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The detrimental effects of post-mastectomy radiotherapy on breast reconstruction are well known. We report our experience with a delayed-immediate approach involving an initial subcutaneous implant with definitive reconstruction after adjuvant radiotherapy. Patients were identified retrospectively from hospital, theatre and implant registry records. Details regarding demographics, cancer pathology, surgical data and oncological therapies were collected. Primary outcomes included complication rates of first-stage surgery and time to definitive reconstruction. A total of 115 patients underwent mastectomy and temporary subcutaneous implant (36 nipple sparing) between 2008 and 2019. Five were smokers with eleven having a body mass index > 30. The median age was 46 years (27–76 years) and tumour size 50 mm. Almost 95% underwent radiotherapy, 82% chemotherapy and 70% had axillary node clearance. Median mastectomy weight was 464 g (123–1300 g) with median temporary implant volume 375 cc (180–655 cc). Complications of first-stage surgery at three months included 5.2% implant loss (n = 6), 14.8% infection rate, 17.4% readmission rate and 10.4% returned to theatre. Reconstructive failure occurred in four cases (3.5%). A total of 76 patients completed definitive reconstruction, including 26 autologous, 21 latissimus dorsi with implant, and 28 implant-only reconstructions. The median time to reconstruction following the completion of radiotherapy was 12 months. This increased in those who had implant complications (28 vs. 15 months) or radiotherapy (16 vs. 10 months) versus those without. Delayed-immediate breast reconstruction using a temporary subcutaneous implant has been shown to be a safe, feasible and potentially beneficial method than simple mastectomy and delayed reconstruction with a complication rate comparable to that of immediate implant reconstruction. [ABSTRACT FROM AUTHOR]

This work formulates the hazard prediction problem while addressing the research question: Can machine learning create a model to automatically recognize patterns that correspond to hazard state conditions during a mission-critical operation? Supervised learning models were trained and tested on data observed from mission simulators, which allowed for safe observation of dynamic system states and undesirable casualty events. The prediction task was formulated as a binary classification problem, producing the probability of being in a hazard state at time t and providing situational awareness of a possible imminent loss. Several modeling architectures were investigated: neural networks, logistic regression, a support vector machine (SVM), and random forest models. The models were tuned, trained, evaluated using K-fold cross validation, and compared across a range of metrics to assess prediction quality. Computation time for training convergence and propensity for over-fitting were assessed across model architectures. Results showed that hazard states, without pre-specification, are predictable from limited system state data, enabling the possibility for real-time anticipation and loss avoidance. • We formulate the hazard prediction problem to recognize precarious conditions. • Modeling is anchored in an established theoretical framework from safety science. • Hazard state labels are derived using a novel back-labeling algorithm. • Generalizations to robotic surgery, semiconductor manufacturing, transportation, etc. • Machine learning from simulated data for rare and undesirable events is discussed. [ABSTRACT FROM AUTHOR]

Summary Peripheral nerve lesions provoke apoptosis in the dorsal horn of the spinal cord. The cause of cell death, the involvement of neurons, and the relevance for the processing of somatosensory information are controversial. Here, we demonstrate in a mouse model of sciatic nerve injury that glutamate-induced neurodegeneration and loss of γ-aminobutyric acid (GABA)ergic interneurons in the superficial dorsal horn promote the transition from acute to chronic neuropathic pain. Conditional deletion of Grin1 , the essential subunit of N- methyl- d -aspartate-type glutamate receptors (NMDARs), protects dorsal horn neurons from excitotoxicity and preserves GABAergic inhibition. Mice deficient in functional NMDARs exhibit normal nociceptive responses and acute pain after nerve injury, but this initial increase in pain sensitivity is reversible. Eliminating NMDARs fully prevents persistent pain-like behavior. Reduced pain in mice lacking proapoptotic Bax confirmed the significance of neurodegeneration. We conclude that NMDAR-mediated neuron death contributes to the development of chronic neuropathic pain. [ABSTRACT FROM AUTHOR]

