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Objective: This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer.Summary of Background Data: The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer.Methods: Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods.Results: Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% (P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P Conclusion: In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.

BackgroundGlioblastoma is the most aggressive type of brain cancer with high-levels of intra- and inter-tumour heterogeneity that contribute to its rapid growth and invasion within the brain. However, a spatial characterisation of gene signatures and the cell types expressing these in different tumour locations is still lacking.MethodsWe have used a deep convolutional neural network (DCNN) as a semantic segmentation model to segment seven different tumour regions including leading edge (LE), infiltrating tumour (IT), cellular tumour (CT), cellular tumour microvascular proliferation (CTmvp), cellular tumour pseudopalisading region around necrosis (CTpan), cellular tumour perinecrotic zones (CTpnz) and cellular tumour necrosis (CTne) in digitised glioblastoma histopathological slides from The Cancer Genome Atlas (TCGA). Correlation analysis between segmentation results from tumour images together with matched RNA expression data was performed to identify genetic signatures that are specific to different tumour regions.ResultsWe found that spatially resolved gene signatures were strongly correlated with survival in patients with defined genetic mutations. Further in silico cell ontology analysis along with single-cell RNA sequencing data from resected glioblastoma tissue samples showed that these tumour regions had different gene signatures, whose expression was driven by different cell types in the regional tumour microenvironment. Our results further pointed to a key role for interactions between microglia/pericytes/monocytes and tumour cells that occur in the IT and CTmvp regions, which may contribute to poor patient survival.ConclusionsThis work identified key histopathological features that correlate with patient survival and detected spatially associated genetic signatures that contribute to tumour-stroma interactions and which should be investigated as new targets in glioblastoma. The source codes and datasets used are available in GitHub:https://github.com/amin20/GBM_WSSM.

OBJECTIVE Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized complications of long-segment spinal fusion. Previous studies have suggested that ligament augmentation can decrease rates of PJF by reducing junctional stress and strengthening upper instrumented vertebrae (UIVs) and adjacent segments. However, there is a paucity of long-term data on the efficacy of ligament augmentation in preventing PJF. In this study, the authors sought to determine the effect of ligament augmentation on rates of PJF in a cohort of adult spinal deformity patients with at least 1 year of follow-up. METHODS They conducted a retrospective analysis of ligament augmentation in a consecutive series of surgical patients with adult spinal deformity. Data on patient demographics, surgical characteristics, and surgery for PJF were collected. The minimum follow-up was 12 months. Univariate and multivariate analyses were performed to identify factors associated with reoperation for PJF. RESULTS The authors identified a total of 242 patients (166 women [68.6%]) with ligament augmentation whose mean age was 66 years. The mean number of fused levels was 10, with a UIV distribution as follows: 90 upper thoracic UIVs (37.2%) and 152 lower thoracic UIVs (62.8%). Compared to a historical cohort of 77 patients treated before implementation of ligament augmentation, reoperation for PJF was significantly lower with ligament augmentation (15.6% vs 3.3%, p < 0.001). In a multivariate model, only ligament augmentation (OR 0.184, 95% CI 0.071–0.478, p = 0.001) and number of fused levels (OR 0.762, 95% CI 0.620–0.937, p = 0.010) were associated with reductions in reoperation for PJF. CONCLUSIONS Ligament augmentation was associated with significant reductions in the rate of reoperation for PJF at 12 months in a cohort of adult spinal deformity patients. The most dramatic reduction was seen among patients with lower thoracic UIV. These data suggest that in appropriately selected patients, ligament augmentation may be a valuable adjunct for PJF reduction; however, long-term follow-up is needed.

OBJECTIVE Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF. METHODS A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported. RESULTS A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2–4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01–1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01–1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05–3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility. CONCLUSIONS After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.

Potential climate-related impacts on future crop yield are a major societal concern. Previous projections of the Agricultural Model Intercomparison and Improvement Project’s Global Gridded Crop Model Intercomparison based on the Coupled Model Intercomparison Project Phase 5 identified substantial climate impacts on all major crops, but associated uncertainties were substantial. Here we report new twenty-first-century projections using ensembles of latest-generation crop and climate models. Results suggest markedly more pessimistic yield responses for maize, soybean and rice compared to the original ensemble. Mean end-of-century maize productivity is shifted from +5% to −6% (SSP126) and from +1% to −24% (SSP585)—explained by warmer climate projections and improved crop model sensitivities. In contrast, wheat shows stronger gains (+9% shifted to +18%, SSP585), linked to higher CO2 concentrations and expanded high-latitude gains. The ‘emergence’ of climate impacts consistently occurs earlier in the new projections—before 2040 for several main producing regions. While future yield estimates remain uncertain, these results suggest that major breadbasket regions will face distinct anthropogenic climatic risks sooner than previously anticipated. Climate change affects agricultural productivity. New systematic global agricultural yield projections of the major crops were conducted using ensembles of the latest generation of crop and climate models. Substantial shifts in global crop productivity due to climate change will occur within the next 20 years—several decades sooner than previous projections—highlighting the need for targeted food system adaptation and risk management in the coming decades.

