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Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS. [ABSTRACT FROM AUTHOR]

Lithium (Li), a widely used drug for bipolar disorder management, is associated with many side effects due to systemic exposure. The localized delivery of lithium through implants could be an approach to overcome this challenge, for which biodegradable magnesium (Mg)-based materials are a promising choice. In this study, we focus on Mg-Li thin film alloys as potential Li-releasing implants. Therefore, we investigated the in vitro short-term corrosion behavior and cytocompatibility of two alloys, Mg-1.6wt%Li and Mg-9.5wt%Li. As glial cells are the key players of foreign body responses to implants, we used human glial cell lines for cytocompatibility studies, and a murine brain slice model for a more holistic view at the neuroinflammatory response. We found that Mg-1.6wt%Li corrodes approximately six times slower than Mg-9.5wt%Li. Microscopic analysis showed that the material surface (Mg-1.6wt%Li) is suitable for cell adhesion. The cytocompatibility test with Mg-1.6wt%Li and Mg-9.5wt%Li alloy extracts revealed that both cell types proliferated well up to 10 mM Mg concentration, irrespective of the Li concentration. In the murine brain slice model, Mg-1.6wt%Li and Mg-9.5wt%Li alloy extracts did not provoke a significant upregulation of glial inflammatory/ reactivity markers (IL-1β, IL-6, FN1, TNC) after 24 h of exposure. Furthermore, the gene expression of IL-1β (up to 3-fold) and IL-6 (up to 16-fold) were significantly downregulated after 96 h, and IL-6 downregulation showed a Li concentration dependency. Together, these results indicate the acute cytocompatibility of two Mg-Li thin film alloys and provide basis for future studies to explore promising applications of the material. We propose the idea of lithium delivery to the brain via biodegradable implants to reduce systemic side effects of lithium for bipolar disorder therapy and other neurological applications. This is the first in vitro study investigating Mg-xLi thin film degradation under physiological conditions and its influence on cellular responses such as proliferation, viability, morphology and inflammation. Utilizing human brain-derived cell lines, we showed that the material surface of such a thin film alloy is suitable for normal cell attachment. Using murine brain slices, which comprise a multicellular network, we demonstrated that the material extracts did not elicit a pro-inflammatory response. These results substantiate that degradable Mg-Li materials are biocompatible and support the further investigation of their potential as neurological implants. [Display omitted] [ABSTRACT FROM AUTHOR]

High reactivity to psychosocial stress during childhood increases the risk of future psychological and physiological disorders. The main objective of this study was to investigate associations between children's moderate-to-vigorous physical activity (MVPA) and physiological and psychological reactions to acute psychosocial stress. Randomized cross-over study comparing two groups. After a 7-day accelerometer-based measurement of MVPA, 110 children aged 10–13 years (48 female) were categorized into a low (< 30 min/d) or a high MVPA group (> 60 min/d). On separate laboratory appointments, participants completed the Trier Social Stress Test for Children (TSST-C) and a non-stressful control task in randomized order. Stress reactivity was assessed from saliva cortisol, heart rate variability and self-reported anxiety. In repeated measures analyses of variance, main effects of condition indicated higher stress reactivity in the TSST-C compared to control for cortisol and anxiety, with more pronounced effects in girls compared to boys. Differences in heart rate variability disappeared after controlling for confounding variables. No interactions with MVPA were found. A main effect of MVPA indicated generally lower cortisol reactivity in the high compared to the low MVPA group. The TSST-C is suitable for induction of psychosocial stress in the laboratory, but sex-specific differences have to be considered. Children who met the WHO recommendations for MVPA exhibited generally lower endocrine reactivity to both laboratory tasks combined, underlining the potential role of regular physical activity in the regulation of the stress response in early developmental stages. Further studies are necessary to ascertain causal associations. [ABSTRACT FROM AUTHOR]

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis. [ABSTRACT FROM AUTHOR]

Transcranial direct current stimulation (tDCS) has been used for over twenty years to modulate cortical (particularly motor corticospinal) excitability both during (online) and outlasting (offline) the stimulation, with the former effects associated to the latter. However, tDCS effects are highly variable, partially because stimulation intensity is commonly not adjusted individually (in contrast to transcranial magnetic stimulation, TMS). In Experiment 1, we therefore explored an empirical approach of personalizing tDCS intensity for the primary motor cortex (M1) based on dose-response curves (DRCs), individually relating tDCS Intensity (in steps from 0.3 to 2.0 mA) and Polarity (anodal, cathodal) to the online modulation of concurrent TMS motor evoked potentials (MEP), assessing DRC reliability across two separate days. No robust DRCs could be observed, neither at the individual nor at the group level, with the only robust effect being a (paradoxical) MEP facilitation during cathodal tDCS at 2.0 mA, but no modulation at traditional intensities of or near 1 mA. In Experiment 2, we therefore attempted to replicate the classical bidirectional online MEP modulation during 1 mA tDCS that had been reported by several of the early seminal tDCS papers. We either closely recreated stimulation parameters and temporal protocol of these original studies (Experiment 2A) or slightly modernized them according to current standards (Experiment 2B). In neither experiment did we observed any significant online MEP modulation. We conclude that an empirical titration of individually effective tDCS intensities may not be feasible as online tDCS effects do not appear to be sufficiently robust. • tDCS effects suffer from high variability, also due to lack of intensity adjustment. • Aim: personalize tDCS intensity based on the online modulation of TMS-evoked MEPs. • Exp. 1: MEPs during anodal/cathodal tDCS of M1 at 6 intensities up to 2.0 mA. • Exp. 2: MEPs during anodal/cathodal tDCS of M1 at standard intensity of 1 mA. • No reproducible online tDCS effects, questioning empirical intensity adjustment. [ABSTRACT FROM AUTHOR]