Breast cysts are common in the adult female population, but are rarely reported in children. We here report the case of a young adolescent girl presenting with a large breast cyst who required cystectomy to prevent permanent skin damage. We describe the case of a 13 year-old girl presenting with a large solitary breast cyst. Due to its size, the cyst caused a significant and visible bulge leading to a shape change of the breast and an increasing awareness of this change by the patient. Repeated aspirations were undertaken which, however, could not resolve the patient's symptoms permanently. With time, the skin overlying the cyst became increasingly attenuated and thinned. When the skin started to become discoloured, surgery was offered in the form of a cystectomy to prevent permanent skin damage. Following cystectomy, the breast returned to its normal shape and the skin changes improved. Assessment of a patient with an adolescent breast cyst should involve a gynaecological history and a hormone profile in girls reporting menstrual irregularities. Surgery should be reserved for selected patients and only in the late stages of breast development and with consideration of cosmesis with regards to scar placement and blunt dissection supporting skin recovery in patients with evolving skin changes. [ABSTRACT FROM AUTHOR]

Background Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention. Methods All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Children’s Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed. Results A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3). Conclusions CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The importance of the early recognition of shock in patients presenting to emergency departments is well recognized, but at present, there is no agreed practical definition for undifferentiated shock. The main aim of this study was to validate an a priori clinical definition of shock against 28-day mortality. DESIGN, SETTING AND SUBJECTS: This prospective, observational, cross-sectional, single-center study was conducted in Hong Kong, China. Data were collected between July 1, 2012, and January 31, 2013. An a priori definition of shock was designed, whereby patients admitted to the resuscitation room or high dependency area of the emergency department were divided into 1 of 3 groups-no shock, possible shock, and shock. The primary outcome was 28-day mortality. Secondary outcomes were in-hospital mortality or admission to the intensive or coronary care unit. MEASUREMENTS AND MAIN RESULTS: A total of 111 patients (mean age, 67.2 ± 17.1 years; male = 69 [62%]) were recruited, of which 22 were classified as no shock, 54 as possible shock, and 35 as shock. Systolic blood pressure, mean arterial pressure, lactate, and base deficit correlated well with shock classifications (P < .05). Patients who had 3 or more positively defined shock variables had a 100% poor composite outcome rate (5 of 5). Patients with 2 shock variables had a 66.7% (4 of 6) poor composite outcome rate. CONCLUSIONS: A simple, practical definition of undifferentiated shock has been proposed and validated in a group of patients presenting to an emergency department in Hong Kong. This definition needs further validation in a larger population and other settings. [ABSTRACT FROM AUTHOR]

Outcomes of definitive implant-based reconstruction using a delayed-immediate approach in the context of anticipated post-mastectomy radiotherapy. P128. [Extracted from the article]

Background: Hemidiaphragm paralysis from phrenic nerve injury is a known complication of congenital cardiac surgery. Return of diaphragm function has been reported; however, prior studies on this subject have been limited by small numbers, static assessment methods, or observation of plicated or non-plicated patients alone. To describe return of function, we reviewed fluoroscopy and ultrasonography in all diagnosed cases of diaphragmatic paralysis. Methods: Surgical cases at our institution between 1991 and 2010 were identified for patients with postoperative hemidiaphragm paralysis diagnosed by chest X-ray, ultrasound, or fluoroscopy. Follow-up ultrasound and fluoroscopic studies were reviewed for return of diaphragm function. Results: Seventy-two cases of postoperative hemidiaphragm paralysis were identified. Forty cases were plicated prior to discharge. Plicated patients were younger at time of diagnosis (median 46 days average 3.6 months; p = 0.025) and had a larger proportion of single ventricle diagnoses (48% vs 16%) compared with non-plicated patients. Twenty-six patients with paralysis were excluded in follow-up due to lack of studies documenting diaphragm function after the diagnostic study. Of the remaining 46 cases, median follow-up was 353 days (range: 6 days to 17 years). Plicated and non-plicated patients regained function at similar frequency (60% and 54.8%, respectively). Plication status, Risk Adjustment for Congenital Heart Surgery (RACHS) 1 score, age at diagnosis, and side of paralysis did not predict failure of recovery. Conclusions: In the current era, return of diaphragm function after phrenic nerve injury sustained during congenital cardiac surgery is a known occurrence; however, predicting recovery continues to be difficult. [Copyright &y& Elsevier]