It is well established that physical activity reduces all-cause mortality and can prolong life. Ultra-endurance running (UER) is an extreme sport that is becoming increasingly popular, and comprises running races above marathon distance, exceeding 6 h, and/or running fixed distances on multiple days. Serious acute adverse events are rare, but there is mounting evidence that UER may lead to long-term health problems. The purpose of this review is to present the current state of knowledge regarding the potential long-term health problems derived from UER, specifically potential maladaptation in key organ systems, including cardiovascular, respiratory, musculoskeletal, renal, immunological, gastrointestinal, neurological, and integumentary systems. Special consideration is given to youth, masters, and female athletes, all of whom may be more susceptible to certain long-term health issues. We present directions for future research into the pathophysiological mechanisms that underpin athlete susceptibility to long-term issues. Although all body systems can be affected by UER, one of the clearest effects of endurance exercise is on the cardiovascular system, including right ventricular dysfunction and potential increased risk of arrhythmias and hypertension. There is also evidence that rare cases of acute renal injury in UER could lead to progressive renal scarring and chronic kidney disease. There are limited data specific to female athletes, who may be at greater risk of certain UER-related health issues due to interactions between energy availability and sex-hormone concentrations. Indeed, failure to consider sex differences in the design of female-specific UER training programs may have a negative impact on athlete longevity. It is hoped that this review will inform risk stratification and stimulate further research about UER and the implications for long-term health.

Background Delirium is a distressing neurocognitive disorder recently linked to sleep disturbances. However, the longitudinal relationship between sleep and delirium remains unclear. This study assessed the associations of poor sleep burden, and its trajectory, with delirium risk during hospitalization. Methods About 321 818 participants from the UK Biobank (mean age 58 ± 8 years [SD]; range 37–74 years) reported (2006–2010) sleep traits (sleep duration, excessive daytime sleepiness, insomnia-type complaints, napping, and chronotype—a closely related circadian measure for sleep timing), aggregated into a sleep burden score (0–9). New-onset delirium (n = 4 775) was obtained from hospitalization records during a 12-year median follow-up. About 42 291 (mean age 64 ± 8 years; range 44–83 years) had repeat sleep assessment on average 8 years after their first. Results In the baseline cohort, Cox proportional hazards models showed that moderate (aggregate scores = 4–5) and severe (scores = 6–9) poor sleep burden groups were 18% (hazard ratio = 1.18 [95% confidence interval: 1.08–1.28], p < .001) and 57% (1.57 [1.38–1.80], p < .001), more likely to develop delirium, respectively. The latter risk magnitude is equivalent to 2 additional cardiovascular risks. These findings appeared robust when restricted to postoperative delirium and after exclusion of underlying dementia. Higher sleep burden was also associated with delirium in the follow-up cohort. Worsening sleep burden (score increase ≥2 vs no change) further increased the risk for delirium (1.79 [1.23–2.62], p = .002) independent of their baseline sleep score and time lag. The risk was highest in those younger than 65 years at baseline (p for interaction Conclusion Poor sleep burden and worsening trajectory were associated with increased risk for delirium; promotion of sleep health may be important for those at higher risk.

ZusammenfassungWir berichten über einen Fall, bei dem makroskopische und mikroskopische Veränderungen des Verstibularnervs nach radiochirurgischer Behandlung eines intrameatalen Vestibularisschwannoms beobachtet wurden. Der Fallbericht zeigt das erste Mal ein morphologisches Korrelat der unerwünschten Effekte der Gamma-Knife-Therapie von Vestibularisschwannomen und unterstreicht, dass trotz eines deutlichen Abstands zum bestehenden Tumor degenerative Veränderungen der neuralen Strukturen erwartet werden können.

High nitrogen (N) fertiliser inputs together with a low N use efficiency in intensive sugarcane systems indicate substantial losses of fertiliser N to the environment and therefore the need to reconsider N fertiliser rate management. However, the effect of N fertiliser rates on the fate of fertiliser N in plant and soil, and on N fertiliser loss is largely unknown. This study established the response of 15N fertiliser recoveries to N rates on a tropical commercial sugarcane farm in Australia on a Luvisol. The experiment over 10 months included three N fertiliser rates, 150, 200 (the recommended rate) and 250 kg N ha−1 applied as 15N-labelled urea (5 atom%) and a non-fertilised control. Fertiliser 15N uptake increased from 39 to 65 kg N ha−1 with increasing N rates, accounting for 26% of the N applied across N rates. Fertiliser 15N contributed 22–33% to total N uptake and increased soil-N uptake compared to the control. Fertiliser 15N in the soil down to 1.0 m at harvest was consistent across N rates (36–39 kg N ha−1), indicating a fixed capacity of the soil to immobilise fertiliser N. Increasing N rates did not contribute to increased sugar yield or retention of soil N but increased N fertiliser loss, ranging from 48 to 60% of the applied N. This study demonstrates that 50% of the applied N was lost from an intensive sugarcane system under current best management practices, highlighting the need to target these large environmental N losses in future recommendations.

Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence. The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded. An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124–20,284) in 2004 to 21,408 (95% CI = 12,882–29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85–7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, s = 0.802, p

OBJECTIVE The background for this investigation was the dramatic course of a 14-year-old girl with a spontaneous hemorrhage in the area of the conus medullaris resulting in a complete cross-sectional syndrome with bladder and bowel dysfunction. Despite immediate surgical treatment, the patient showed close to no postoperative improvement. Subsequent histopathological examination of the removed masses revealed a cavernoma. To better understand the link between the site and symptoms of conus medullaris lesions, the authors performed a literature search and then histological examination of the conus medullaris of 18 cadaveric specimens from body donors. METHODS After a literature search regarding the histological features of the structure of the conus medullaris did not lead to satisfying results, the authors performed histological examination of the conus medullaris in 18 cadaveric specimens from body donors. The largest (a) and smallest (b) diameters of the conus medullaris were measured, noting individual variations in the distance from the caudal ending of the gray matter to the macroscopically visible end of the conus medullaris. Correlations of these differences with sex, body height, gray matter transverse diameter, and cross-sectional area at the end of the gray matter were analyzed. RESULTS Gray matter displayed in the form of a butterfly figure was found along almost the entire length of the conus medullaris. The specific slide containing the end of the gray matter was noted. The distance between the caudal ending of the gray matter in the conus and the macroscopical end of the conus medullaris was defined as the gray matter to cone termination (GMCT) distance. There were great individual variations in the distance from the caudal ending of the gray matter to the macroscopically visible end of the conus medullaris. Analysis of the correlations of these differences with sex, body height, gray matter transverse diameter, and cross-sectional area at the end of the gray matter showed no significant sex-specific differences in the GMCT distance. Patient body height and transverse diameter at the end of the gray matter were found to be correlated positively with the GMCT distance. Moreover, greater height also correlated positively with the cross-sectional area at the end of the gray matter. CONCLUSIONS This report is, to the authors’ knowledge, the first published description of the histological structure of the conus medullaris and can serve as the basis for a better understanding of neurological deficits in patients with a conus medullaris syndrome. Findings that gray matter can be detected far into the conus medullaris, with large individual differences in the endpoint of the gray matter, are important for operative care of intramedullary masses and vascular malformations in this area. It is therefore important to use electrophysiological monitoring during these operations.

Background The benefit of adjuvant therapy in synovial sarcoma (SS) treatment is under debate. Long-term follow-up data are missing. Methods SS patients treated in the consecutive trials CWS-81, CWS-86, CWS-91, CWS-96, CWS-2002-P, and the SoTiSaR-registry till 2013 were analyzed. Results Median age of 185 patients was 13.9 years (0.1–56)—with median follow-up of 7.4 years for 163 survivors. Most tumors (76%) were located in extremities. Size was 10 cm in 13 (7%) (13 missing). In 84 (45%) tumors, first excision was complete (R0 corresponding to IRS-I-group) and in 101 (55%) marginal (R1 corresponding to IRS-II-group). In a subsequent surgical intervention during chemotherapy, R0-status was accomplished in 23 additional IRS-II-group patients with secondary surgery. Radiotherapy was administered to 135 (73%), thereof 62 with R0-status and 67 R1-status (6 missing information). Adjuvant chemotherapy was administered to all but six patients. 5-year event-free (EFS) and overall survival (OS) was 82.9% ± 5.7 (95%CI) and 92.5% ± 3.9. Local and metastatic relapse-free survival was 91.3% ± 4.3 and 92.3% ± 4.1 at 5 years, respectively. In the multivariate analysis, tumor size and no chemotherapy were independently associated with EFS. Size and site were associated with OS. In a detailed analysis of local and metastatic events, tumor size was associated with an independent risk for developing metastases. No independent factor for suffering local recurrence could be identified. Discussion Omission of chemotherapy in a non-stratified way seems not justified. Size governs survival due to high linear association with risk of suffering metastatic recurrence in a granular classification.

MRI-based screening in women with a ≥ 25% lifetime risk of breast cancer , but no identifiable genetic mutations may be associated with false positives. This study examined the psychological impact of abnormal screens and biopsies in non-mutation carriers participating in high-risk screening with no personal history of breast cancer. Non-mutation carriers participating in the High-Risk Ontario Breast Screening Program at two sites were mailed demographic surveys, psychological scales, and chart review consent. Scales included the Consequences of Screening in Breast Cancer questionnaire, Lerman Breast Cancer Worry Scale, and Worry Interference Scale. Missing data were managed with multiple imputation. Multivariable regression was used to assess whether abnormal screens or biopsies were associated with adverse psychological effects. After contacting 465 participants, 169 non-mutation carriers were included. Median age was 46 years (range 30–65). Over a median 3 years of screening, 63.9% of women experienced at least one abnormal screen, and 24.9% underwent biopsies. Statements relating to cancer worry/anxiety scored highest, with 19.5% indicating they worried “a lot”. Higher scores among anxiety-related statements were strongly associated with higher dejection scores. Overall, coping and daily functioning were preserved. Women indicated some positive reactions to screening, including improved existential values and reassurance they do not have breast cancer. Abnormal screens and biopsies were not significantly associated with any psychological scale, even after adjustment for patient characteristics. Non-mutation carriers undergoing MRI-based screening had considerable baseline anxiety and cancer worry, although daily functioning was not impaired. Abnormal screens and biopsies did not appear to have adverse psychological effects.

Circadian biology modulates almost all aspects of mammalian physiology, disease, and response to therapies. Emerging data suggest that circadian biology may significantly affect the mechanisms of susceptibility, injury, recovery, and the response to therapy in stroke. In this review/perspective, we survey the accumulating literature and attempt to connect molecular, cellular, and physiological pathways in circadian biology to clinical consequences in stroke. Accounting for the complex and multifactorial effects of circadian rhythm may improve translational opportunities for stroke diagnostics and therapeutics.

