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Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.

We have investigated the interaction of α1 - and α2 -adrenoceptor subtypes in producing isometric contractions to NA in mouse whole spleen. The α1 -adrenoceptor antagonist prazosin (10-8 M) or the α2 -adrenoceptor antagonist yohimbine (10-6 M) alone produced only small shifts in NA potency in wild type (WT) mice, but the combination produced a large shift in NA potency. In spleen from α1A/D -KO mice, the effects of prazosin and the combination of prazosin and yohimbine were similar to their effects in WT mice. Hence, in α1A/D -KO mice, in which the only α1 -adrenoceptor present is the α1B -adrenoceptor, prazosin still antagonized contractions to NA. The α1A -adrenoceptor antagonist RS100329 (3 × 10-9 M) produced significant shifts in the effects of higher concentrations of NA (EC50 and EC75 levels) and the α1D -adrenoceptor antagonist BMY7378 (3 × 10-8 M) produced significant shifts in the effects of lower concentrations of NA (EC25 and EC50 levels). The effects of BMY7378 and RS00329 demonstrate α1D -adrenoceptor and α1A -adrenoceptor components and suggest that the α1B -adrenoceptor interacts with an α1D -adrenoceptor, and to a lesser extent an α1A -adrenoceptor, at low, and an α1A -adrenoceptor at high, NA concentrations. This study demonstrates the complex interaction between α1 - and α2 -adrenoceptor subtypes in producing contractions of mouse spleen and may have general implications for α-adrenoceptor mediated control of smooth muscle.

Purpose Patients enrolled in Phase 1 clinical trials have typically exhausted standard therapies and often are choosing between a clinical trial and hospice care. Significant symptom burden can result in early trial discontinuation and confound trial outcomes. This study aimed to examine differences in study duration, symptom burden, adverse events (AE), and quality of life (QOL) between those receiving structured palliative care versus usual supportive care. Patients and methods Sixty‐eight patients enrolled in phase 1 clinical trials and 39 of their CGs were randomly assigned to receive structured palliative care or usual supportive care. Patient QOL was measured monthly using the Functional Assessment of Cancer Therapy and Memorial Symptom Assessment Scale. The Quality of Life in Life‐Threatening Illness–Family Care Version and Caregiver Reaction Assessment were used for CGs. AEs and use of palliative care resources were compared between arms. Results Mean duration of the phase 1 study was 142 days in the palliative care arm versus 116 days in the usual care arm (p = 0.55). Although not statistically significant, patients in the palliative care arm experienced fewer AEs and better QOL, as did their CGs, compared to those receiving usual care. Conclusions Phase 1 patients and their CGs have physical and psychosocial needs warranting palliative care services. Results suggest that structured palliative care is associated with the increased duration of the study and improved patient and CG QOL., Phase 1 patients and their caregivers have physical and psychosocial needs warranting palliative care services. Providing structured palliative care servies to this population was associated with increased duration on phase 1 study and improved patient and caregiver QOL.

The COVID‐19 pandemic has raised a wide range of challenges for school leaders that they now (rapidly) have to address. Consequently, they also turn to informal learning networks, in order to share and collect information and reach out to their communities. In this context, the current study investigates the underlying networks structures among school leaders, what type of information is being shared, and what differences can be identified when comparing a nation‐wide and a localized sample. We collected data from a US nation‐wide sample of 15 relevant Twitter conversations, as well as Tweets from an US urban mid‐sized public school district. Using a mixed‐methods approach, we discovered several key structural dimensions and a host of highly influential actors. Moreover, we found semantic evidence for users sharing information on topics such as status reports. Finally, we discovered that the urban sample did not overly use the nation‐wide, very specific approach of including COVID‐19 related hashtags. Instead, they used more localized terminologies. These findings are valuable for policy makers, as they map the underlying communication patterns and provide valuable insights into who is moving what types of resources as part of the emerging governance approach on social media. Practitioner notesWhat is already known about this topic Informal networks can be instrumental in providing support during challenging circumstances.School leaders hold a critical position in these networks by accessing and sharing just‐in‐time information and knowledge.Social media provide a wide range of affordances that can support the development of informal networks. What this paper adds Insights into the intersection between leadership and social networks.Information on how school leaders turn to informal networks on social media to access and share information that can help them to face the challenges caused by the global COVID‐19 pandemic.Results on underlying informal learning network structures and topical discussions of a US nation‐wide data sample. Implications for practice and/or policy Insights are provided on how informal online networks develop, which can be instrumental when considering other networks that are of interest to practitioners and policy makers.Types of information and resources that are being shared are unraveled, which can act as an indicator of what type of information and resources school leaders are looking for, particularly in the face of a crisis like the global COVID‐19 pandemic.Differences are shown in how informal learning networks are used comparing a nation‐wide exchange with a localized, urban discussion, which can help to better target the applicable audiences.

