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Objectives To explore expert perspectives on risks associated with the pediatric electronic health record (EHR) for intimate partner violence (IPV) survivors and their children and to identify strategies that may mitigate these risks. Methods We conducted semistructured interviews with multidisciplinary pediatric IPV experts (nursing, physicians, social workers, hospital security, IPV advocates) recruited via snowball sampling. We coded interview transcripts using thematic analysis, then consolidated codes into themes. Results Twenty-eight participants completed interviews. Participants identified the primary source of risk as an abuser's potential access to a child's EHR by legal and illegal means. They noted that abuser's access to multiple pediatric EHR components (eg, online health portals, clinical notes, contact information) may result in escalated violence, stalking, and manipulation of IPV survivors. Suggested risk mitigation strategies included limited and coded documentation, limiting EHR access, and discussing documentation with the IPV survivor. Challenges to using these strategies included healthcare providers’ usual practice of detailed documentation and that information documented may confer both risk and benefit concurrently. Reported potential benefits of the pediatric EHR for IPV survivors included ensuring continuity of care, decreasing need to repeatedly talk about trauma histories, and communication of safety plans. Conclusions Our findings suggest the pediatric EHR may confer both risks and benefits for IPV survivors and their children. Further work is needed to develop best practices to address IPV risks related to the pediatric EHR, to ensure consistent use of these practices, and to include these practices as standard functionalities of the pediatric EHR.

Chronic infections and the subsequent immune response have recently been shown to be risk factors for cognitive decline and Alzheimer disease and related dementias (ADRD). While some studies have shown an association between cytomegalovirus (CMV), a chronic and highly prevalent infection, and cognition and/or ADRD, these studies have been limited by nonrepresentative and small samples. Using 2016 data on 5,617 adults aged 65 years or more from the Health and Retirement Study, we investigated the cross-sectional associations of both CMV serostatus and immunoglobulin G (IgG) antibody response with cognitive function using linear regression models adjusting for age, sex, race/ethnicity, and educational attainment. We further investigated potential effect-measure modification by educational attainment. Overall, both CMV seropositivity and higher IgG antibody response were associated with lower cognitive function, though the relationship was not statistically significant in adjusted models. Among participants with less than a high school diploma, CMV seropositivity and being in the first tertile of IgG response, relative to seronegative persons, were associated with lower scores on the Telephone Interview for Cognitive Status (−0.56 points (95% confidence interval: −1.63, 0.52) and −0.89 points (95% confidence interval: −2.07, 0.29), respectively), and the relationship was attenuated among those with higher education. Our results suggest that CMV may be a risk factor for cognitive impairment, particularly among persons with fewer educational resources.

Objectives Previous research has documented a consistent association between current socioeconomic status (SES) and cytomegalovirus (CMV). Early life is likely a critical period for CMV exposure and immune development, but less is known about early-life socioeconomic factors and CMV, particularly in older age populations. Using data from the Health and Retirement Study, we investigated the association between life course socioeconomic disadvantage and immune response to CMV among older adults. Methods Using ordered logit models, we estimated associations between several measures of socioeconomic disadvantage and the odds of being in a higher CMV Immunoglobulin G (IgG) response category in a sample of 8,168 respondents aged older than 50 years. Results We found a significant association between educational attainment and CMV IgG response. Those with less than a high school education had 2.00 (95% confidence interval [CI]: 1.67–2.40) times the odds of being in a higher CMV category compared to those with a college degree or greater. In addition, we also observed a significant association with parental education and CMV response. Individuals with parents having 8 years or less of schooling had 2.32 (95% CI: 2.00–2.70) times the odds of higher CMV response compared to those whose parents had greater than high school education. Discussion CMV IgG levels in older adults are associated with both early-life and adult SES. Life course socioeconomic disadvantage may contribute to disparities in immunological aging.

Osteochondral lesions of the talus (OLT) are often associated with ankle pain and dysfunction. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Chronic ankle ligament instability and subsequent microtrauma may lead to insidious development of an OLT. Medial-sided lesions are more common (67%) than lateral-sided lesions. For acute lesions that are nondisplaced, nonoperative management is initially performed, with a 4-6 week period of immobilization and protected weight bearing. Symptomatic improvement results in more than 50% of patients by 3 months. Acute osteochondral talus fractures, which have a bone fragment thickness greater than 3 mm with displacement will benefit from early surgical intervention. These injuries should undergo primary repair via internal fixation with bioabsorbable compression screws 3.0 mm or smaller using at least 2 points of fixation. Acute lesions that are too small for fixation can be treated with morselization and reimplantation of the cartilage fragments. If OLTs are persistently symptomatic following an appropriate course of nonoperative treatment, various reparative and restorative surgical options may be considered on the basis of diameter, surface area, depth, and location of the lesion. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. Cancellous bone graft augmentation may be used for subchondral cysts with volume greater than 100 mm3 or with those with a depth of more than 10 mm. Debridement, curettage, and bone marrow stimulation is a reparative technique that may be considered in lesions demonstrating a diameter less than 10 mm, with surface area less than 100 mm2, and a depth less than 5 mm. This technique is commonly performed arthroscopically using curettes and an arthroscopic shaver to remove surrounding unstable cartilage. A microfracture awl of 1 mm or less is used to puncture the subchondral bone with 3-4 mm of spacing between to induce punctate bleeding. Initial ( Lesions greater than 1.29 cm2, cystic lesions, and lesions that have failed prior treatment are potential candidates for osteochondral autograft transplantation. The autograft is typically harvested from the lateral femoral condyle of the ipsilateral knee with an optimal plug depth and diameter of 12-15 mm. Transplantation often involves open technique and may even require malleolar osteotomy for perpendicular access to the defect, as well as visualization of a flush, congruent graft fit. Good to excellent outcomes have been reported in up 87.4% of cases with the most common complication being donor site morbidity in up to 15% of cases. Failure rates increased significantly in lesions larger than 225 mm2. Scaffold-based therapies, such as matrix-associated chondrocyte implantation, can be employed in primary or revision settings in lesions larger than 1 cm2, including uncontained shoulder lesions with or without cysts. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. This technique requires an initial procedure for chondrocyte harvest and a secondary procedure for transplantation of the scaffold. Outcomes have been good to excellent in up to 93% of cases; however, this technique requires a two-stage procedure and can be cost-prohibitive. Particulated juvenile cartilage is a restorative technique that employs cartilage allograft from juvenile donors. The cartilage is placed into the defect and secured with fibrin glue in a single-stage procedure. Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. This may be an alternative option for contained lesions between 10 and 15 mm in diameter. Osteochondral allograft plugs are an option for larger contained lesions (>1.5 cm in diameter) and in patients with knee osteoarthritis (OA) and concern for donor site morbidity. Furthermore, bulk osteochondral allograft from a size-matched talus can also be used for even larger, unstable/uncontained shoulder lesions. An anterior approach is often employed and fixation is achieved via placement of countersunk headless compression screws. Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis.