In order to effectively control spread of coronavirus 2019 (COVID-19), it is essential that jurisdictions have the capacity to rapidly trace close contacts of each and every case. Best practice guidance on how to implement such programs is urgently needed. We describe the early experience in the City and County of San Francisco (CCSF), where the City’s Department of Health expanded contact tracing capability in anticipation of changes in San Francisco’s ‘shelter in place’ order between April and June 2020. Important prerequisites to successful scale-up included a rapid expansion of the COVID-19 response workforce, expansion of testing capability, and other containment resources. San Francisco’s scale-up offers a model for how other jurisdictions can rapidly mobilize a workforce. We underscore the importance of an efficient digital case management system, effective training, and expansion of supportive service programs for those in quarantine or isolation, and metrics to ensure continuous performance improvement.

Introduction An anatomical study was conducted to test a modified C-shaped flap designed for patients undergoing a keyhole approach and/or minicraniotomy for retrosigmoid approach (KRSA). Materials and Methods Ten heads specimens were used. The surgical technique investigated was based on a 4-cm C-shaped skin incision with medial convexity (placed 8 cm laterally to the external occipital protuberance, with the lower edge terminating 1.5 to 2 cm above the mastoid tip), which followed by careful subperiosteal dissection and completed by reflecting and securing the skin flap layer anteriorly and the muscle flaps superiorly and inferiorly by stitches. Anatomical findings, including depth of surgical corridor till to the cerebellopontine cistern (CPC) as well as the sparing of neurovascular structures, were evaluated in every specimen. Results Twenty surgical approaches to CPC were conducted, resulting in a short working distance to the target (32 mm) without any need for a self-retaining retractor. In every specimen, the integrity of occipital muscles and cutaneous nerves was maintained, and a solid multilayer closure was always achieved. These data suggest that landmarks-based design of this C-shaped incision could be helpful in avoiding damages to the soft tissues encountered during KRSA. Conclusion This modified approach provides a wide surgical corridor to access the CPC while ensuring the minimal invasiveness of the standard S-shaped incision. Compared with the latter, it preserves better the integrity of the surrounding soft tissues and appears less likely to cause any iatrogenic injury to occipital muscles and cutaneous nerves.

Vaccination using the adenoviral vector COVID-19 vaccine ChAdOx1 nCoV-19 (AstraZeneca) has been associated with rare vaccine-induced immune thrombotic thrombocytopenia (VITT). Affected patients test strongly positive in platelet factor 4 (PF4)/polyanion enzyme immunoassays (EIAs), and serum-induced platelet activation is maximal in the presence of PF4. We determined the frequency of anti-PF4/polyanion antibodies in healthy vaccinees and assessed whether PF4/polyanion EIA+ sera exhibit platelet-activating properties after vaccination with ChAdOx1 nCoV-19 (n = 138) or BNT162b2 (BioNTech/Pfizer; n = 143). In total, 19 of 281 participants tested positive for anti-PF4/polyanion antibodies postvaccination (All: 6.8% [95% confidence interval (CI), 4.4-10.3]; BNT162b2: 5.6% [95% CI, 2.9-10.7]; ChAdOx1 nCoV-19: 8.0% [95% CI, 4.5% to 13.7%]). Optical densities were mostly low (between 0.5 and 1.0 units; reference range

Background The objective was to compare computed tomography (CT)-guided thoracic sympathicolysis (CTSy) and video-assisted thoracoscopic sympathectomy (VATS) with regard to their feasibility, the occurrence of minor and major complications, and the clinical outcome. Materials and Methods In this study, 88 patients treated by CTSy and 86 patients treated by VATS were retrospectively included. CTSy was performed after establishing the entry plane below the level of the intervertebral space T2/3 via a dorsolateral approach using a 22-G coaxial needle. On average of 5 mL of a sympathicolytic mixture was instilled. VATS was performed under intubation anesthesia. After insertion of the instruments via a minithoracotomy, the parietal pleura was dissected and the sympathetic trunk severed below T2. The interventions were performed unilaterally, the contralateral side being treated after approximately 6 weeks. All patients evaluated their sense of discomfort before treatment as well as 2 days, 6, and 12 months after, on the basis of a Dermatology Quality of Life Index and additionally the side effects that occurred. Results Both treatments led to a marked reduction of symptoms, whereby mild recurrent sweating occurred over the further course, significantly higher in the CTSy patient group. Short-term miosis and ptosis were rarely found in both groups. As the most common side effect, transient compensatory sweating was reported by 16/88 patients after CTSy and 10/86 patients after VATS. Pneumothoraces developed postoperatively in 7/86 cases. Temporary pain after thoracotomy was experienced by 12/86 patients. Conclusion For patients with palmar hyperhidrosis, CTSy and VATS represented a minimally invasive treatment option that provided a high and largely equivalent level of benefit.