Cryptic species are morphologically identical but genetically distinct, and are prominent across numerous phyla. The coexistence of such closely related species on local scales would seem to run counter to traditional coexistence and competition theory; it has been hypothesized as a consequence of differences in their resource use or tolerances to environmental conditions. We developed an individual-based model of a community of three cryptic Litoditis marina (nematode) species, to understand how individual-level interspecific and intraspecific interactions might explain the coexistence of these closely related species. The model incorporates individuals' reproduction, competition, dispersal and resource use. Data characterizing the cryptic species (growth rates, dispersal ability, competitive interactions and responses to changing environmental conditions) were obtained from laboratory experiments involving both mono- and multispecific nematode cultures, and are used to parameterize the model. Simulation studies are used to investigate which individual-level mechanisms of dispersal and interaction lead to the characteristic population-level patterns observed experimentally. Our results highlight the key role of intraspecific competition in mediating dispersal and therefore co-occurrence of the cryptic species. The differences in dispersal also influence the response of the cryptic species to competition, a combination of factors that provides an explanation for their co-occurrence. These results provide insights into how changes in individual-level processes can be amplified to affect population-level co-occurrence.

BACKGROUND/OBJECTIVES: To examine the prevalence of potentially inappropriate medication (PIM) prescribing and its association with healthcare utilization and related expenditures utilizing nationally representative data from the United States. DESIGN: Retrospective cohort study. SETTING: The 2011–2015 Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: Community-dwelling sample of U.S. adults aged 65 and older during the first round of each MEPS cycle. MEASUREMENTS: A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria(®) was used to estimate the prevalence of PIM prescribing over the study period. Negative binomial models were assembled to examine associations between PIM exposure and healthcare utilization including hospitalizations, emergency department (ED) visits, and outpatient provider visits. Generalized linear models with the log link function and gamma distribution were used to analyze associations between PIM exposure and healthcare expenditures. Sensitivity analyses were conducted utilizing inverse probability treatment weighting using propensity scores for being prescribed a PIM. RESULTS: The period prevalence of PIM prescribing over the 5-year sample was 34.4%. PIM prescribing was positively associated with hospitalizations (adjusted incidence rate ratio [aIRR] = 1.17; 95 confidence interval [CI] = 1.08–1.26; P < .001), ED visits (aIRR = 1.26; 95% CI = 1.17–1.35; P < .001), and outpatient provider visits (aIRR = 1.18; 95% CI = 1.14–1.21; P < .001). PIM exposure was associated with higher marginal costs within outpatient visits ($116; 95% CI = $105–$243; P < .001), prescription medications ($128; 95% CI = $72–$199; P < .001), and total healthcare expenditures ($458; 95% CI = $295–$664; P < .001). Similar results were found in our propensity score analyses. CONCLUSION: PIMs continue to be prescribed at a high rate among older adults in the United States. Our results suggest that receipt of PIMs is associated with higher rates of healthcare utilization and increased costs across the healthcare continuum. Further work is needed to implement evidence-based deprescribing interventions that may in turn reduce unnecessary healthcare utilization.

Introduction In clinical practice, observational scales are the most common approach used to assess gait pattern in people with neurological disorders. The Gait Assessment and Intervention Tool (GAIT) is an observational gait scale, and it has proved to be the most comprehensive, homogeneous, and objective of all the observational gait scales studied in people with neurological conditions. Objective To study the construct validity of the GAIT in people with multiple sclerosis (MS). Design An observational study was conducted. Setting Multiple Sclerosis Foundation in Madrid (Spain). Patients Thirty-five patients with MS were assessed. Main outcome measure(s) GAIT construct validity was assessed using the following scales: Rivermead Visual Gait Assessment (RVGA), Tinetti Gait Scale (TGS), 10-Meter Walking Test (10MWT), Timed Up&Go (TUG), Hauser Ambulatory Index (HAI), Multiple Sclerosis Walking Scale-12 (MSWS-12), Functional Gait Assessment (FGA), Modified Ashworth Scale (MAS), and Rivermead Mobility Index (RMI). Results A total of 35 subjects with MS were assessed. The correlations between the GAIT and the RVGA were excellent (r > .90) and moderate with TGS (values between -.62 and -.59). Correlations with HAI, FGA, MSWS-12, and RMI were moderate (with values between .57 and .67). Correlations were lower for the velocity scales TUG and MAS. Conclusions The construct validity of the GAIT is high, as a measure of gait coordination in people with MS. Specifically, there was excellent correlation with the RVGA. There was a moderate correlation for the GAIT with measures of functional mobility, but a lesser correlation of the GAIT with measures restricted to temporal gait characteristics (speed measures) or measurements of impairments underlying gait patterns such as balance or muscle tone.

