the formation of products with low reactivity to ozone and has biological effects. The O 3 /UV process did not enhance the transformation rate but positively affected mineralization and significantly decreased the ecotoxicity of the treated solutions. Ozonation was cost-effective, but O 3 /UV is a much safer technology to minimize environmental impacts because it effectively reduces the ecotoxicity and the bacterial growth inhibition effect of the treated solution. The observed differences between SMT and SMP are primarily related to the transformation of the N-containing rings. Our results showed a correlation between the reactivity of the N-containing groups of SAs, the rate of mineralization, and the change in ecotoxicity and antibacterial effect and emphasized the need for toxicological characterization of the treated samples. The removal of parent compounds is not sufficient to avoid the release of toxic substances into the environment. [Display omitted] • VUV light doubled the transformation and highly enhanced the mineralization rate. • O 3 -resistant toxic intermediates form in the case of ozonation. • UV/O 3 combination did not enhance the transformation rate compared to ozonation. • The growth inhibition effect of treated solutions was different for SMT and SMP. • Ozonation has the lowest E EO value, but UV/O 3 is the recommended method. [ABSTRACT FROM AUTHOR]

Staphylococcus aureus (S. aureus) as a major pathogen is implicated in a wide range of foodborne and hospital-acquired infections, its methicillin resistant variants contribute to the spread of β-lactam antibiotic resistance. It is essentially important to destroy these pathogens, their resistance genes and the antibiotics in wastewaters. For this purpose reactions of reactive radicals (advanced oxidation processes), first of all hydroxyl radicals (•OH), are suggested. Here the radiolysis of water supplied these radicals. In the experiments B.01755 oxacillin sensitive and B.02174 resistant S. aureus strains were used to study their behaviorr in suspensions under the effect of irradiation in presence and absence of oxacillin. Oxacillin inactivation depended on concentration of the antibiotic used (0.042 and 1 g dm−3), higher concentration required a higher dose. When 106–109 CFU cm−3 S. aureus suspensions were irradiated with γ-radiation the bacteria were inactivated at low absorbed doses: 4 orders of magnitude decrease ocurred in the number of culturable cells at ∼0.6 kGy dose. Both cell membrane and DNA suffered considerable damages during irradiation. Due to the membrane damage the cells could not be stained, and the DNA content of cells in several days period was released into the solution. In DNA damage the oxacillin resistance mecA gene was also modified, it did not multiply in PCR test. These findings are important from the point of view of applying irradiation technology to stop the spread of antibiotic resistance. [Display omitted] • Purified wastewater irradiation with dose <2 kGy stops spread of antibiotic resistance. • Oxacillin in irradiated solutions loses ability to retard multiplication of S. aureus. • Products of oxacillin degradation do not have antimicrobial activity. • Both cell membrane and DNA suffer considerable damages during irradiation. • In DNA damage oxacillin resistant mecA gene was modified, did not multiply in PCR. [ABSTRACT FROM AUTHOR]

Abstract Objective Neuropeptide Y (NPY) is one of the most potent orexigenic peptides. The hypothalamic paraventricular nucleus (PVN) is a major locus where NPY exerts its effects on energy homeostasis. We investigated how NPY exerts its effect within the PVN. Methods Patch clamp electrophysiology and Ca2+ imaging were used to understand the involvement of Ca2+ signaling and retrograde transmitter systems in the mediation of NPY induced effects in the PVN. Immuno-electron microscopy were performed to elucidate the subcellular localization of the elements of nitric oxide (NO) system in the parvocellular PVN. In vivo metabolic profiling was performed to understand the role of the endocannabinoid and NO systems of the PVN in the mediation of NPY induced changes of energy homeostasis. Results We demonstrated that NPY inhibits synaptic inputs of parvocellular neurons in the PVN by activating endocannabinoid and NO retrograde transmitter systems via mobilization of Ca2+ from the endoplasmic reticulum, suggesting that NPY gates the synaptic inputs of parvocellular neurons in the PVN to prevent the influence of non-feeding-related inputs. While intraPVN administered NPY regulates food intake and locomotor activity via NO signaling, the endocannabinoid system of the PVN selectively mediates NPY-induced decrease in energy expenditure. Conclusion Thus, within the PVN, NPY stimulates the release of endocannabinoids and NO via Ca2+-influx from the endoplasmic reticulum. Both transmitter systems appear to have unique roles in the mediation of the NPY-induced regulation of energy homeostasis, suggesting that NPY regulates food intake, energy expenditure, and locomotor activity through different neuronal networks of this nucleus. Graphical abstract Image 1 Highlights • NPY increases the intracellular Ca2+ level of PVN neurons by mobilizing the Ca2+ from ER. • NPY inhibits the input of these neurons by endocannabinoids and NO. • IntraPVN administered NPY regulates food intake and locomotor activity via NO signaling. • IntraPVN administered NPY regulates energy expenditure via the endocannabinoid system. • NPY regulates the energy expenditure and food intake via different neuronal networks of the PVN. [ABSTRACT FROM AUTHOR]