Background and Aim: Immune-modulating molecules mainly act on innate immune cells, which are central to early defense against invading pathogens and contribute to developing adaptive immunity. Yeast-extracted β-glucan, a model immune-modulating molecule, is widely used in several animal species; however, its effect on horse immune parameters has not been thoroughly investigated yet. This study aimed to evaluate the effects of orally administered β-glucan on selected innate immune parameters in horses. Materials and Methods: Eighteen thoroughbred horses were assigned equally into three groups as follows: One control group (no β-glucan) and two β-glucan experimental groups (one received 125 mg and the other 2 g of β-glucan per day for 28 days). Blood samples were collected before and at the end of the experiment for hematological analysis, whole blood phagocytosis, respiratory burst assays, and to assess the serum lysozyme and complement hemolytic activities. Results: At the end of the experiment, significant decreases (p

Introduction Humanism in surgery is an emerging priority in surgical education. Its emphasis on the patient experience is a key component of the therapeutic relationship between surgeons and their patients. However, the documented high rates of compassion fatigue and burnout among surgical trainees and staff can serve as a barrier in delivering care with empathy and compassion. As such, this systematic review seeks to characterize the outcomes regarding interventions that aim to broadly improve humanism within surgery. Methods A systematic search of 4 electronic databases (EMBASE, MEDLINE, PsycINFO, and Cochrane CENTRAL) was conducted through an independent double selection and extraction process from database inception to March 20, 2020. The inclusion criteria consisted of interventional studies aiming to improve humanism in surgery at all levels of training. A qualitative synthesis and thematic analysis were performed. Results A total of 19 studies (1 RCT, 14 prospective cohort, and 4 cross-sectional studies), with 20 intervention arms, were included from the initial 745 studies that were eligible for title screening. Studies included a total of 1763 surgical trainees at varying levels of training. Two major strategies for improving humanism were identified: (1) directly through the development of empathetic communication skills (n = 11) and (2) indirectly through programs aimed at reducing levels of compassion fatigue and emotional exhaustion by addressing trainee burnout (n = 9). A total of 70% (14/20) of the studied interventions were successful in improving empathy in surgical trainees. Conclusion Interactive workshops around the principles of empathetic communication with patient simulations and small group learning were effective at improving empathy in surgical trainees. Furthermore, mindfulness-based training and the provision of physical resources to support trainee well-being consistently improved rates of burnout among surgical trainees. Overall, further investigation is necessary to better understand methods of improving empathy in surgery.

In the context of increasing electrification and the automation of future mobility, research and development of efficient powertrains requires enhanced test methods. One important aspect to consider is the complex interactions among a smart driving strategy, traffic flow, an individual vehicle's energy demand and emissions, and the corresponding overall values. Until now, the respective development domains of traffic flow control, powertrain control, component design, and intervehicle communication have usually been considered separately. This article presents a methodology that combines these areas and enables developers to obtain deep and highly realistic system insights, taking into account the mutual interactions among the domains. For this purpose, an X-in-the-loop validation platform is constructed that builds upon vehicular networking, road traffic, and a vehicle simulator, all coupled with two real drive-unit component test benches. We further show how this methodology can be used to investigate the effects of a novel predictive powertrain control algorithm that takes vehicle-to-everything (V2X) communication into account. Focusing on a typical urban reference route, we demonstrate that our algorithm enables performance to be maintained using electric motors with reduced specifications.

OBJECTIVE Moderate- to vigorous-intensity physical activity (MVPA) improves cardiovascular health. Few studies have examined MVPA timing. We examined the associations of timing of bout-related MVPA with cardiorespiratory fitness and cardiovascular risk in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS Baseline 7-day hip-worn accelerometry data from Look AHEAD participants (n = 2,153, 57% women) were analyzed to identify bout-related MVPA (≥3 METs/min for ≥10 min). Cardiorespiratory fitness was assessed by maximal graded exercise test. Participants were categorized into six groups on the basis of the time of day with the majority of bout-related MVPA (METs × min): ≥50% of bout-related MVPA during the same time window (morning, midday, afternoon, or evening), RESULTS Cardiorespiratory fitness was highly associated with timing of bout-related MVPA (P = 0.0005), independent of weekly bout-related MVPA volume and intensity. Importantly, this association varied by sex (P = 0.02). In men, the midday group had the lowest fitness (β = −0.46 [95% CI −0.87, −0.06]), while the mixed group in women was the least fit. Framingham risk score (FRS) was associated with timing of bout-related MVPA (P = 0.02), which also differed by sex (P = 0.0007). The male morning group had the highest 4-year FRS (2.18% [0.70, 3.65]), but no association was observed in women. CONCLUSIONS Timing of bout-related MVPA is associated with cardiorespiratory fitness and cardiovascular risk in men with type 2 diabetes, independent of bout-related MVPA volume and intensity. Prospective studies are needed to determine the impacts of MVPA timing on cardiovascular health.

To understand practices of umbilical venous catheter (UVC) insertion in tertiary level neonatal intensive care units (NICU) and investigate the outcomes of subsequent attempts following a failed initial attempt.Prospective, multi-center observational study of UVC insertions at tertiary level NICUs between March 2019 and January 2020.Of the 101 UVCs inserted at 4 centers, seventy-two (71%) were central at the first attempt and 50% were central at subsequent attempts. Patients with at least 1 failed attempt at insertion were less likely to have a centrally placed UVC (Repetitive attempts and manipulations were less likely to be beneficial in the successful central placement of UVC in neonates. Additionally, repetitive attempts at insertion prolonged the overall duration of the procedure.

