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Background and aims Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. Methods A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access . Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. Results Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. Conclusions In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Funding: J.H.D. was funded by the Irish Research Council Enterprise Partnership Scheme, supported by the Petroleum Infrastructure Program. Field work on Little Saltee in 2018 and 2019 and S.d.G. were funded by the BlueFish project, funded by the European Regional Development fund through the Ireland Wales Cooperation Programme 2014−2020. Fieldwork on Eynhallow and St. Kilda was supported by Orkney Islands Council, the University of Aberdeen, the National Trust for Scotland and Talisman Energy (UK) Ltd. E.W.J.E. was funded by a Marine Alliance for Science and Technology for Scotland and University of Aberdeen studentship. Fieldwork elsewhere was funded by the EU Atlantic area INTERREG program via the Future of the Atlantic Marine Environment (FAME) project and by the RSPB, JNCC, Fair Isle Bird Observatory Trust and Marine Scotland, through the Seabird Tracking And Research (STAR) project. G.E.A. was funded by the MarPAMM project supported by the EU INTERREG VA Programme, managed by the Special EU Programmes Body (SEUPB). Habitat-use and distribution models are essential tools of conservation biology. For wide-ranging species, such models may be challenged by the expanse, remoteness and variability of their habitat, these challenges often being compounded by the species' mobility. In marine environments, direct observations and sampling are usually impractical over broad regions, and instead remotely sensed proxies of prey availability are often used to link species abundance or foraging behaviour to areas that are expected to provide food consistently. One source of food consumed by many marine top predators is fisheries waste, but habitat-use models rarely account for this interaction. We assessed the utility of commercial fishing effort as a covariate in foraging habitat models for northern fulmars Fulmarus glacialis, a species known to exploit fisheries waste, during their summer breeding season. First, we investigated the prevalence of fulmar-vessel interactions using concurrently tracked fulmars and fishing vessels. We infer that over half of our study individuals associate with fishing vessels while foraging, mostly with trawl-type vessels. We then used hidden Markov models to explain the spatio-temporal distribution of putative foraging behaviour as a function of a range of covariates. Persistent commercial fishing effort was a significant predictor of foraging behaviour, and was more important than commonly used environmental covariates retained in the model. This study demonstrates the effect of commercial fisheries on the foraging distribution and behaviour of a marine top predator, and supports the idea that, in some systems, incorporating human activities into distribution studies can improve model fit substantially. Publisher PDF

Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.

Background: Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. Aim: The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. Settings and participants: We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person’s hospitalization in which they died. Results: Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. Conclusions: Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Predicting the distribution and behaviour of animals is a fundamental objective in ecology and a cornerstone of conservation biology. Modelling the distribution of ocean-faring species like seabirds remains a significant challenge due to ocean dynamics, colony-specific effects and the vast ranges seabirds can cover. We used a spatial and behavioural approach to model the distribution of the Manx shearwater Puffinus puffinus, a pelagic, central-place forager that can cover great distances while foraging. GPS data from birds tagged in 2 colonies over 3 yr were modelled with a range of environmental predictors of marine productivity. For both colonies, transitions to foraging behaviour correlated with chlorophyll a, and the distribution of foraging behaviour was also associated with areas of high chlorophyll a concentration in coastal but not offshore areas for one colony. Furthermore, there was evidence for colony differences in habitat use, prevalence of nocturnal foraging, and for some competitive exclusion on foraging grounds, even though the colonies were 170 km apart. Despite the extensive dataset, our models had modest predictive power, which we suggest can probably only be improved by including biotic interactions, including more direct measures of food resource distribution. Our results highlight the importance of including spatial complexity and data from multiple sites when predicting the distribution of wide-ranging predators, because patterns of distribution and habitat use likely differ across the range of a population.

Type I interferon (IFN-I) and T helper 17 (TH17) drive pathology in neuromyelitis optica spectrum disorder (NMOSD) and in TH17-induced experimental autoimmune encephalomyelitis (TH17-EAE). This is paradoxical because the prevalent theory is that IFN-I inhibits TH17 function. Here we report that a cascade involving IFN-I, IL-6 and B cells promotes TH17-mediated neuro-autoimmunity. In NMOSD, elevated IFN-I signatures, IL-6 and IL-17 are associated with severe disability. Furthermore, IL-6 and IL-17 levels are lower in patients on anti-CD20 therapy. In mice, IFN-I elevates IL-6 and exacerbates TH17-EAE. Strikingly, IL-6 blockade attenuates disease only in mice treated with IFN-I. By contrast, B-cell-deficiency attenuates TH17-EAE in the presence or absence of IFN-I treatment. Finally, IFN-I stimulates B cells to produce IL-6 to drive pathogenic TH17 differentiation in vitro. Our data thus provide an explanation for the paradox surrounding IFN-I and TH17 in neuro-autoimmunity, and may have utility in predicting therapeutic response in NMOSD., Type I IFN has apposing effects in neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS). Here the authors perform molecular profiling of NMOSD patients and mouse mechanistic experiments of neuro-inflammation to show that IFN-I stimulates pathogenic Th17 via IL-6 production by B cells.

