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Neel S Vaidya,1,2 Arvin Daneshmand,3 Randy J Epstein,1,2 Parag A Majmudar,1,2 Michael W Belin,4,5 Edward C Parsons,5 Roy S Rubinfeld5– 7 1Chicago Cornea Consultants, Highland Park, IL, USA; 2Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA; 3Georgetown University Medical School, Washington, DC, USA; 4Department of Ophthalmology, University of Arizona, Tucson, AZ, USA; 5CXL Ophthalmics, LLC, Encinitas, CA, USA; 6Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Cente, Washington, DC, USA; 7Re:Vision Private Practice, Rockville, MD, USACorrespondence: Neel S Vaidya, Chicago Cornea Consultants, 806 Central Ave Suite 300, Highland Park, IL, 60035, USA, Email nsv@chicagocornea.comPurpose: To assess the change in corneal pachymetry after a novel epithelium-on (EpiSmart®) corneal crosslinking procedure (CXL).Methods: Eyes treated as part of the open-label, non-controlled arm of the study “Collagen Crosslinking with Ultraviolet-A in Asymmetric Corneas” (NCT01097447) were examined at baseline, 3-, 6- and 12-months post-CXL. Thinnest pachymetry readings based on Pentacam (OCULUS GmbH, Wetzlar, Germany) were recorded.Results: A total of 101 eyes met the study inclusion criteria. Thinnest pachymetric readings at baseline averaged 451 ± 50 microns. The mean (± SD) minimum thickness was 450 ± 46 microns at 3 months, 452 ± 47 microns at 6 months, and 451 ± 48 microns at 12 months post-CXL. The changes from baseline (mean ± SE) at 3, 6, and 12 months post-CXL were − 1.2 ± 1.5 microns, 0.5 ± 1.6 microns, and 0.4 ± 1.6 microns, respectively. Student’s t-tests showed no statistically significant change in pachymetry from baseline for any exam period.Conclusion: This study demonstrated that, after EpiSmart® epithelium-on CXL, there was no substantial corneal thinning observable on Scheimpflug tomography out to 12 months.Keywords: corneal thinning, cross-linking, epithelium-on, keratoconus, pachymetry, post-surgical ectasia

Boundary lines for telemetry data have been used widely among International Space Station (ISS) flight controllers on their displays. These programmable lines are used as important references to aid in anomaly detection and response. Investigating how ISS flight controllers currently use boundary lines helps us understand how potentially anomalous data is handled under conditions of uncertainty and ambiguity. In future deep space exploration missions, anomalies are expected to occur despite our best efforts to avoid them. As crews get farther away from Earth, significant communication delays will be inevitable, and as real-time support becomes less practical, more responsibility will need to be placed on autonomous monitoring and anomaly response. It is unclear what role visualization might play in situation awareness for these future missions. Can visualization techniques be used to alert users to potentially worrisome data values when continuous monitoring is not possible?

Background and Purpose: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective of this study is to describe multidimensional outcomes, identify predictors of worse outcomes, and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or transient ischemic attack, a baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 5, presenting within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale score of 0 to 1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16, and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines-Stroke participating hospitals (age, 65±14; 42% women; final diagnosis of ischemic stroke, 90%; transient ischemic attack, 10%; 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid recipients, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, and extremity weakness. Similar outcomes were noted for the alteplase-treated and untreated groups. Alteplase-treated patients were younger (64±13 versus 67±1.4) with higher NIHSS (2.9±1.4 versus 1.7±1.4). After adjusting for age, sex, race/ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an association with Stroke Impact Scale-16 in the restricted sample of baseline NIHSS score 3–5. Few symptomatic intracerebral hemorrhages were recorded ( Conclusions: A large proportion of stroke patients presenting with low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort, but a suggestion of efficacy was noted in the NIHSS 3–5 subgroup. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02072681.

Mycobacterium bovis (M. bovis) infection has been identified in both domestic and wild animals and may threaten the conservation of vulnerable species including African lions (Panthera leo). There is a need to develop accurate ante-mortem tools for detection of M. bovis infection in African big cat populations for wildlife management and disease surveillance. The aim of this study was to compare the performances of two immunological assays, the QuantiFERON®-TB Gold Plus (QFT) Mabtech Cat interferon gamma release assay (IGRA) and QFT CXCL9 gene expression assay (GEA), which have both shown diagnostic potential for M. bovis detection in African lions. Lion whole blood (n=47), stimulated using the QFT platform, was used for measuring antigen-specific CXCL9 expression and IFN-γ production and to assign M. bovis infection status. A subset (n=12) of mycobacterial culture-confirmed M. bovis infected and uninfected African lions was used to compare the agreement between the immunological diagnostic assays. There was no statistical difference between the proportions of test positive African lions tested by the QFT Mabtech Cat IGRA compared to the QFT CXCL9 GEA. There was also a moderate association between immunological diagnostic assays when numerical results were compared. The majority of lions had the same diagnostic outcome using the paired assays. Although the QFT Mabtech Cat IGRA provides a more standardized, commercially available, and cost-effective test compared to QFT CXCL9 GEA, using both assays to categorize M. bovis infection status in lions will increase confidence in results.

