Search

The objective of this study was to determine the effect of transcatheter mitral valve repair (TMVr) on hospitalization rates by assessing pre- and postprocedural hospitalization patterns.TMVr has emerged as the treatment of choice for selected patients with mitral regurgitation, but the impact of these procedures on hospital utilization remains unclear.All patients who underwent TMVr in Ontario, Canada, between 2011 and 2017 were included in this observational study using population-based data. Hospitalization person-year rates were assessed in the years before and after TMVr and 4 predefined intervals: 1 to 30, 31 to 90, 91 to 182, and 183 to 365 days. Main outcomes of interest were all-cause and heart failure (HF) hospitalizations. Poisson regression models were used to compare incidence rates across all time periods.The study cohort included 523 patients. In the year preceding TMVr, 66.2% of patients were hospitalized compared with 47.4% in the year following. There were stepwise increases in both all-cause and HF hospitalization rates in the periods preceding the index procedure, and all postprocedural periods had significantly lower hospitalization rates. The adjusted rate ratios for all-cause and HF-related hospitalization in the year after TMVr were 0.65 (95% CI: 0.56-0.76) and 0.38 (95% CI: 0.29-0.51), respectively. All time periods had significant reductions in all-cause and HF hospitalization in the adjusted analysis.In this population-based study, significant reductions were observed in both all-cause and HF-related hospitalizations in all time periods after TMVr compared with the year prior. This suggests that TMVr has a sustained effect on hospitalization rates despite a high-risk population.

Based on the literature, 294 shoulder arthrodeses after brachial plexus injury in adults were assessed, mostly male; the mean age of the patients was 33 years, and the mean follow-up time was 5.5 years. The most common cause of injury was a traffic accident, especially on a motorcycle. Arthrodesis position ranged from 15 to 40 degrees of flexion, 15 to 60 degrees of abduction, and 0 to 50 degrees of internal rotation with the predominance of position by the 30-30-30 rule. Plates, screws, and external fixation were used for stabilization. The complication rate was at the level of 28%, the most common complication being delayed union or nonunion. Active movements of flexion and abduction averaged 61 and 56 degrees, respectively, while reaching the hand to the mouth, front pocket, and buttock was feasible for 69%, 71%, and 38%, respectively, after surgery. Shoulder pain was present in 77% of patients, and 28% experienced no relevant pain reduction after surgery. The subjective satisfaction rate was 82% based on significant improvement and satisfaction reported by patients after arthrodesis. Arthrodesis of the shoulder, in adult patients after brachial plexus palsy, can reduce shoulder pain, increase stability, and result in a range of motion that increases the possibility of carrying out everyday activities. This affects the high level of subjective patient satisfaction after surgery.Cite this article: EFORT Open Rev 2021;6:797-807. DOI: 10.1302/2058-5241.6.200114

Reinforcement learning (RL) is an attractive way to implement high-level decision-making policies for autonomous driving, but learning directly from a real vehicle or a high-fidelity simulator is variously infeasible. We therefore consider the problem of transfer reinforcement learning and study how a policy learned in a simple environment using WiseMove can be transferred to our high-fidelity simulator, W ise M ove . WiseMove is a framework to study safety and other aspects of RL for autonomous driving. W ise M ove accurately reproduces the dynamics and software stack of our real vehicle. We find that the accurately modelled perception errors in W ise M ove contribute the most to the transfer problem. These errors, when even naively modelled in WiseMove , provide an RL policy that performs better in W ise M ove than a hand-crafted rule-based policy. Applying domain randomization to the environment in WiseMove yields an even better policy. The final RL policy reduces the failures due to perception errors from 10% to 2.75%. We also observe that the RL policy has significantly less reliance on velocity compared to the rule-based policy, having learned that its measurement is unreliable.