Conventional ex-ante evaluations rely on a mix of economic, environmental, and social indicators to assess the potential impacts of Genetically Modified (GM) crops prior to their commercial release. While these predictive studies have produced useful knowledge, they have also consistently overestimated the ex-post outcomes of GM crops for African smallholder farmers. Yet these same assessment methods remain the dominant approach to project farmer outcomes for a new suite of soon-to-be commercialized GM staple crops. The research presented in this paper offers a different evaluative approach for these new GM crops by taking inspiration from farming systems research (FSR). We use the conceptual starting point of FSR scholarship—the farming system—to conduct an exploratory predictive analysis of three GM crops currently in the experimental pipeline: Water Efficient Maize for Africa (WEMA) in Kenya, disease-resistant matooke banana in Uganda, and Bt cowpea in Burkina Faso. Our findings suggest that the lofty projected benefits of these crops are unlikely to be realized by many, if not most, smallholder farmers due to incongruences with the farming systems they are designed to benefit. This research demonstrates the importance of using farming system-based evaluation methods to better anticipate likely farm-level outcomes of new breeding technologies.

Purpose: Holmium laser enucleation of the prostate (HoLEP) entails both enucleation and morcellation. Only three popular prostate morcellation devices (PMDs) are available for this procedure. In th...

Objectives To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale. Design Systematic review. Setting and Participants Frail residents living in nursing homes. Methods MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language. Results Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1–79.5% (frail) to 28.5–75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried’s phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cutoffs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively. Conclusion In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes. Electronic Supplementary Material Supplementary material is available for this article at 10.1007/s12603-021-1694-3 and is accessible for authorized users.

INTRODUCTION Rates of osteoporosis evaluation and management after primary fragility fractures have remained low in recent years. The extent to which this treatment gap affects patients with diabetes is unclear. This study aimed to compare the risk of secondary fractures and rates of osteoporosis diagnosis and management after sentinel fractures in patients with and without diabetes. METHODS A propensity score-matched cohort study was conducted using the PearlDiver database. Patients aged 50 years and older with primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other locations were identified. Rates of secondary fractures, dual radiograph absorptiometry (DXA) scans, charted osteoporosis diagnoses (International Classification of Diseases, Ninth and Tenth Revisions), and osteoporosis pharmacotherapy within 2 years were compared for patients with and without diabetes using multivariable logistic regression. RESULTS Matching yielded 27,052 patients in each cohort. Index humerus fractures were more common in the diabetic cohort (15.0% versus 11.6%, P < 0.001), whereas wrist fractures were more prevalent among the nondiabetic cohort (15.2% versus 19.3%, P < 0.001). Incidence of secondary fractures at 2 years was higher for diabetic patients than nondiabetic patients (5.2% versus 4.7%; odds ratio [OR] 1.08; 95% confidence interval [CI], 0.99 to 1.17). Diabetic patients were significantly less likely to receive a DXA scan (13.2% versus 13.5%; OR 0.93; 95% CI, 0.88 to 0.98), be diagnosed with osteoporosis (9.3% versus 11.9%; OR 0.77; 95% CI, 0.73 to 0.82), or start pharmacotherapy (8.1% versus 8.7; OR 0.93; 95% CI, 0.87 to 0.99). CONCLUSION Despite diabetes being a well-established risk factor for fragility fractures, diabetic patients were significantly less likely to receive DXA scan evaluation, be formally diagnosed with osteoporosis, or be treated with osteoporosis pharmacotherapy after a sentinel fragility fracture. Incidence of secondary fractures within 2 years was also higher among diabetic patients.

OBJECTIVES: To understand responses of primary care clinics to inclusion in a tiered total cost of care insurance benefit design. STUDY DESIGN: We used a qualitative design beginning with longitudinal analysis of administrative data on consumer clinic choice, clinic tier placement, and clinic actions, followed by in-depth interviews with key informants from clinics, administering health plans, and program administrators. METHODS: We collected data via semistructured interviews with purposively sampled key informants selected from clinics that prospectively reduced prices to move to, or remain in, a tier with lower cost sharing. Data from interview transcripts were coded using qualitative coding software and analyzed for thematic responses. RESULTS: Our findings suggest that clinics respond to the incentives in the tiered cost-sharing benefit design. Two motivations cited by clinics are (1) concern over developing a reputation as a high-cost clinic and (2) concern about the possible loss of patients due to higher cost sharing. Some clinics have agreed to price reductions or risk-sharing arrangements to move to, or remain in, a tier with lower cost sharing. Clinic informants reported that price reductions alone are not scalable. They sought greater transparency in tier assignment and increased data sharing to help them reduce costly or unnecessary utilization. CONCLUSIONS: Managers of primary care clinics respond to a tiered benefit design that holds them accountable for total cost of care. They respond by offering price discounts and expressing interest in reducing costly referrals and unnecessary use of services.

Kidney fibrosis constitutes the shared final pathway of nearly all chronic nephropathies, but biomarkers for the non-invasive assessment of kidney fibrosis are currently not available. To address this, we characterize five candidate biomarkers of kidney fibrosis: Cadherin-11 (CDH11), Sparc-related modular calcium binding protein-2 (SMOC2), Pigment epithelium-derived factor (PEDF), Matrix-Gla protein, and Thrombospondin-2. Gene expression profiles in single-cell and single-nucleus RNA-sequencing (sc/snRNA-seq) datasets from rodent models of fibrosis and human chronic kidney disease (CKD) were explored, and Luminex-based assays for each biomarker were developed. Plasma and urine biomarker levels were measured using independent prospective cohorts of CKD: the Boston Kidney Biopsy Cohort, a cohort of individuals with biopsy-confirmed semiquantitative assessment of kidney fibrosis, and the Seattle Kidney Study, a cohort of patients with common forms of CKD. Ordinal logistic regression and Cox proportional hazards regression models were used to test associations of biomarkers with interstitial fibrosis and tubular atrophy and progression to end-stage kidney disease and death, respectively. Sc/snRNA-seq data confirmed cell-specific expression of biomarker genes in fibroblasts. After multivariable adjustment, higher levels of plasma CDH11, SMOC2, and PEDF and urinary CDH11 and PEDF were significantly associated with increasing severity of interstitial fibrosis and tubular atrophy in the Boston Kidney Biopsy Cohort. In both cohorts, higher levels of plasma and urinary SMOC2 and urinary CDH11 were independently associated with progression to end-stage kidney disease. Higher levels of urinary PEDF associated with end-stage kidney disease in the Seattle Kidney Study, with a similar signal in the Boston Kidney Biopsy Cohort, although the latter narrowly missed statistical significance. Thus, we identified CDH11, SMOC2, and PEDF as promising non-invasive biomarkers of kidney fibrosis.