Several Candida species, the best known example of which is Candida albicans , are opportunistic human pathogens that are responsible for frequent nosocomial infections. A worrisome aspect of the currently available treatments of candidemia is the steady development of resistance to antifungals among these potentially life threatening fungi. Under these circumstances the search for novel drug targets is a well justified research direction. We propose that the principles of signal transduction therapy by targeting protein phosphatases can be adopted as these enzymes carry out important physiological functions in Candida. We demonstrate that C. tropicalis, C. albicans, C. dubliniensis , and S. cerevisiae exhibit the largest repertoire of protein phosphatases among the investigated fungi. Together with other opportunistic pathogen Candida species and the members of the Saccharomycetales order, they expanded their phosphatome by repeated gene duplications. We noted that evolution generated a set of fungus specific phosphatases which can be targeted without the danger of causing undesirable side effects in the human body. Based on the conflicting criteria of effectiveness and selectivity, we identified and characterized 7 phosphatases that are potent virulence determinants and may be utilized as potential antifungal drug targets. Image 1 • The phosphatases of 11 opportunistic pathogen Candida species were surveyed. • From 66 to 79 conserved phosphatases per species were identified. • Frequent gene duplications expanded the phosphatome of these pathogens. • 7 novel phosphatases were pinpointed as putative drug targets. [ABSTRACT FROM AUTHOR]

To determine the effects of exergaming on quality of life (QoL), motor, and clinical symptoms in subacute stroke patients. A pseudorandomized controlled trial, using a before-after test design. University hospital. Subacute, ischemic stroke outpatients (N=3857), 680 of whom were randomized and 641 completed the study. We determined the effects of 5 times a week twice daily (EX2; 50 sessions; n=286) and once daily (EX1; 25 sessions; n=272) exergaming and low-intensity standard care (control [CON]; 25 sessions; n=83) on clinical, mobility, blood pressure (BP), and QoL outcomes. The primary outcome was Modified Rankin Scale. Secondary outcomes were activities of daily living, 5 aspects of health-related QoL, Beck Depression Inventory, 6-minute walk test (6MWT), Berg Balance Scale (BBS), and static balance (center of pressure). During exercise, the peak heart rate was 134, 134, and 126 beats per minute in the EX2, EX1, and CON groups, respectively. mRS improved similarly in the EX2 (–1.8; effect size, d=–4.0) and EX1 (–1.4; d=–2.6) groups, but more than in the CON group (–0.7; d=–0.6). QoL, Barthel Index, BBS, 6MWT, and standing posturography improved more in the EX2 group and the same in the EX1 and CON groups. Systolic and diastolic resting BP decreased more in the EX2 and EX1 groups than in the CON group. The intervention effects did not differ between men (n=349) and women (n=292). Twice daily compared with once daily high-intensity exergaming or once daily lower intensity standard care produced superior effects on clinical and motor symptoms, BP, and QoL in male and female subacute ischemic stroke participants. [ABSTRACT FROM AUTHOR]

Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception. This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed. 414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction. The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema. Treatment study level III. [ABSTRACT FROM AUTHOR]