The aim of this study is to identify [1] facilitators and barriers to cross-cultural communication with Canadian immigrants during the breast cancer (BC) surgical consultation and [2] the impact of cultural sensitivity training on the perception of cross-cultural communication barriers. A 29-item questionnaire mailed to 450 surgeons was developed based on the Ottawa Decision Support Framework, informed by interviews with BC practitioners and a literature review. The inclusion criteria are English-speaking general surgeons practicing in Vancouver, Montreal, and Toronto, home to > 60% of Canada’s immigrant population. The association between surgeon characteristics and barriers to communication was assessed using the chi-square or Fisher’s exact test. Univariate and multivariable logistic regression models estimated odds ratios and 95% confidence intervals for the association between frequent perception of each barrier to communication and gender, career stage, and percentage of foreign-born patients. Between June and September 2017, 130 surveys were returned for a 29% response rate. The majority of practitioners reported experiencing language barriers in consultation with immigrant patients (71.4%). In the patient-provider relationship, the most commonly reported barrier was the patient’s lack of medical understanding (81.4%). At the system level, the absence of a relative for translation was the most frequently encountered challenge (77.1%). On multivariable analysis adjusting for career stage and percentage of foreign-born patients, female gender of a surgeon was associated with more frequent perception of barriers related to language (OR 4.91, [95% CI 1.43, 16.82; p = 0.0114]), the patient’s desired role in decision-making (OR 3.000 [95% CI 1.116–8.059; p = 0.0294]), and poor access to interpreters (OR 3.63 [95% CI 1.24, 10.64; p = 0.0189]). Furthermore, on multivariable analysis adjusting for gender and career stage, surgeons identified as having

When should business-to-business firms encourage their salespeople to advocate for the customer in pricing negotiations? This research extends dual agency theory to the sales domain to address this question. In Study 1, the authors examine discount negotiations with secondary data from a major U.S. distributor. They find that the customer and seller both experience the most favorable outcomes when the salesperson advocates strongly for both parties; advocacy for either party alone is counterproductive. Study 2 confirms these results using matched survey, pricing, and profit data and demonstrates a key boundary condition: broad customer–seller ties enable the synergy between customer advocacy and seller advocacy by enhancing the firms’ abilities to monitor the salesperson. In Study 3, experiments with business-to-business buyers replicate key findings and provide evidence for theorized mechanisms. This research emphasizes the interdependence between the salesperson’s dual roles and demonstrates how the salesperson can serve as an effective agent of both the customer and seller, thereby mitigating challenges associated with role conflict.

BACKGROUND: There is a paucity of evidence regarding the role of food timing on cardiometabolic health and weight loss in adults. OBJECTIVES: To determine whether late eating is cross-sectionally associated with obesity and cardiometabolic risk factors at baseline; and whether late eating is associated with weight loss rate and success following a weight loss intervention protocol. Also, to identify obesogenic behaviors and weight loss barriers associated with late eating. METHODS: Participants were recruited from a weight-loss program in Spain. Upon recruitment, the midpoint of meal intake was determined by calculating the midway point between breakfast and dinner times, and dietary composition was determined from diet recall. Population median for the midpoint of meal intake was used to stratify participants into early (before 14:54) and late (after 14:54) eaters. Cardiometabolic and satiety hormonal profiles were determined from fasting blood samples collected prior to intervention. Weekly weight loss and barriers were evaluated during the ∼19-wk program. Linear and logistic regression models were used to assess differences between late and early eaters in cardiometabolic traits, satiety hormones, obesogenic behaviors, and weight loss, adjusted for age, sex, clinic site, year of recruitment, and baseline BMI. RESULTS: A total of 3362 adults [mean (SD): age: 41 (14) y; 79.2% women, BMI: 31.05 (5.58) kg/m(2)] were enrolled. At baseline, no differences were observed in energy intake or physical activity levels between early and late eaters (P >0.05). Late eaters had higher BMI, higher concentrations of triglycerides, and lower insulin sensitivity compared with early eaters (all P

Healthcare organisations rely on their financial stakeholders for capital to invest in state-of-the-art buildings, equipment, innovation and the delivery of healthcare services. Nevertheless, relations between healthcare organisations and their financial stakeholders have not been well studied. Here, we studied the relations between Dutch healthcare organisations and two of their main financial stakeholders (banks and health insurers) against the backdrop of system reforms and the financial crisis. We conducted a survey of healthcare executives to evaluate their relations with banks and health insurers in terms of power, legitimacy and urgency. These three attributes are based on the salience model of Mitchel, Agle and Wood (1997). We further tested for differences in power, legitimacy and urgency across organisational sector and size. The results showed that healthcare organisations value banks as legitimate stakeholders with a well-demarcated influence and a clear-cut function. The relationship with health insurers is more complex. Healthcare organisations experience considerable influence from health insurers but question the legitimacy of their claims. Since health insurers play a crucial role in the Dutch healthcare system, these findings question the workability of the relationship between healthcare organisations and health insurers and the position of health insurers in the overall healthcare sector. Our results are relevant to countries with public-private health systems and contribute to the development of the salience model by showing the individual value of stakeholder attributes and the relevance of context.

This paper presents a real-time capable nonlinear model predictive control (NMPC) strategy to effectively control the driving performance of an electric vehicle (EV) while optimizing thermal utilization. The prediction model is based on an experimentally validated two-node lumped parameter thermal network (LPTN) and one-dimensional driving dynamics. An efficient solver for the trajectory tracking problem is exported using acados and deployed on a dSPACE SCALEXIO embedded system. The lap time of a high-load driving cycle compared to a state-of-the-art derating strategy improved by 2.56% with an energy consumption reduction of 2.43% while respecting the temperature constraints of the electric drive.