Maternal diet during pregnancy is a modifiable behaviour which plays an important role in maternal, neonatal and child health outcomes. Thus, knowledge of predictors of dietary quality and dietary inflammatory potential in European countries may contribute to developing maternal diet-related public health policies that target specific at-risk populations in Europe. We used harmonised data from >26,000 pregnant women enrolled in the ALSPAC, EDEN, Generation R, Lifeways, REPRO_PL, ROLO and SWS cohorts, as part of the ALPHABET consortium. Maternal dietary quality and inflammatory potential were assessed using the Dietary Approaches to Stop Hypertension (DASH) and the energy-adjusted Dietary Inflammatory Index (E-DII). We conducted an individual participant data meta-analysis to investigate the maternal sociodemographic, health and behavioural predictors of maternal diet before and during pregnancy. DASH and E-DII scores were moderately correlated: from −0.63 (95% CI: −0.66, −0.59) to −0.48 (95% CI: −0.49, −0.47) across cohorts. Higher maternal age, education, household income, and physical activity during pregnancy were associated with a better dietary quality and a more anti-inflammatory diet. Conversely, multiparity and smoking during pregnancy were associated with a poorer dietary quality and a more proinflammatory diet. Women with obesity had a poorer pregnancy dietary quality than women with a normal body mass index range. The results will help identify population subgroups who may benefit from targeted public health strategies and interventions aimed at improving women's dietary quality during pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death. Methods: We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID. Results: Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3. Conclusions: Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts. [ABSTRACT FROM AUTHOR]

The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high-risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace and/or none), mild (1), moderate (2) or moderate to severe (3-4). The patients were 74 ± 7.8 years old. 65% of the patients were male. Mean cardiopulmonary bypass time was 115 ± 37 minutes and mean cross-clamp time was 71 ± 23 minutes. There was a significant improvement in preoperative vs postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); P = 0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months' (range 3 - 19 months') and in 16 patients at a median of 34 months' postoperatively (range 21 - 53 months') showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months' were 88% and 81% respectively. Mitral valve reoperation was conducted in 1 patient (2%), who was suffering of endocarditis. Stroke occurred in 2 patients (7%). Cardiac arrhythmia was observed in 15 patients (35%). 8 patients (19%) suffered from atrial fibrillation and 7 patients (16%) displayed atrioventricular blockage. 10 patients (23%) could be treated conservatively and 5 patients (12%) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high-risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66% of them could be treated successfully by conservative procedures. [ABSTRACT FROM AUTHOR]

In patients who have hip fractures, treatment within 24 hours reduces mortality and complication rates. A similar relationship can be assumed for patients who have hip periprosthetic femoral fractures (PPFs) owing to the similar baseline characteristics of the patient populations. This monocentric retrospective study aimed to compare the complication and mortality rates in patients who had hip PPF treated within and after 24 hours. In total, 350 consecutive patients who had hip PPF in a maximum-care arthroplasty and trauma center between 2006 and 2020 were retrospectively evaluated. The cases were divided into 2 groups using a time to surgery (TTS) of 24 hours as the cutoff value. The primary outcome variables were operative and general complications as well as mortalities within 1 year. Overall, the mean TTS was 1.4 days, and the 1-year mortality was 14.6%. The TTS ≤ 24 hours (n = 166) and TTS > 24 hours (n = 184) groups were comparable in terms of baseline characteristics and comorbidities. Surgical complications were equally frequent in the 2 groups (16.3 versus 15.2%, P =.883). General complications occurred significantly more often in the late patient care group (11.4 versus 28.3%, P <.001). In addition, the 30-day mortality (0.6 versus 5.5%, P =.012), and 1-year mortality (8.3 versus 20.5%, P =.003) rates significantly increased in patients who had TTS > 24 hours. Cox regression analysis yielded a hazard ratio of 4.385 (P <.001) for the TTS > 24 hours group. Prompt treatment is required for patients who have hip PPF to reduce mortality and overall complications. [ABSTRACT FROM AUTHOR]

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis. [ABSTRACT FROM AUTHOR]

The duration of extracorporeal membrane oxygenation (ECMO) has been historically confined in many centers to two weeks. We evaluated the cost-effectiveness of additional weeks on ECMO beyond two weeks for newborns with congenital diaphragmatic hernia (CDH) who may require longer stays to maximize survival potential. We modeled lifetime outcomes using a decision tree from the US societal perspective. Survival at discharge, probability of long-term sequelae, direct medical costs, indirect costs, and quality-adjusted life years (QALY) for long-term disability were considered. Considering the nature of severity of CDH, we used $200,000 per QALY as the willingness-to-pay threshold in the base case. The lifetime costs per CDH infant generated from staying on ECMO for ≤2 weeks, 2–3 weeks, and >3 weeks are $473,334, $654,771, $1,007,476, respectively (2018 USD), and the total QALYs gained from each treatment arm are 1.83, 3.6, and 5.05. In the base case, the net monetary benefits are −$108,034 for ECMO ≤2 weeks, $64,258 for 2–3 weeks, and $2955 for >3 weeks. In probabilistic simulations, a duration of ≤2 weeks is dominated by a duration of 2–3 weeks in 65.3% of cases and dominated by > 3 weeks in 60.2% of cases. A duration of 2–3 weeks is more cost-effective than >3 weeks in 68.6% of simulations. Our findings suggest that 2–3 weeks of ECMO may be the most cost-effective for CDH infants that are unable to wean off at 2 weeks from the US societal perspective. Regardless of ECMO duration, ECMO use generates positive incremental NMB at WTP of $200,000 if the survival probability is greater than 0.3. Future research must be conducted to evaluate the long-term outcomes and sequelae of CDH patients post-discharge to better inform the clinical decision-making in neonatal intensive care unit. [ABSTRACT FROM AUTHOR]

Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation. [ABSTRACT FROM AUTHOR]

Advances in the molecular epidemiological studies of the Human Immunodeficiency Virus (HIV) at the Robert Koch Institute (RKI) by laboratory and bioinformatic automation should allow the processing of larger numbers of samples and more comprehensive and faster data analysis in order to provide a higher resolution of the current HIV infection situation in near real-time and a better understanding of the dynamic of the German HIV epidemic. The early detection of the emergence and transmission of new HIV variants is important for the adaption of diagnostics and treatment guidelines. Likewise, the molecular epidemiological detection and characterization of spatially limited HIV outbreaks or rapidly growing sub-epidemics is of great importance in order to interrupt the transmission pathways by regionally adapting prevention strategies. These aims are becoming even more important in the context of the SARS-CoV2 pandemic and the Ukrainian refugee movement, which both have effects on the German HIV epidemic that should be monitored to identify starting points for targeted public health measures in a timely manner. To this end, a next level integrated genomic surveillance of HIV is to be established. [ABSTRACT FROM AUTHOR]

Irreversible, end-stage biventricular heart failure is associated with mortality rates of up to 100%. Despite the increasing application of ventricular assist devices (VADs), many centers lack experience with total artificial heart (TAH) implantation techniques. We present a surgical technique consisting of the implantation of 2 HeartMate 3 VADs in the setting of a TAH as a bridge to transplantation strategy. [ABSTRACT FROM AUTHOR]

This review comprises 2 main subjects: the percutaneous and surgical closure of the left atrial appendage (LAA) and atrial septal defect (ASD). The aim of the authors was to provide a detailed description of: 1) anatomy of LAA, normal interatrial septum, and the various types of ASD as revealed by noninvasive imaging techniques; 2) preprocedure planning of secundum ASD and LAA percutaneous closure; 3) key steps of the procedural guidance emphasizing the role of 2-dimensional/3-dimensional transesophageal echocardiography; and 4) surgical closure of LAA and ASD. • Imaging is of fundamental relevance for LAA and ASD percutaneous and surgical closure. • Key elements for LAA closure include anatomic characterization, ruling out thrombus, measurements of orifice, and depth. • Key elements for ASD closure include assessment of type, size, rims, and hemodynamic consequences. [ABSTRACT FROM AUTHOR]

With increasing publications, it's hard to keep up with surgical literature. Social media is a valuable educational resource with global reach. We sought to analyze the impact of an automated social media strategy for the Journal of Pediatric Surgery (JPS). Analytics for March–August 2019 were retrospectively reviewed for automated posts using a SocialPilot queue from the journal's RSS feed. Descriptive and inferential statistics were utilized to analyze performance, including journal article views. One hundred sixty-five posts amassed 512,316 impressions and 9,795 article views. Facebook had greater overall impact (p < 0.01). Twitter was stronger when adjusted by number of followers (p < 0.01). Engagements and article views had strong correlation between platforms (p < 0.01). Day of the week had limited impact. Photographs were the preferred content format (p < 0.05). Topic had the highest effect on performance (p < 0.05) – with colorectal, EA/TEF, and general pediatric surgery leading to higher reach and engagement. ECMO/CDH was the least popular. Comments and shares were negligible. We reached 3,105 users, with 59 article views per post. Topic had the strongest effect on performance. For comparison, custom infographics reached 7,368 users and averaged 101 article views. Alternative knowledge dissemination strategies are likely needed to foster online discussion and build more robust forums for collaboration. Retrospective, Non-clinical Study. Level III. [ABSTRACT FROM AUTHOR]

Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%–6.3%). We evaluated adolescent patients (12–18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications. A total of 144 patients were enrolled. One hospital (n = 9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41–412.90, p < 0.01) and braided suture (OR 12.10, CI 1.54–95.25, p = 0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results. Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons. Prognosis study (retrospective study) Level II [ABSTRACT FROM AUTHOR]

In this study we examined what are the markers of immigrant naturalisation as seen from the perspectives of recipient nationals. Social markers are perceptual signposts that receiving nationals use in deciding whether a non-native born is a member of the destination country. In short, what should immigrants do in order to be accepted by receiving nationals as "one of us". Cross national data on 20 indicators of "everyday nationhood" were collected from five countries – Singapore, Japan, Australia, Finland, and Canada. The markers highlight common dispositions, activities, or social norms that are associated with citizenship. Exploratory factor analysis in each sample consistently demonstrated a two-factor structure model that supports the contemporary ethnic-civic distinction, but the markers that make up each of the two dimensions vary between countries. No metric equivalence was found, and that the markers have culture-specific meanings. The framework offers a novel insight to intercultural relations. The results suggest that adaptation and social inclusion need to consider the norms and values practised in the recipient society, and how immigration may redefine intergroup boundaries. [ABSTRACT FROM AUTHOR]

Nearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers. The study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC3) and Pediatric Cardiac Critical Care Consortium (PC4) centers. Clinical data from PC4 centers were merged with chest tube data from PAC3 centers. Practices and outcomes were compared across centers in univariate and multivariable analysis. The cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤.03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P <.0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P <.001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P =.59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P =.31), and had the shortest length of stay for 7 of 10 operations. This study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay. [ABSTRACT FROM AUTHOR]