Concepts related to visualization minimalism, such as ‘chartjunk’ and ‘data-ink’, have received significant attention in the visualization literature and have been subject to intense debate and disagreement. Much of the focus has been on determining whether and how non-essential visual elements influence comprehension, and performance of users. Less attention has been placed on the perspectives of visualization practitioners, including the ways in which such concepts are used and understood within the context of a community of practice. In this paper, we investigate conversations on Twitter regarding visualization minimalism, focusing on the ways in which design knowledge is negotiated and applied. Our findings suggest that there is a vibrant community of practice engaged in deliberations on topics relating to visualization minimalism. We suggest more research should focus on visualization practice and the social dimensions of how design knowledge is negotiated and used.

Under the best of circumstances, learning to conduct qualitative research is challenging, both intellectually and emotionally. Engaging in such learning in difficult situations, such as a global pandemic, may heighten challenges while creating opportunities for truly deep learning. The purpose of this paper is to provide methodological insights to guide the growth of new qualitative researchers and inform the design of introductory methods courses based on the learning experiences of a group of graduate students conducting their first qualitative research projects. We present students’ experiences with choosing and planning a project, navigating relationships with study participants, and conducting observations and interviews. Explicit connections to qualitative methodology are offered for every stage of student research engagement. An analysis of the student authors’ experiences highlights the associated learning and innovation necessary to adapt to adversity when conducting qualitative research. Advancements in research reciprocity and human connection are presented, as experienced by the student authors. We conclude with implications and insights for teaching and learning qualitative research and ethical considerations that transcend pandemic circumstances. It is the intent of this manuscript to support the development of deep reflexive practice for new qualitative researchers, effective instructional approaches for those who teach research methods, and an insight into the power of diverse student researchers learning new skills together for the global research community.

Background and Purpose: Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. Methods: A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. Results: Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. Conclusions: Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT 02072681.

STUDY OBJECTIVES: Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. METHODS: Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. RESULTS: Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74–0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). CONCLUSIONS: More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes. CITATION: Donovan LM, Fernandes LA, Williams KM, et al. Agreement of sleep specialists with registered nurses’ sleep study orders in supervised clinical practice. J Clin Sleep Med. 2020;16(2):279–283.

Introduction Falls are associated with negative health outcomes such as injury and mortality, as well as increased healthcare usage and costs. Risk factors for falls are multifactorial and include polypharmacy and the use of certain medications (1). Aim To develop and validate a medication-related fall (MRF) screening and scoring tool. Methods The MRF tool was developed from medication classes associated with falling in the Polypharmacy Guidance Realistic Prescribing 2018 (2), and additional medications identified and categorised by specialist and consultant pharmacists and physicians across a region of the United Kingdom. Medication classes were categorised as high-risk (three points), moderate-risk (two points) or low-risk (one point) in their ‘potential to cause falls’. The overall medication-related fall risk for the patient was determined by summing the scores for all medications. The MRF was validated using Delphi consensus methodology, whereby three iterative rounds of online surveys were conducted using SurveyMonkey®. Delphi panel experts were defined as individuals with recognised expertise in geriatric medicine and pharmacotherapy in older people. Twenty-two experts determined their agreement with the falls risk associated with each medication on a 5-point Likert scale with accompanying written feedback. Only medications with at least 75% of respondents agreeing or strongly agreeing were retained in the next round. Following the first validation round, any proposed criteria that did not meet retention requirements were removed. The second and third rounds of the survey were created based on the panel comments from the previous round. Results Consensus was reached for 19 medications/medication classes to be included in the final version of the MRF tool (table) and to reject eight medications/medication classes. Consensus was not reached regarding eight medications and they were not included in the final version of the tool. Conclusion The MRF tool is simple and feasible to use in healthcare settings to evaluate and optimise medications as a standalone screening instrument or as part of a multidisciplinary intervention to reduce fall risk and negative fall-related outcomes. The score from the MRF tool has potential for use as a clinical parameter to evaluate prescribing appropriateness. References (1) Public Health England (2020) Falls: applying All Our Health. Available at https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health Guidance Falls: applying All Our Health. (Accessed: 4th April 2020) (2) Scottish Government Polypharmacy Model of Care Group (2018). Polypharmacy Guidance, Realistic Prescribing. 3rd Edition.

Clinical reasoning encompasses the process of data collection, synthesis, and interpretation to generate a working diagnosis and make management decisions. Situated cognition theory suggests that knowledge is relative to contextual factors, and clinical reasoning in urgent situations is framed by pressure of consequential, time-sensitive decision-making for diagnosis and management. These unique aspects of urgent clinical care may limit the effectiveness of traditional tools to assess, teach, and remediate clinical reasoning.Using two validated frameworks, a multidisciplinary group of clinicians trained to remediate clinical reasoning and with experience in urgent clinical care encounters designed the novel Rapid Evaluation Assessment of Clinical Reasoning Tool (REACT). REACT is a behaviorally anchored assessment tool scoring five domains used to provide formative feedback to learners evaluating patients during urgent clinical situations. A pilot study was performed to assess fourth-year medical students during simulated urgent clinical scenarios. Learners were scored using REACT by a separate, multidisciplinary group of clinician educators with no additional training in the clinical reasoning process. REACT scores were analyzed for internal consistency across raters and observations.Overall internal consistency for the 41 patient simulations as measured by Cronbach's alpha was 0.86. A weighted kappa statistic was used to assess the overall score inter-rater reliability. Moderate reliability was observed at 0.56.To our knowledge, REACT is the first tool designed specifically for formative assessment of a learner's clinical reasoning performance during simulated urgent clinical situations. With evidence of reliability and content validity, this tool guides feedback to learners during high-risk urgent clinical scenarios, with the goal of reducing diagnostic and management errors to limit patient harm.