Abstract: Purpose: To estimate the direct and indirect pathways between education and diabetes. Methods: We examined the relative contribution of eight different pathways between education and diabetes incidence over a 9-year period in Ontario, Canada. Our data source was respondents (35–60 years of age) to the 2000–2001 Canadian Community Health Survey individually linked with physician and hospital administrative data. Our sample contained 11,899 participants with no previous diagnosis of diabetes. The direct and indirect effects of education level on incident diabetes were estimated using Aalen additive hazard models. Results: Not having completed secondary education was associated with 120 extra diabetes cases per 10,000 men per year and 43 additional diabetes cases per 10,000 women per year, compared with having Bachelors education or higher. Body mass index accounted for 13 of the 120 extra diabetes cases among men, and 24 of the 43 additional diabetes cases for women. Conclusions: Of the mediating pathways examined in this paper, body mass index was the pathway through which the largest number of diabetes cases was mediated among men and women. A substantial number of excess diabetes cases among respondents with lower education levels, in particular among men, were not mediated through any of the eight pathways examined. [Copyright &y& Elsevier]

Abstract: Acyclic acetals and ketals undergo transacetalisation in the presence of catalytic quantities of indium(III) triflate (In(OTf)3) and diols or triols under solvent-free conditions to generate the corresponding cyclic acetals and ketals in excellent yield. The methodology has been further developed to encompass a tandem acetalisation-acetal exchange protocol, which provides a facile and high yielding route to cyclic ketals from unreactive ketones under very mild reaction conditions. [Copyright &y& Elsevier]

Abstract: PreBCR signaling is critical for B cell development and normally depends on the association of a nascent, component Ig H chain with the surrogate L chain (SLC), which helps ensure that only B cells that synthesize structurally sound antibody can develop. How the invariant and λ-like SLC vets billions of unique VH domains for compatibility with polymorphic κ and λ L chains is unclear, because the SLC is composed of not only the Ig domains of VpreB and λ5, but also the unique regions (URs) that reside at what would be the L chain CDR3. We evaluated the contribution of the Ig and UR domains of λ5 to H chain screening by evaluating the preBCR-forming capability of λ5 mutants with a diverse panel of H chains. Using transformed mouse B cells, we demonstrate that the Ig domain of λ5 was sufficient and its UR dispensable for the rejection of VHQ52 and VH10 SLC-incompatible H chains. In contrast, the λ5 UR was necessary to discriminate between SLC-incompatible and -compatible VH81X H chains. Substituting the Ig domains of λ5 with equivalent κ sequences impaired the SLC''s ability to escort all H chains to the surface. Two SLC-incompatible H chains were able to form surface BCRs with two κ L chains, indicating that the SLC''s ability to predict the L chain compatibility of a H chain is not absolute. In sum, λ5 differentially relies on the λ-like Ig and UR to probe H chain structure to best accommodate diversity among H chains. [Copyright &y& Elsevier]