Background Cancer cachexia negatively affects quality of life (QoL) and increases symptom burden. A multimodal treatment approach may optimize cachexia outcomes, including QoL. We evaluated QoL and symptoms over time among patients attending a multidisciplinary clinical service for cancer cachexia. Methods Adults with cancer who attended the clinical service three times between 2017 and 2020 were included. Quality of life and symptoms were assessed using the European Organization for Research and Treatment of Cancer Quality of life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL) and the Functional Assessment Anorexia/Cachexia Therapy (FAACT) questionnaires. Physical function was assessed using the 30s sit-to-stand test and handgrip strength. Results Overall, 162 patients (age = 67.2 ± 12.0 years) were included. Mean six-month weight loss at baseline was 10.4% ± 9.4%. Mean body weight was stable between clinic visits (P = 0.904) and no change in sit-to-stand repetitions (P = 0.133) or handgrip strength (P = 0.734) occurred over time. Improvements in EORTC QLQ-C15-PAL overall QoL (Δ10.7 ± 2.5, P < 0.001), physical function (Δ8.0 ± 2.4, P = 0.003) and emotional function (Δ11.4 ± 2.9, P < 0.001) occurred by the second visit. EORTC QLQ-C15-PAL fatigue (Δ13.8 ± 2.9, P < 0.001), pain (Δ10.3 ± 3.3, P = 0.007), nausea/vomiting (Δ16.1 ± 3.0, P < 0.001) and appetite symptoms (Δ25.9 ± 3.8, P < 0.001) also improved by the second visit. FAACT total score (Δ14.6 ± 2.7, P < 0.001), anorexia-cachexia symptoms (Δ6.6 ± 1.1, P< 0.001), and physical (Δ3.7 ± 0.70, P < 0.001), emotional (Δ1.9 ± 0.60, P = 0.005) and functional wellbeing (Δ2.7 ± 0.71, P = 0.001) improved by the second visit. All improvements in EORTC QLQ-C15-PAL and FAACT outcomes were maintained at the third visit. Conclusion Significant improvements in QoL and symptoms were associated with attending a cancer cachexia clinical service. Our findings support using multidisciplinary, multimodal cancer cachexia treatment approaches to improve patient wellbeing.

Age-related cardiac amyloidosis results from deposits of wild-type tranthyretin amyloid (ATTRwt) in cardiac tissue. ATTR may play a role in carpal tunnel syndrome (CTS) and in spinal stenosis (SS), indicating or presaging systemic amyloidosis. We investigated consecutive patients undergoing surgery for SS for ATTR deposition in the resected ligamentum flavum (LF) and concomitant risk of cardiac amyloidosis. Each surgical specimen (LF) was stained with Congo red, and if positive, the amyloid deposits were typed by mass spectrometry. Patients with positive specimens underwent standard of care evaluation with fat pad aspirates, serum and urine protein electrophoresis with immunofixation, free light-chain assay

Dysregulation of glutamatergic neural circuits has been implicated in a cycle of toxicity, believed among the neurobiological underpinning of Alzheimer’s disease. Previously, we reported preclinical evidence that the glutamate modulator riluzole, which is FDA approved for the treatment of amyotrophic lateral sclerosis, has potential benefits on cognition, structural and molecular markers of ageing and Alzheimer’s disease. The objective of this study was to evaluate in a pilot clinical trial, using neuroimaging biomarkers, the potential efficacy and safety of riluzole in patients with Alzheimer’s disease as compared to placebo. A 6-month phase 2 double-blind, randomized, placebo-controlled study was conducted at two sites. Participants consisted of males and females, 50 to 95 years of age, with a clinical diagnosis of probable Alzheimer’s disease, and Mini-Mental State Examination between 19 and 27. Ninety-four participants were screened, 50 participants who met inclusion criteria were randomly assigned to receive 50 mg riluzole (n = 26) or placebo (n = 24) twice a day. Twenty-two riluzole-treated and 20 placebo participants completed the study. Primary end points were baseline to 6 months changes in (i) cerebral glucose metabolism as measured with fluorodeoxyglucose-PET in prespecified regions of interest (hippocampus, posterior cingulate, precuneus, lateral temporal, inferior parietal, frontal); and (ii) changes in posterior cingulate levels of the neuronal viability marker N-acetylaspartate as measured with in vivo proton magnetic resonance spectroscopy. Secondary outcome measures were neuropsychological testing for correlation with neuroimaging biomarkers and in vivo measures of glutamate in posterior cingulate measured with magnetic resonance spectroscopy as a potential marker of target engagement. Measures of cerebral glucose metabolism, a well-established Alzheimer’s disease biomarker and predictor of disease progression, declined significantly less in several prespecified regions of interest with the most robust effect in posterior cingulate, and effects in precuneus, lateral temporal, right hippocampus and frontal cortex in riluzole-treated participants in comparison to the placebo group. No group effect was found in measures of N-acetylaspartate levels. A positive correlation was observed between cognitive measures and regional cerebral glucose metabolism. A group × visit interaction was observed in glutamate levels in posterior cingulate, potentially suggesting engagement of glutamatergic system by riluzole. In vivo glutamate levels positively correlated with cognitive performance. These findings support our main primary hypothesis that cerebral glucose metabolism would be better preserved in the riluzole-treated group than in the placebo group and provide a rationale for more powered, longer duration studies of riluzole as a potential intervention for Alzheimer’s disease.

Background Educating and training clinicians to deliver nutrition interventions is critical to improve population health. However, the adequacy of nutrition education within primary care adult and family nurse practitioner (ANP/FNP) curricula has not been addressed. Purpose The purpose of this study was to describe faculty perceptions of nutrition education in ANP/FNP programs. Methods We used a cross-sectional design to gather data on nutrition education. The survey was administered to a convenience sample of faculty from the United States. Results Our response rate was 47.8% (N = 49). The mean ± SD hours of nutrition education was 14.4 ± 14.6. One-fourth of schools reported that their students received at least 25 hours of nutrition education. Most participants thought it was very or extremely important (75.6%) that their students become more educated about nutrition. Conclusions There is a need and desire for more nutrition education within nursing graduate curricula. Novel strategies to implement nutrition education in nurse practitioner curriculum are needed.