Background When students with intellectual disability (ID) experience pain, the pain may limit the extent to which they may engage in school activities. Although school nurses are primarily responsible for addressing students’ pain, there are many barriers to identifying pain in students with ID. Aims The purpose of the present study was to describe pain assessment practices of school nurses for students with and without ID. Design A retrospective review was conducted of 4,660 school health office visit records for elementary school students presenting to the health office with headache, stomachache, or sore throat. Methods Data were extracted and transcribed to a matrix. Data extracted included school grade, referral source, visit month, gender, cognitive ability, chief concern, pain assessment, external contact, and disposition. Descriptive statistics were calculated. Results School nurses spent more time on average addressing pain in neurotypical students than in students with ID. Neurotypical students more often presented with a teacher and were dismissed from school, but parents and guardians were contacted less often for these students, when compared to students with ID. Quantified pain ratings were documented for 1% of visits. Conclusions Because pain intensity ratings were rarely documented, the utility of such ratings in the school setting may be low. Alternatively, obtaining pain intensity ratings from younger children may be challenging without the use of appropriate tools. Nurses, teachers, and other staff providing education and care to students with ID may require pain training. Implementation of tools that elicit student pain information from parents/guardians in the school setting could decrease point-of-care contact during the school day and proactively provide information on unique child pain behaviors.

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of − $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Aims The national PrEP programme launched in Ireland in November 2019 with tenofovir/emtricitabine free to those meeting eligibility criteria. We assessed the impact of the first year of the PrEP programme on new HIV diagnoses in the largest sexual health and HIV service in Ireland. Methods A free PrEP service was established in November 2019. We reviewed the number of new diagnoses of HIV between November 2018–2019, before the introduction of the national PrEP programme and compared this with the number of new HIV diagnosis between November 2019–2020. Results There were 95 new HIV diagnoses (63.3% MSM) between November 2018 and 2019 and 73 new HIV diagnoses (65.7% MSM) between November 2019 and 2020. There was a statistically significant decline in new HIV diagnoses between the 2 years ( P = 0.0003). 546 patients were prescribed PrEP as of December 2020.106 patients (19.4%) changed their PrEP dosing regimen due to lockdown. 178 individuals (32.6%) had a rectal infection diagnosed. Conclusion There has been a reduction in new HIV diagnoses in our cohort (although this has occurred during a global pandemic). It is too early to say if PrEP reduces late presentations of HIV based on our findings. A significant number of rectal infections were identified in the PrEP clinic suggesting ongoing risk despite pandemic restrictions. Further research into sexual practices during COVID-19 is needed to assess if this had an impact on the lower rates of HIV acquisition.

Background: Phosphorodiamidate morpholino oligomer (PMO)-mediated exon skipping is currently used in clinical development to treat Duchenne muscular dystrophy (DMD), with four exon-skipping drugs achieving regulatory approval. Exon skipping elicits a truncated, but semi-functional dystrophin protein, similar to the truncated dystrophin expressed in patients with Becker Muscular dystrophy (BMD) where the disease phenotype is less severe than DMD. Despite promising results in both dystrophic animal models and DMD boys, restoration of dystrophin by exon skipping is highly variable, leading to contradictory functional outcomes in clinical trials. Objective: To develop optimal PMO dosing protocols that result in increased dystrophin and improved outcome measures in preclinical models of DMD. Methods: Tested effectiveness of multiple chronic, high dose PMO regimens using biochemical, histological, molecular, and imaging techniques in mdx mice. Results: A chronic, monthly regimen of high dose PMO increased dystrophin rescue in mdx mice and improved specific force in the extensor digitorum longus (EDL) muscle. However, monthly high dose PMO administration still results in variable dystrophin expression localized throughout various muscles. Conclusions: High dose monthly PMO administration restores dystrophin expression and increases muscle force; however, the variability of dystrophin expression at both the inter-and intramuscular level remains. Additional strategies to optimize PMO uptake including increased dosing frequencies or combination treatments with other yet-to-be-defined therapies may be necessary to achieve uniform dystrophin restoration and increases in muscle function.