Purpose: To describe the prevalence and nature of anisometropic refractive errors in children with unilateral coronal craniosynostosis. Methods: Retrospective chart review of children with unilateral coronal craniosynostosis who underwent ophthalmic evaluation, including refraction. Results: Refraction was available for 25 of 61 children with unilateral coronal craniosynostosis. Of the 25, 56% had amblyogenic anisometropia. Of these, 79% had the greater refractive error contralateral to the coronal synostosis, mostly (91%) consisting of greater with-the-rule astigmatism in the contralateral eye. Seventy-two percent of Hispanic children had amblyogenic anisometropia, compared with only 14% of non-Hispanic children (p= 0.02). Although Hispanic children tended to receive both surgery and ophthalmic evaluation at older ages than non-Hispanic children, these factors did not appear to account for the difference between ethnicities. There was no detectable association between anisometropia and the timing of fronto-orbital advancement surgery. Conclusions: Children with unilateral coronal craniosynostosis are at increased risk of developing amblyogenic levels of anisometropia in the eye contralateral to the synostosis and require early evaluation and refraction even in the absence of strabismus.▪ [Copyright &y& Elsevier]

Abstract: Alcohols are transformed directly into either acyclic or cyclic acetals in both tandem and sequential oxidation/acetalization processes using manganese dioxide, trialkyl orthoformates and catalytic quantities of indium triflate. [Copyright &y& Elsevier]

Abstract: Acyclic acetals and ketals undergo exchange reactions in the presence of catalytic quantities of indium(III) triflate and diols to generate the corresponding cyclic acetals and ketals in excellent yield. The protocol is rapid, employs mild conditions and can be adapted to employ solvent-free reaction conditions. We have further developed this methodology to encompass a tandem acetalisation-acetal exchange protocol which provides facile access to cyclic ketals from unreactive ketones also under very mild, solvent-free reaction conditions. [Copyright &y& Elsevier]

B Introduction: b Post-mastectomy radiotherapy is known to adversely affect outcomes of reconstructive surgery with the optimum surgical strategy in this scenario a focus of research. Oncological treatment included post-mastectomy radiotherapy in 93.5% of patients, with 82.2% having chemotherapy. [Extracted from the article]

Abstract: Aldehydes and ketones are rapidly transformed into either acyclic or cyclic acetals at room temperature in high yields and in very short reaction times using catalytic quantities of indium triflate, in contrast to previous reports. [Copyright &y& Elsevier]

Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services). We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion , and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death. Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HR adj. = 1.28; 95 CI = 1.05, 1.55), suicide (HR adj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HR adj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HR adj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes. Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada. • Our study explored income inequality and deaths of despair among Canadians. • Greater income inequality predicted an increased hazard of deaths of despair. • Stress, social cohesion, and service access influenced mortality outcomes. [ABSTRACT FROM AUTHOR]

Here we introduce the concept of utilizing microalgal cultures grown in sealed enclosures located in open-oceans to sequester CO 2 from both the atmosphere and flue gases. This method of sequestering CO 2 overcomes the major limitations of sequestering appreciable CO 2 using existing technologies, such as microalgae cultured in open ponds, photobioreactors, or continuous bioreactors on land or near shore. Open ponds require vast surface areas and generally have low net productivity due to light and temperature limitations during the night and winter periods. Continuous algal bioreactors are much more productive, but this comes at the expense of controlling the parameters of the bioreactors, such as light regimes and temperature. The additional energy inputs used to control the parameters of the bioreactors negate their effectiveness of sequestering CO 2 on a global scale. Near shore photobioreactors lack the capacity to be scaled up to sequester appreciable CO 2 . Alternatively, we propose that atmospheric CO 2 and/or the flue gases (containing CO 2 , NO x and SO x ) can be collected and transferred to enclosed vessels or bags containing algal cultures situated in the open-oceans. The productivity of the enclosed cultures could be optimized by moving the bags to various locations in the oceans, allowing for control of temperature, irradiance, and hours of daylight. Theoretical calculations using demonstrated CO 2 sequestration efficiencies and production rates of microalgal batch cultures suggest that 4 cylindrical enclosures, each with a diameter of 100 m and a depth of 40 m would be able to sequester the CO 2 emitted by a 500 MW coal-fired generating plant. On a grander scale, using the same CO 2 consumption rates and the enclosures described above, roughly 14,000 enclosures could reduce the CO 2 in the troposphere by 1 ppm on a yearly basis, representing half of the total CO 2 added to the atmosphere annually. [ABSTRACT FROM AUTHOR]