INTRODUCTION: Poor sleep is prevalent among individuals with social anxiety disorder (SAD) and may negatively affect exposure therapy outcomes. Poor sleep may impair memory and learning, and thus compromise fear extinction learning thought to take place in exposure therapy. We examined poor sleep as a predictor of exposure therapy outcomes for SAD and the moderating role of D-cycloserine (DCS) on this relationship. METHODS: Participants were 152 individuals with a primary diagnosis of SAD. As part of a randomized clinical trial evaluating the efficacy of DCS for enhancing the effects of exposure therapy, they completed self-report baseline measure of sleep quality, and self-report sleep diaries assessing sleep duration (total sleep time [TST]) and sleep quality the nights prior to and after treatment sessions. RESULTS: Poorer baseline sleep quality was significantly associated with slower improvement over time and worse symptom outcomes at the end of treatment and follow-up after controlling for baseline symptoms of depression and social anxiety. Greater TST the night prior to treatment predicted lower SAD symptoms at the next session, after controlling for symptoms at the previous session. There was no relation between prior or subsequent night sleep quality on symptoms at the next session. No associations were moderated by DCS. CONCLUSIONS: We replicated and extended findings indicating that poor sleep quality is associated with poorer exposure therapy outcomes for SAD. Assessing for sleep difficulties prior to treatment initiation and incorporating sleep interventions into treatment may enhance exposure therapy outcomes for SAD.

The impact of antithrombin III activity (AT-III) on prophylactic enoxaparin anti-factor Xa concentration (anti-Xa) is unknown in high-risk trauma patients. So too is the optimal anti-Xa-adjusted enoxaparin dosage. This prospective, randomized, pilot study sought to explore the association between AT-III and anti-Xa goal attainment and to preliminarily evaluate two enoxaparin dosage adjustment strategies in patients with subprophylactic anti-Xa. Adult trauma patients with Risk Assessment Profile (RAP) ≥ 5 prescribed enoxaparin 30 mg subcutaneously every 12 h were eligible. AT-III and anti-Xa were drawn 8 h after the third enoxaparin dose and compared between patients with anti-Xa ≥ 0.1 IU/mL (goal; control group) or anti-Xa

BACKGROUND AND PURPOSE: AVFs of the foramen magnum region, including fistulas of the marginal sinus and condylar veins, have complex arterial supply, venous drainage, symptoms, and risk features that are not well-defined. The purpose of this study was to present the angioarchitectural and clinical phenotypes of a foramen magnum region AVF from a large, single-center experience. MATERIALS AND METHODS: We retrospectively reviewed cases from a 10-year neurointerventional data base. Arterial and venous angioarchitectural features and clinical presentation were extracted from the medical record. Venous drainage patterns were stratified into 4 groups as follows: type 1 = unrestricted sinus drainage, type 2 = sinus reflux (including the inferior petrosal sinus), type 3 = reflux involving sinuses and cortical veins, and type 4 = restricted cortical vein outflow or perimedullary congestion. RESULTS: Twenty-eight patients (mean age, 57.9 years; 57.1% men) had 29 foramen magnum region AVFs. There were 11 (37.9%) type 1, nine (31.0%) type 2, six (20.7%) type 3, and 3 (10.3%) type 4 fistulas. Pulsatile tinnitus was the most frequent symptom (82.1%), followed by orbital symptoms (31.0%), subarachnoid hemorrhage (13.8%), cranial nerve XII palsy (10.3%), and other cranial nerve palsy (6.9%). The most frequent arterial supply was the ipsilateral ascending pharyngeal artery (93.1% ipsilateral, 55.5% contralateral), vertebral artery (89.7%), occipital artery (65.5%), and internal carotid artery branches (48.3%). CONCLUSIONS: We present the largest case series of foramen magnum region AVFs to date and show that clinical features relate to angioarchitecture. Orbital symptoms are frequent when sinus reflux is present. Hemorrhage was only observed in type 3 and 4 fistulas.

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

Objectives: A 24-hour day is made up of time spent in a range of physical activity (PA) behaviours, including sleep, sedentary time, standing, light-intensity PA (LIPA) and moderate-to-vigorous PA (MVPA), all of which may have the potential to alter an individual’s health through various different pathways and mechanisms. This study aimed to explore the relationship between PA behaviours and the gut microbiome in older adults. Design: Cross-sectional study. Settings and Participants: Participants (n=100; age 67.76 years [3.02]; 44% female) from the Mitchelstown Cohort Rescreen (MCR) Study (2015-2017). Methods: Participants provided measures of gut microbiome composition (profiled by sequencing 16S rRNA gene amplicons), and objective measures of PA behaviours (by a 7-day wear protocol using an activPAL3 Micro). Results: Standing time was positively correlated with the abundance of butyrate-producing and anti-inflammatory bacteria, including Ruminococcaceae, Lachnospiraceae and Bifidobacterium, MVPA was positiv ely associated with the abundance of Lachnospiraceae bacteria, while sedentary time was associated with lower abundance of Ruminococcaceae and higher abundance of Streptococcus spp Conclusion: Physical activity behaviours appear to influence gut microbiota composition in older adults, with different PA behaviours having diverging effects on gut microbiota composition. yes

Objective Childhood exposure to intimate partner violence (IPV) is a pervasive public health epidemic with profound impact on child health. While past work has demonstrated how abusive partners exert control over IPV survivors in a variety of settings (eg workplace, courts, home), scant research has examined how IPV power and control behaviors manifest themselves in pediatric healthcare settings. In this study, we explore the perspectives of pediatric IPV experts about: (1) behaviors used by abusive partners to control IPV survivors in pediatric healthcare settings; (2) how controlling behaviors impact healthcare access and quality; and (3) recommendations for the pediatric healthcare team. Methods Individual semi-structured interviews were conducted with pediatric IPV experts recruited through snowball sampling. Interviews were individually coded by two research team members and analyzed using thematic analysis. Results Twenty-eight pediatric IPV experts participated. Participants described several types of controlling behaviors including limiting healthcare access, dominating conversations during medical visits, controlling medical decision making, and manipulating perceptions of the healthcare team. Participants acknowledged the challenges of recognizing controlling behaviors and provided several recommendations to addressing behaviors such as leveraging the expertise of multidisciplinary teams. Conclusions Participants described how abusive partners may attempt to control or discredit their partners in pediatric healthcare settings, using subtle behaviors that may be easily missed by the healthcare team. These results set the stage for further research and clinical practice innovation including triangulating the findings with IPV survivors, examining how frequently these behaviors occur, and developing multidisciplinary IPV training for the pediatric healthcare team.

