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Objective To evaluate pre - to post-season differences in individual subtests of the Visio-Vestibular Examination (VVE) in healthy middle and high school athletes. Methods This prospective cohort study recruited participants from a private suburban United States secondary school. Participants completed a demographic questionnaire prior to the start of their season. A proxy for head impact exposure was estimated by incorporating previously published head impact frequencies by team and sport. The VVE was completed pre - and post-season and consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Generalized estimating equations were employed to assess the relative risk of an abnormal VVE outcome based on testing session (pre - vs. post-season). Results Participants included middle and high school athletes (n = 115; female = 59 (51.3%); median age at first assessment = 14.9 years, [IQR = 13.6, 16.0]) during 2017/18 - 2019/20 school years. During pre-season testing, accommodation (10.0%) and complex tandem gait (9.2%) had the largest proportion of abnormal outcomes, while smooth pursuits (10.6%) and convergence (9.5%) had the largest proportion of abnormal outcomes post-season. When assessing the effect of testing session on the relative risk of any abnormal VVE subtest, there were no significant findings (P ≥ 0.25). Additionally, there were no significant effects of testing session when adjusting for estimated head impact exposure for any VVE subtest (P ≥ 0.25). Conclusions Visio-vestibular function as measured by the VVE does not change from pre - to post-season in otherwise healthy adolescent athletes. Our findings suggest that the VVE may be stable and robust to typical neurodevelopment occurring in this dynamic age group and help inform post-injury interpretation of visio-vestibular impairments.

Purpose The purpose of this evidence search was to review past and current kangaroo care practice and explore the Iiterature relating to improving kangaroo care for preterm infants. Method A literature review of evidence was undertaken in order to answer pre specified questions. The literature search was undertaken on CINAHL, Google Scholar and Pubmed. Key search terms were kangaroo care, skin to skin care, kangaroo mother care, preterm infants, benefits, practices, enablers and education. Conclusion A lack of training and formal education greatly inhibits kangaroo care provision in the neonatal environment. The level of confidence a nurse has in their ability to decide whether the infant is clinically stable or not, will determine if kangaroo care is offered. Neonatal nurse education is imperative in order to improve kangaroo care practice in the clinical setting.

This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.

Background Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10–24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10–24 years by age group (10–14 years, 15–19 years, and 20–24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10–24 years with that in children aged 0–9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10–24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39–1·59) worldwide in people aged 10–24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10–14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15–19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1–4 years (2·4%), and around a third less than in females aged 1–4 years (2·5%). The proportion of global deaths in people aged 0–24 years that occurred in people aged 10–24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%. Interpretation Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10–24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Funding Bill & Melinda Gates Foundation.

The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty.We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board.A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P .001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months.Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.

Our aim in this study was to refine and pilot a video-based telehealth intervention to reduce diabetes distress, depressive symptoms and hypoglycemia fear in parents of school-age children with type 1 diabetes and to assess for changes in child glycated hemoglobin (A1C).We recruited 41 parents of children (5 to 12 years) to participate in a manualized, video-based telehealth intervention (Cognitive Adaptions to Reduce Emotional Stress [CARES]). Of these, 29 parents completed either a 12-week (n=13) or 8-week (n=16) version of CARES based on the timing of their recruitment. We assessed feasibility (i.e. attrition, attendance) and parent satisfaction with CARES. We used repeated-measures analysis of variance with parent group (8 vs 12 sessions) as a between-subject variable and time as a within-subject variable to measure change in our dependent variables.Mostly mothers participated (97.3%). Parents' mean age was 39.65±6.84 years and children's mean age was 9.86±1.57 years at pretreatment. CARES had low attrition (20% to 25%) and good attendance (96% to 98%). Parents also reported high levels of treatment satisfaction (85%). There were significant main effects for time for parent-reported diabetes distress and depressive symptoms at posttreatment and 3-month follow-up. There was a statistical trend suggesting a time × group interaction for parent depressive symptoms at posttreatment. There was a significant main effect for time for hypoglycemia fear at the 3-month follow-up but no change at posttreatment. There was no change in child A1C at posttreatment.CARES showed high parent satisfaction, good feasibility and promising results for reducing diabetes distress in parents of school-age children with type 1 diabetes.