Purpose To prospectively evaluate interobserver agreement for small bowel ultrasound (SBUS) in newly diagnosed and relapsing Crohn’s disease. Methods A subset of patients recruited to a prospective trial comparing the diagnostic accuracy of MR enterography and SBUS underwent a second SBUS performed by one of a pool of six practitioners, who recorded the presence, activity and location of small bowel and colonic disease. Detailed segmental mural and extra-mural observations were also scored. Interobserver variability was expressed as percentage agreement with a construct reference standard, split by patient cohort, grouping disease as present or absent. Prevalence adjusted bias adjusted kappa (PABAK), and simple percentage agreement between practitioners, irrespective of the reference standard, were calculated. Results Thirty-eight patients (11 new diagnosis, 27 relapse) were recruited from two sites. Overall percentage agreement for small bowel disease presence against the consensus reference was 82% (52–95% (95%CI)), kappa coefficient (κ) 0.64, (substantial agreement) for new diagnosis and 81%, κ 0.63 (substantial agreement) for the relapsing cohort. Agreement for colonic disease presence was 64%, κ 0.27 (fair agreement) in new diagnosis and 78%,κ 0.56 (moderate agreement) in the relapsing cohort. Simple agreement between practitioners was 84% and 87% for small bowel and colonic disease presence respectively. Practitioners agreed on small bowel disease activity in 24/27 (89%) where both identified disease. Kappa agreement for detailed mural observations ranged from κ 0.00 to 1.00. Conclusion There is substantial practitioner agreement for small bowel disease presence in newly diagnosed and relapsing CD patients, supporting wider dissemination of enteric US.

Primary dural diffuse large B-cell lymphoma (PD-DLBCL) is a rare and aggressive B-cell non-Hodgkin lymphoma (NHL) that can present in intracranial or intraspinal locations. While the optimal management is unknown, PD-DLBCL therapy is often mirrored after primary central nervous system lymphoma (PCNSL) therapy and aggressive treatment with a high dose Methotrexate (MTX)-based regimen is frequently used. Our comprehensive, retrospective study of 24 reported cases of PD-DLBCL provide the most complete analysis of this rare disease including data on biology, treatment outcomes and survival. Our findings demonstrate good outcomes following induction treatment with R-CHOP, suggesting that these cases can be treated as DLBCL rather than PCNSL, obviating the need for more aggressive and toxic approaches. The durable responses following R-CHOP also confirm that PD-DLBCL is not protected by the blood brain barrier. Data in this paper were presented in part at the 2017 American Society of Hematology Annual Meeting, abstract # 4166.

The frequency and consequences of bullying directed at school nurses (SNs) are poorly understood. The purpose of this study was to describe the prevalence and impact of bullying directed at school nurses, determine predictors of bullying directed at school nurses, and evaluate the individual and organizational impact of exposure to bullying directed at school nurses. School nurses ( n = 334) completed an online survey comprised of the Negative Act Questionnaire–Revised, Perceived Stress Scale, National Institute for Occupational Safety and Health General Social Survey 2010 Quality of Worklife Module, Michigan Organizational Assessment Questionnaire, and open response items to determine their experiences with, and impact of, bullying. Descriptive and inferential statistics were calculated for quantitative data, while content analysis was used to analyze responses to open-ended survey items. One third of participants reported occasional or frequent bullying. Content analysis revealed three themes, including unexpected parent behavior, staff incivility, and formal reporting. Findings support the development of an educational intervention to assist school nurses in the prevention and management of bullying exposure.

Background Challenges still exist in differentiating pancreatic adenocarcinoma from benign disease. The use of adjuvant testing of tissue biopsies has demonstrated potential diagnostic value. We designed a proof of concept study to first validate four individual immunohistochemistry biomarkers and then combine them into a panel to boost overall diagnostic sensitivity. Methods Malignant and benign pancreas from 27 pancreaticoduodenectomy specimens underwent immunohistochemistry staining with VHL, IMP3, S100A4, S100P. Using ROC curve analysis, threshold criteria for number of cells staining were chosen for each biomarker. Biomarkers were then evaluated as a panel for their ability to discriminate malignant from benign specimens. Results Diagnostic sensitivity of VHL, IMP3, S100A4, and S100P were 75.0%, 79.2%, 45.8%, and 0%. When VHL, IMP3, and S100A4 were grouped into a panel, they were able to distinguish cancer from normal tissue with a sensitivity of 100% and a specificity of 96%. Conclusions The high diagnostic value of an IHC panel consisting of VHL, IMP3, and S100A4 on surgical specimens suggests the need for future prospective studies of these biomarkers on biopsy specimens.

Purpose Undergraduate nursing faculty face challenges when teaching pediatric clinicals. Changes to pediatric care and hospital admissions have contributed to a shortage of clinical sites where students can learn to care for children with varied nursing needs. The purpose of this study was to describe benefits and barriers of pediatric clinical placements with a school health component. Design and methods A qualitative analysis of 38 student reflective journals was conducted to identify experiences following student participation in school nursing clinicals. Results Three themes and three sub-themes were identified. Major themes included: benefits of the clinical experience, suggestions for improvement, and an appreciation for the school nurse role with subthemes of greater responsibility than anticipated, resource constraints, and lack of support. Conclusions School nursing clinical experiences allow nursing students to interact with children with broad range of ages, abilities, and health statuses, and preview a professional pathway they may otherwise never be exposed to. School nursing experiences also help nurse educators address the shortage of inpatient pediatric clinical site placements while facilitating student exposure to the impact of social justice and social determinants on child health. Practice implications Nurse educators are encouraged to incorporate school nursing clinical experiences in pediatric curricula. Partnering with school districts in which student enrollment reflects diversity in culture, socio-economic status, and access to healthcare should be a priority so students may see first-hand the impact of social determinants on the health of clients and populations.