Introduction One of the most significant challenges nowadays is to educate and predict the predispositions of young surgeons taking into consideration that every ability has its own learning curve. Aim To determine the influence of selected factors and examine the shape and the length of the learning curve in performing simple tasks on an endoscopic simulator. Material and methods Twenty students took part in 4 training sessions with a one-week break between sessions. They were training 12 min and performed three tasks at every session on the endoscopic simulator. To identify whether selected factors influence the time of completing tasks, the participants were asked to fill in questionnaires. All participants also completed the Minnesota Manual Dexterity Test (MMDT) to assess hand-eye coordination. Results Our research reveals that regardless of activities performed in free time, the shape of the learning curve was logarithmic. Improvement after the fourth session ranged from 50% to 75%. Performing specific activities in the free time did not influence the results achieved on the simulator. No statistically significant correlation between MMDT results and the time to accomplish each task was found. Conclusions This study has shown that the length of the learning curve of performing simple tasks is quite short and the shape is logarithmic. It suggests that more complex exercises should be included in the training programme.

COVID-19 (from Coronavirus Disease 2019) is an acute infectious disease of the respiratory system caused by infection with the SARS-CoV-2 virus. It was first recognized and described in December 2019. Research shows that after COVID-19, patients experience fatigue, shortness of breath, neuropsychological symptoms and neurological symptoms. In the presented article, the study aims to evaluate the effectiveness of the orginal training program in improving the patient’s endurance, strength and balance after recovering from COVID-19.

The Multilevel Educational and Motivational Intervention in Patients after Myocardial Infarction (MEDMOTION) project will be adopted to support adherence to the study treatment in the Evaluation Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome (ELECTRA-SIRIO 2) a randomized clinical trial. A prespecified sub-analysis of the ELECTRA-SIRIO 2 trial will be performed to evaluate the impact of the results of MEDMOTION diagnostic questionnaires on the clinical outcomes. The study population will comprise of 4,500 patients consecutively admitted to the study centres due to acute coronary syndrome. The MEDMOTION project involves the following interventions: patients’ education, motivation, reminding to take medications and to attend consecutive medical appointments. Dedicated questionnaires will be applied to diagnose study participants with regard to their readiness for discharge from the hospital at the end of initial hospitalization, the risk of non-adherence to the medication at the end of 3rd and 12th month of follow up, and the functioning in disease at the end of 3rd and 12th month of follow up. The primary safety composite endpoint of this study is type 2, 3 or 5 bleeding according to the BARC criteria, occurring during the first 12 months after ACS. The primary efficacy endpoint is the composite of death from any cause, the first nonfatal MI, or the first nonfatal stroke. The key secondary endpoint, net clinical effect, was defined as the composite of death from any cause, a nonfatal MI or a nonfatal stroke, and the first occurrence of BARC type 2, 3, or 5 bleeding. Concluding, it is expected that the comprehensive approach designed in the MEDMOTION project, including use of diagnostic questionnaires, will significantly contribute to obtaining a high level of adherence to medication and improving clinical outcomes in the ELECTRA-SIRIO 2 trial.

The Canadian Adverse Driving Conditions (CADC) dataset was collected with the Autonomoose autonomous vehicle platform, based on a modified Lincoln MKZ. The dataset, collected during winter within the Region of Waterloo, Canada, is the first autonomous driving dataset that focuses on adverse driving conditions specifically. It contains 7,000 frames of annotated data from 8 cameras (Ximea MQ013CG-E2), lidar (VLP-32C), and a GNSS+INS system (Novatel OEM638), collected through a variety of winter weather conditions. The sensors are time synchronized and calibrated with the intrinsic and extrinsic calibrations included in the dataset. Lidar frame annotations that represent ground truth for 3D object detection and tracking have been provided by Scale AI.