Objectives: To assess clinically asymptomatic infants with single-ventricle physiology (SVP) for sleep-disordered breathing (SDB) in the supine and car seat positions using polysomnography. Polysomnography results also were compared with results of a standard Car Seat Challenge to measure the dependability of the standard Car Seat Challenge.Study Design: This was an observational study of 15 infants with SVP. Polysomnography data included Obstructive Index, Central Index, Arousal Index, Apnea Hypopnea Index, and sleep efficiency. Polysomnography heart rate and oxygen saturation data were used to compare polysomnography with the standard Car Seat Challenge.Results: Polysomnography demonstrated that all 15 infants had SDB and 14 had obstructive sleep apnea (Obstructive Index ≥1/hour) in both the supine and car seat positions. Infants with SVP had a statistically significant greater median Obstructive Index in the car seat compared with supine position (6.3 vs 4.2; P = .03), and median spontaneous Arousal Index was greater in the supine position compared with the car seat (20.4 vs 15.2; P = .01). Comparison of polysomnography to standard Car Seat Challenge results demonstrated 5 of 15 (33%) of infants with SVP with abnormal Obstructive Index by polysomnography would have passed a standard Car Seat Challenge.Conclusions: Infants with SVP without clinical symptoms of SDB may be at high risk for SDB that appears worse in the car seat position. The standard Car Seat Challenge is not dependable in the identification of infants with SVP and SDB. Further studies are warranted to further delineate its potential impact of SDB on the clinical outcomes of infants with SVP. [ABSTRACT FROM AUTHOR]

Background: Ingenol mebutate (IngMeb) 0.015% or 0.05% is approved for actinic keratosis (AK) areas of 25 cm2 or less; some patients require treatment of larger fields.Objective: To determine efficacy and safety of IngMeb 0.027% in areas of AK of up to 250 cm2 during an 8-week initial assessment period and extended 12-month follow-up.Methods: This phase 3, randomized, double-blind, vehicle-controlled trial (NCT02361216) enrolled adult patients with 5 to 20 AK lesions on the face/scalp (25-250 cm2) or chest (approximately 250 cm2). Patients received once-daily IngMeb or vehicle for 3 consecutive days on the full face, full balding scalp, or approximately 250 cm2 on the chest. The primary endpoint was complete AK clearance (AKCLEAR 100; week 8). Additional endpoints included partial AK clearance (AKCLEAR 75), recurrence, patient satisfaction, cosmetic outcome, and safety.Results: IngMeb was superior to vehicle for complete AK clearance (21.4% vs 3.4%, P < .001) and AK clearance of 75% or greater (59.4% vs 8.9%, P < .001) at week 8. Probability of sustained clearance during the 12-month follow-up was 22.9% for patients treated with IngMeb. Increased treatment satisfaction and cosmetic outcomes were observed with IngMeb versus vehicle. No unexpected safety signals were identified.Limitations: Localized skin responses hindered maintenance of double-blinding.Conclusions: IngMeb 0.027% was superior to vehicle for treatment of AK areas of up to 250 cm2. The safety profile of IngMeb was as expected. [ABSTRACT FROM AUTHOR]

Academic medicine is experiencing an exponential increase in knowledge, evidenced by approximately 2.5 million new articles published each year. As a result, staying apprised of practice-changing findings as a busy clinician is nearly impossible. The traditional methods of staying up to date through reading textbooks and journal articles or attending an annual conference are no longer enough. These old approaches do not distribute knowledge equally around the world or inform practitioners adequately of what they need to provide the best patient care. Luckily, digital technology, which contributed to our ability to generate this explosion in research, also holds the solution. We believe the improved filtration and curation of new knowledge will come through the combination of three elements: machine learning, crowd-sourcing, and new digital platforms. Machine learning can be harnessed to identify high-quality research while avoiding unconscious bias towards authors, institutions, or positions, and to create personalized reading lists that encompass essential articles while also addressing personal knowledge gaps. The crowd can also serve to curate the best research through an open-source platform that exposes each step of the research process, from developing questions through discussion of findings, functionally replacing editorial boards with crowd peer-review. Finally, embracing new digital platforms and multimedia delivery formats will move academic medicine into the 21st century, broadening its reach to diverse, international, and multigenerational learners. The digital age will continue to change life as we know it, but we have the power – and the responsibility – to control how it transforms academic medicine. V (Expert). [ABSTRACT FROM AUTHOR]

Bronchoscopy is the standard of care for diagnosis and treatment of foreign body aspiration (FBA). Drawbacks of this approach include its invasiveness, the potential for exacerbation of reactive airway disease, and the need for general anesthesia. Computed tomography (CT) can potentially identify patients with FBA, thereby avoiding unnecessary bronchoscopies in patients with at-risk reactive airways. A retrospective review was performed to identify patients who underwent CT and/or bronchoscopy for suspected foreign body aspiration (FBA) from June 2012 to September 2018. Variables included clinical history, exam findings, radiographic findings, and operative findings. A telephone survey was performed for patients who had a CT without bronchoscopy. Three radiologists performed rereads of all CTs. A total of 133 patients were evaluated for FBA, and 84 were treated with bronchoscopy. For those with a CT demonstrating a foreign body, findings were confirmed on bronchoscopy in 17/18 (94.4%). For those with bronchoscopy alone, 39/64 (60.9%) were found to have a foreign body (p < 0.01). CT excluded FBA in 49 patients. Sensitivity was 100%, specificity was 98%, and interobserver reliability was excellent (κ = 0.88). CT is an accurate and reliable diagnostic tool in the evaluation of FBA that can increase the rate of positive bronchoscopy. Retrospective comparative study. Level III. [ABSTRACT FROM AUTHOR]