Sleep VA-ECHO (Veterans Affairs–Extension for Community Healthcare Outcomes) is a national telementorship program intended to improve knowledge about sleep disorders among non-specialty providers. The project goal was to describe the characteristics of Sleep VA-ECHO participants from primary care and their use of program-obtained knowledge in practice. Sleep VA-ECHO consisted of 10 voluntary, 75-min teleconference sessions combining didactics and case discussion. Out of 86 participants, 21 self-identified as primary care team members and completed a program evaluation. Participants self-reported their application of knowledge gained, including changes to practice as a result of program participation. These 21 participants represented 18 sites in 11 states and attended a median of 5.0 sessions. They included physicians (29%), nurse practitioners (24%), and registered nurses (24%). Nearly all participants (95%) reported using acquired knowledge to care for their own patients at least once a month; 67% shared knowledge with colleagues at least once a month. Eighty-five percent reported improved quality of sleep care for their patients, and 76% reported an expanded clinical skillset. The greatest self-reported change in practice occurred in patient education about sleep disorders (95%) and non-pharmacologic management of insomnia (81%).

Roy S Rubinfeld,1 Glenwood G Gum,2 Jonathan H Talamo,1,3 Edward C Parsons1 1CXL Ophthalmics, LLC, Encinitas, CA, USA; 2Absorption Systems California, LLC, San Diego, CA, USA; 3Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USACorrespondence: Roy S RubinfeldCXL Ophthalmics, LLC, 3131 Connecticut Avenue NW #2809, Washington DC, 20008, USATel +1 240 305-1010Email rsrubinfeld@gmail.comPurpose: To evaluate effects of sodium iodide (NaI) on riboflavin concentration in corneal stroma before and during ultraviolet A (UVA) light exposure using a novel transepithelial corneal collagen crosslinking (CXL) procedure (EpiSmart CXL system, CXL Ophthalmics, Encinitas CA).Methods: Riboflavin solutions with NaI (Ribostat, CXL Ophthalmics, Encinitas CA) and without NaI were used for CXL in rabbits using EpiSmart. A pilot study determined sufficient riboflavin loading time. Four rabbits were dosed and monitored. Riboflavin fluorescence intensity was assessed from masked slit-lamp photos. A 12 min loading time was selected. Sixteen additional rabbits received the two formulae in contralateral eyes for CXL. Riboflavin uptake was assessed at 0, 10, 15, 20, 25, and 30 min of UVA exposure using a scale for riboflavin fluorescence previously validated against stromal concentration. Post sacrifice, corneal stromal samples were analyzed for concentrations of riboflavin and riboflavin 5ʹ-phosphate.Results: Eyes dosed with NaI riboflavin had higher riboflavin grades compared to eyes dosed with the NaI-free riboflavin formulation immediately after riboflavin loading and persisting throughout UVA exposure, with significantly higher (P < 0.01 to < 0.05) riboflavin grades from 15 through 25 min of UVA exposure. Riboflavin grades decreased more slowly in eyes dosed with NaI riboflavin through 25 minutes of UVA exposure. Minor conjunctival irritation was noted with or without NaI.Conclusion: The addition of NaI to riboflavin solution is associated with increased riboflavin concentration in corneal stroma throughout a clinically relevant time course of UVA exposure. This effect may be a combination of enhanced epithelial penetration and reduced riboflavin photodegradation and should enhance intrastromal crosslinking.Keywords: corneal crosslinking, crosslinking, riboflavin, iodide, keratoconus, ectasia

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients’ experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645–1651.

Understanding transmission of severe acute respiratory syndrome coronavirus 2 informs infection prevention practices. Air sampling devices were placed in patient hospital rooms for consecutive collections with and without masks. With patient mask use, no virus was detected in the room. High viral load and fewer days from symptom onset were associated with viral particulate dispersion.