Background Upper extremity injuries have a significant impact on social and professional life. They represent about 10% of visits to emergency departments. Nerve lacerations are one of the biggest problem because loss of innervation results in muscle atrophy, decreased sensibility, and therefore permanent dysfunction. Appropriate treatment is very important for patients to regain function. Materials and Methods The study included 41 patients, 30 men and 11 women who underwent nerve repair surgery in the middle and distal forearm level in the years 2001–2017. The patients’ age ranged from 9 to 73 years with an average of 37 years. They were divided into 3 groups with repaired median, ulnar and both nerves. We determined time from injury to nerve repair, assessed sensitivity in index and little finger with a two-point discriminator, and muscle strength by measuring adduction of the little finger and palmar abduction of the thumb.Results were rated based on Medical Research Council Scale (MRC). In addition, general hand disability was assessed according to the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH). Results There was a statistically significant (p = 0.0197), positive correlation (r > 0) between the period from injury to surgery and the DASH score, and statistically significant difference (p = 0.0001) in return of muscular function between groups with median, ulnar and both nerves injury. Also correlation between patients age and score of DASH was statistically significant (p = 0.0140) with positive correlation (r > 0). There was no statistically significant difference in the return of sensitivity (p = 0.4337) and the DASH score (p = 0.3831) between these three groups. Conclusions Patients with shorter time from injury to repair and at a younger age had better DASH results. The median nerve had the best motor function between the groups. There was no difference in sensitivity or DASH scores between groups.

In order to identify the attitudes of consumers towards innovative food products, including functional foods, qualitative research was carried out in 2019 to find out what are the components of these attitudes in relation to innovative food, on the example of functional food, in the conditions of the growing global tendency to care for health and convenience. As a result of the research carried out using the focus group interview (FGI) methodology, it was found that innovative food is associated with a new taste or packaging, increased nutritional value, as well as health related attributes. Often, in studies, consumers also referred to the reduction or complete elimination of allergenic ingredients and other chemical ingredients, e.g. preservatives, flavor enhancers. Consumers accept these innovations in different ways, generally showing skepticism about “improving” food by enriching it with various ingredients, while positively referring to changes related to the reduction in the content of nutrients considered harmful to health, e.g. fat, sugar or salt. It was also noted that innovativeness treated as a personality trait is accompanied by such features as: openness, tolerance, optimism, life satisfaction, while people lacking tendency to accept innovation are usually pessimistic about the world, attached to tradition or thrifty. It was also noted that consumers similarly perceive innovative and functional food, indicating that functional products are food with a specific health purpose, with a modified composition. The interviewees also indicated that it is possible to increase the interest of consumers in purchasing new food products or functional food through, inter alia, well targeted marketing messages, and it is necessary to take into account the legal regulations regarding their wording when formulating them. This applies in particular to the possibility of using nutrition and health claims in the case of products enriched with ingredients with a declared health-related effect.

This article presents an analysis of the formation of organized interest groups in the post-communist context and organizational populations over time. We test two theories that shed doubt on whether vital rates of interest groups are explained by individual incentives, namely, the political opportunity structure and population ecology theory. Based on an analysis of the energy policy and higher education policy organizations active at the national level in Hungary, Poland, and Slovenia, we find that while the period of democratic and economic transition indeed opened up the opportunity structure for organizational formations, it by no means presented a clean slate. Communist-era successor and splinter organizations survived the collapse of communism, and all three countries entered transition with relatively high density rates in both organizational populations. We also find partial support for the density dependence hypothesis. Surprisingly, the EU integration process, the intensity of legislative activity, and media attention do not seem to have meaningfully influenced founding rates in the two populations.

Emergency department cesarean section for placental abruption is an uncommon surgical procedure that requires anticipation in the prehospital environment as well as preemptive recognition of impending fetal demise by the emergency physician. The presence of an obstetrician ready to perform immediate cesarean section on an unstable patient with placental abruption may be lifesaving for both the mother and the fetus. However, there are no specific guidelines for prehospital recognition of patients with placental abruption that require emergency cesarean section. While the emergency department is not the optimum surgical theatre for an emergency cesarean section, placental abruption often deteriorates so quickly that even a few minutes of delay can have catastrophic consequences for both mother and fetus. We describe a case of placental abruption following moderate motor vehicular trauma in an eight month pregnant woman whose only complaint was moderate abdominal pain. The emergency physician’s suspicion based on the mechanism of injury caused her to mobilize the obstetrician, who was ready to perform an emergency department cesarean section with successful delivery of the fetus. Subsequent managing of the mother’s surgical incision and coagulopathy was performed in the operating room. This case highlights the importance of vigilance that prehospital providers, emergency department physicians, and obstetricians should have for a pregnant patient involved in a motor vehicle crash.