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Graphical abstract Highlights • One step process to extract particles from leaves. • Antioxidant activity of leaves is associated to their ascorbic acid and polyphenols contents. • Concentration of the extract is a key parameter for a successful antisolvent precipitation. • Pressure had the strongest effect on particle size in antisolvent process. Abstract An extensive study has been carried out where CO 2 has been used both as solvent and antisolvent to appreciate orange leaves as a source of powerful antioxidant nanoparticles. In the former case, the leaves were processed directly to yield particles in the nano or micrometer range. In the latter case, a conventional ethanolic extraction of orange leaves was carried out before the orange leaves were subjected to supercritical conditions to extract the particles with high antioxidant activity. Thus, different pressure (80–300 bar), temperature (40–100 °C) and liquid extract concentration (10–42 mg/mL) levels were studied. When CO 2 was used as the solvent, agglomerates with low antioxidant activity precipitated. Higher pressure and temperature levels were required to obtain powder precipitation. However, when CO 2 was used as the antisolvent, polyphenols with high antioxidant activity (3–4.65) in the nanometer range (60–73 nm) would precipitate. The efficiency of the process was determined by the antioxidant compound concentration ratio of the extract. Vessel pressure was the main influencing variable with regards to impact on particle size and antioxidant activity. The smallest particle size and greatest precipitate yields were obtained at high pressure and low temperature. [ABSTRACT FROM AUTHOR]

Abstract Acculturation of short-term international sojourners, such as expats and international students, has received considerable attention from scholars in the past decades. Acculturation is commonly defined as the interplay between cultural maintenance, the sojourner's desire to maintain their home culture identity, and host country participation, their desire to initiate contact with members of the host society. The present paper focuses on the role that Social Network Sites (SNS) play in the acculturation process of this group. Through a survey, we examined how 126 short-term sojourners in the Netherlands use SNS to interact with relations in both home and host country, and how this affects their cultural maintenance and host country participation. Furthermore, we examined psychological alienation and online social support as possible mediators. Our results show that on the one hand SNS contact with home country relations is positively related to online social support. On the other hand, it is also related to psychological alienation, which in turn is related to cultural maintenance. This shows that sojourners who keep in touch with friends and family at home also experience more loneliness and homesickness, and place more emphasis on their own cultural heritage. Finally, we found that SNS contact with host country relations predicts host country participation. Through online activities, sojourners are able to foster social interaction and strengthen friendships with locals. [ABSTRACT FROM AUTHOR]

Abstract We explored unsupervised machine learning algorithms, specifically graph analytics, applied to behaviors observed in heterogeneous network sensor data for discovering anomalous behavior that could include novel attacks. In addition, we explored the potential difficulties with applying unsupervised machine learning approaches to anomaly detection in a network-defense context to understand how to integrate inherently imperfect anomaly-detection approaches into the workflow of a cyber defense infrastructure. Two general approaches can be used to discover anomalies: (1.) detecting rarity, i.e. , finding those activities that are observed the least frequently in a set of observations, and (2.) detecting novelty, i.e. , finding activities with the lowest estimated probability of observation based on prior observations of baseline (presumably "normal") data. This effort will describe the case of detecting rarity. In this paper, we describe the entire pipeline starting from explaining the data used, the data ingest, the quantization of features, application of graph analytics to the data, post-processing to reduce results, and measuring the performance. A network-penetration experiment was setup to conduct the network attacks and generate the data that is the input to this work. Baseline methods are proposed and compared to the main method that is described in this paper. [ABSTRACT FROM AUTHOR]

Background The HeartMate 3 (HM3; Abbott Laboratories, Lake Forest, Ill) left ventricular assist device (LVAD) received its Conformité Européenne mark for Europe in October 2015 and is currently under investigation of the Food and Drug Administration to gain approval in the United States. Within this study, we present the first real-world experiences, 1-year outcomes, and adverse events of a single-center cohort treated with the HM3. Methods We prospectively studied midterm results of 27 consecutive patients receiving the HM3 at a single institution. After HM 3 implantation, survival, causes of death, and complications were recorded for all patients. Follow up was 100% complete. Results Twenty-seven patients were enrolled into the study. Within 1 year after HM3 implantation, 3 patients underwent heart transplantation and 3 patients died. Thirty-day survival was 88.9%, 6-month 85.2%, and 1-year survival 85.2%. No pump thrombosis and no strokes were observed within the study group. One incident of gastrointestinal bleeding was observed (3.7%). Right heart failure was diagnosed in 1 patient after HM3 implantation (3.7%). No technical complications of the pump were documented. No pump exchanges were necessary. The main complication was LVAD-related infection (22.2%). Conclusions The novel LVAD HM3 has already shown excellent Conformité Européenne mark trial results. Within this cohort, 1-year survival after HM3 implantation was 85%. The HM3 showed excellent midterm results with 0% stroke and 0% pump thrombosis rates 1 year after implantation. [ABSTRACT FROM AUTHOR]

Despite great advances in technology and medical care, device infection and pump thrombosis remain major difficulties in the therapy with left ventricular assist devices. When medical treatment fails, operative left ventricular assist devices exchange is the only curative option. We present a step by step guide to the conventional exchange procedure via lateral thoracotomy as well as a guide to the exchange from an older to a new generation device. [ABSTRACT FROM AUTHOR]