Mazen M Sinjab,1,2 Roy S Rubinfeld,3,4 Kirsten Wagner,5,6 Edward C Parsons Jnr,7 Arthur B Cummings,8 Michael W Belin9 1Dr. Mazen Eye Clinic, Medcare Hospitals and Centres, Dubai, United Arab Emirates; 2Al Zahra Medical Group, Damascus, Syria; 3Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Center, Washington, DC, USA; 4Re:Vision Private Practice, Rockville, MD, USA; 5Department of Ophthalmology, Medstar Georgetown University Hospital, Washington, DC, USA; 6Department of Ophthalmology, Medstar Washington Hospital Center, Washington, DC, USA; 7CXL Ophthalmics, Encinitas, CA, USA; 8Wellington Eye Clinic, Dublin, Ireland; 9Department of Ophthalmology, University of Arizona, Tucson, AZ, USACorrespondence: Roy S Rubinfeld 3131 Connecticut Ave, NW, #2809, Washington, DC, 20008, USAEmail Doctor@revisedeye.comPurpose: To assess the effectiveness of a novel treatment for patients with advanced corneal ectasia and loss of visual acuity (VA). Conductive keratoplasty (CK) is performed to improve VA followed by epithelium-on (epi-on) corneal crosslinking (CXL) to stabilize the cornea after CK.Methods: Retrospective, exploratory cohort study. Patients with keratoconus or postsurgical ectasia and best spectacle-corrected distance VA (CDVA) ≤ 20/40 were included. Conductive keratoplasty was performed (ViewPoint CK System, Refractec, Inc., Bloomington, MN); followed a day later by epi-on CXL (CXLUSA/CXLO, Bethesda, MD/CXLO Encinitas, CA). Measures included uncorrected distance visual acuity (UDVA) and CDVA, as well as refractive and tomographic measures and tomographic indices.Results: Data from 50 eyes of 45 patients were analyzed. Mean follow-up was 15.1 ± 12.2 months (range: 2 to 51). Overall, UDVA and CDVA improved postoperatively. Subjective refraction and tomographic metrics did not show consistent changes, but changes in tomographic indices were associated with treatment follow-up time. At the 1-year visit, mean UDVA significantly improved over baseline (P = 0.009) by approximately 3 lines; mean CDVA improved significantly (P = 10− 5) by approximately 2 lines. No eye lost lines of CDVA. Change in the Index of Surface Variance (ISV) was associated with treatment, and the D-Index trended over follow-up time.Conclusion: Conductive keratoplasty with a proprietary epi-on CXL treatment improved vision in patients with advanced ectasia This CK/epi-on CXL treatment offers the possibility of improved VA for patients with compromised vision due to ectasia.Keywords: conductive keratoplasty, CK, corneal crosslinking, crosslinking, keratoconus, ectasia, thermokeratoplasty

Introduction Newspapers contribute to public understanding and perceptions of health-related issues (1,2). Examination of news media reporting to elucidate how the public conceptualise and understand medicines use in dementia has been limited to date. Aim To investigate communication to the public about medications used in dementia via newspaper articles. Methods A systematic content analysis explored communication in the 10 highest circulated UK newspapers about medications used in dementia, over a 10-year period from 2010 to 2019. LexisNexis UK was searched using terms relating to medications and treatment in dementia (both for dementia and for other co-morbid conditions), and articles relating to medicines use in dementia were identified for inclusion. A standardised coding frame was developed, piloted, and used to code all included articles across three domains: structure (bibliographic details); content (information within each article); and judgement and rating (subjective variable related to information presented, and scored from 0-10). Where an article was linked to a scientific journal article, this was retrieved, and the content cross-checked. A second researcher independently coded a random sample (10%) of articles. Level of intercoder agreement was determined by calculation of Cohen’s kappa value. Results One hundred articles satisfied the inclusion criteria. The newspapers which most frequently contained relevant articles were: the Daily Mail (n = 33) and the Daily Express (n = 30), followed by the Daily Mirror (n = 12), the Guardian (n = 11), the Mail on Sunday (n = 5), the Sunday Express (n = 3), the i (n = 3), the Metro (n = 1), the Daily Star (n = 1) and the People (n = 1). The largest numbers of articles were published in 2011 and 2012 (n=18) and the smallest number in 2019 (n = 4), with no apparent trend observed over the study period. Main article themes were: benefits and effectiveness, risk and harm, lack of diagnosis, and funding and potential future drug developments. Starting therapy early and continuing in later stages of dementia were reported to maintain function and independence and slow decline. Antipsychotics, sedatives and opioid analgesics were considered to worsen symptoms and increase risk of death. Lack of dementia diagnosis resulted in inability to obtain dementia medication when people needed and would benefit from it. Lack of funding was highlighted as a barrier to research. Most articles were written from a clinical perspective (n=82). Half had a negative slant, 46% had a positive slant and 4% were neutral. Almost half were judged to be excellent quality (45%), 35% were considered average and 20% were judged as poor quality. Cohen’s kappa values ranged from 0.63 to 1.00, indicating satisfactory agreement between coders. Conclusion There remains scope for improvement in quality of mass media communication regarding medications used in dementia. Strengths of this study include the systematic approach employed in content analysis, while limitations include exclusion of the Sun, the Times and the Telegraph due to lack of availability of circulation figures, and exclusion of media sources other than newspapers. References (1) Akintola O, Lavis JN, Hoskins, R. Print media coverage of primary healthcare and related research evidence in South Africa. Health Res Policy Syst. 2015;13:68. (2) Stanford FC, Tauqeer Z, Kyle TK. Media and its influence on obesity. Curr Obes Rep. 2018; 7(2):186–92.