BACKGROUND The image-guided operating room (OR) is an emerging standard for dealing with complex cases in many surgical disciplines including neurosurgery, thoracic surgery, maxillofacial trauma, and orthopedic surgery. Its use in head and neck oncological surgery is not well established. The primary aim of this study was to assess the image quality of cone-beam CT (CBCT) under real clinical conditions. The secondary aim was to assess the effect on surgical performance and decision making. METHODS Intraoperative 3D imaging was performed using a CBCT capable C-Arm mounted on a multi-axis robot (Siemens Zeego) in the image-guided OR. All patients had immediate preoperative imaging taken with further intraoperative imaging performed as required. Ten initial patients, comprising 28 intraoperative scans, were used for questionnaire-based image reviews conducted with experienced head and neck clinicians. Scans were assessed for aspects of both image quality and clinical utility, on separate 5-point Likert scales (1-5). RESULTS The median rating for bony detail was 4 out of 5. Vascular detail was increased (P < 10-8 ) from 1 to 3 with the use of IV contrast (region of interest CT# was 284 HU [SD, 47 HU]). Images were rated as 4 for freedom from artifact. Soft tissue definition was 2, with no significant improvement (P = .2) with the addition of IV iodinated contrast. Surgeons rated the greatest clinical utility (4) for the CBCT when assessing postreconstruction imaging of a complex case. CONCLUSIONS The image quality of CBCT in the image-guided OR is good for bony detail and complex oncological reconstructions in the head and neck setting but probably has limited benefit for intraoperative soft tissue delineation. Future studies must also focus on clinical outcomes to help demonstrate the value of the image-guided OR.

Background The Gait Assessment and Intervention Tool (G.A.I.T.) has been shown to be a comprehensive and objectively scored tool to assess gait in people with neurologic disease. However, there is only an English version of the scale, the language in which it was developed. Objective To carry out a cross-cultural adaptation of the Gait Assessment and Intervention Tool (G.A.I.T.) scale for its use in the Spanish-speaking population, and to study the content validity of the Spanish version. Design A cross-cultural adaptation and validation study of the G.A.I.T. Setting University Laboratory (Alcorcon, Madrid, Spain). Participants Not applicable. Methods or interventions Cross-cultural adaptation of a scale. Main outcome measurements The Spanish version of the G.A.I.T. was obtained using the double-translation and back-translation method, and a subsequent Expert Committee revision. The Expert Committee studied the content validity of the Spanish G.A.I.T. using the content validity index (CVI). Results The final version of the G.A.I.T. in Spanish was obtained after the cross-cultural process. The CVI was found to be excellent for the overall G.A.I.T. (0.94), and excellent for 87% of its 31 items (≥0.78). CVI was good for 10% of the items (arm swing and toes, CVI ≥0.72). Although 3% of items (shoulder and elbow position) showed CVI = 0.28, these items were retained for completeness. Conclusions The Spanish version of the G.A.I.T. was developed through a cross-cultural adaptation process from its original version in English, and according to an Expert Committee it has an excellent overall content validity.

Focal epilepsy (FE) is clinically highly heterogeneous. It has been shown recently that not only rare but also a subset of common genetic variants confer risk for FE. The relatively modest power of genetic studies in FE suggests a high genetic heterogeneity of FE when grouped as one disorder. We hypothesize that the clinical heterogeneity of FE is correlated with genetic heterogeneity on a common risk variant level. To test the hypothesis, we used an FE polygenic risk score "FE-PRS" that combines small effect sizes of thousands of common variants from the largest FE-GWAS (genome-wide association study) into a single measure. We grouped 414 individuals with FE according to common clinical features into subgroups, either by one feature at a time or by all features combined in a cluster analysis. We examined their association with FE-PRS compared to 20 435 matched population controls and observed heterogeneous FE-PRS burden among the subgroups. The highest phenotypic variance explained by FE-PRS was identified in a cluster analysis-defined FE subgroup where all individuals had unknown etiologies and psychiatric comorbidities, and the majority had early onset seizures. Our results indicate that genetic factors associated with FE have differential burden among FE subtypes. Future studies using better-powered FE-PRS might have clinical utility.