This study assessed the feasibility and benefits of high-intensity interval training (HIIT) plus lifestyle education among inactive adults with celiac disease. Forty-one participants were randomized to receive the intervention (HIIT plus lifestyle education; HIIT+) for 12 weeks or waitlist control (WLC). Testing was completed at baseline, immediately post-intervention, and 3 months post-intervention. Generalized estimating equations were used to assess changes in the outcome variables over time between the groups. Mean percent of age-predicted maximum heart rate was 97.9% and average rating of perceived exertion was 6.33 (out of 10) during HIIT intervals. Following the intervention, the HIIT+ showed enrichment in relative abundance of Parabacteroides and Defluviitaleaceae_UCG_011 while WLC showed enrichment in relative abundance of Roseburia intestinalis, Klebsiella, and Adlercreutzia. A unique set of taxa were differentially abundant between the groups at 3 months post-intervention. HIIT+ participants experienced a reduction in resting heart rate (−6.6 bpm) immediately post-intervention compared with WLC. Further research is needed to establish an optimal HIIT protocol that may improve maximal oxygen uptake and metabolic syndrome biomarkers. Findings from this pilot study provide preliminary evidence that an HIIT intervention is feasible for inactive adults with celiac disease and leads to favourable changes in resting heart rate alongside potentially beneficial shifts in gut microbiota. Trial registration number: ClinicalTrials.gov number NCT03520244. Novelty: HIIT leads to potentially beneficial changes in the gut microbiota of adults with celiac disease. An HIIT exercise intervention is feasible and well tolerated for patients with celiac disease.

Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.

Activating variants in the platelet-derived growth factor receptor β gene (PDGFRB) have been associated with Kosaki overgrowth syndrome, infantile myofibromatosis, and Penttinen premature aging syndrome. A recently described phenotype with fusiform aneurysm has been associated with mosaic PDGFRB c.1685A > G p.(Tyr562Cys) variant. Few reports however have examined the vascular phenotypes and mosaic effects of PDGFRB variants. We describe clinical characteristics of two patients with a recurrent mosaic PDGFRB p.(Tyr562Cys) variant identified via next-generation sequencing-based genetic testing. We observed intracranial fusiform aneurysm in one patient and found an additional eight patients with aneurysms and phenotypes associated with PDGFRB-activating variants through literature search. The conditions caused by PDGFRB-activating variants share overlapping features including overgrowth, premature aged skin, and vascular malformations including aneurysms. Aneurysms are progressive and can result in morbidities and mortalities in the absence of successful intervention. Germline and/or somatic testing for PDGFRB gene should be obtained when PDGFRB activating variant-related phenotypes are present. Whole-body imaging of the arterial tree and echocardiography are recommended after diagnosis. Repeating the imaging study within a 6- to 12-month period after detection is reasonable. Finally, further evaluation for the effectiveness and safety profile of kinase inhibitors in this patient population is warranted.

The use of intracranial stents in neurointerventional surgery has been practiced for decades. However, the spectrum of treatable pathology, available devices, and clinical adoption of intracranial stents has exploded in recent years. Diagnostic neuroradiologists play a critical role in the evaluation of these devices after deployment, yet may not be familiar with state-of-the-art intracranial stent devices and indications. This review provides an overview of intracranial stents for cerebrovascular disease, with 3 chief learning objectives: 1) to understand the basic principles of stent design, biomechanics, and deployment, and the resulting influence on cerebrovascular hemodynamics; 2) to be familiar with the spectrum of intracranial pathology amenable to endovascular stent placement; and 3) to recognize the radiographic appearance of successful intracranial stent deployment and intracranial stent‐related complications.Learning Objective: Recognize the key principles of design (form), current indications (function), and potential complications of intracranial stents used in neurointerventional surgery

This work reports on two debated points related to the metal content of cotton fiber and its influence on processing. The first issue is if the metal levels of raw fibers are naturally deposited during fiber development or if the levels are influenced by weathering and harvesting conditions present after boll opening. This was tested by harvesting bolls just as they were opening and after the opened bolls were allowed to field age. The second issue relates to the importance of metal levels on fiber dyeability. Results indicate that the metal levels of newly-opened cotton were not appreciably different from those of aged cotton bolls and that the fiber metal levels after scouring and bleaching had little correlation with dye uptake. Additionally, some metal levels exceeded those previously reported and the environment appeared to have a stronger influence on fiber Ca and Mg levels than did cultivar differences.

Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation.The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups.Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation.The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Wild-type transthyretin (ATTRwt) amyloid deposits have been found in the ligamentum flavum of patients undergoing surgery for spinal stenosis. The relationship between ATTRwt and ligamentum flavum thickness is unclear. We used pre-operative magnetic resonance imaging (MRI) to analyze ligamentum flavum thickness in lumbar spinal stenosis patients with and without ATTRwt amyloid.We retrospectively identified 178 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 253 specimens was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and ATTRwt was confirmed using mass-spectrometry and gene sequencing.Twenty four of the 178 patients (13.5%) were found to have ATTRwt in the ligamentum flavum. Forty ATTRwt specimens and 213 non-ATTRwt specimens were measured. Mean ligamentum flavum thickness was 4.92 (±1.27) mm in the ATTRwt group and 4.00 (±1.21) mm in the non-ATTRwt group (p 0.01). The ligamentum flavum was thickest at L4-L5, with a thickness of 5.15 (±1.27) mm and 4.23 (±1.29) mm in the ATTRwt and non-ATTRwt group, respectively (p = 0.007). There was a significant difference in ligamentum flavum thickness between ATTRwt and non-ATTRwt case for both patients younger than 70 years (p = 0.016) and those older than 70 years (p = 0.004). ATTRwt patients had greater ligamentum flavum thickness by 0.83 mm (95% confidence interval (CI): 0.41-1.25 mm, p 0.001) when controlled for age and lumbar level.Patients with ATTRwt had thicker ligamentum flavum compared to patients without ATTRwt. Further studies are needed to investigate the pathophysiology of ATTRwt in ligamentum flavum thickening.

Background The use of helicopter emergency medical services (HEMS) for trauma patients has been debated since its introduction. We aim to compare outcomes for trauma patients transported by ground EMS (GEMS) vs. HEMS using raw and adjusted mortality in a level 1 trauma center. Methods A 6-year retrospective cohort study utilizing our level 1 trauma center registry for patients transferred by GEMS or HEMS was performed. Demographics and outcome measures were compared. Raw and adjusted mortality was evaluated. Adjusted mortality was determined incorporating confounders, including patient demographics, comorbid conditions, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale score, and EMS transport time. Chi-square, multivariable logistic regression, and independent sample T-test were utilized with significance, defined as P < .05. Results Of 12 633 patients, 10 656 were transported via GEMS and 1977 with HEMS. Mean age was 55 for GEMS and 40 for HEMS ( P < .001). Mean ISS was 9.29 and 11.73 for GEMS and HEMS ( P < .001). Mean Revised Trauma Score was higher (less severe) for GEMS vs. HEMS (7.6 vs. 7.12, P < .001). Mean transport times for GEMS and HEMS was 39.45 vs. 47.29 minutes ( P = .02). Raw mortality was 2.55% (307/10 656) for GEMS and 6.78% (134/1977) for HEMS. Adjusted mortality revealed a 16.6% increased mortality for GEMS compared to HEMS (adjusted odds ratio = 1.166, 95% CI: .815-1.668). Conclusions Air-lifted trauma patients were younger, more severely injured, and more hemodynamically unstable and required longer transport time but experienced lower adjusted mortality. Future research is needed to investigate whether reducing transport times and augmenting the advanced care already implemented by HEMS crews can improve outcomes.