Introduction Initiating treatment with continuous positive airway pressure (CPAP) traditionally relies on in-person visits with trained therapists to provide hands-on instruction regarding CPAP usage and mask fit. To overcome geographic barriers and reduce COVID-19 transmission, health systems increasingly rely on remote set-ups of mailed equipment. Despite a strong rationale for the mailed approach, relative effectiveness is unclear. Methods Our VA medical center shifted from in-person to mailed CPAP dispensation during the COVID-19 pandemic in March 2020. Using VA administrative and wireless CPAP usage data, we assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP for the first time from July 2019 to August 2020. Our primary outcome was mean nightly usage over the first 90 days. We compared patients with in-person vs. mailed CPAP dispensation using generalized linear models adjusted for age, gender, race, and Charlson Comorbidity Index. Among patients with >1 hour of overall usage, we compared secondary outcomes of leak, apnea hypopnea index (AHI), and obstructive/central apnea indices. Results We identified 693 patients with newly diagnosed OSA whose CPAP was provided in-person and 296 who had CPAP mailed. Nightly usage in the first 90 days was modest in both groups (in-person: 149.7, mailed: 152.9 min/night), and we did not detect a difference in adjusted models (+7.6 min/night, 95%CI -13.6–28.8). We also did not detect a difference in 95th percentile leak (-1.2 liter/minute, 95%CI -3.3-0.9). Device-detected AHI was relatively low overall (in-person: 3.2, mailed: 4.1 events/hour), but was greater in the mailout group (+1.0/hour, 95%CI 0.2–1.7). AHI differences appeared to be driven by obstructive (+0.5/hour, 95%CI 0.2–0.8) but not central events (-0.1, 95% CI -0.2–0.4). Risk of AHI>5 was comparable between groups (in-person: 17.3%, mailed: 19.0%, OR 1.2, 95%CI 0.8–1.7). Conclusion We were able to switch from an in-person to a mail-based system of CPAP initiation without a change in CPAP adherence or mask leak. While AHI was slightly greater in the mailed group, the clinical significance of this finding is unclear. Future work will need to evaluate the impact of remote CPAP dispensation on patient-centered outcomes. Support (if any) VA Health Services Research and Development, CDA 18–187

Data presented in this study is publicly available at https://figshare.com/s/45bd5369a97b4c2489bf (accessed on 25 October 2021).Ethical permission for the study was provided by the University of Pretoria (ECO20-14), and this manuscript has been approved for publication by the Royal Veterinary College (PPS_01715). Permission to carry out research in the region was granted by the Northern Cape Department of Environment and Nature Conservation.; International audience; Simple SummaryDiagnostic tests used in animals are ideally extensively trialled to ensure that practitioners have confidence in the results; the ideal target should be 100% of infected animals testing positive (sensitivity), and 100% of uninfected animals testing negative (specificity). In these trials, a gold standard is necessary, against which the diagnostic tests may be compared. Commonly, tests of wild animals are not extensively trialled due to shortages of samples and the rarity of gold standard tests. This study uses samples collected for the purpose of diagnosing Mycobacterium suricattae infection in meerkats and estimates the sensitivity and specificity of available tests, both individually, and in combination. A small number of post-mortems (gold standard) were carried out, providing definitive evidence of infected animals against which to compare the tests. In addition, test results were unconventionally compared to survival times and clinical characteristics, aiming to quantify the prognostic capabilities of the tests. The study therefore not only estimates the required parameters against which to assess these tests, but also provides a model for future assessment of diagnostic tests in imperfect field scenarios. Wildlife diseases are increasingly recognised as important to society, and so methods to better quantify these are increasingly important.AbstractDiagnostic tests are used to classify individual animals’ infection statuses. However, validating test performance in wild animals without gold standard tests is extremely challenging, and the issue is further complicated in chronic conditions where measured immune parameters vary over time. Here, we demonstrate the value of combining evidence from different diagnostic approaches to aid interpretation in the absence of gold standards, large sample sizes, and controlled environments. Over a two-year period, we sampled 268 free-living meerkats (Suricata suricatta) longitudinally for Mycobacterium suricattae (a causative agent of tuberculosis), using three ante-mortem diagnostic tests based on mycobacterial culture, and antigen-specific humoral and cell-mediated immune responses, interpreting results both independently and in combination. Post-mortem cultures confirmed M. suricattae infection in 22 animals, which had prior ante-mortem information, 59% (13/22) of which were test-positive on a parallel test interpretation (PTI) of the three ante-mortem diagnostic assays (95% confidence interval: 37–79%). A similar ability to detect infection, 65.7% (95% credible interval: 42.7–84.7%), was estimated using a Bayesian approach to examine PTI. Strong evidence was found for a near doubling of the hazard of death (Hazard Ratio 1.75, CI: 1.14–2.67, p = 0.01), associated with a positive PTI result, thus demonstrating that these test results are related to disease outcomes. For individual tests, small sample sizes led to wide confidence intervals, but replication of conclusions, using different methods, increased our confidence in these results. This study demonstrates that combining multiple methodologies to evaluate diagnostic tests in free-ranging wildlife populations can be a useful approach for exploiting such valuable datasets.

Nurses new to Maternal-Child units in hospital organizations need reality based in-service education in new employee orientation. Experienced nurses must have current, cutting edge staff development sessions that replicate practice scenarios to facilitate currency in practice. Annual clinical skills reaffirmation and new employee orientation commonly include clinical simulation activities that enhance critical thinking, assess clinical competency and reduce the potential for errors in practice. Practice repetition in the Education Department lab setting is a protected area to learn and refine clinical care skills and procedures. Case scenarios through use of clinical simulation are posed to provide current practice initiatives that enhance the nurses’ ability to provide safe, competent patient care. Keywords: Clinical Simulation, Nurse Educators, Nurse Practice, Staff Development

Purpose Noninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population. Methods We created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year. Results We present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days). Conclusions Our RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.