Innovative peer-to-peer teaching has the potential to emphasize student self-learning and reduce the workload of the instructor. This single-blinded randomized crossover trial was conducted to evaluate whether peer-to-peer teaching is not inferior to standard teaching in basic airway management for undergraduate nursing students. Forty-eight students with the peer-to-peer learning had significantly higher skill rating scores with a large effect size (Cohen's d of 1.07 (p -value.002) for oropharyngeal airway insertion, 1.14 (p -value <.001) for nasopharyngeal airway insertion, and 0.81 (p -value.003) for bag-mask ventilation). There was no difference between preknowledge and postknowledge scores (p -value of.13 and.22, respectively). Both groups reported higher confidence. Nursing students trained in basic airway management by the peer-to-peer method did not show inferiority compared with the standard group. • There is a potential impact of an innovative teaching method. • The peer-to-peer model used self-instruction videos in support of peer-to-peer instruction combined with guided debriefing. • The structured curriculum model for peer-to-peer instruction of basic airway management was not inferior to standard instructor-led teaching in knowledge, skill, or attitude (confidence). • The students had an opportunity to develop their teaching skills through the peer-to-peer method. • The peer-to-peer teaching method has the benefit of reducing cost and instructor workload. [ABSTRACT FROM AUTHOR]

In rectal cancer, the presence of extramesorectal/lateral pelvic lymph node (LPN) is associated with higher risk of locoregional and distant recurrences. LPNs are not typically resected during a standard total mesorectal excision (TME) procedure, and the optimal management for these patients is controversial. We assessed the safety and efficacy of adding a radiation therapy boost to clinically positive LPN during neoadjuvant chemoradiation therapy for rectal cancer. We analyzed nonmetastatic, lymph node positive rectal adenocarcinoma patients treated with neoadjuvant chemoradiation therapy followed by TME between May 2011 and February 2018. Patients without LPN involvement received external beam radiation therapy (45 Gy in 25 fractions) to the primary tumor and regional draining lymph node basins followed by a boost (5.4 Gy in 3 fractions) to gross disease. Patients with clinically positive LPN that would not be removed during TME received an additional boost (up to a total dose between 54.0 and 59.4 Gy) to the involved LPNs. We compared locoregional control, overall survival, progression-free survival, and treatment-related toxicity between these 2 groups. Fifty-three patients were included in this analysis with median follow-up of 30.6 months for the LPN– group (n = 41) and 19.9 months for the LPN+ group (n = 12). There was no difference in 3-year overall survival (90.04% vs 83.33%, P =.890) and progression-free survival (80.12% vs 80.21%, P =.529) between the 2 groups. We did not observe any LPN recurrences. There were no differences in rates of acute grade 3+ or chronic toxicities. Despite the well-documented negative prognostic effect of LPN metastasis, we observed promising outcomes for LPN+ patients treated with an additional radiation boost. Our results suggest that radiation therapy boost to clinically involved, unresected LPN is an effective treatment approach with limited toxicity. Additional studies are needed to optimize treatment strategies for this unique patient subset. [ABSTRACT FROM AUTHOR]

Many online resources currently provide healthcare information to the public. In 2015, the Society of Thoracic Surgeons (STS) created a multimedia web portal (ctsurgerypatients.org) to educate the public regarding cardiothoracic surgery and provide an informative tool to which cardiothoracic surgeons could refer patients. A patient education task force was created, and disease-specific content was created for 25 pathological conditions. After launching the website online, a marketing campaign was initiated to make STS members aware of its availability. Website visits were monitored, and an online survey for public users was created. An email survey was sent to STS members to evaluate awareness and content. Surveys were analyzed for effectiveness and utilization by both public users and STS member surgeons. From 2016 to 2018, the website had more than 1 million visits, with visits increasing yearly. Surveyed user ratings of the website were positive regarding quality and utility of the information provided. STS member response was poor (379 responses of 6347 emails), and 78.3% of responders were unaware of the website. Surgeon responders were positive about the content, though many still refrain from referring patients. Online education for cardiothoracic surgery is seeing increased public use, with high ratings for content and utility. Despite aggressive marketing to STS members, most remain unaware of this website's existence. Those who are aware approve of its content, but adoption of referring patients to it has been slow. Improved strategies are necessary to make surgeons aware of this STS-provided service and increase patient referrals to it. [ABSTRACT FROM AUTHOR]

Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching tributaries of the thoracic duct may require lengthy management at significant cost to patient and clinical team. This paper aims to provide an up-to-date review to support clinical management. The term 'chyle' was combined with 'breast' or 'axilla.' EMBASE, Medline and PubMed database searches were conducted. All papers published in English were included with no exclusion date limits. 51 cases from 31 papers. All were female (mean age = 53.3yrs). 47/51 leaks were left-sided. 5/51 underwent sentinel node biopsy, 19/51 level II axillary node clearance (ANC), 23/51 level III ANC, 5/51 not specified. 59% (30/51) of leaks were identified within 2 postoperative days (mean = 3.3days). 96% initially managed conservatively: Drain = 38/51; low-fat diet = 34/51; compression bandaging = 20/51; Aspiration = 6/51. 40/51 (78%) were successfully managed conservatively, 11 patients returned to theater for secondary management. 7/11 recorded volumes >500mls/24 hrs before secondary surgery. Mean resolution time from initial surgery was 17.3days (range = 4–64days). No statistically significant difference (p = 0.72) in time to resolution between conservatively and surgically managed patients. Chyle leaks are rarely seen following axillary surgery. Aberrant thoracic duct anatomy represents the likeliest aetiology. We advocate early recognition and tailored individual management. Conservative management with non-suction drainage, low-fat diet and axillary compression bandaging appear effective where output <500ml/24 hrs. Secondary surgical management should be considered in high chylous output (<500mls/24 hrs) patients unresponsive to conservative measures. We propose a management algorithm to aide clinicians. [ABSTRACT FROM AUTHOR]

Inpatient discharge education is often suboptimal. Measures of parents' perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents' perceived and actual comprehension. We 1) compared parent perceived and actual comprehension of discharge instructions and 2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension). Prospective cohort study of English/Spanish-speaking parents (n = 192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension. Medication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41%–87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio 3.6; 95% confidence interval 2.9–4.7) and low health literacy (adjusted odds ratio 1.9; 1.3–2.6) were associated with overestimation of comprehension. Parental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the long term trends of lower limb amputation and revascularisation in Hungary over 14 years. This was a retrospective cohort study that included all patients who underwent lower limb amputation or revascularisation over a 14 year period (2004–2017) in Hungary. Inpatient administrative data claims covering the entire beneficiary population were incorporated. Lower limb amputations (both minor and major) and revascularisation procedures (both open and endovascular) were identified in the claims files. Incidence rates were calculated and time trends were assessed via a generalised additive model. From 2004 to 2017, a total of 121 351 lower limb amputations (61 154 minor; 60 197 major) and 149 355 revascularisation procedures (89 243 open; 60 112 endovascular) were detected in 140 581 patients. The number of minor amputations decreased moderately in the last few years of the study period, while major amputations showed a slight decline (15%) beginning after 2013, which was more marked (22%) following adjustment for age. While the crude incidence of open vascular surgery procedures decreased by 31% (from 74.5/105 to 51.4/105), endovascular procedures showed growth by 79% (from 33.7/105 to 60.4/105) over the whole observation period. Observed amputation and revascularisation trends in Hungary are similar to the international experience. The major difference is a more than one decade lag in the starting point of the decline of amputations and in the move towards endovascular procedures. The number of amputations is more than twofold higher and the number of revascularisations is close to half that reported internationally. This comprehensive report of two vascular care performance indicators reveals an east/west vascular health divide in Europe and indicates the need to improve amputation prevention. [ABSTRACT FROM AUTHOR]