For several years, the standard implantation strategy of ventricular assist devices has involved a full sternotomy approach. However, less invasive implantation techniques are now becoming increasingly popular as they are associated with reduction of trauma, blood loss, and arrhythmogenic complications, as well as a decreased duration of intensive care unit and in-hospital stay. Thus, due to miniaturization and increasing technical improvement of ventricular assist devices, less invasive strategies for implantation, explantation, exchange, and concomitant cardiac procedures are on the rise. In this review article, we report on the state of the art of less invasive techniques for implantation, explantation, exchange, and combined cardiac procedures of ventricular assist devices. [ABSTRACT FROM AUTHOR]

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Background The novel HeartMate 3 (HM3) left ventricular assist device (LVAD) received its CE mark in October 2015. It is a new compact LVAD featuring fully magnetically levitated pump, artificial pulse, large pump gaps, and a modular driveline. Here, we present outcomes and adverse events of a single-center cohort 6 months after HM3 implantation. Methods We retrospectively studied a patient cohort of 27 patients who were supported with the HM3 at a single institution. We excluded patients with biventricular assist devices and other types of assist devices as well as LVAD exchange and re-operative procedures. Results Twenty-seven patients were enrolled into the study. Within 1 year after HM3 implantation, 1 patient received a heart transplant and 3 patients died. Thirty-day survival was 88.9% and 6 months 85.2%. No pump thrombosis and no strokes were observed within 6 months. Right heart failure was diagnosed in 1 patient after HM3 implantation (3.7%). No technical complications of the pump were documented. No pump exchanges were necessary. Conclusions The novel LVAD HM3 has already shown good CE mark trial results. Within this first report after the CE mark trial, the 6-month survival after HM3 implantation was 85.2%. The HM3 showed excellent midterm results with 0% stroke and 0% pump thrombosis rates 6 months after implantation. [ABSTRACT FROM AUTHOR]

Knowledge about placebo mechanisms in patients with chronic pain is scarce. Fibromyalgia syndrome (FM) is associated with dysfunctions of central pain inhibition, and because placebo analgesia entails activation of endogenous pain inhibition, we hypothesized that long-term exposure to FM pain would negatively affect placebo responses. In our study we examined the placebo group (n = 37, mean age 45 years) from a 12-week, randomized, double-blind, placebo-controlled trial investigating the effects of milnacipran or placebo. Twenty-two patients were classified as placebo nonresponders and 15 as responders, according to the Patient Global Impression of Change scale. Primary outcome was the change in pressure pain sensitivity from baseline to post-treatment. Secondary outcomes included ratings of clinical pain (visual analog scale), FM effect (Fibromyalgia Impact Questionnaire), and pain drawing. Among placebo responders, longer FM duration was associated with smaller reductions in pressure pain sensitivity (r = .689, P = .004), but not among nonresponders (r = -.348, P = .112). In our study we showed that FM duration influences endogenous pain regulation, because pain levels and placebo-induced analgesia were negatively affected. Our results point to the importance of early FM interventions, because endogenous pain regulation may still be harnessed at that early time. Also, placebo-controlled trials should take FM duration into consideration when interpreting results.Perspective: This study presents a novel perspective on placebo analgesia, because placebo responses among patients with chronic pain were analyzed. Long-term exposure to fibromyalgia pain was associated with lower placebo analgesia, and the results show the importance of taking pain duration into account when interpreting the results from placebo-controlled trials. [ABSTRACT FROM AUTHOR]

The effects of extracellular calcium on osteogenic differentiation capacity of human bone-derived mesenchymal stromal cells with special regard to connexin 43 (cx43) have been investigated by means of cell culture experiments. Mesenchymal stromal cells isolated from human cancellous bone were cultured on tissue culture plates at different calcium ion (Ca 2+ ) concentrations (1.8 mmol l −1 , 10 mmol l −1 , 20 mmol l −1 ). Cell responses were evaluated by quantitative RT-PCR, immunofluorescence staining, and Lucifer Yellow fluorescence uptake experiments. It could be shown that increasing Ca 2+ concentrations correlate with increasing cx43 and bone sialoprotein mRNA levels as well as with enhanced cx43 fluorescence signaling and matrix mineralization of the cultures as shown by von Kossa staining. Hemichannel gating – assessed by Lucifer Yellow uptake – increases with increasing extracellular Ca 2+ concentrations suggesting that regulatory effects at the hemichannel level are calcium-dependent. [ABSTRACT FROM AUTHOR]

The ant colony algorithm has good performance in solving small-scale discrete problems, but still has the shortcomings of poor convergence and tendency to fall into local optimum when dealing with large-scale data. In order to solve these problems, we propose a multi-ant colony algorithm based on finite history archiving and the boxed pigs game model. Firstly, the heterogeneous multi-ant colony system is constructed by ant colony system and max–min ant colony system to enrich the diversity of populations. Second, the limited history archiving strategy is used to enhance the path guidance to enable faster convergence. In addition, the co-evolution of populations is achieved by constructing the boxed pigs game model to increase the performance of the algorithm. Finally, the leveling mechanism is used to help the algorithm escape from the local optimum when it stagnates, thereby improving the accuracy of the solution. The effectiveness of the algorithm is verified by testing benchmark instances of traveling salesman problem. The experimental results show that the improved algorithm has significantly improved in terms of convergence and solution accuracy. • A multi-ant colony optimization algorithm is proposed to solve the TSP. • A finite history archiving strategy effectively enhances convergence. • The boxed pigs game model was constructed to improve the accuracy of the algorithm. • The performance of HAGACO is validated by instances of different scales in TSPLIB. • HAGACO has effective competitiveness and robustness relative to other advanced heuristics. [ABSTRACT FROM AUTHOR]