Background: Little is known about sleep and circadian rhythms in survivors of acute respiratory failure (ARF) after hospital discharge.Objectives: To examine sleep and rest-activity circadian rhythms in ARF survivors 3 months after hospital discharge, and to compare them with a community-dwelling population.Methods: Sleep diary, actigraphy data, and insomnia symptoms were collected in a pilot study of 14 ARF survivors. Rest-activity circadian rhythms were assessed with wrist actigraphy and sleep diary for 9 days, and were analyzed by cosinor and non-parametric circadian rhythm analysis.Results: All participants had remarkable actigraphic sleep fragmentation, 71.5% had subclinical or clinical insomnia symptoms. Compared to community-dwelling adults, this cohort had less stable rest-activity circadian rhythms (p < 0.001), and weaker circadian strength (p < 0.001).Conclusion: Insomnia and circadian disruption were common in ARF survivors. Sleep improvement and circadian rhythm regularity may be a promising approach to improve quality of life and daytime function after ARF.

We present a patient who experienced insufflation of air under the left eyelid when using continuous positive airway pressure (CPAP) via an oronasal mask. The patient had a lacrimal stent in place for many years, which was a predisposing factor for this complication. Lacrimal stents are frequently used in the treatment of epiphora (excessive tearing) secondary to obstruction of the lacrimal drainage system. In this case, we review the pathophysiology of air regurgitation into the eye with CPAP use and methods previously described to address this rare complication. We also present a novel intervention for this rare complication, the total face mask. By additionally covering the eyes, a total face mask allows equalization of pressure on both sides of the lacrimal system. With a total face mask, our patient was able to successfully use CPAP.

CITATIONPalen BN, He K, Redinger J, Parsons EC. A change of heart. J Clin Sleep Med. 2019;15(10):1543–1545.

Background People living with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD) suffer impaired quality of life due to burdensome symptoms and depression. The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial aims to determine the effect of a multidisciplinary, team-based intervention on quality of life in people with these common diseases. Methods/design The ADAPT trial is a two-site, patient-level randomized clinical trial that examines the effectiveness of the ADAPT intervention compared to usual care on patient-reported quality of life at 6 months in veterans with CHF, COPD or ILD with poor quality of life and increased risk for hospitalization or death. The ADAPT intervention involves a multidisciplinary team—a registered nurse, social worker, palliative care specialist, and primary care provider (with access to a pulmonologist and cardiologist)—who meet weekly to make recommendations and write orders for consideration by participants’ individual primary care providers. The nurse and social worker interact with participants over six visits to identify and manage a primary bothersome symptom and complete a structured psychosocial intervention and advance care planning. The primary outcome is change in patient-reported quality of life at 6 months as measured by the Functional Assessment of Chronic Illness Therapy-General questionnaire. Secondary outcomes at 6 months include change in symptom distress, depression, anxiety, disease-specific quality of life hospitalizations, and advance care planning communication and documentation. Intervention implementation will be assessed using a mixed-methods approach including a qualitative assessment of participants’ and intervention personnel experiences and a quantitative assessment of care delivery, resources, and cost. Discussion The ADAPT trial studies an innovative intervention designed to improve quality of life for veterans with common, burdensome illnesses by targeting key underlying factors—symptoms and depression—that impair quality of life but persist despite disease-specific therapies. Leveraging the skills of affiliate health providers with physician supervision will extend the reach of palliative care and improve quality of life for those with advanced disease within routine outpatient care. The hybrid effectiveness/implementation design of the ADAPT trial will shorten the time to broader dissemination if effective and create avenues for future research. Trial registration ClinicalTrials.gov, NCT02713347. Registered March 19, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3417-1) contains supplementary material, which is available to authorized users.

Buffer zones, calculated by flight-initiation distance (FID), are often used to reduce anthropogenic disturbances to wildlife, but FID can vary significantly across life-history stages. We examined the behavioral effect of potential natural (gulls and shorebirds) and anthropogenic (pedestrians) disturbance sources to staging roseate (Sterna dougallii) and common tern (S. hirundo) flocks from July to September in 2014 and 2015 at Cape Cod, Massachusetts, USA. We estimated the proportion of the flock exhibiting different responses to potential disturbance sources as a function of distance, flock size, percent roseate terns, and local disturbance rates, using Bayesian zero-and-one inflated beta regression. The proportion of tern flocks responding to the presence of shorebirds by flying was low (0.01 +/- 0.001 [SE]) and did not vary by distance or other covariates, whereas the proportion flying in response to gulls increased as distance decreased, with smaller flocks, and with flocks with a larger proportion of roseate terns being more sensitive to gull presence. Prolonged flight response rapidly increased in probability from 0.0 to as much as 1.0 as distance from pedestrians to the flock decreased from 100 m and was much more likely with smaller flocks. Pedestrian activity levels also had an effect on flock responses; those engaged in active behaviors such as jogging were more likely to cause flushing than those engaged in passive behaviors. Terns seemed to view pedestrians as more of a threat than shorebirds and gulls, even though gulls are frequent kleptoparasites of terns. Pedestrians >120 m from a tern flock generally elicited the same probability of flight response as shorebirds and gulls. We recommend managers maintain anthropogenic disturbance levels at or below the intensity of those from natural sources at sites where recreation and wildlife values are both important. Because staging tern flocks may use a variety of areas within a site, we recommend instituting a 100-m buffer around areas potentially used by staging flocks at Cape Cod, where we studied every location roseate terns are known to use in large numbers. For other sites used by mixed-species tern flocks, we recommend the use of our field and analytical methods to develop appropriate buffer distances that will keep pedestrians far enough away to reduce the likelihood of flight and other non-locomotive anti-predator behaviors. These buffer zones will also benefit other species sensitive to human activity. (c) 2018 The Wildlife Society. Cape Cod National Seashore; United States Geological SurveyUnited States Geological Survey; CNY Wildfowlers Association; Edna Baily Sussman Foundation The use of trade, product, or firm names is for descriptive purposes only and does not imply endorsement by the United States Government. The USFWS provided necessary resources to complete the study. M. E. Hake, R. P. Cook, J. J. Taylor, and K. E. Iaquinto provided logistical support and site access. J. L. Correia, J. C. May, S. S. Brady, and P. L. Gallo assisted with data collection. The Cape Cod National Seashore, United States Geological Survey, CNY Wildfowlers Association, and Edna Baily Sussman Foundation provided funding. Public domain – authored by a U.S. government employee