Cloud computing has rapidly become a viable competitor to on-premise infrastructure from both management and cost perspectives. This research provides insight into cluster computing performance and variability in cloud-provisioned infrastructure from two popular public cloud providers. A comparative examination of the two cloud platforms using synthetic benchmarks is provided. In this article, we compared the performance of Amazon Web Services Elastic Compute Cluster (EC2) to the Google Cloud Platform (GCP) Compute Engine using three benchmarks: STREAM, IOR, and NPB-EP. Experiments were conducted on clusters with increasing nodes from one to eight. We also performed experiments over the course of two weeks where benchmarks were run at similar times. The benchmarks provided performance metrics for bandwidth (STREAM), read and write performance (IOR), and operations per second (NPB-EP). We found that EC2 outperformed GCP for bandwidth. Both provided good scalability and reliability for bandwidth with GCP showing a slight deviation during the two-week trial. GCP outperformed EC2 in both the read and write tests (IOR) as well as the operations per second test. However, GCP was extremely variable during the read and write tests over the two-week trial. Overall, each platform excelled in different benchmarks and we found EC2 to be more reliable in general.

The central scene of Adam Mickiewicz’s historic tale Konrad Wallenrod [Konrad Wallenrod] (canto IV) is, diegetically speaking, a singing contest. Its poetic presentation is deeply anchored in Homeric, Pauline, and Troubadour traditions of agon intended both as musicopoetic rivalry and as spiritual struggle. What is at stake here are identities: Konrad-Alf’s national/moral identity on the one hand, and the poem’s medial identity (literary/musical) on the other. Walterscottian stylisation used here by Mickiewicz is typically taken to neutralise the text’s overt and covert musical genetic self-identifications, which make up for the text’s self-presentation as a song to be “sung in the tender reader’s soul” (VI, in fine). The division of the work into musical numbers, with a variety of genres represented (hymn, different types of song, tale, ballad), is notoriously ignored. Critics take such musical paratextes as mere signs of historical convention, taking Mickiewiczian “singing” to be a dead metaphor for “storytelling in verse”, sometimes going so far as to misread or misquote the last lines of the source text. The present paper challenges this common anti-musical interpretation, thus shedding new light on Wallenrod’s contest ballad “Alpuhara” [“Alpuhara”] and its disturbing musical shape.

The purpose of this study is to outline a new approach to the comparative analysis of student finance systems based on social rights, an approach widely applied in other areas of social policy. It ...

Introduction. Physical activity is known to be an important factor influencing health throughout human life. This issue has become crucial for public health due to the aging of the population in both developed and developing countries. Aim. is to present a literature review on the forms of physical activity undertaken by the elderly, as well as on issues related to physical activity and the population aging. Material and methods. The study was prepared on the basis of a review of Polish and foreign literature. The following databases and data sources were used: EBSCO, ScienceDirect and Google Scholar. An additional source of data were the websites of the Central Statistical Office. Strictly defined key phrases were used during the collection of literature. The work has been divided into thematic subsections on the aging of the society, the impact of physical activity on health and the main topic, i.e. forms of physical activity selected by the elderly. Analysis of the literature. The number of elderly people in Polish society has increased by almost 3.7 million over three decades. Therefore, an important topic is prophylaxis aimed at increasing the number of days in good health, largely covering the broadly understood activation of the elderly. The available data indicate that only 12% of elderly people undertake physical activity once a week. The most common form of spending free time actively is walking (as many as 73% of people in this population declare this form of physical activity in one of the presented studies). Conclusion. Organized forms of physical activity are undertaken much less frequently by the analyzed age group mainly due to financial limitations and limited availability of sports infrastructure.