Adipose-derived stem/progenitor cells (ADSPCs) are under investigation in many clinical applications for their regenerative potential in a variety of autoimmune, degenerative, and inflammatory diseases. Adipose tissue, which is mainly harvested by manual liposuction, is the main source of these ADSPCs. In the past years, a variety of different liposuction devices have been commercialized. To ensure a high quality of obtained ADSPCs, it is crucial to show the advantages and disadvantages of frequently used liposuction methods. For this reason, the objective of this study was to compare ADSPCs harvested by either the suction-assisted LipiVage200-5 or the water-assisted Body-Jet system. The proliferation potential of ADSPCs, harvested from 20 patients, was assessed by cumulative population doublings (cumPD), population doubling time (PDT), colony-forming units (CFU), and cell metabolism assays. To prove the multipotency of the primary isolated cells, ADSPCs were induced to differentiate into adipogenic, osteogenic, and chondrogenic lineages. Our data show a significantly higher cumPD, as well as a significantly lower PDT for cells obtained by the Body-Jet system. No significant differences were found regarding the CFU efficiency and the cell metabolism. Furthermore, we showed that the adipogenic, osteogenic, and chondrogenic potential of ADSPCs is similar in both groups. In our study, we provide evidence that the cell characteristics and the functional properties of ADSPCs isolated after liposuction with different techniques are largely similar. However, we observed a significantly higher cumPD and a slightly higher adipogenic potential in cells isolated after liposuction with the Body-Jet system. Different cannula sizes and sheer stresses in the used methods might play a role here. [ABSTRACT FROM AUTHOR]

• Different types of neighborhood design support different physical activities. • Neighborhood design was associated with participation in physical activity but not with the volume of physical activity undertaken. • Compared with curvilinear neighborhoods, neighborhoods with grid street patterns were more likely to have their adult residents undertake transportation walking and cycling, leisure cycling, active transportation, and vigorous-intensity physical activity. • Compared with curvilinear neighborhoods, neighborhoods with warped-grid street patterns were more likely to have their adult residents undertake transportation cycling, active transportation, and vigorous-intensity physical activity. • After statistical adjustment for reasons of residential choice and other sociodemographic characteristics, neighborhood design was associated with physical activity. Cross-sectional studies provide useful insight about the associations between the built environment and physical activity (PA), particularly when reasons for neighborhood choice are considered. Our study analyzed the relationship between levels of weekly transportation and leisure PA among 3 neighborhood designs, statistically adjusting for sociodemographic characteristics and reasons for neighborhood choice. A stratified random sample of adults (age ≥20 years) living in Calgary (Canada) neighborhoods with different neighborhood designs (grid, warped-grid, and curvilinear) and socioeconomic status completed a self-administered questionnaire capturing PA, sociodemographic characteristics, and reasons for neighborhood choice (response rate = 10.1%; n = 1023). Generalized linear models estimated associations between neighborhood design and transportation and leisure PA outcomes (participation (any vs. none) and volume (metabolic equivalent: h/week)), adjusting for neighborhood socioeconomic status, sociodemographic characteristics (gender, age, ethnicity, education, household income, marital status, children, vehicle access, dog ownership, and injury), and reasons for neighborhood choice (e.g., proximity and quality of recreational and utilitarian destinations, proximity to work, highway access, aesthetics, and sense of community). Overall, 854 participants had resided in their neighborhood for at least 12 months and provided complete data. Compared with those living in curvilinear neighborhoods, grid neighborhood participants had greater odds (p < 0.05) of participating in any transportation walking (odds ratio (OR) = 2.17), transportation and leisure cycling (OR = 2.39 and OR = 1.70), active transportation (OR = 2.16), and high-intensity leisure PA (≥6 metabolic equivalent; OR = 1.74), respectively. There were no neighborhood differences in the volume of any transportation or leisure PA undertaken. Adjustment for neighborhood selection had minimal impact on the statistical or practical importance of model estimates. Neighborhood design is associated with PA patterns in adults, independent of reasons for neighborhood choice and sociodemographic factors. Image, graphical abstract [ABSTRACT FROM AUTHOR]