Honest signaling mechanisms can function to appropriate care to hungry offspring and avoid misdirected care of unrelated offspring. Begging, the behavior by which offspring solicit food and parental care, may be an honest signaling mechanism for need, as well as association of parents and offspring. Roseate terns (Sterna dougallii) exhibit prolonged parental care during the postbreeding staging period, offering an ideal system in which to study begging as an honest signaling mechanism. We conducted focal sampling during two premigratory staging seasons (2014 and 2015) at Cape Cod National Seashore, Massachusetts, USA to determine whether postfledging tern begging behavior was an honest signal for need and parent–offspring association. Based on honest signaling theory, we expected begging behavior to be highest during times of high perceived need, and we expected to see a decrease in begging behavior as young terns became increasingly independent of the care‐giving parent. Also, we predicted that young terns would be more likely to beg at parents than nonparents. We found that young roseate terns begged at their parents more often than nonparents; however, they did not always beg at parents. Model predictions of begging probability showed a linear relationship between begging and time of day and date of season, such that begging increased with time of day and decreased with date of season, respectively. Our results provide evidence for honest parent–offspring interactions and are inconsistent with parent–offspring conflict theory but suggest that begging may play a complex role in postfledging parent–offspring interactions. OPEN RESEARCH BADGES This article has been awarded Open Data, Open materials Badges. All materials and data are publicly accessible via the Open Science Framework at https://doi.org/10.5281/zenodo.2656718.

Seabird demography and spatial distribution outside of the breeding season are poorly understood, and migratory stopover and staging sites represent important energetic bottlenecks during the avian annual cycle. We quantified hatch-year Roseate Tern (Sterna dougallii) weekly residency, weekly recruitment rate into the staging population, and derived weekly staging population growth rate during two postbreeding, premigratory staging seasons (2014 and 2015) at Cape Cod National Seashore, Massachusetts, USA. We also estimated hatch-year tern stopover duration at Cape Cod staging grounds. Tern residency probability at Cape Cod National Seashore during 2014 and 2015 was nearly 1 during the first weeks of the season and decreased steadily over the last 4 weeks to ~0.5 in the final week of the study. Recruitment rates into the staging population, representing the weekly per capita change in hatch-year terns present during the staging season, indicated that most terns arrived on the staging grounds during the first weeks of the staging season (16 July to 19 August). We also identified differences in staging duration between birds from the two breeding regions. Hatch-year terns from the southernmost region spent less time staging at Cape Cod National Seashore than their northern counterparts in both 2014 and 2015. These differences may indicate alternative staging strategies for individuals originating in different regions and possibly reveal differences in resource conditions between these areas, for example, in the availability of ephemeral prey fish.

In South Africa, the largest proportion of the African wild dog (

Lion (

Introduction The prevalence of sleep-disordered breathing is increasing, and there are insufficient sleep medicine specialists to meet the clinical demand of caring for these patients. One way to meet this clinical need is to train primary care and internal medicine physicians to provide some of the care. However, trainees in these specialties often receive very little training on practical aspects of the management of obstructive sleep apnea (OSA). We developed an experiential workshop to address this need at our institution. Methods For approximately 60 internal medicine residents, we ran a 2.5-hour workshop consisting of two 20-minute didactic presentations to the whole audience and two 40-minute breakout sessions, led by eight facilitators. During the breakout sessions, the residents interacted with equipment such as positive airway pressure (PAP) devices and interfaces, reviewed sleep testing and PAP download reports, and participated in guided small-group discussions. Results We received 40 evaluation surveys with at least partial responses. Only 50% of respondents had received prior formal instruction on PAP devices. Both subjective and objective knowledge scores improved on the postworkshop questions compared to the preworkshop questions. Trainee comments were extremely positive, indicating that they enjoyed the format of the session. Discussion This curriculum provides an interactive educational session focused on practical aspects of OSA management relevant to primary care physicians and internists. It was well received and could be adapted to suit other time frames and other groups of learners.

De-energizing equipment does not absolve the facility from the responsibility of performing an arc flash analysis or providing the necessary PPE.