Objectives Factors that influence decision of non–vitamin K antagonist oral anticoagulants (NOACs) use among older atrial fibrillation (AF) patients in long-term care (LTC) facilities have not been well studied. The aim of this study was to assess whether increased frailty influenced physicians to prescribe NOACs over warfarin. Design We retrospectively reviewed the electronic medical record (EMR) and pharmacy data of 25 LTC facilities in Ontario, Canada, in May 2015. The diagnosis of AF was ascertained from EMR and confirmed by complete chart review of a random sample of the cohort. A score of ≥2 on the Changes in Health, End-stage disease, Signs, and Symptoms (CHESS) scale was used as a surrogate marker of frailty. Measures Multivariable logistic regression model was used to assess whether a higher frailty score is associated with the use of NOACs in comparison to warfarin, independent of potential patient-level confounders. Setting and participants In total, 3378 active residents were assessed in 25 LTC facilities. All the residents were ≥65 years old. We identified 433 residents with AF; 273 (63%) AF residents were on anticoagulation therapy and included in the analysis. Results Residents were more often treated with NOACs (n = 159; 58%) in comparison to warfarin (n = 114; 42%). A CHESS score of ≥2 increased the odds of prescribing NOACs by 2.46 times [95% confidence interval (CI) 1.11, 5.49; P = .03] when adjusted for important patient-level factors. Patients with hypertension had a trend of increased NOAC prescriptions but did not reach statistical significance [odds ratio 2.1 (95% CI 0.91, 4.81), P = .08]. None of the patient-level factors were associated with NOAC prescriptions. Conclusions and Implications In this real world cohort of AF patients in LTC who are prescribed an oral anticoagulation therapy, a higher CHESS score (≥2) is associated with increased use of NOACs in comparison to warfarin.

BACKGROUND: Whole-body MRI (WB-MRI) could be an alternative to multimodality staging of colorectal cancer, but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in colorectal cancer.METHODS: The Streamline C trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed colorectal cancer. Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or polyp cancer. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs), and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN43958015, and is complete.FINDINGS: Between March 26, 2013, and Aug 19, 2016, 1020 patients were screened for eligibility. 370 patients were recruited, 299 of whom completed the trial; 68 (23%) had metastasis at baseline. Pathway sensitivity was 67% (95% CI 56 to 78) for WB-MRI and 63% (51 to 74) for standard pathways, a difference in sensitivity of 4% (-5 to 13, p=0·51). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (95% [95% CI 92-97]) and standard pathways (93% [90-96], p=0·48). Agreement with the multidisciplinary team's final treatment decision was 96% for WB-MRI and 95% for the standard pathway. Time to complete staging was shorter for WB-MRI (median, 8 days [IQR 6-9]) than for the standard pathway (13 days [11-15]); a 5-day (3-7) difference. WB-MRI required fewer tests (median, one [95% CI 1 to 1]) than did standard pathways (two [2 to 2]), a difference of one (1 to 1). Mean per-patient staging costs were £216 (95% CI 211-221) for WB-MRI and £285 (260-310) for standard pathways.INTERPRETATION: WB-MRI staging pathways have similar accuracy to standard pathways and reduce the number of tests needed, staging time, and cost.FUNDING: UK National Institute for Health Research.

Muons from extensive air showers appear as rings in images taken with imaging atmospheric Cherenkov telescopes, such as VERITAS. These muon-ring images are used for the calibration of the VERITAS telescopes, however the calibration accuracy can be improved with a more efficient muon-identification algorithm. Convolutional neural networks (CNNs) are used in many state-of-the-art image-recognition systems and are ideal for muon image identification, once trained on a suitable dataset with labels for muon images. However, by training a CNN on a dataset labelled by existing algorithms, the performance of the CNN would be limited by the suboptimal muon-identification efficiency of the original algorithms. Muon Hunters 2 is a citizen science project that asks users to label grids of VERITAS telescope images, stating which images contain muon rings. Each image is labelled 10 times by independent volunteers, and the votes are aggregated and used to assign a `muon' or `non-muon' label to the corresponding image. An analysis was performed using an expert-labelled dataset in order to determine the optimal vote percentage cut-offs for assigning labels to each image for CNN training. This was optimised so as to identify as many muon images as possible while avoiding false positives. The performance of this model greatly improves on existing muon identification algorithms, identifying approximately 30 times the number of muon images identified by the current algorithm implemented in VEGAS (VERITAS Gamma-ray Analysis Suite), and roughly 2.5 times the number identified by the Hough transform method, along with significantly outperforming a CNN trained on VEGAS-labelled data.