[Display omitted] This study mainly intended to identify changes in the thermal conductivity of distilled water (DW) because of the addition of Zirconium oxide (ZrO 2) and Silicon carbide (SiC) nanoparticles. Keeping this in view, the study considered hybrid nanofluid samples developed with the help of ZrO 2 (dp: 20 nm)-SiC (dp: 45––60 nm) nanoparticles. Initially, the research involved conducting XRD, TEM, EDX and FESEM tests which allowed for conducting phase and structural analysis and also facilitated the study of nanoparticles' microstructure. In the next step, a magnetic stirrer and ultrasonic vibrator were used in sequential steps for dispersing and homogenizing Nanomaterials in distilled water. The volume concentration (φ) was kept between 0.025 and 0.1 % during the synthesis of samples. Then the samples were checked to evaluate their thermal conductivity through the transient hot wire method. In this way, the thermal conductivity of all samples was evaluated for temperatures between 20 and 60 °C. The results indicated a positive association of the thermal conductivity of nanofluid with parameters like temperature and solid volume fraction. It was noted that ZrO 2 -SiC/DW hybrid nanofluid depicted a nearly 25.75 % increase in thermal conductivity at a 0.1 % volume fraction of nanoparticles and a temperature of 60 °C. The value of the thermal conductivity ratio of ZrO 2 -SiC/DW was determined using the proposed mathematical correlation. The fitting method was applied to experimental data which depicted the R-Square value of 0.9906 which is considerably high. It was found that the proposed equation gave an acceptable value of the maximum margin of deviation (i.e.,1.15 %). [ABSTRACT FROM AUTHOR]

Growing extraction and usage of rare earth elements and yttrium (REY) for medical and industrial applications has resulted in increased discharges into the marine environment. Using Mytilus spp. Mussels and Tapes spp. clams as bioindicator organisms, we analyzed 15 REY in soft tissues of specimens collected at two potentially polluted sites in Southern Norway: in the vicinity of an industry producing gadolinium-based MRI contrast agents (GBCAs) (Lindesnes) and in an industrially-affected fjord (Porsgrunn). The spatial distribution of REY and shale-normalized fractionation patterns were determined to assess the potential anthropogenic contribution of REY at the sites. At both sites, the REY fractionation pattern in soft tissue was characterized by enrichment of light rare earth elements (LREE) over heavy rare earth elements (HREE), while also displaying negative cerium and small positive gadolinium (Gd) anomalies. LREEs contributed to over 80% of the total REY concentrations, with increasing relative enrichment following higher total REY. Gd anomalies remained conserved in most sites despite significant differences in total REY; however, a high Gd anomaly (Gd/Gd* = 4.4) was found downstream of the GBCA industry spillwater outlet, indicating biotic uptake of excess anthropogenic Gd at this site. Total REY concentrations in clams in Porsgrunn were one order of magnitude higher than in mussels in Lindesnes. This may be attributable to freshwater influences in Porsgrunn, where clams collected closer to the river mouth had significantly higher total REY concentrations. This study constitutes the first assessment of REY concentrations in marine bivalves in Norway and can provide useful information for future biomonitoring studies on REY contamination. [Display omitted] • Rare earth elements were measured in marine bivalves at two potential release hot spots in Norway. • Mytilus spp. downstream a Gd-based contrast agent producing industry outfall accumulated Gd. • Tapes spp. had high levels of rare earth elements in a freshwater influenced industrial area. • Normalized patterns showed light rare earth element enrichment, negative Ce- and positive Gd anomalies. [ABSTRACT FROM AUTHOR]

We present a case of a patient who suffered subarachnoid haemorrhage (SAH), complicated by takotsubo syndrome, paroxysmal atrial fibrillation and ECG repolarisation abnormality, compatible with Brugada phenocopy. The early repolarisation morphology showed a paradox association with the cardiac cycle length; a relationship not yet documented in SAH. Our observation also sheds light on the genesis of the "spiked helmet" ECG sign. [ABSTRACT FROM AUTHOR]

Indication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging. In this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers. Clinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed. There were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)]. Optimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes. [ABSTRACT FROM AUTHOR]