A ocupação do território na Região Noroeste do RS consolidou unidades de produção com características distintas. Frente a isso, o presente trabalho teve o objetivo de analisar e diagnosticar a produção agropecuária do município de Santa Rosa, RS, e propor estratégias de desenvolvimento. Estudou-se a evolução da agricultura, o zoneamento agroecológico, a tipologia, a modelização e a caracterização técnica, econômica e ambiental dos sistemas de produção. A pesquisa foi realizada através de entrevistas semiestruturadas com trinta e cinco agricultores, em duas etapas, nos anos de 2016 e 2017, assim como utilizou-se de dados secundários e mapas. Como resultados, constatou-se que os solos são favoráveis à prática da agricultura e predominam unidades de produção familiar. Nos últimos vinte anos, houve substancial crescimento da produção de leite, grãos, fruticultura e olericultura e redução da suinocultura e área cultivada de soja. Foram caracterizadas quatro zonas agroecológicas sob a ótica do desenvolvimento e a história agrária foi agrupada em quatro períodos de acordo com fatos ecológicos, técnicos e socioeconômicos. Foram identificados treze tipos de sistemas de produção e cinco casos especiais. Apenas o caso familiar com produção de grãos e venda de excedentes não atinge o nível de reprodução social, ou seja, renda agrícola mensal de um salário mínimo por unidade de trabalho familiar, mais décimo terceiro. Estes agricultores deveriam ter prioridades de ação, assim como os agricultores familiares que apresentam baixa produção de leite. Recomenda-se investir em projetos de conversão ou adequação da produção, assistência técnica e assessoria ambiental para estes agricultores.

In the past few decades, a faster uptake has been noticed for offsite construction techniques, as supported by several relevant research streams. This study focused on the perceptions of stakeholders, which is an important research field, in terms of the manifold experiences and their critical role in decision-making. The purpose of this work was to gather quantifiable information regarding benefits and barriers of offsite construction to assist in the development or improvement of tools and strategic guidelines for the decision-making process. In total, 24 papers were selected by combining the systematic review with the snowball sampling technique to survey and quantify the perceptions of 1,625 stakeholders, and to obtain 238 barrier indexes and 99 benefit indexes. A hierarchical cluster analysis was also conducted to frame 10 clusters for benefits and another 10 for barriers. In addition, a co-citation analysis was carried out to identify 7 clusters and the associated connections between them. A database was provided with barriers and benefits, ranked by their relevance to offsite construction, as well as the bibliometrics and co-citation analysis that may help choose the best-fit source/perception for the purpose of the readers. Resumo Nas últimas décadas, observou-se uma aceitação mais rápida das técnicas de construção offsite, apoiadas por várias correntes de pesquisa relevantes. Este estudo concentrou-se nas percepções de stakeholders, que em função do seu papel fundamental no processo decisório aliado à diversidade de suas experiências, caracterizam um campo importante de pesquisa. O objetivo deste trabalho foi reunir informações quantificáveis sobre os benefícios e barreiras da construção offsite para auxiliar no desenvolvimento e/ou aprimoramento de ferramentas e diretrizes estratégicas para o processo de tomada de decisão. Por meio de combinação entre as técnicas de Revisão Bibliográfica Sistemática e Amostragem Bola de Neve, foram selecionados 24 artigos, que totalizaram 1.625 percepções de stakeholders, 238 indicadores de barreiras e 99 indicadores de benefícios. Também foi realizada uma análise de agrupamentos para estruturar 10 grupos para benefícios e outros 10 para barreiras. Além disso, foi realizada uma análise de co-citação para identificar 7 grupos e as conexões associadas entre eles. A pesquisa resultou em um banco de dados com barreiras e benefícios da construção offsite, classificados conforme sua relevância para os stakeholders. Foram agregadas análises bibliométrica e de cocitação para auxiliar o leitor na escolha da fonte/percepção mais adequada aos seus objetivos.

This article provides an overview of some of the demographics of youth experiencing homelessness and examples of how Cooperative Extension is working with this population around the country. A discussion of the needs of this population is provided, along with strategies for how Extension can connect with current efforts to reach youth experiencing homelessness to build resilience. Data are summarized from a webinar for Extension professionals. Education in this area is worthwhile to youth development professionals who may be interested in designing new programs, expanding current programs, finding new program partnerships, and using programs to support youth experiencing homelessness. Local and national-level programs that are designed to reach youth experiencing homelessness are highlighted. The structure and resources of the Cooperative Extension system nationwide are ideal to provide supplementary support to youth experiencing homelessness in a variety of settings. This article is an invitation to expand this conversation and further explore the needs of youth experiencing homelessness and Extension’s capacity to respond.

Climate change will have dire consequences and collaborative efforts are required to quickly develop and assess mitigation solutions. Agriculture is the primary source of the powerful greenhouse gas (GHG) nitrous oxide (N2O) and an important source of GHG emissions. Due to sampling limitations, N2O measurements have traditionally been sparse; approximately 75% of sites we reviewed sampled for fewer than 50 days within a year. Nitrous oxide emissions are highly variable and short-lived peak emission periods may contribute more than 50% to annual emissions. Gap filling around these peaks, if measured at all, can result in poor estimations under the standard practice using area under the curve. Improved gap filling methods that reflect covariate data will likely reduce uncertainty and improve annual N2O estimates. The Global N2O Database was created to serve as a repository for these datasets as well as become a resource for publicly available data and analytical advances.

INTRODUCTION Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States. METHODS Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals. RESULTS A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common. CONCLUSION Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries. LEVEL OF EVIDENCE Level III.