BACKGROUND CONTEXT Extension of long posterior cervical fusions into the thoracic spine has been recommended to decrease the risk of kyphosis and spondylolisthesis at the cervico-thoracic junction. In recent years, several studies have addressed this question with conflicting results. We hypothesized that extension of posterior cervical fusions into the upper thoracic spine improved clinical outcomes while decreasing kyphosis. PURPOSE To investigate if it is safe to stop at C7 spinal level during multilevel posterior cervical decompression and fusion surgery. STUDY DESIGN/SETTING Analysis of routinely collected data. PATIENT SAMPLE A total of 264 adult patients undergoing mutlilevel posterior cervical decompression and fusion. OUTCOME MEASURES Estimated blood loss, operative time, length of hospital stay, cervical lordosis, C2-C7 sagittal plumbline, T1 slope, visual analog scale, Oswestry Disability Index and revision rate METHODS Analysis of multicenter radiographic and clinical databases of patients who had undergone a three or more-level posterior cervical fusion for degenerative disease from January 2013 to May 2015, with at least two years of postop data. Patients were divided into three groups: Group I (fusion terminating at C6), Group II (fusion terminating at C7), Group III (fusion extending into the thoracic spine). All radiographic measurements were performed by an independent, experienced clinical researcher. RESULTS A total of 264 patient cases were reviewed and sorted into the three outlined groups, Group I (n=80), Group II (n=88) and Group III (n=96). Demographically, mean age, percentage of nonsmokers and anterior support were greater in Group III than in Groups I and II (p 0.05). Rate of revision was not clinically or statistically significantly different (p>0.05) between Group I (8.8%), Group II (7.95%) and Group III (9.4%). The majority of the revision surgeries occurred between two to five years postop. Groups I and II had greater number of subjacent degeneration/spondylolisthesis compared to Group III (3.8% vs 3.4% vs 1.2%). There were significant improvements in mean clinical outcomes (ie, visual analog scale [VAS] and Oswestry Disability Index [ODI]) at two years postoperative in the three groups, but there were no statistically significant differences between the groups (p>0.05). All groups had similar postop rate of return to work status (group I vs group II vs group III: 11.4 % vs 14.7% vs 12.5%). CONCLUSIONS All groups had similar clinical and radiographic outcomes and comparable revision rates. Higher EBL, OR and LOS in Group III suggest that, absent focal C7-T1 pathology, extension of posterior cervical fusions into the thoracic spine may not be necessary. Extension of posterior cervical fusions into the thoracic spine may be recommended for higher risk patients with limitations to strong C7 bone anchorage. In others, it is safe to stop at C7. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

COVID-19 restructured the health care delivery process, catapulting telemedicine to the mainstream. The Johns Hopkins After Care Clinic (JHACC) continued transprofessional health care delivery in the telemedicine space by shifting to remote, asynchronous collaboration and a triage system. In 1 month after starting telemedicine, the JHACC had 907 encounters for 376 unique patients. Most patients reported satisfaction with their visits. Telemedicine lengthened visit completion times. Providers encountered many failed call attempts and limited access to videoconferencing. Barriers to sustainable interprofessional telemedicine include poor social determinants of health, limited reimbursement for nonphysician health professionals, and increased clinical and administrative time.

Evidence suggests that twenty first century college students have less aptitude and less interest in academic learning than their predecessors. This poses a challenge to faculty who are charged with passing knowledge to the next generation of teachers, scientists, managers and others whose field necessitates a degree from a college or university. The authors examine this assertion by taking a closer look at how faculty provide intellectual stimuli to their students, how technology helps or hinders learning, and the complex relationship between faculty and students. Three broad themes are explored: helping students understand the higher education experience, keeping students engaged in and out of class, and continuously assessing for improvement in students’ relationships with those charged with educating them. Specific recommendations, grounded in research, are made for each area explored. The authors conclude that making changes in how faculty approach the experiences students have, will significantly improve the quality of those experiences.

BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years.MethodsA total of 626 patients were randomized to BMCs or Matrix2 coils. Detailed methods and 1-year results have been published previously.ResultsOf 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (PConclusionsAfter 5 years Matrix2 coils were non-inferior to BMCs but no benefit was demonstrated. Post-treatment residual angiographic aneurysm filling (Raymond III) is strongly associated with TAR (P

Background and purposeAutomated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast.Materials and methodsWe reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA ± CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (>6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of

Objective This case addresses the issue of surreptitious adulteration of cannabis. Many with opioid and substance use disorders use cannabis while receiving office-based opioid treatment (OBOT), making it valuable to understand the rationale for its use. Further study of the effects that cannabis use has on OBOT success or failure is necessary. Case summary A 50-year-old man receiving OBOT continually tested positive in urine drug screenings (UDSs) for fentanyl, while abstaining from all opiates, but he endorsed smoking cannabis 2-3 times weekly as a self-reported headache reliever and a sleep aid. After changing the source from which he bought cannabis, his UDS became negative for fentanyl. He was maintained on a stable dose of buprenorphine with a consistent UDS after this intervention and was able to make many positive lifestyle changes as a result (i.e., maintaining a relationship with his girlfriend, continuing attendance at support groups, and pursuing employment opportunities). Practice implications The consequences of cannabis use on OBOT success are highly variable and dependent on many factors. Although the concern regarding adulteration of cannabis exists, there is no systematic monitoring or reliable data on its frequency or the magnitude of its effect, which generates a demand for further research and exploration. Depending on state-specific regulations, patients may be able to obtain cannabis from reliable, regulated (nonadulterated) sources. However, providers must thoroughly consider the barriers to patients obtaining medicinal or legalized cannabis.

Background Wild-type transthyretin amyloid (ATTRwt) has been noted to deposit in the ligamentum flavum of the spine. Prior studies have focused on ATTRwt in the lumbar region, but studies discussing its presence in other levels of the spine are lacking. We report on the presentation of patients with confirmed amyloid in the cervicothoracic regions and discuss the literature to date. Methods We retrospectively identified patients at a single institution who underwent surgery for spinal stenosis and had pathologic specimens sent for amyloidosis testing with Congo red staining. ATTRwt was confirmed by the presence of transthyretin amyloid by typing and the absence of mutations in the TTR gene sequence. A final study group of patients with ATTRwt and spinal involvement was established (n = 27). Results Of 27 patients with amyloid in the spine, 24 (89%) had amyloid present in the lumbar region, 2 (7%) had amyloid in the cervical region, and 1 (4%) had amyloid in the thoracic region. The median age at which patients in the study underwent surgery was 71 years (interquartile range: 9). Spinal stenosis was the indication for surgery in 26 of 27 (96%) patients. Surgery involved 1 or 2 spinal levels in 24 of 27 (89%) patients. Conclusions ATTRwt amyloid predominantly deposits in the lumbar region, but it can also be present in the cervical and thoracic regions. While the lumbar regions should remain a focus for evaluation of ATTRwt amyloidosis, the cervicothoracic region should not be ignored.