This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured. Competing risks time to event analyses determined the association between these factors and unanticipated interstage readmission. Readmission center variation was examined using funnel plots. Unanticipated interstage readmissions occurred in 66% of 815 patients at 50 centers. The median readmission length of stay was 2 days (interquartile range: 0-6) and median time to first readmission was 29 days (interquartile range: 9-63). Most readmissions were prompted by minor changes in clinical status (64%), whereas only 6% were major adverse event readmissions. Independent readmission risk factors included genetic syndrome (HR = 1.40, 95% CI: 1.05-1.88), center volume (small vs large HR = 1.32, CI: 1.04-1.66, medium vs large HR = 1.35, CI: 1.09-1.68), preoperative ventricular dysfunction (HR = 2.02, CI: 1.31-3.10), tricuspid regurgitation (HR = 1.36, CI: 1.08-1.72), duration of circulatory arrest (HR = 0.99, CI: 0.989-0.998), and undergoing Hybrid procedure relative to Norwood/right ventricle to pulmonary artery conduit (HR = 1.40, CI: 1.02-1.93). There was significant center variation in the number of readmissions and duration of readmissions. Unanticipated readmissions are common during the interstage period with notable center variation. However, these readmissions are short and are rarely in response to major adverse events. [ABSTRACT FROM AUTHOR]

Anthropogenic contaminants reach the marine environment mostly directly from land-based sources, but there are cases in which they are emitted or re-mobilized in the marine environment itself. This paper reviews the literature, with a predominant focus on the European environment, to compile a list of contaminants potentially released into the sea from sea-based sources and provide an overview of their consideration under existing EU regulatory frameworks. The resulting list contains 276 substances and for some of them (22 antifouling biocides, 32 aquaculture medicinal products and 34 warfare agents) concentrations and toxicity data are additionally provided. The EU Marine Strategy Framework Directive Descriptor 8, together with the Water Framework Directive and the Regional Sea Conventions, provides the provisions against pollution of marine waters by chemical substances. This literature review should inform about the current state of knowledge regarding marine contaminant sources and provide support for setting-up of monitoring approaches, including hotspots screening. [ABSTRACT FROM AUTHOR]

A biomimetic strategy was developed in order to prepare organically modified hydroxyapatite (ormoHAP) with spherical shape. The technical approach is based on electric field-assisted migration of calcium ions and phosphate ions into a hydrogel composed of carboxymethylated gelatin. The electric field as well as the carboxymethylation using glucuronic acid (GlcA) significantly accelerates the mineralization process, which makes the process feasible for lab scale production of ormoHAP spheres and probably beyond. A further process was developed for gentle separation of the ormoHAP spheres from the gelatin gel without compromising the morphology of the mineral. The term ormoHAP was chosen since morphological analyses using electron microscopy (SEM, TEM) and element analysis (EDX, FT-IR, XRD) confirmed that carboxymethylated gelatin molecules use to act as organic templates for the formation of nanocrystalline HAP. The hydroxyapatite (HAP) crystals self-organize to form hollow spheres with diameters ranging from 100 to 500 nm. The combination of the biocompatible chemical composition and the unique structure of the nanocomposites is considered to be a useful basis for future applications in functionalized degradable biomaterials. Statement of Significance A novel bioinspired mineralization process was developed based on electric field-assisted migration of calcium and phosphate ions into biochemically carboxymethylated gelatin acting as organic template. Advantages over conventional hydroxyapatite include particle size distribution and homogeneity as well as achievable mechanical properties of relevant composites. Moreover, specifically developed calcium ion or phosphate ion release during degradation can be useful to adjust the fate of bone cells in order to manipulate remodeling processes. The hollow structure of the spheres can be useful for embedding drugs in the core, encapsulated by the highly mineralized outer shell. In this way, controlled drug release could be achieved, which enables advanced strategies for threating bone-related diseases, e.g. osteoporosis and multiple myeloma. [ABSTRACT FROM AUTHOR]

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion. [ABSTRACT FROM AUTHOR]

In recent years, a trend toward a declining proportion of male births has been noted in several, but not all, industrialized countries. The underlying reason for the drop in the sex ratio is unclear, but one theory states that widespread environmental endocrine disrupting chemicals affecting the male reproductive system in a negative manner could be part of the explanation. The present study was designed to investigate whether the urinary phthalate, pyrethroids and polycyclic aromatic hydrocarbons metabolites concentrations were associated with sperm Y:X ratio. The study population consisted of 194 men aged under 45 years of age who attended infertility clinic in Lodz, Poland for diagnostic purposes with normal semen concentration of 20–300 mln/ml or with slight oligozoospermia (semen concentration of 15–20 mln/ml) (WHO, 1999). The Y:X ratio was assessed by fluorescent in situ hybridization. Urinary concentrations of 1-hydroxypyrene were measured by high performance liquid chromatography, phthalate metabolites were analyzed using a procedure based on the LC-MS/MS methods and metabolites of synthetic pyrethroids were assessed by gas chromatography ion-tap mass spectrometry method. After adjustment for potential confounders (past diseases, age, abstinence, smoking, alcohol consumption, sperm concentration, motility, morphology) 5OH MEHP, CDCCA to TDCCA and 1-OHP was negatively related to Y:X sperm chromosome ratio (p = 0.033, p < 0.001, p = 0.047 respectively). As this is the first study to elucidate the association between the level of metabolites of widespread environmental endocrine disrupting chemicals (phthalates, synthetic pyrethroids, polycyclic aromatic hydrocarbons) on sex chromosome ratio in sperm therefore, these findings require further replication in other populations. [ABSTRACT FROM AUTHOR]