IntroductionShift work causes misalignment between internal circadian time and the external light/dark cycle and is associated with metabolic disorders and cancer. Approximately 20% of the working population in industrialised countries work permanent or rotating night shifts, exposing this large population to the risk of circadian misalignment-driven disease. Analysis of the impact of shift work on chronic inflammatory diseases is lacking. We investigated the association between shift work and asthma.MethodsWe describe the cross-sectional relationship between shift work and prevalent asthma in >280000 UK Biobank participants, making adjustments for major confounding factors (smoking history, ethnicity, socioeconomic status, physical activity, body mass index). We also investigated chronotype.ResultsCompared with day workers, ‘permanent’ night shift workers had a higher likelihood of moderate-severe asthma (OR 1.36 (95% CI 1.03 to 1.8)) and all asthma (OR 1.23 (95% CI 1.03 to 1.46)). Individuals doing any type of shift work had higher adjusted odds of wheeze/whistling in the chest. Shift workers who never or rarely worked on nights and people working permanent nights had a higher adjusted likelihood of having reduced lung function (FEV1 ConclusionsThe public health implications of these findings are far-reaching due to the high prevalence and co-occurrence of both asthma and shift work. Future longitudinal follow-up studies are needed to determine if modifying shift work schedules to take into account chronotype might present a public health measure to reduce the risk of developing inflammatory diseases such as asthma.

To establish the intrarater reliability of lower limb circumference measures in a sample of individuals who are diagnosed with lower limb lymphoedema and to evaluate if change in limb position has an effect on the reliability of circumferential measures. A sample of forty-one adults diagnosed with a lower limb lymphoedema were recruited. Participants had their affected leg measured three times by a qualified therapist during a standard outpatient appointment: twice in a lying position and once in sitting with knee flexed at 90°. To examine the intrarater reliability, interclass correlation coefficients (ICC) with 95% confident intervals were calculated. Excellent intrarater reliability was established at each measurement point and for the sum of circumferential measures when the limb remeasured in the same position by the same therapist. Changing the position of the limb resulted in lower intrarater reliability values at 10 and 30 cm from the base of the foot. The current study provides evidence for the intrarater reliability of lower limb circumference measures and highlights the need for consistency when remeasuring and monitoring the limb of those diagnosed with lower limb lymphoedema. Lymphoedema is a significant problem for breast cancer survivors but also provides lifetime risk to all survivors of lymph node surgery for solid tumours. The monitoring and surveillance of leg circumference measures of people diagnosed with lower limb lymphoedema has been a valuable instrument when reviewing progress of this chronic condition.

Therapeutic vaccines are intended for the treatment of established diseases by harnessing the patient's own immune system. In this article we discuss therapeutic areas that are of relevance for therapeutic vaccination, i.e., oncology and neurodegenerative diseases. Clinical and regulatory aspects related to the manufacture and clinical use of actively personalized cancer vaccines are thoroughly reviewed. This applies to the regulatory classification of genomic sequencing approaches to identify tumor-specific mutations, combination therapies with checkpoint inhibitors, clinical study designs, and the use of suitable adjuvants and drug substances. Huge amounts of data (big data) are increasingly being generated in the area of personalized therapies; we briefly address the impact and usability of big data in regulatory procedures.

Summary Background & aims Children on long-term tube-feeding often need special treatment for oral feeding transitioning. Rapid tube-weaning programs usually result in short-term reductions in food intake and weight loss. This study examined the long-term effects of a “Graz-model” based weaning program on nutritional status and growth. Methods Children aged 0.5–13.0 years on long-term enteral nutritional support (ENS) participated in a three-week multidisciplinary weaning treatment. Data were collected at baseline, after completing the program, and at six and 12 months. Height/length, weight and BMI z-scores were determined according to the WHO growth standards. Energy and protein intake were assessed and presented as % of recommended daily allowance (RDA) values. Results Study participants (n = 58) were 64% male. Four children did not complete the three-week program due to acute illnesses. Complete weaning (from 100% ENS to 100% oral) was achieved in 22 children and partial weaning (at least 80% reduction of ENS) in 23 children. No demographic or clinical success predictors were identified. Thirty of the 45 weaned children completed the 12-month follow-up. A significant reduction in energy intake was observed at the three-week time-point [mean (SE): 56 (5.8)% versus 80 (4.7)%, p = 0.001]. This was followed by improvements in eating skills leading to energy intake at 12 months which did not significantly differ from baseline (p = 0.392). Mean (SE) baseline protein intake was 187 (13.0) %RDA. No significant difference from baseline were noted at 12 months (p = 0.301). Estimated mean (SD) height-, weight- and BMI z-scores at baseline were −2.11(0.28), −1.48(0.25), −0.13(0.31), respectively. No significant differences in growth data were observed over time. Conclusions Short-term reductions in nutritional intake and body weight observed after an intensive weaning program were reversible, and growth patterns were stable over 12 months. Further follow-up is recommended to ensure continued positive development in these children.

Due to the SARS CoV-2-virus (COVID-19), anxiety, distress, and insecurity occur more frequently. In particular, infected individuals, their relatives, and medical staff face an increased risk of high psychological distress as a result of the ongoing pandemic. Thus, structured psychosocial emergency concepts are needed. The University hospital of Essen has taken up this challenge by creating the PEC concept to reduce psychosocial long-term consequences for infected patients, relatives, and medical staff at the university hospital. The concept includes professional medical as well as psychological support to convey constructive coping strategies and the provision of adequate tools such as the low-threshold online training program (CoPE It), which is accessible via the webpage www.cope-corona.de.