BackgroundThe COVID-19 pandemic continues to affect the United States and the world. Media reports have suggested that the wave of the alpha variant in the Spring of 2021 in the US caused more cases among younger patients and racial and ethnic subgroups.ApproachWe analyzed electronic health record data from a multihospital health system to test whether younger patients accounted for more cases and more severe disease, and whether racial disparities are widening. We compared demographics, patient characteristics, and hospitalization variables for patients admitted from November 2020 through January 2021 to those admitted in March and April 2021.ResultsWe analyzed data for 37, 502 unique inpatients and outpatients at 21 hospitals from November 1, 2020 to April 30, 2021. Compared to patients from November through January, those with positive tests in March and April were younger and less likely to die. Among patients under age 50, those with positive tests in March and April were three times as likely to be hospitalized and twice as likely to require ICU admission or mechanical ventilation. Individuals identified as Black represented a greater proportion of cases and hospitalizations in March and April as compared to November through January.ConclusionsWe found that relative COVID-19 hospitalization rates for younger individuals and individuals identified as Black were rising over time. These findings have important implications for ongoing public health measures to mitigate the impact of the pandemic.

Interferon (IFN)-β is a popular therapy for multiple sclerosis (MS). However, 25–40% of patients are nonresponsive to this therapy, and it worsens neuromyelitis optica (NMO), another neuroinflammatory disease. We previously identified, in both NMO patients and in mice, that IFN-β treatment had inflammatory effects in T Helper (TH) 17-induced disease through the production of the inflammatory cytokine IL-6. However, other studies have shown that IFN-β inhibits the differentiation and function of TH17 cells. In this manuscript, we identified that IFN-β had differential effects on discrete stages of TH17 development. During early TH17 development, IFN-β inhibits IL-17 production. Conversely, during late TH17 differentiation, IFN-β synergizes with IL-23 to promote a pathogenic T cell that has both TH1 and TH17 characteristics and expresses elevated levels of the potent inflammatory cytokines IL-6 and GM-CSF and the transcription factor BLIMP. Together, these findings help resolve a paradox surrounding IFN-β and TH17-induced disease and illuminate the pathways responsible for the pathophysiology of NMO and MS patients who are IFN-β nonresponders.

Background Patients who receive palliative care are less likely to die in hospital. Objective To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. Research design Population-based decedent cohort study using linked health administrative data in Ontario, Canada. Subjects A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. Exposure Physician annual rate of referral to palliative care (high, average, low). Measures Odds of death in hospital versus home, adjusted for patient characteristics. Results There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. Conclusions and relevance An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence.PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool).Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III-IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence.This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.

Background Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs. Methods Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital. Results There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement). Conclusions Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Background Ventra hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence. Methods PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool). Results Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III–IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence. Conclusion This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research., To identify predictors of ventral hernia recurrence, prognostic data were extracted from 20 years of available literature and subsequently meta-analysed. New knowledge is presented regarding patient demographics, hernia characteristics, intraoperative factors and postoperative variables that predispose to recurrence. This review should inform best practice and future research.

Key Points Question How is palliative care being delivered to patients with noncancer illness (ie, chronic organ failure and dementia), and is it being delivered differently than for patients with cancer? Findings In this cohort study, among 145 709 adults who died of cancer or terminal noncancer illness and received palliative care in their last year of life, palliative care was more likely to be initiated earlier, initiated in the hospital setting, and delivered across multiple care settings in patients with cancer than in those with organ failure or dementia. Patients with cancer were more likely to receive care using a consultative or specialist model instead of a generalist model and received palliative care more often from general practitioners and physicians with subspecialty training compared with patients with chronic organ failure or dementia. Meaning Differences in the delivery of palliative care across distinct types of serious illness have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings., Importance Palliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking. Objective To examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer. Design, Setting, and Participants This population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada. Exposures Cause of death (chronic organ failure, dementia, or cancer). Main Outcomes and Measures Components of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death. Results A total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, −18.3%) or dementia (3922 [27.9%]; absolute difference, −13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%). Conclusions and Relevance In this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings., This cohort study examines the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer.

This chapter describes the Instrument and Controls (I&C) concepts and challenges specific to iPWR development. The new smaller dimensions, differing geometries, and harsher environments in iPWR designs will necessitate advanced sensor technologies and advanced instrumentation processing solutions. Regulatory issues and licensing concerns evolving from the new environment and advanced designs provide a new challenge to both the designers and the regulators. Licensing requirements associated with Probabilistic Risk Assessment (PRA), Cybersecurity, and Common Cause Failure (CCF) are just a few of the requirements that are being addressed by designers and regulators in the new IPWR environment. These new concepts in sensor design, processing methodology, and licensing requirements are bringing about a paradigm shift in traditional nuclear instrumentation design and methodology. This chapter highlights the requirements, challenges, and potential solutions for this new I&C world.