Although intraoperative emergencies are uncommon,1 we need to develop evidence‐informed and contextualized guidance for intraoperative emergencies involving patients with COVID‐19. At our academic pediatric hospital, we assembled a multi‐disciplinary team to examine and adapt intraoperative emergency workflows to ensure safety for patients with suspected COVID‐19 infection, and limit exposure for healthcare providers, with a focus on system improvement (rather than individual performance).

Background Docetaxel, the standard chemotherapy for metastatic castration-resistant prostate cancer (CRPC) also enhances the survival of patients with metastatic castration-sensitive prostate cancer (CSPC) when combined with androgen-deprivation therapy. Focal Adhesion Kinase (FAK) activation is a mediator of docetaxel resistance in prostate cancer cells. The aim of this study was to investigate the effect of the second generation FAK inhibitor VS-6063 on docetaxel efficacy in pre-clinical CRPC and CSPC models. Methods Docetaxel-resistant CRPC cells, mice with PC3 xenografts, and ex vivo cultures of patient-derived primary prostate tumors were treated with VS-6063 and/or docetaxel, or vehicle control. Cell counting, immunoblotting, and immunohistochemistry techniques were used to evaluate the treatment effects. Results Docetaxel and VS-6063 co-treatment caused a greater decrease in the viability of docetaxel-resistant CRPC cells, and a greater inhibition in PC3 xenograft growth compared to either monotherapy. FAK expression in human primary prostate cancer was positively associated with advanced tumor stage. Patient-derived prostate tumor explants cultured with both docetaxel and VS-6063 displayed a higher percentage of apoptosis in cancer cells, than monotherapy treatment. Conclusions Our findings suggest that co-administration of the FAK inhibitor, VS-6063, with docetaxel represents a potential therapeutic strategy to overcome docetaxel resistance in prostate cancer.

Lipids are known to influence tumour growth, inflammation and chemoresistance. However, the association of circulating lipids with the clinical outcome of metastatic castration-resistant prostate cancer (CRPC) is unknown. We investigated associations between the plasma lipidome and clinical outcome in CRPC. Lipidomic profiling by liquid chromatography-tandem mass spectrometry was performed on plasma samples from a Phase 1 discovery cohort of 96 CRPC patients. Results were validated in an independent Phase 2 cohort of 63 CRPC patients. Unsupervised analysis of lipidomic profiles (323 lipid species) classified the Phase 1 cohort into two patient subgroups with significant survival differences (HR 2.31, 95% CI 1.44-3.68, p = 0.0005). The levels of 46 lipids were individually prognostic and were predominantly sphingolipids with higher levels associated with poor prognosis. A prognostic three-lipid signature was derived (ceramide d18:1/24:1, sphingomyelin d18:2/16:0, phosphatidylcholine 16:0/16:0) and was also associated with shorter survival in the Phase 2 cohort (HR 4.8, 95% CI 2.06-11.1, p = 0.0003). The signature was an independent prognostic factor when modelled with clinicopathological factors or metabolic characteristics. The association of plasma lipids with CRPC prognosis suggests a possible role of these lipids in disease progression. Further research is required to determine if therapeutic modulation of the levels of these lipids by targeting their metabolic pathways may improve patient outcome.

Objectives/Hypothesis Providing image guidance in a 3-dimensional (3D) format, visually more in keeping with the operative field, could potentially reduce workload and lead to faster and more accurate navigation. We wished to assess a 3D virtual-view surgical navigation prototype in comparison to a traditional 2D system. Methods Thirty-seven otolaryngology surgeons and trainees completed a randomized crossover navigation exercise on a cadaver model. Each subject identified three sinonasal landmarks with 3D virtual (3DV) image guidance and three landmarks with conventional cross-sectional computed tomography (CT) image guidance. Subjects were randomized with regard to which side and display type was tested initially. Accuracy, task completion time, and task workload were recorded. Results Display type did not influence accuracy (P > 0.2) or efficiency (P > 0.3) for any of the six landmarks investigated. Pooled landmark data revealed a trend of improved accuracy in the 3DV group by 0.44 millimeters (95% confidence interval [0.00–0.88]). High-volume surgeons were significantly faster (P 0.28). Conclusion Real-time 3D image guidance did not influence accuracy, efficiency, or task workload when compared to conventional triplanar image guidance. The subtle pooled accuracy advantage for the 3DV view is unlikely to be of clinical significance. Experience level was strongly correlated to task completion time and workload but did not influence accuracy. Level of Evidence N/A. Laryngoscope, 126:1510–1515, 2016

Although there is some evidence that setting performance criteria may improve oral reading fluency interventions, little is known about the generalized effects of these criteria. The present study trained two third-grade students to three different fluency levels on instructional passages and assessed generalized performance in corresponding high word-overlap passages within an alternating treatments design. Results indicated no discernable differences across experimental conditions. Follow-up analyses revealed that generalized gains per trial were actually larger in lower criterion conditions, suggesting that performance criteria may not be as helpful as previously thought. The results are discussed in terms of the need to empirically investigate the number of instructional trials necessary to maximize instructional efficiency. Copyright © 2016 John Wiley & Sons, Ltd.