Background Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage is characterized by a highly complex pathophysiology and results in neurologic deterioration after the inciting bleed. Despite its significant consequences, prompt diagnosis can be elusive and treatment is often administered too late. Early brain injury, which occurs within the first 72 hours after ictus, may be an important factor for delayed cerebral ischemia and poor overall outcome. Here, we explore the purported clinical and pathologic manifestations of early brain injury to identify biomarkers that could have prognostic value. Methods We review the literature and discuss potential emerging markers of delayed cerebral ischemia in the context of early brain injury. Results The following clinical features and biomarkers were examined: global cerebral edema, ictal loss of consciousness, ultra early angiographic vasospasm, continuous electroencephalogram monitoring, systemic inflammatory response syndrome, cellular mediators of the inflammatory response, and hematologic derangements. Conclusions Some of these markers possess independent value for determining the risk of complications after aneurysmal subarachnoid hemorrhage. However, their use is limited because of a variety of factors, but they do provide an avenue of further study to aid in diagnosis and management. [ABSTRACT FROM AUTHOR]

Alcohol availability is positively associated with alcohol use and harms, but the influence of socioeconomic status (SES) on these associations is not well established. This population-based cross-sectional study examined neighbourhood-level associations between physical alcohol availability (measured as off- and on-premise alcohol outlet density) and 100% alcohol-attributable emergency department (ED) visits by neighbourhood SES in Ontario, Canada from 2017 to 2019 (n = 19,740). A Bayesian spatial modelling approach was used to assess associations and account for spatial autocorrelation, which produced risk ratios (RRs) and 95% credible intervals (95% CrI). Each additional off-premise alcohol outlet in a neighbourhood was associated with a 3% increased risk of alcohol-attributable ED visits in both men (RR = 1.03, 95%CrI: 1.02–1.04) and women (RR = 1.03, 95% CrI: 1.02–1.04). Positive associations were also observed between on-premise alcohol outlet density and alcohol-attributable ED visits, although effect sizes were small. A disproportionately greater association with ED visits was observed with increasing alcohol outlet density in the lowest compared to higher SES neighbourhoods. Reducing physical alcohol availability may be an important policy lever for reducing alcohol harm and alcohol-attributable health inequities. • Little is known about the impact of alcohol availability on alcohol harm by SES. • Alcohol outlet density was associated with higher alcohol-attributable ED visits. • Low vs. high SES areas had higher outlet density and ED visits. • Alcohol outlet density had larger impact on ED visits in low vs. high SES areas. • Restricting physical alcohol availability may reduce alcohol harm inequities. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, multiple child health experts postulated that the stay-at-home orders would negatively impact child abuse and neglect. We aimed to examine the impact of the COVID-19 pandemic on child abuse and neglect in children ages 18 and under; and review author recommendations for future emergency lockdown procedures. We completed a systematic search of articles across five databases. Review-level studies were included if they examined any abuse or neglect related outcomes in children and youth (e.g., injuries, case openings), and were published in English. We completed quality appraisals of each included article using the Health Evidence™ tool. We categorized the findings by data source including administrative and survey data, or other data sources. We also narratively summarized reported recommendations. In total, 11 reviews were included. Two reviews were of strong quality, 7 moderate, and 2 were weak. Overall, studies within reviews that reported from administrative data sources demonstrated decreased child abuse and neglect outcomes compared to before the pandemic. Studies using cross-sectional data demonstrated increases. Reviews with mixed results often reported increases in emotional, neglect and psychological abuse cases and decreases physical and sexual abuse cases. This study found consistent results across reviews; depending on the data source and study design, child abuse and neglect outcomes either increased or decreased during the COVID-19 pandemic. Future work should enhance data collection methods for surveillance and intervention of child abuse and neglect during public health emergencies when traditional mechanisms are limited, with an increased focus on the rigor of reporting. [ABSTRACT FROM AUTHOR]