The role and the use of left ventricular assist device (VAD) as mechanical circulatory support for the treatment of chronic heart failure has grown enormously in the setting of decreased transplant rates worldwide. This increase in VAD use is based on novel technologies, smaller pump size, and increased surgical expertise. These factors have resulted in minimally invasive surgery becoming the procedure of choice in many centers for left VAD implantation, explantation, and exchange. Less invasive procedures use smaller incisions, produce less blood loss, and result in shorter hospital stays and lower costs. With these techniques, complication rates have decreased, survival rates have increased, and the long-term outcomes have improved significantly. In this article, we describe the minimally invasive “Hannover implantation technique,” which is the procedure of choice in our institution. [ABSTRACT FROM AUTHOR]

Calcium phosphate phases are increasingly used for bone tissue substitution, and the load bearing properties of these inherently brittle biomaterials are increased by inclusion of organic components. Monetite prepared using mineralization of gelatine pre-structured through phosphate leads to a significantly increased biaxial strength and indirect tensile strength compared to gelatine-free monetite. Besides the mechanical properties, degradation in physiological solutions and osteoblast and osteoclast cell response were investigated. Human bone marrow stromal cells (hBMSCs) showed considerably higher proliferation rates on the gelatine modified monetite than on polystyrene reference material in calcium-free as well as standard cell culture medium (α-MEM). Osteogenic differentiation on the material was comparable to polystyrene in both medium types. Osteoclast-like cells derived from monocytes were able to actively resorb the biomaterial. Osteoblastic differentiation and perhaps even more important the cellular resorption of the biomaterial indicate that it can be actively involved in the bone remodeling process. Thus the behavior of osteoblasts and osteoclasts as well as the adequate degradation and mechanical properties are strong indicators for bone biocompatibility, although in vivo studies are still required to prove this. Statement of Significance New and unique? A low temperature precipitationprocessforcalcium anhydrous hydrogen phosphateallows for the first time to produce monolithic compact composites of monetite and gelatine. The composite is degradable and resorbable. To prove that, the question arises: what is bone biocompatibility? The reaction of both mayor cell types of bone represents this biocompatibility. Therefore, human bone marrow stromal cells were seeded revealing the materials pro-osteogenic properties. Monocyte cultivation, becoming recently focus of interest, revealed the capability of the biomaterial to be actively resorbed by derived osteoclast-like cells. Not new but necessary ismechanical characterization, which is often only investigated as uniaxial property. Here, a biaxial method is applied, to characterize the materials properties closer to its application loads. [ABSTRACT FROM AUTHOR]

The Black Sea is a semi-enclosed basin subject to major anthropogenic pressures, including marine litter and plastic pollution. Due to numerous large rivers draining into the basin and a population settled along the coast, the region could accumulate significant amounts of floating litter over time. Until now, only limited field data were available, and litter quantities and distribution remained unknown. In this study, floating marine macro litter (FMML) was assessed at the regional Black Sea scale for the first time, showing relatively high litter densities across the basin that reached a weighted mean of 81.5 items/km2. Monitoring data revealed an accumulation of floating items offshore in the eastern part of the basin, resembling on a small scale a 'garbage patch', where litter items were trapped, showing elevated densities in comparison to their surrounding areas. Most of these items were made of plastic materials (ca. 96%) and included large numbers of plastic and polystyrene fragments of small size ranges (2.5–10 cm). Harmonised field data collection through consistent and regular monitoring programmes across the region is essential to establish baselines and thresholds for large scale assessment at international level. [Display omitted] • There are high densities of floating marine macro litter in the Black Sea basin. • Floating items accumulate offshore in the eastern basin forming a 'garbage patch'. • Plastic materials and large numbers of fragments dominate litter composition. • Harmonised data collection is needed to set baselines for large-scale assessment. [ABSTRACT FROM AUTHOR]

Background Actinic keratosis therapy can elicit unsightly and painful local skin responses; assessment of treatment satisfaction and health-related quality of life (QoL) is important. Ingenol mebutate gel is a novel topical field therapy for actinic keratosis. Objective Post-hoc analyses were performed based on patient-reported outcomes from phase-III trials (n = 1005) to assess the effects of ingenol mebutate on QoL and the relationship between both QoL and treatment satisfaction, and degree of lesion clearance. Methods Patients received ingenol mebutate or vehicle for self-application to a 25-cm 2 contiguous area: 0.015% once daily for 3 consecutive days (face/scalp) or 0.05% once daily for 2 consecutive days (trunk/extremities). QoL (Skindex-16) and Treatment Satisfaction Questionnaire for Medication data were recorded. Results Significant, positive associations between Treatment Satisfaction Questionnaire for Medication score and degree of clearance were identified for patients in the face/scalp (effectiveness P < .0001 and global satisfaction P = .0002) and trunk/extremities ( P < .0001 and P = .0014, respectively) groups. There was a significant association between Skindex-16 score and clearance for patients in the face/scalp group for change in symptoms ( P = .0218), emotions ( P = .0002), and overall Skindex-16 score ( P = .0006) from baseline. Limitations Clinical trial population findings may not be generalizable to clinical practice. Conclusion Ingenol mebutate significantly improved patients' QoL and treatment satisfaction. Improvements were associated with higher degrees of actinic keratosis lesion clearance. [ABSTRACT FROM AUTHOR]