POINTS CLES Selon des donnees emergentes, les personnes hypertendues ou diabetiques qui contractent le coronavirus du syndrome respiratoire aigu severe 2 (SRAS-CoV-2) et qui recoivent un diagnostic de maladie a coronavirus 2019 (COVID-19) courent un risque accru d’insuffisance respiratoire

Background A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada. Methods We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC). Results We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and Conclusions High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

To perform a comparative analysis of postthyroidectomy radioactive iodine ablation dosing with or without the implementation of a diagnostic whole-body scan in patients with well-differentiated thyroid cancer.Decision analysis model.Hospital or ambulatory center.A decision tree model was created to determine the cost-effectiveness of radioactive iodine ablation dosed with diagnostic whole-body scans versus empiric radioactive iodine ablation in patients with differentiated thyroid cancer undergoing postthyroidectomy ablation. The decision tree was populated with values from the published literature. Costs were represented by 2020 Medicare reimbursement rates (US dollars), and morbidity and survival data were used to calculate quality-adjusted life-years. The incremental cost-effectiveness ratio was the primary outcome.Empiric radioactive iodine dosing was the dominant economic strategy, producing 0.94 more quality-adjusted life-years while costing $1250.07 less than management with a diagnostic whole-body scan. Sensitivity analyses upheld these results except in cases involving a large discrepancy in successful ablation rates between the diagnostic and empiric treatment arms.For patients with differentiated thyroid cancer requiring postthyroidectomy ablation, it is more cost-effective to administer radioactive iodine empirically.

IMPORTANCE: The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear. OBJECTIVE: To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020. STUDY SELECTION: Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES: Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points). RESULTS: Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I(2) = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I(2) = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), −0.12; [95% CI, −0.20 to −0.03]; I(2) = 0%; Edmonton Symptom Assessment Scale score mean difference, −1.6 [95% CI, −2.6 to −0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, −0.24 to 0.61]; I(2) = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, −6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, −0.09 to 0.23]; I(2) = 68%). CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

An international cohort study of 8910 patients[1][1] that found no association between use of renin–angiotensin–aldosterone system (RAAS) inhibitors and risk of in-hospital death has been retracted over concerns of the validity of its data sources.[2][2] We had included this article in our

Rates of injury to school-aged athletes are of concern to pediatric providers and can be prevented when players, coaches, and parents recognize and address pain. The aim of the present study was to evaluate the use of a pain-reporting tool. In this study, 34 baseball players aged 10–16 years reported pain surrounding 135 separate pitching experiences. Those participating in another sport on the same day as pitching rated pain intensity as significantly higher than those who did not. Approximately 19 pitches were thrown before participants noticed pain. Ice and analgesics were used appropriately to manage pain. School nurses are well positioned to discuss pain reporting and common injuries with young athletes, parents, and athletic coaches. Sharing proactive ways to elicit information about pain is suggested. Implications for future research include the study of young athlete experiences with pain and development of educational initiatives regarding the importance of reporting pain.

ObjectiveFew studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.MethodsA team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.ResultsSurveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).ConclusionsImportant barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Following the increase in both evidence and awareness of the impact that social determinants and social injustices have on health, it is clear to educators that nursing students must be prepared to address and ameliorate such concerns for patients. This paper describes the approach of one nursing program to community health nursing education. The SON located in a highly diverse city, approaches community health education through the lens of the social determinants of health. Going forward, nursing programs must consider social determinants and health equity when planning community courses and across the curriculum. Approaches to community health education with a focus on health promotion for nursing students, such as the courses described in this article, may help nursing programs meet the learning needs of students and the changing face of healthcare.

Successful completion of the National Council Licensure Examination for Registered Nurses (NCLEX-RN) is important to both new graduate nurses and schools of nursing (SONs); therefore, it is crucial for nursing faculty to prepare students to pass this examination. This article reports results of a literature review aiming to identify effective approaches to strengthen NCLEX-RN success for prelicensure nursing students. SONs have worked to improve student critical thinking, test-taking skills, and psychosocial well-being. SON should consider multifaceted approaches to help students find success on the NCLEX-RN.