The complexity of a vast number of real world tasks provides a great challenge for the currently available robots due to their limited capabilities. Thus, multiple robots would need to form...

Rising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians.We used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences.At baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores-7.4% and 7.6%, respectively (P.001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation.We found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.

Plastic waste poses an ecological challenge1. While current plastic waste management largely relies on unsustainable, energy-intensive, or even hazardous physicochemical and mechanical processes, enzymatic degradation offers a green and sustainable route for plastic waste recycling2. Poly(ethylene terephthalate) (PET) has been extensively used in packaging and for the manufacture of fabrics and single-used containers, accounting for 12% of global solid waste3. The practical application of PET hydrolases has been hampered by their lack of robustness and the requirement for high processing temperatures. Here, we use a structure-based, deep learning algorithm to engineer an extremely robust and highly active PET hydrolase. Our best resulting mutant (FAST-PETase: Functional, Active, Stable, and Tolerant PETase) exhibits superior PET-hydrolytic activity relative to both wild-type and engineered alternatives, (including a leaf-branch compost cutinase and its mutant4) and possesses enhanced thermostability and pH tolerance. We demonstrate that whole, untreated, post-consumer PET from 51 different plastic products can all be completely degraded by FAST-PETase within one week, and in as little as 24 hours at 50 °C. Finally, we demonstrate two paths for closed-loop PET recycling and valorization. First, we re-synthesize virgin PET from the monomers recovered after enzymatic depolymerization. Second, we enable in situ microbially-enabled valorization using a Pseudomonas strain together with FAST-PETase to degrade PET and utilize the evolved monomers as a carbon source for growth and polyhydroxyalkanoate production. Collectively, our results demonstrate the substantial improvements enabled by deep learning and a viable route for enzymatic plastic recycling at the industrial scale.

Modernist planners were given the opportunity to apply the idea of the Modern Movement in the implementation of cities transforming after the World War II blitz, which was not possible before in long-term evolving structures. However, they could not alter everything: some urban and even architectural elements were necessary to be preserved. As a result, the elements of the ancient landscapes of these cities—historical objects and spaces—necessary for the continuity of evidence of history and identity were preserved, often being completely reconstructed. Finally, in some of these cities, both old and new elements contribute to the contemporary urban landscape. The aim of the research is to examine two key categories of urban structure in this perspective: (1) architectural dominants (landmarks) and (2) urban network nodes. For this purpose, (1) the changes in the number and rank of the spaces through which the landmarks expositions were carried out are compared, and (2) the changes in the rank of nodes in the urban structure, both these in the pre-war and in the present structures, as well as changes in their distribution and concentration areas are analyzed. The number of individual elements is compared and the changes in the structure of their arrangement are analyzed with the use of a polygon grid. A medium-scale European city (Bialystok) is used as the case study. Results of our analysis indicate that the post-war reconstruction led to a decrease in the number of elements of the urban grid (streets, nodal points), especially those of low rank. The rank of many others also decreased: 57% of all nodal points within the historical grid of the selected area does not exist in the post-war structure. The number of main rank directions of exposition decreased by 18% and in the subordinate group by 38%. The research is an attempt to construct a new criteria of evaluating changes in the quality of the cityscape, which is described in the article.