Integrated medical curricular changes are altering the historical regional anatomy approach to abdominal dissection. The renal system is linked physiologically and biochemically to the cardiovascular and respiratory systems; yet, anatomists often approach the urinary system as part of the abdomen and pelvic regions. As part of an integrated curriculum, the renal system must be covered relatively quickly after the thorax in the cadaver laboratory, often without the opportunity to fully appreciate the rest of the abdominal contents. This article provides dissection instructions that follow one of the historical surgical approaches for nephrectomy, including preservation of the posterior abdominal wall neurovasclature. Dissection procedures were developed for first-year medical students, intending this posterior approach to the kidneys to be their first introduction to the renal system. It has been successfully implemented with the first-year medical students at the University of New England, College of Osteopathic Medicine. Utilizing this posterior approach to the kidney enabled the study of the anatomy of the kidneys, suprarenal glands, and renal vessels, as well as the muscles of the lumbar spine, while maintaining the integrity of the anterior abdominal wall and peritoneal cavity for future gastrointestinal and reproductive system-based dissections.

Previous preclinical studies of localized intraoperative virtual endoscopy-image-guided surgery (LIVE-IGS) for skull base surgery suggest a potential clinical benefit.The first aim was to evaluate the registration accuracy of virtual endoscopy based on high-resolution magnetic resonance imaging under clinical conditions. The second aim was to implement and assess real-time proximity alerts for critical structures during skull base drilling.Patients consecutively referred for sinus and skull base surgery were enrolled in this prospective case series.Five patients were used to check registration accuracy and feasibility with the subsequent 11 patients being treated under LIVE-IGS conditions with presentation to the operating surgeon (phase 2).Sixteen skull base patients were endoscopically operated on by using image-based navigation while LIVE-IGS was tested in a clinical setting.Workload was quantitatively assessed using the validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire.Real-time localization of the surgical drill was accurate to ~1 to 2 mm in all cases. The use of 3-mm proximity alert zones around the carotid arteries and optic nerve found regular clinical use, as the median minimum distance between the tracked drill and these structures was 1 mm (0.2-3.1 mm) and 0.6 mm (0.2-2.5 mm), respectively. No statistical differences were found in the NASA-TLX indicators for this experienced surgical cohort.Real-time proximity alerts with virtual endoscopic guidance was sufficiently accurate under clinical conditions. Further clinical evaluation is required to evaluate the potential surgical benefits, particularly for less experienced surgeons or for teaching purposes.

Grb10 is an intracellular adaptor protein which binds directly to several growth factor receptors, including those for insulin and insulin-like growth factor receptor-1 (IGF-1), and negatively regulates their actions. Grb10-ablated (Grb10(-/-) ) mice exhibit improved whole body glucose homeostasis and an increase in muscle mass associated specifically with an increase in myofiber number. This suggests that Grb10 may act as a negative regulator of myogenesis. In this study, we investigated in vitro, the molecular mechanisms underlying the increase in muscle mass and the improved glucose metabolism. Primary muscle cells isolated from Grb10(-/-) mice exhibited increased rates of proliferation and differentiation compared to primary cells isolated from wild-type mice. The improved proliferation capacity was associated with an enhanced phosphorylation of Akt and ERK in the basal state and changes in the expression of key cell cycle progression markers involved in regulating transition of cells from the G1 to S phase (e.g., retinoblastoma (Rb) and p21). The absence of Grb10 also promoted a faster transition to a myogenin positive, differentiated state. Glucose uptake was higher in Grb10(-/-) primary myotubes in the basal state and was associated with enhanced insulin signaling and an increase in GLUT4 translocation to the plasma membrane. These data demonstrate an important role for Grb10 as a link between muscle growth and metabolism with therapeutic implications for diseases, such as muscle wasting and type 2 diabetes.