272 Background: Rule OP-35, which characterizes treatment-related complications of patients receiving outpatient chemotherapy that result in a potentially avoidable emergency department (ED) visit or hospitalization, was developed to encourage practices to build treatment models that reduce such events. However, defining visits as potentially avoidable based on symptoms may not capture the complexity of caring for oncology patients. We aim to evaluate the effectiveness of OP-35 in identifying preventable ED visits by real world standards at an academic institution. Methods: A retrospective analysis was performed reviewing ED visits at the Sidney Kimmel Cancer Center (SKCC) at Thomas Jefferson University for oncology patients from 10/1/2020 to 1/31/2021. Each patient received care at SKCC had received intravenous or oral chemotherapy in the preceding 30 days, and each encounter was classified as potentially avoidable by OP-35 criteria. Two investigators independently conducted chart reviews to determine whether these visits were potentially avoidable, recording whether the patient attempted to contact their care team prior to the ED encounter and assessing if the concern could have been managed in a timely manner in an outpatient setting. The two records were then compared, and the principal investigator served as an arbiter for determining if a visit was potentially avoidable in instances where the investigators disagreed. Results: We reviewed 144 total encounters and excluded events from patients with either acute leukemia or breast cancer on hormone therapy only, leaving 107 encounters for analysis. After evaluating the clinical circumstances, we determined that 29% of these ED encounters were potentially avoidable. Applying New York University Emergency Department Algorithm (NYU-EDA) criteria, 69% of encounters were considered potentially avoidable. Patients called for advice before seeking ED care in 53% of unavoidable encounters compared to 26% of potentially avoidable encounters. An additional 14% of visits deemed unavoidable were from patients sent directly from clinic. For potentially avoidable encounters, 60% of patients were discharged directly from the ED. In comparison, 8% of unavoidable encounters led to discharge from the ED. Pain was the most common reason for encounters and 53% of these visits were considered potentially avoidable. Conclusions: We found that approximately 30% of ED encounters deemed avoidable by OP-35 criteria were considered potentially avoidable following clinician review. In the majority of cases patients were referred to the ED following initial outpatient attempts at management. NYU-EDA criteria for preventability did not correlate with OP-35 nor clinician consensus regarding potentially avoidable encounters. More work remains in refining tools to identify potentially avoidable ED visits for oncology patients.

Over the past three decades, the incidence and prevalence of neuroendocrine tumors have gradually increased. Due to the slow-growing nature of these tumors, most cases are diagnosed at advanced stages. Prognosis and survival are associated with location of primary lesion, biochemical functional status, differentiation, initial staging, and response to therapy. Octreotide, the first synthetic somatostatin analog, was initially used for the management of gastrointestinal symptoms associated with functional carcinoid tumors. Its commercial development over time led to long-acting repeatable octreotide acetate, a long-acting version that provided greater administration convenience. Recent research demonstrates that octreotide's efficacy has evolved beyond symptomatic management to targeted therapy with antitumoral effects. This review examines the history and development of octreotide, provides a synopsis on the classification, grading, and staging of neuroendocrine tumors, and reviews the evidence of long-acting repeatable octreotide acetate as monotherapy and in combination with other treatment modalities in the management of non-pituitary neuroendocrine tumors with special attention to recent high-quality Phase III trials.

School nurses are afforded minimal resources related to assessing pain in students with intellectual disability (ID) and have called for continuing education. The purpose of this study was to measure the effectiveness of an education program regarding best practices for assessing pain in students with ID. Educational sessions were presented to 248 school nurses. Pre-, post-, and follow-up surveys measured (1) difficulty school nurses face when assessing pain, (2) knowledge and use of pain assessment methods, and (3) intent to change and actual changes to professional practices. Participants experienced less difficulty assessing pain following the educational program. Almost all participants intended to change pain assessment practices, but large caseloads limited new practice adoption. Policy makers must consider population size and acuity when determining school nurse staffing. Trainings and other resources should be made available to school nurses in order to make pain assessments for students with ID more thorough and efficient.

KEY POINTS Emerging data suggest that people with hypertension or diabetes who are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and diagnosed with coronavirus disease 2019 (COVID-19) are at an increased risk of respiratory failure and death. These patients are often

Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population‐based cohort study using linked health administrative data in Ontario, Canada of 74 986 community‐dwelling adults with heart failure who died between 2010 and 2015. Seventy‐five percent of community‐dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI , 2.03–2.20]; P CI , 9.34–15.11]; P CI , 6.41–10.27]; P Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end‐of‐life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end‐of‐life care in people dying with chronic noncancer illness.

Background Pancreatic carcinosarcomas (PCS) are rare aggressive biphasic malignancies with a poor prognosis. We aimed to improve the understanding of PCS by analyzing variables that influence the mortality of PCS patients. Methods The Surveillance, Epidemiology, and End Results database was queried for cases of PCS from 1973 to 2016. Cases were analyzed for patient demographics, tumor characteristics, and surgical intervention. Kaplan-Meier and Cox regression analyses were applied to investigate the overall survival (OS) and prognostic factors. Results Thirty-nine cases of PCS were identified along with the disease demographics and characteristics. The majority of patients had a regionally invasive or metastatic disease. There was a significant decrease in OS with the increase of the tumor extension. Conversely, surgery showed to improve OS in the crude analysis, including patients that underwent lymphadenectomy. In addition, the unadjusted Cox regression results showed decreased hazard ratios with a local disease versus distant metastasis and with cancer-directed surgery versus no surgery. Nevertheless, the adjusted Cox regression results revealed that metastatic disease was the only significant predictor of survival. Conclusions This population-based study provides some insight to a very rare disease by analyzing 39 cases of PCS. Our finding suggests considering PCS as a nonsurgical disease and reserving surgery solely for patients with a localized disease in combination or after neoadjuvant therapy. Consequently, there is a need to further investigate novel therapies for this aggressive malignancy.