The radiometric quality of remotely sensed imagery is crucial for precision agriculture applications because estimations of plant health rely on the underlying quality. Sky conditions, and specifically shadowing from clouds, are critical determinants in the quality of images that can be obtained from low-altitude sensing platforms. In this work, we first compare common deep learning approaches to classify sky conditions with regard to cloud shadows in agricultural fields using a visible spectrum camera. We then develop an artificial-intelligence-based edge computing system to fully automate the classification process. Training data consisting of 100 oblique angle images of the sky were provided to a convolutional neural network and two deep residual neural networks (ResNet18 and ResNet34) to facilitate learning two classes, namely (1) good image quality expected, and (2) degraded image quality expected. The expectation of quality stemmed from the sky condition (i.e., density, coverage, and thickness of clouds) present at the time of the image capture. These networks were tested using a set of 13,000 images. Our results demonstrated that ResNet18 and ResNet34 classifiers produced better classification accuracy when compared to a convolutional neural network classifier. The best overall accuracy was obtained by ResNet34, which was 92% accurate, with a Kappa statistic of 0.77. These results demonstrate a low-cost solution to quality control for future autonomous farming systems that will operate without human intervention and supervision.

This essay examines life writing by English author Virginia Woolf (1882-1941) and Yankton Dakota writer Zitkala-Ša (1876-1938), specifically Woolf’s memoir, “A Sketch of the Past,” written in 1939-40 and first published in Moments of Being in 1976, and Zitkala-Ša’s autobiographical essays, published in the Atlantic Monthly in 1900. This comparative study explores how both women establish selfhood amid competing pressures vying for their minds and bodies; how mothers and maternal loss shape their autobiographies; how physical and psychological place and displacement influence their life writing; and how matters of audience affect their literary self-portraits. Reading Woolf and Zitkala-Ša together yields fresh insights into the intersections of race, class, gender, and feminism in women’s writing. Este ensaio examina as escritas de si da autora inglesa Virginia Woolf (1882-1941) e da escritora Yankton Dakota Zitkala-Ša (1876-1938), especificamente o memoir de Woolf, "A Sketch of the Past", escrito em 1939-40 e publicado pela primeira vez em Moments of Being, em 1976, e os ensaios autobiográficos de Zitkala-Ša, publicados no Atlantic Monthly em 1900. Este estudo comparativo explora como ambas as mulheres estabelecem suas individualidades em meio a pressões concorrentes que competem por suas mentes e corpos; como a figura de suas mães e a perda materna moldam suas autobiografias; como lugares físicos e psicológicos e o deslocamento influenciam suas escritas de si; e como questões relativas ao público leitor afetam seus autorretratos literários. Ler Woolf e Zitkala-Ša juntas produz novos insights sobre as interseções de raça, classe, gênero e feminismo na escrita das mulheres.

PURPOSE 131I-metaiodobenzylguanidine (MIBG) is an active radiotherapeutic for neuroblastoma. The primary aim of this trial was to identify which of three MIBG regimens was likely associated with the highest true response rate. PATIENTS AND METHODS Patients 1-30 years were eligible if they had relapsed or refractory neuroblastoma, at least one MIBG-avid site, and adequate autologous stem cells. Patients received MIBG 18 mCi/kg on day 1 and autologous stem cell on day 15. Patients randomly assigned to arm A received only MIBG; patients randomly assigned to arm B received intravenous vincristine on day 0 and irinotecan daily on days 0-4; patients randomly assigned to arm C received vorinostat (180 mg/m2/dose) orally once daily on days 1 to 12. The primary end point was response after one course by New Approaches to Neuroblastoma Therapy criteria. The trial was designed with 105 patients to ensure an 80% chance that the arm with highest response rate was selected. RESULTS One hundred fourteen patients were enrolled, with three ineligible and six unevaluable, leaving 105 eligible and evaluable patients (36 in arm A, 35 in arm B, and 34 in arm C; 55 boys; and median age 6.5 years). After one course, the response rates (partial response or better) on arms A, B, and C were 14% (95% CI, 5 to 30), 14% (5 to 31), and 32% (18 to 51). An additional five, five, and four patients met New Approaches to Neuroblastoma Therapy Minor Response criteria on arms A, B, and C, respectively. On arms A, B, and C, rates of any grade 3+ nonhematologic toxicity after first course were 19%, 49%, and 35%. CONCLUSION Vorinostat and MIBG is likely the arm with the highest true response rate, with manageable toxicity. Vincristine and irinotecan do not appear to improve the response rate to MIBG and are associated with increased toxicity.