Conventional computed tomography (CT) imaging is the standard imaging technique for temporal bone diseases, whereas cone-beam CT (CBCT) imaging is a very fast imaging tool with a significant less radiation dose compared with conventional CT. We hypothesize that a system for intraoperative cone-beam CT provides comparable image quality to diagnostic CT for identifying temporal bone anatomical landmarks in cadaveric specimens.Cross-sectional study.University tertiary care facility.Twenty cadaveric temporal bones were affixed into a head phantom and scanned with both a prototype cone-beam CT C-arm and multislice helical CT. Imaging performance was evaluated by 3 otologic surgeons and 1 head and neck radiologist. Participants were presented images in a randomized order and completed landmark identification questionnaires covering 21 structures.CBCT and multislice CT have comparable performance in identifying temporal structures. Three otologic surgeons indicated that CBCT provided statistically equivalent performance for 19 of 21 landmarks, with CBCT superior to CT for the chorda tympani and inferior for the crura of the stapes. Subgroup analysis showed that CBCT performed superiorly for temporal bone structures compared with CT. The radiologist rated CBCT and CT as statistically equivalent for 18 of 21 landmarks, with CT superior to CBCT for the crura of stapes, chorda tympani, and sigmoid sinus.CBCT provides comparable image quality to conventional CT for temporal bone anatomical sites in cadaveric specimens. Clinical applications of low-dose CBCT imaging in surgical planning, intraoperative guidance, and postoperative assessment are promising but require further investigation.

Aims To describe light exposure, sleep–wake patterns, mood, pain and their relationships in adult medical inpatients. Background The hospital environment may contribute to patient discomfort by providing a lighting structure that interferes with circadian rhythmicity, sleep, mood and pain. Design A descriptive correlational design was used in this preliminary study. Methods Between May 2011–April 2012, data were collected from a convenience sample of 23 women and 17 men admitted to a large academically affiliated hospital in the United States. Over 72 hours, light exposure and sleep–wake patterns were continuously measured with wrist actigraph/light meters for each participant. Mood was measured daily using the Profile Of Mood States Brief™ Form. Subjective pain scores were abstracted from medical records. Results Light exposure levels were low: mean daytime light intensity was 104·80 lux. Sleep time was fragmented and low: mean 236·35 minutes of sleep/night. Intra-daily stability scores indicated little sleep–wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. Conclusion Medical inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain, suggesting the need for further investigation to determine if manipulating light exposure for medical inpatients would be beneficial in affecting sleep–wake disturbances, mood and pain.

Objectives/Hypothesis Image-guided surgery (IGS) systems are frequently utilized during cranial base surgery to aid in orientation and facilitate targeted surgery. We wished to assess the performance of our recently developed localized intraoperative virtual endoscopy (LIVE)-IGS prototype in a preclinical setting prior to deployment in the operating room. This system combines real-time ablative instrument tracking, critical structure proximity alerts, three-dimensional virtual endoscopic views, and intraoperative cone-beam computed tomographic image updates. Study Design Randomized-controlled trial plus qualitative analysis. Methods Skull base procedures were performed on 14 cadaver specimens by seven fellowship-trained skull base surgeons. Each subject performed two endoscopic transclival approaches; one with LIVE-IGS and one using a conventional IGS system in random order. National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores were documented for each dissection, and a semistructured interview was recorded for qualitative assessment. Results The NASA-TLX scores for mental demand, effort, and frustration were significantly reduced with the LIVE-IGS system in comparison to conventional navigation (P

Background The purpose of this study was to evaluate the efficacy of preoperative versus intraoperative mandibular contouring using rapid prototyping technology. Methods Ten patients requiring mandibular reconstruction had a preoperative mandibular plate contoured to a fabricated 3D mandibular model based on preoperative imaging. A traditional intraoperative plate was also contoured. Two surgeons blinded to the study compared the plates with respect to conformance, surface-area contact, and best overall match. A cost–benefit analysis was then performed. Results The average time to contour was 867 ± 243 seconds and 833 ± 289 seconds for the preoperative and intraoperative plates, respectively (p = .83). Interobserver analysis revealed no statistically significant differences in conformance (p = .38) or surface area contact (p = .14). In 7 of 9 cases, the preoperative plate was selected for the final reconstruction. In 1 case, an intraoperative plate was not contoured because of the lateral extent of the tumor. Conclusion In cases of mandibular distortion secondary to disease, pathologic fracture or defects involving multiple mandibular subsites this method is particularly advantageous. © 2013 Wiley Periodicals, Inc. Head Neck 36: 828–833, 2014