Tuberculosis (TB) in humans is a global public health concern and the discovery of animal cases of Mycobacterium tuberculosis (Mtb) infection and disease, especially in multi-host settings, also has significant implications for public health, veterinary disease control, and conservation endeavors. This paper describes a fatal case of Mtb disease in a free-ranging African elephant (Loxodonta africana) in a high human TB burden region. Necropsy revealed extensive granulomatous pneumonia, from which Mtb was isolated and identified as a member of LAM3/F11 lineage; a common lineage found in humans in South Africa. These findings are contextualized within a framework of emerging Mtb disease in wildlife globally and highlights the importance of the One Health paradigm in addressing this anthroponotic threat to wildlife and the zoonotic implications.

Mycobacterium bovis is the cause of tuberculosis (TB) in a wide range of species, including white rhinoceroses (Ceratotherium simum). Control of the disease relies on the indirect detection of infection by measuring pathogen-specific responses of the host. These are poorly described in the white rhinoceros and this study aimed to characterize the kinetics of immune responses to M. bovis infection in this species. Three white rhinoceroses were infected with M. bovis and their immune sensitization to this pathogen was measured monthly for 20 months. Cell-mediated immunity was characterized in whole blood samples as the differential release of interferon-gamma in response to bovine purified protein derivative (PPDb) and avian PPD (PPDa) as well as the release of this cytokine in response to the M. bovis proteins 6 kDa early secretory antigenic target (ESAT-6)/10 kDa culture filtrate protein (CFP-10). Humoral immunity was quantified as the occurrence or the magnitude of antibody responses to the proteins ESAT-6/CFP-10, MPB83, MPB83/MPB70, and PPDb. The magnitude and duration of immune reactivity varied between individuals; however, peak responses to these antigens were detected in all animals circa 5-9 months postinfection. Hereafter, they gradually declined to low or undetectable levels. This pattern was associated with limited TB-like pathology at postmortem examination and appeared to reflect the control of M. bovis infection following the development of the adaptive immune response. Measurement of these markers could prove useful for assessing the disease status or treatment of naturally infected animals. Moreover, immune responses identified in this study might be used to detect infection; however, further studies are required to confirm their diagnostic utility.

Introduction Pulmonary equipment has become ubiquitous in clinical care. Basic device troubleshooting and mechanical manipulation skills are crucial to the practicing physician yet are frequently neglected in standard pulmonary curricula. Methods We developed a hands-on pulmonary curriculum for medical residents and students, focusing on oxygen delivery, spirometry, positive airway pressure devices, thoracostomy, and tracheostomy knowledge. The curriculum, consisting of five 1-hour sessions, offers hands-on experience with basic pulmonary equipment relevant to the ICU and/or pulmonary clinic. Each session is led by a pulmonologist or critical care facilitator and designed for a learning audience of 10–15 internal medicine trainees and medical students. More than 11 sessions have been conducted since curriculum implementation. Results Voluntary, immediate, pre- and postsession surveys assessed objective subject knowledge, perceived subject understanding, and perceived effectiveness of this hands-on format versus a conventional lecture style. A total of 52 learners returned surveys. Aggregate responses demonstrated that these sessions were typically the first formal training learners had received in these subject areas. Subject knowledge and perceived level of subject understanding both improved, and respondents reported the hands-on style of teaching was more effective than conventional lecture format. Discussion Focused on practical knowledge, this pulmonary hands-on curriculum addresses a knowledge gap for medical trainees, has been enthusiastically received by trainees, and provides a useful resource for faculty wishing to teach about these devices.

Sleep disturbance frequently affects patients with chronic obstructive pulmonary disease (COPD), and is associated with reduced quality of life and poorer outcomes. Data indicate that smokers with preserved pulmonary function have clinical symptoms similar to those meeting spirometric criteria for COPD, but little is known about the driving factors for sleep disturbance in this population of emerging interest.To compare the magnitude and correlates of sleep disturbance between smokers with preserved pulmonary function and those with airflow obstruction.Using cross-sectional data from the COPD Outcomes-Based Network for Clinical Effectiveness and Research Translation multicenter registry, we identified participants clinically identified as having COPD with a smoking history of at least 20 pack-years and either preserved pulmonary function or airflow obstruction. We quantified sleep disturbance by T-score measured in the sleep disturbance domain of the Patient-Reported Outcomes Information System questionnaire, and defined a minimum important difference as a T-score difference of two points. We performed univariate and multivariable linear regression to evaluate correlates within each group.We identified 100 smokers with preserved pulmonary function and 476 with airflow obstruction. The sleep disturbance T-score was 4.1 points greater among individuals with preserved pulmonary function (95% confidence interval [CI], 2.0-6.3). In adjusted analyses, depression symptom T-score was associated with sleep disturbance in both groups (airflow obstruction: β, 0.61 points; 95% CI, 0.27-0.94; preserved pulmonary function: β, 0.25 points; 95% CI, 0.12-0.38). Of note, lower percent predicted FEVAmong smokers with clinically identified COPD, the severity of sleep disturbance is greater among those with preserved pulmonary function compared with those with airflow obstruction. Nonrespiratory symptoms, such as depression, were associated with sleep disturbance in both groups, whereas the relationship of sleep disturbance with FEV

Background Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.