Rationale: Patients with COVID-19 critical illness are at high risk for multiorgan dysfunction, most commonly acute kidney injury (AKI). We sought to characterize the rates of thrombotic and hemorrhagic complications in patients with COVID-19 ARDS as a function of coexisting AKI. Methods: We performed a single-center retrospective analysis of all patients with severe COVID-19 infection, admitted to ICU level of care between 3/1/2020 and 6/1/2020, and we obtained patient data through the Research Patient Data Registry. We excluded patients who did not develop AKI, those who were admitted with a primary medical problem unrelated to coexisting COVID-19 infection, and those with end stage renal disease. We stratified patients into two cohorts: Those with AKI not requiring renal replacement therapy (RRT) and AKI requiring RRT. All data collection was approved by the IRB at Mass General Brigham (IRB #2020P001674). All data was analyzed using Excel and R version 4.0.1 (2020-06-06) when comparing groups-medians and interquartile ranges are reported. Pearson's Chi-squared test was used during statistical analysis. Results: 272 patients were identified, of which 136 patients were excluded from further study due to reasons as above. Of the remaining 136 patients analyzed, all developed AKI as per AKIN criteria, and we identified those who did not require RRT (100), and those who were initiated on RRT (36). Median age was 66 ± 9.75, and 57 ± 7.12, respectively. 38% (38/100) and 27.7% (10/36) were female, respectively. Complications investigated included non-cerebrovascular hemorrhage (17% vs. 38.88%, p 0.014), cerebrovascular hemorrhage (4% vs. 16.66%, p 0.033), thromboembolic phenomena (24% vs 38.8%, p 0.136) and overall ICU Mortality (48% vs 38.8%, p 0.45). Conclusions: Patients with COVID-19 ARDS and associated AKI had a high number of hemorrhagic and thromboembolic complications. There is a higher incidence of hemorrhagic and thromboembolic complications in the AKI-RRT group, with CVA-and non-CVAhemorrhagic complications being statistically significant. Overall ICU mortality was apparently lower in the AKIRRT group, without reaching statistical significance. Our data highlight a clinically most relevant topic, defining COVID-19 patients with AKI as a high-risk population for thromboembolic and hemorrhagic complications, and underlining the importance of careful decisions regarding prophylactic anticoagulant strategies.

Introduction:Acute kidney injury (AKI) is a common complication in critically ill patients and has been extremely common during the 2020 COVID-19 pandemic in patients admitted to the adult intensive care unit with severe viral pneumonia and acute respiratory distress syndrome. We investigated the incidence and outcomes of AKI in this population comparing the COVID-19 pandemic to the H1N1 pandemic of 2009. Methods: We performed a single-center retrospective analysis of all patients with severe COVID-19 infection, admitted to ICU level of care between 3/1/2020 and 6/1/2020 and we obtained patient data via the research patient data registry. We excluded patients who were admitted with a complaint unrelated to their COVID-19 infection and patients with end-stage renal disease. We stratified patients based on presence of AKI and further stratified the AKI group for the need for Renal Replacement Therapy (RRT). All data collection was approved by the IRB at Mass General Brigham (IRB #2020P001674). All data was analyzed using Excel and R version 4.0.1 (2020-06-06). When comparing groups, medians and interquartile ranges are reported. Wilcoxon Rank Sum test was used for statistical analysis. Results: 272 patients were identified of which 31 patients were excluded from further study due to reasons as above. The remaining 241 patients were analyzed, and the median age was 64 (52-72) with, 40.6% females. 79.6% (192) of patients were Intubated with a median lowest PaO2/FiO2 ratio of 124 (91.4-177.5).105/241 (43.5%) did not develop AKI and 136/241 (56.4%) developed AKI, of which 36 had AKI requiring RRT. Patients with AKI had a higher length of hospitalization (20 ± 10.75 vs 15 ± 8.5, p 0.055), Increased pressor days (11 ± 9 vs 4 ± 6.5, P