Once HDR displays were developed, a constant question persisted about how much dynamic range is needed for display. If one uses physical scene luminances or human visual system threshold detections to answer this question, the needed ranges are unachievable at exorbitant cost, and likely to remain so for decades. Therefore we designed studies to find the range that is preferred by human observers, and for suprathreshold appearances. Two studies address the diffuse reflective regions, and a third study tested preferences of highlight regions. Test images were specifically designed to test these limits without the perceptual conflicts that usually occur in these types of studies. For the diffuse range, we found displays capable of a dynamic range between 0.1 and 650 cd/m2 match the average preferences. However, to satisfy 90% of the population, a dynamic range from 0.005 to ∼3,000 cd/m2 is needed. Since a display should be able to produce values brighter than the diffuse white maximum, as in specular highlights and emissive sources, the highlight study concludes that the average preferred maximum luminance for highlight reproduction satisfying 50% of viewers is ∼2,500 cd/m2. This value increases to marginally over 20,000 cd/m2 when catering to 90%. Though there is some variability in preferred brightness between certain demographics, the call for a more capable display is still evident, as preferred luminances found in this study exceed even the best of consumer displays today.

This study sought to evaluate whether a one-trial brief experimental analysis (OTBEA) would reliably and validly identify effective treatments to improve oral reading fluency for 6 elementary school students referred for reading problems. An OTBEA was conducted with each participant to assess the effects of skill- and performance-based treatment components. Following the OTBEA, an extended analysis was conducted using an alternating treatments design to experimentally assess whether predictions generated by the OTBEA would be accurate across sessions, time, and stimulus materials. OTBEA results suggested that 3 participants required a treatment package containing both performance-based and skill-based instructional components and that the other 3 participants might only need performance-based interventions. Results indicate that predictions were accurate for those participants requiring both types of intervention components, but that predictions for the remaining participants met with mixed results in the extended analysis. Results are discussed in terms of further refining brief experimental analysis methods to make them more efficient for educators while ensuring valid results.

Response to Intervention provides a continuum of instruction across intensity levels through multitiered intervention models. A lot of work to date has been devoted to how to configure tiers to ensure the appropriate increases in intensity. Much less work has been devoted to making adjustments within tiers to attempt to forestall the need for moving students to a more intense level of instruction when the student is not making adequate progress. This article provides a simple model for evaluating the current instruction to look for areas in which it can be adjusted before more restrictive measures are taken. The model draws from the literature on functional assessment of academic performance. Teachers and consultants are advised to check (a) the skills targeted for instruction, (b) guided practice, (c) independent practice, (d) implementation fidelity, and (e) the motivating conditions that are present during instruction. The role of each area in student learning and progress is discussed, and recommendations are made for adjustments. © 2012 Wiley Periodicals, Inc.

Background. Scapular tip osteomyogenous free flaps have been described for complex palate reconstruction. Minimal osteotomies are needed because of the similar shapes of the scapula and palate. We compared the bony morphology of the palate and scapular tip to determine the suitability of the scapular tip for palate reconstruction. Methods. We analyzed facial and chest CT images of 10 patients, comparing the morphology of 3 simulated palate resection specimens (total palate, subtotal palate, and hemipalate) with corresponding simulated scapular tip bone flaps from the same patient. Results. Conformance distances between palates and simulated flaps were small, indicating close shape similarity. Median conformance distances were 3.44 mm for hemipalatectomy, 3.56 mm for subtotal palatectomy, and 3.71 mm for total palatectomy. Six outlier observations accrued from 2 patients. Conclusions. Based on this analysis, there is close similarity between the shapes of the palate and the scapular tip. This similarity supports use of the scapular tip flap for selected palate defects. V C 2012 Wiley Periodicals, Inc. Head Neck 34: 1377-1382, 2012

Flash cards have been shown to be useful for teaching sight-word reading. To date, the most effective flash-card instruction method is incremental rehearsal (IR). This method involves the instructor interspersing unknown stimulus items into the presentation of known stimulus items. In this study, we compared IR to a modified IR procedure—strategic incremental rehearsal (SIR)—to determine whether the effects of IR might be improved by incorporating variables likely to increase word acquisition. These included increased opportunities to respond to unknown stimuli, using learner responding as a basis for changing instructional items, and systematic prompting methods. An A-B-A-B design was used to compare the effects of IR and SIR for increasing sight-word reading with 4 elementary school students. Results indicated that students read more words correctly with SIR than with IR. In addition, similar patterns of responding were seen at a 2-week follow-up.