The KM3NeT Collaboration runs a multi-site neutrino observatory in the Mediterranean Sea. Water Cherenkov particle detectors, deep in the sea and far off the coasts of France and Italy, are already taking data while incremental construction progresses. Data Acquisition Control software is operating off-shore detectors as well as testing and qualification stations for their components. The software, named Control Unit, is highly modular. It can undergo upgrades and reconfiguration with the acquisition running. Interplay with the central database of the Collaboration is obtained in a way that allows for data taking even if Internet links fail. In order to simplify the management of computing resources in the long term, and to cope with possible hardware failures of one or more computers, the KM3NeT Control Unit software features a custom dynamic resource provisioning and failover technology, which is especially important for ensuring continuity in case of rare transient events in multi-messenger, French National Research Agency (ANR) ANR-15-CE31-0020, Centre National de la Recherche Scientifique (CNRS), Commission Europeenne (FEDER fund), European Union (EU), Institut Universitaire de France (IUF), France, IdEx program, Univearths Labex program at Sorbonne Paris Cite, France ANR-10-LABX-0023 ANR-11-IDEX-000502, Paris Ile-de-France Region, France, Shota Rustaveli National Science Foundation of Georgia (SRNSFG), Georgia FR-18-1268, German Research Foundation (DFG), Greek Ministry of Development-GSRT, Istituto Nazionale di Fisica Nucleare (INFN), Ministero dell'Istruzione, dell'Universita e della Ricerca (MIUR), PRIN 2017 program Italy NAT-NET 2017W4HA7S, Ministry of Higher Education, Scientific Research and Professional Training, Morocco, Netherlands Organization for Scientific Research (NWO) Netherlands Government, National Science Center, Poland National Science Centre, Poland 2015/18/E/ST2/00758, National Authority for Scientific Research (ANCS), Romania, Ministerio de Ciencia, Innovacion, Investigacion y Universidades (MCIU), Spain, Programa Estatal de Generacion de Conocimiento (MCIU/FEDER) PGC2018-096663-B-C41 PGC2018-096663-A-C42 PGC2018-096663-B-C43 PGC2018-096663-BC44, Severo Ochoa Centre of Excellence, MultiDark Consolider (MCIU), Spain, Junta de Andalucía, Generalitat Valenciana, Spain: Grisolia GRISOLIA/2018/119, Generalitat Valenciana CIDEGENT/2018/034, La Caixa Foundation LCF/BQ/IN17/11620019, EU: MSC program, Spain 713673

The integration and synthesis of the data in different areas of science is drastically slowed and hindered by a lack of standards and networking programmes. Long-term studies of individually marked animals are not an exception. These studies are especially important as instrumental for understanding evolutionary and eco-logical processes in the wild. Furthermore, their number and global distribution provides a unique opportunity to assess the generality of patterns and to address broad-scale global issues (e.g. climate change)., To solve data integration issues and enable a new scale of ecological and evolution-ary research based on long-term studies of birds, we have created the SPI-Birds Network and Database (www.spibirds.org)—a large-scale initiative that connects data from, and researchers working on, studies of wild populations of individually recognizable (usually ringed) birds. Within year and a half since the establishment, SPI-Birds has recruited over 120 members, and currently hosts data on almost 1.5 million individual birds collected in 80 populations over 2,000 cumulative years, and counting., SPI-Birds acts as a data hub and a catalogue of studied populations. It prevents data loss, secures easy data finding, use and integration and thus facilitates collab-oration and synthesis. We provide community-derived data and meta-data stand-ards and improve data integrity guided by the principles of Findable, Accessible, Interoperable and Reusable (FAIR), and aligned with the existing metadata lan-guages (e.g. ecological meta-data language)., The encouraging community involvement stems from SPI-Bird's decentralized ap-proach: research groups retain full control over data use and their way of data management, while SPI-Birds creates tailored pipelines to convert each unique data format into a standard format. We outline the lessons learned, so that other communities (e.g. those working on other taxa) can adapt our successful model. Creating community-specific hubs (such as ours, COMADRE for animal demogra-phy, etc.) will aid much-needed large-scale ecological data integration., The SPI-Birds have been supported by an NWO personal grant (grant number 016.Veni.181.054) to A.C., and a Research Council of Norway grant: 223257 (SFF-III) and 267511 (EVOCLIM).