Bone conduction implants based on percutaneous abutment acoustic transmission have been implemented in patients with satisfactory outcomes. However, adverse soft tissue outcomes present a limitation. Transcutaneous bone conduction devices (t-BCDs) are an alternative that may mitigate these complications. A retrospective review was performed of patients who underwent implantation of a t-BCD from 2013 to 2017. Surgical outcomes were reviewed including wound complications, frequency of device use, patient concerns regarding the device, and reported patient satisfaction. A total of 37 patients were implanted with the bone-anchored hearing aids, BAHA Attract (Cochlear™ Baha® Implant System). Average follow-up time was 271.8 days. Postoperatively, 7 (18.9%) patients complained of soft tissue changes or issues with wound healing. Twelve (32.4%) patients requested adjustment of their devices. The t-BCD is an excellent option for hearing rehabilitation. Overall, the complication rate is low, patient satisfaction is high, and successful conversion from a percutaneous device is possible with minimal risk.

Background Pain management is essential for the care of hospitalized children. Although multiple barriers have been identified that interfere with nurses' ability to provide optimal pain management, it is not known how pervasive are these barriers across the United States. Aims This study is the third in a series of studies examining barriers to pediatric pain management. The aim of this study was to examine barriers in different organizations using the same tool during the same period of time. Settings/Participants A sample of 808 nurses from three pediatric teaching hospitals responded to a survey addressing barriers to optimal pain management for children. Results Barriers unanimously identified as being most significant included inadequate or insufficient physician medication orders, insufficient time allowed to premedicate before procedures, insufficient premedication orders before procedures, and low priority given to pain management by medical staff. Conclusions Barriers identified as the most and least significant were similar regardless of hospital location. Revealing similar barriers across multiple pediatric hospitals provides direction for nurses trying to provide solutions to these pain management barriers.

The reinforcement learning (RL) community has made great strides in designing algorithms capable of exceeding human performance on specific tasks. These algorithms are mostly trained one task at the time, each new task requiring to train a brand new agent instance. This means the learning algorithm is general, but each solution is not; each agent can only solve the one task it was trained on. In this work, we study the problem of learning to master not one but multiple sequentialdecision tasks at once. A general issue in multi-task learning is that a balance must be found between the needs of multiple tasks competing for the limited resources of a single learning system. Many learning algorithms can get distracted by certain tasks in the set of tasks to solve. Such tasks appear more salient to the learning process, for instance because of the density or magnitude of the in-task rewards. This causes the algorithm to focus on those salient tasks at the expense of generality. We propose to automatically adapt the contribution of each task to the agent’s updates, so that all tasks have a similar impact on the learning dynamics. This resulted in state of the art performance on learning to play all games in a set of 57 diverse Atari games. Excitingly, our method learned a single trained policy - with a single set of weights - that exceeds median human performance. To our knowledge, this was the first time a single agent surpassed human-level performance on this multi-task domain. The same approach also demonstrated state of the art performance on a set of 30 tasks in the 3D reinforcement learning platform DeepMind Lab.

How do caregivers make decisions about participating in morally contested care, such as abortion? Debates about conscience in the delivery of health care generally assume that participation decisions stem from religious beliefs and moral values. Few studies have examined this question in the context of everyday practice. Drawing on 50 interviews with the staff of a labor and delivery unit offering abortion care including nurses, maternal fetal medicine specialists, obstetrics and gynecology residents, and anesthesiologists we show that respondents have varied definitions of "participation" in abortion care and that participation decisions are driven by an array of factors beyond personal beliefs. We present a conceptual model of "moral work" that shows conscience to be an emerging, iterative process influenced not only by beliefs religious and non-religious but also by personal and work experiences and social and institutional contexts. Our study brings new insights into understanding conscience and participation in contested care.