Background Hyperplasia of the choroid plexus represents a rare cause of communicating hydrocephalus in children. Recent work has associated such disease with genetic abnormalities (such as perturbations in chromosome 9). Given such extensive cerebrospinal fluid (CSF) overproduction, patients with choroid plexus hyperplasia often fail CSF diversion and therefore require adjuvant interventions. Case Description We present the case of a male infant with a ventriculoperitoneal shunt and radiographic choroid hyperplasia who presented to our institution with a massive abdominal hydrocele caused by an inability to absorb the significant amount of CSF drainage into the abdomen. Conclusion The child was treated with an endoscopic third ventriculostomy and choroid plexus coagulation; however, he still required CSF diversion via a ventriculoatrial shunt. A genetic workup showed tetraploidy of chromosome 9. We discuss criteria for selection of treatment strategies, including endoscopic third ventriculostomy with choroid plexus coagulation and/or CSF diversion, that may prevent the need for re-operation in select patients with hydrocephalus due to choroid plexus hyperplasia.

BACKGROUND By statute, pediatric passengers transported in motor vehicles need to be appropriately restrained. The National Highway Traffic Safety Administration (NHTSA) estimates that currently only 2% of children do not wear safety restraints. This study aimed primarily to evaluate the use of pediatric restraints (seat belts) in motor vehicle collisions (MVCs) transported to our Level I pediatric trauma center (PTC) compared with historical NHTSA controls. METHODS A 4-year review utilized our Level I PTC registry for patients younger than 16 years, involved in an MVC. Appropriate booster seat/child restraints were verified by EMS, fire rescue, and patient/family. Odds ratios were used to compare occurrences and χ for categorical values with significance defined as p

BACKGROUND Carotid cavernous fistulas (CCF) often present with diplopia secondary to cranial nerve palsy (CNP). Immediate development of postoperative CNP has been described in the literature. This study described delayed-onset of CNP after complete and reconfirmed obliteration of the CCF and resolution of initial CNP. METHODS A retrospective analysis was performed on patients with indirect CCF between 1987 and 2006 at 4 academic endovascular centers. Details of the endovascular procedures, embolic agents used, and complications were studied. Partial or complete obliteration was determined. Immediate and delayed cranial nerve palsies were independently assessed. RESULTS A total of 267 patients with symptomatic indirect CCF underwent transvenous endovascular treatment. Four patients (1.5%) developed delayed abducens nerve (VI) palsy after complete resolution of presenting symptoms after embolization. Delayed presentation ranged between 3 and 13 months after complete resolution of initial double vision and cranial nerve palsies. Transvenous coil embolization through the inferior petrosal sinus was performed in all 4 affected patients. All had follow-up angiography confirming durable closure of their CCF. MRI did not show new mass lesions or abnormal soft tissue enhancement. In all 4 patients, their abducens nerve (VI) palsy remained. CONCLUSIONS Delayed CNP can develop despite complete endovascular obliteration of the CCF. The cause of delayed CNP is not yet determined, but may represent fibrosis and ischemia. Long-term follow-up is needed even after complete neurological and radiological recovery is attained in the immediate perioperative period.

ObjectiveDamage to the vascular endothelium is strongly implicated in the pathogenesis of idiopathic inflammatory myopathies (IIM). Normally, high-density lipoprotein (HDL) protects the vascular endothelium from damage from oxidized phospholipids, which accumulate under conditions of oxidative stress. The current work evaluated the antioxidant function of HDL in IIM patients.MethodsHDL’s antioxidant function was measured in IIM patients using a cell-free assay, which assesses the ability of isolated patient HDL to inhibit oxidation of low-density lipoproteins and is reported as the HDL inflammatory index (HII). Cholesterol profiles were measured for all patients, and subgroup analysis included assessment of oxidized fatty acids in HDL and plasma MPO activity. A subgroup of IIM patients was compared with healthy controls.ResultsThe antioxidant function of HDL was significantly worse in patients with IIM (n = 95) compared with healthy controls (n = 41) [mean (S.d.) HII 1.12 (0.61) vs 0.82 (0.13), P ConclusionThe antioxidant function of HDL is abnormal in IIM patients and may warrant further investigation for its role in propagating microvascular inflammation and damage in this patient population.

Objective To understand the effect of physician payment incentives on the allocation of health care resources. Data sources/study setting Review and analysis of the literature on physician payment incentives. Study design Analysis of current physician payment incentives and several ways to modify those incentives to encourage increased efficiency. Principal findings Fee-for-service payments can be incorporated into systems that encourage efficient pricing - prices that are close to the provider's marginal cost - by giving consumers information on provider-specific prices and a strong incentive to choose lower cost providers. However, efficient pricing of services ultimately will need to be supplemented by incentives for efficient production of health and functional status. Conclusions The problem with current FFS payment is not paying a fee for each service, per se, but the way in which the fees are determined.

Introduction Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection. Case presentation A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery. Discussion Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status. Conclusion Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries., Highlights • Proximal right subclavian artery injuries secondary to blunt trauma are rare and often associated with significant comorbidities and higher mortality. • Prompt surgical intervention adequately prevented death in our patient and allowed for full functional recovery. • Management of such subclavian artery injuries typically require open surgical intervention given the extent of damage.

Although safeguards requiring emergency care are provided regardless of a patient’s payor status, disparate outcomes have been reported in trauma populations. The purpose of this systematic review and meta-analysis was to determine whether race/ethnicity or insurance status had an effect on mortality and to systematically present the literature in the adult and pediatric trauma populations during the last decade. An online search of PubMed, Cochrane Library, Google Scholar, and SAGE Journals was performed for publications from January 2009 to March 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. The GRADE Working Group criteria were utilized to assess the evidence quality. A meta-analysis was conducted to compare mortality between insured/uninsured and Caucasian/non-Caucasian patients. Our search revealed 680 publications that qualified for evaluation. Of these, 41 were included in the final analysis. Twenty-six studies included adults only, nine studies included pediatric patients only, and six studies evaluated both. Twelve studies evaluated the effects of race/ethnicity, 18 examined insurance status, and 11 investigated both. Uninsured patients had 22% greater odds of death than insured patients (OR 1.22; CI 1.21–1.24). Non-Caucasian patients had 18% greater risk of death than Caucasian patients (OR 1.18; CI 1.17–1.20). Both the adult and pediatric trauma populations suffer outcome disparities based on race/ethnicity and insurance status. Overall, patients without insurance coverage and minority groups (i.e., non-Caucasians) had worse outcomes, as measured by odds of death and all-cause mortality.