Purpose: Target delineation within volumetric imaging is a critical step in the planning process of intensity modulated radiation therapy. In endoluminal cancers, endoscopy often reveals superficial areas of visible disease beyond what is seen on volumetric imaging. Quantitatively relating these findings to the volumetric imaging is prone to human error during the recall and contouring of the target. We have developed a method to improve target delineation in the radiation therapy planning process by quantitatively registering endoscopic findings contours traced on endoscopic images to volumetric imaging.Methods: Using electromagnetic sensors embedded in an endoscope, 2D endoscopic images were registered to computed tomography(CT) volumetric images by tracking the position and orientation of the endoscope relative to a CTimage set. Regions-of-interest (ROI) in the 2D endoscopic view were delineated. A mesh created within the boundary of the ROI was projected onto the 3D image data, registering the ROI with the volumetric image. This 3D ROI was exported to clinical radiation treatment planningsoftware. The precision and accuracy of the procedure was tested on two solid phantoms with superficial markings visible on both endoscopy and CTimages. The first phantom was T-shaped tube with X-marks etched on the interior. The second phantom was an anatomically correct skull phantom with a phantom superficial lesion placed on the pharyngeal surface. Markings were contoured on the endoscope images and compared with contours delineated in the treatment planning system based on the CTimages. Clinical feasibility was tested on three patients with early stage glottic cancer.Image-based rendering using manually identified landmarks was used to improve the registration.Results: Using the T-shaped phantom with X-markings, the 2D to 3D registration accuracy was 1.5–3.5 mm, depending on the endoscope position relative to the markings. Intraobserver standard variation was 0.5 mm. Rotational accuracy was within 2°. Using the skull phantom, registration accuracy was assessed by calculating the average surface minimum distance between the endoscopy and treatment planning contours. The average surface distance was 0.92 mm with 93% of all points in the 2D-endoscopy ROI within 1.5 mm of any point within the ROI contoured in the treatment planningsoftware. This accuracy is limited by the CTimaging resolution and the electromagnetic (EM) sensor accuracy. The clinical testing demonstrated that endoscopic contouring is feasible. With registration based on em tracking only, accuracy was 5.6–8.4 mm. Image-based registration reduced this error to less than 3.5 mm and enabled endoscopic contouring in all cases.Conclusions: Registration of contours generated on 2D endoscopic images to 3D planning space is feasible, with accuracy smaller than typical set-up margins. Used in addition to standard 3D contouring methods in radiation planning, the technology may improve gross tumour volume (GTV) delineation for superficial tumors in luminal sites that are only visible in endoscopy.

In the past decade, American professional psychology has taken significant steps toward a unified statement of the competencies that define the practice of psychology, regardless of specialty. The purpose of this article is to explain the current competency initiative in professional psychology and examine its implications and potential impact on graduate training in school psychology. A brief overview of competency-based training and the current competencies initiative in psychology is presented. Two significant challenges to implement competency-based training are then discussed. The first challenge has to do with conceptualizations of training and practice across accreditation agencies. As a part of the discussion, two recently published competency documents from the Assessment of Competencies Benchmark Workgroup of the American Psychological Association and the National Association of School Psychologists are compared in a content analysis. The second challenge discussed is the difficulties associated with operationalizing and measuring competencies. Specifically, the empirical and consequential bases for existing assessment methods are examined. In spite of current pressure by accrediting agencies to implement a competency-based training model, based on the challenges examined in this article, significant work remains if school psychology trainers want to assure that competency-based training is done well. © 2011 Wiley Periodicals, Inc.

Objectives/Hypothesis: Our group has developed an augmented image guidance system that incorporates intraoperative cone-beam computed tomography (CBCT), virtual or augmented displays, and image registration. We assessed the potential benefits of augmented endoscopy derived from this system for use during skull base navigation. Specifically, we wished to evaluate target localization accuracy and the effect on task workload and confidence. Study Design: Prospective, sequential, paired preclinical trial. Methods: A single cadaver head underwent computed tomography, and critical structures were contoured. The specimen was reimaged after endoscopic dissection and deformable registration allowed contours to be displayed on postablation CBCT imaging. A real-time virtual view including anatomical contours was provided parallel to the real endoscopic image. Twelve subjects were asked to endoscopically localize seven skull base landmarks in a conventional manner. The same exercise was then performed with augmented endoscopy. Precise three-dimensional (3D) localization was recorded with a tracked probe. The NASA task load index was completed after each exercise. A short questionnaire was also administered. Results: The real-time augmented image guidance system aided localization in 85% of responses and increased confidence in 97%. There was a significant reduction in mental demand, effort, and frustration when the technology was employed, with an increase in perceived performance (P < .05). Three dimensional navigational precision was improved for all landmarks. Conclusions: Real-time augmented image-guided surgery increases accuracy and confidence in trainee surgeons and decreases task workload during skull base navigation. This technology shows great promise in assisting in skull base surgery even for experienced surgeons.