High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI − 0.02 to − 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI − 0.15 to − 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P

Introduction: This study examines triquetral fracture data from six hospital centres between 2009 and 2018. The study focuses on elements of triquetral fracture management within these six centres, outlining common fracture patterns, the short-term and long-term outcomes and the common mechanisms of injury. To the authors’ knowledge, this is the largest cohort of triquetral fractures studied to date and outlines investigation recommendations for improved identification of these fractures. Methods: Data was obtained by reviewing the charts of patients presenting to emergency departments within the Nepean and Blue Mountains local health district of New South Wales, Australia. (Nepean Hospital ethics approval no: NBM18/805) Results: Triquetral fractures can be hard to identify with radiography and can be commonly mistaken as lunate fractures.12 Our results indicate that 18.9 per cent of patients required CT imaging to correctly diagnose triquetral fracture. Conclusion: Where there are ongoing symptoms and a high clinical suspicion of a triquetral fracture, CT may be indicated and, in future practice, may be justified as a first line imaging modality. This study also demonstrates that short arm-wrist immobilsing casts are an effective option for managing triquetral fractures.

Domestic animals have been associated with enteric infections in young children and can also be carriers of respiratory viruses. We conducted a cross-sectional assessment of health outcomes in children aged < 5 years associated with animal presence among 793 rural households in Uganda. We recorded the 2-week prevalence of diarrhea and respiratory infections in children, and the number of cows, poultry, sheep/goats, and pigs in the household. We used generalized linear models with robust standard errors to estimate the prevalence ratio (PR) for diarrhea and respiratory infections associated with households owning the above- versus below-median number of animals. We conducted unadjusted and adjusted analyses controlling for socioeconomic, water, sanitation, and hygiene indicators. Children in households with the above-median number (> 5) of poultry had 83% higher diarrhea prevalence than those with ≤ 5 poultry (adjusted PR = 1.83 [1.04, 3.23], P = 0.04). Children in households with the above-median number (> 2) of cows had 48% lower prevalence of respiratory infection than those with ≤ 2 cows (adjusted PR = 0.52 [0.35, 0.76], P < 0.005). There were no other significant associations between domestic animals and child health. Studies should assess if barring chickens from indoor living quarters and sanitary disposal of chicken and other animal feces can reduce childhood zoonotic infections.

In ShortAbsent an understanding of historical and contemporary manifestations of the White supremacist campaign of terror and control of Black bodies, educators will fail to effectively address rac...

The American College of Surgeons requires trauma centers to track the number of injured patients admitted to a surgical service as well as nonsurgical admissions (NSAs) as a quality marker. We aim to compare the relationship between admitting service and outcomes in patients with isolated hip fracture (IHF). A 4-year retrospective cohort review of data collected from a single institution's trauma registry for adult patients with IHF was done. Patients were stratified into 2 groups based on admission to a surgical service versus NSA. Demographic and outcome variables including age, gender, Injury Severity Score (ISS), intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), and mortality rates were compared. Analysis of variance and χ test were used for data analysis with statistical significance defined as p.05. A total of 629 patients with IHF were admitted. Of those, 30 (4.8%) were admitted to a surgical service and 599 (95.2%) were NSAs. Patients admitted to a surgical service were younger but average ISS was similar in both groups. Those admitted to a surgical service had a significantly shorter ICU-LOS than NSA patients (2.97 days vs. 4.91, p.001). Readmission rate at 30 days (3.3% vs. 1.2%, p.05) and DVT rates (0% vs. 0.4%, p.05) were similar between groups. Mortality rates did not differ between groups (3.3% vs. 2.2%, p.05). Patients with hip fracture requiring surgical intervention admitted to a trauma service have a shorter ICU-LOS than those admitted to nonsurgical services. Other quality markers were similar.

This study aimed to identify factors that promote and impede research participation and productivity by Eastern Association for the Surgery of Trauma (EAST) surgeons. In addition, the study aimed to determine what changes can be implemented by surgical departments to improve this research productivity and granting. A 25-question anonymous research survey tool was offered to EAST surgeons. The questions analyzed factors including demographics, career accomplishments, current institution type, educational/research background, perceived barriers to research, and current research productivity, including grants. Chi-square tests were used to analyze significance at P < 0.05. The overall response rate was 26.2 per cent (445/1699). Most respondents reported not having any protected research time (86.3%), and no research resources were provided by their institution (78.7%). Factors that were significantly associated with greater research productivity included protected research time ( P < 0.0001), having a mentor ( P < 0.001), practicing in a university-affiliated hospital ( P < 0.0001), publication(s) before completing residency training ( P = 0.02), having institutional resources dedicated to research ( P = 0.015), and male gender ( P = 0.003). Age, race, marital status, and additional educational qualifications were not associated with statistically significant differences in research productivity in this study ( P > 0.05). EAST surgeons are more likely to have scholarly productivity if they are supported with protected time, mentors, nonclinical staff dedicated to research, a history of research before completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policies.

Background Vedolizumab (VDZ) is effective for treating both adult and pediatric onset inflammatory bowel disease (IBD). Clinical outcomes, however, have been reported to be superior in patients naive to anti-tumor necrosis factor (TNF). With the growing interest in endoscopic endpoints, we aimed to describe rates of mucosal healing in pediatric patients being treated with VDZ and examine the influence of anti-TNF on outcomes. Methods We conducted a retrospective review of all IBD patients ≤21 years of age who initiated VDZ and underwent endoscopy. Primary outcome was mucosal healing (composite of endoscopic [SES-CD] and Mayo score UC) and histological remission [Nancy index-UC and Crohn disease (CD) histologic activity]. Descriptive statistics summarized the data. Comparisons were made for endpoints based on anti-TNF exposure using univariate testing. Results Sixty-eight patients were included in the final analysis; 35 with UC and 33 with CD. Thirty-two patients (22 UC and 10 CD) were anti-TNF-naive and 36 patients (13 UC and 23 CD) were anti-TNF-exposed. The median duration on VDZ before endoscopic assessment was 49 (IQR 32-73) weeks. A total of 38% (25/66) of patients met the primary outcome of mucosal healing and did not differ between anti-TNF-naive or anti-TNF-exposed. Endoscopic remission was achieved by 51% with significantly more anti-TNF naive patients reaching this endpoint (66% vs 40%, P = 0.03). Histologic remission was achieved by 42% of patients with a nonsignificant trend towards improved histologic remission rates in anti-TNF-naive patients (52% vs 33%, P = 0.13). Conclusions VDZ is associated with mucosal healing in pediatric IBD. Anti-TNF exposure significantly impacted endoscopic remission, but not histologic remission in children on VDZ.