Objective The impact of disrupted sleep on the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) is not well understood. Researchers have suggested that comorbid sleep disorders contribute to nonresponse by impairing therapeutic mechanisms such as emotional processing of trauma memories and extinction in cued fear conditioning. Several studies indicate daytime sleepiness, insomnia, and nightmares are correlated with PTSD symptom severity. However, a recent randomized controlled trial found that these sleep disorder symptoms did not affect PTSD symptom change over the course of massed PE (i.e., daily sessions across 2 weeks). Method The current study used an ecologically valid clinical sample to examine whether daytime sleepiness, insomnia, and nightmares interfere with the slope of symptom change in massed PE. Results Results indicate that all 3 sleep disorder symptoms correlate with PTSD symptom severity on the first day of treatment but were not associated with symptom change. Conclusions These findings are consistent with the expectation that the daily structure of massed PE may enhance treatment engagement in patients who are typically drowsy or not well-rested, thus facilitating fear extinction. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Central venous catheters are necessary in treatment and care of pediatric patients with short gut syndrome. Despite necessity, central venous catheters come with the risk of developing CLABSI. This manuscript describes a complex, pediatric gastroenterology patient with multiple risk factors who developed a CLABSI. Short gut syndrome patients can develop skin conditions and complications that may challenge nursing practice to mitigate CLABSI. Further research is needed on preventing CLABSIs in complex pediatric patients to provide the best practice implications for nursing. HIGHLIGHTS Central venous catheter care may be complicated by complex patient considerations. Central-line associated bloodstream infection (CLABSI) risk factors are multifaceted. Case report to highlight patient complexity that challenges bundled practices.

The role of the chief nursing officer is multifaceted and complex. These complexities can be exacerbated during times of turbulence, specifically the COVID-19 pandemic. Understanding communication and collaboration are core to achieving optimal outcomes, this article outlines the experience of 3 chief nursing officers through the COVID-19 pandemic and the value of a structured platform for peer shared learning and support.

Researchers and design engineers are increasingly interested in castellated beams because of their ability to provide greater flexural strength with lower dead loads, as well as provide services and cost-effective structures. The influence of castellation on the bending strength and stiffness of the hot-rolled steel Square Tubular Beams (STBs) and Castellated Tubular Beams (CTBs) with simply supported end conditions were investigated in this study. Totally eight bending tests were carried out on hollow tubular beams with and without castellation under three point bending. The STBs with a nominal steel tube thickness of 2.5 mm are castellated in a hexagonal pattern. The ultimate moments, moment versus mid-span deflection response curves, and failure patterns are provided as part of the test results. The bending tests show that the flexural capacities and stiffness of the hollow tubular sections significantly increased due to the castellation process. Finite element (FE) models of STBs and CTBs were established by including the material and geometric nonlinearity as well as the measured geometric imperfections. The FE models established show good agreement with the experimental test in terms of ultimate bending strength, moment vs. mid-span deflection response, and failure modes.

As of February 2, 2021, the USA has 26,431,799 reported COVID-19 cases with 446,744 deaths. A high mortality rate (15%–40%) was reported among hospitalized patients with COVID-19 during the first wave of the pandemic. However, data regarding variation in COVID-19-related mortality and severity of illness among hospitalized patients with COVID-19 are heterogeneous. In this retrospective single-center study, we aimed to investigate the demographic characteristics, clinical presentations, disease severity, clinical outcomes, and in-hospital mortality of hospitalized patients with COVID-19 during the second wave of the pandemic. Adults with reverse transcription-PCR-confirmed SARS-CoV-2 infection were included. In-hospital mortality due to COVID-19 was the primary outcome, and intensive care unit admission, acute kidney injury, acute respiratory distress syndrome, respiratory failure requiring intubation, and septic shock were the secondary outcomes. A total of 101 adult patients were hospitalized with COVID-19 during the second wave study period. Of 101 patients, 8 were intubated and 6 died. The median duration of hospital stay was 6 days. Patients in the second wave were more likely to receive dexamethasone and remdesivir and less likely to require invasive mechanical ventilation. In-hospital mortality during the second wave was lower (5.9%) compared with the first wave (15.5%). At the last follow-up date, 86.1% were discharged alive from the hospital, 5.9% died and 7.9% were still in the hospital. Multivariate logistic regression showed higher odds of mortality were associated with higher age and elevated lactate dehydrogenase peak.

Aims The aim of this study was to identify the minimal clinically important difference (MCID), minimal important change (MIC), minimal detectable change (MDC), and patient-acceptable symptom state (PASS) in the Forgotten Joint Score (FJS) according to patient satisfaction six months following total hip arthroplasty (THA) in a UK population. Methods During a one-year period, 461 patients underwent a primary THA and completed preoperative and six-month FJS, with a mean age of 67.2 years (22 to 93). At six months, patient satisfaction was recorded as very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied. The difference between patients recording neutral (n = 31) and satisfied (n = 101) was used to define the MCID. MIC for a cohort was defined as the change in the FJS for those patients declaring their outcome as satisfied, whereas receiver operating characteristic curve analysis was used to determine the MIC for an individual and the PASS. Distribution-based methodology was used to calculate the MDC. Results Using satisfaction as the anchor, the MCID for the FJS was 8.1 (95% confidence interval (CI) 3.7 to 15.9; p = 0.040), which was affirmed when adjusting for confounding. The MIC for the FJS for a cohort of patients was 17.7 (95% CI 13.7 to 21.7) and for an individual patient was 18. The MDC90 for the FJS was eight, meaning that 90% of patients scoring more than this will have experienced a real change that is beyond measurement error. The PASS threshold for the FJS was defined as 29. Conclusion The MCID and MIC can be used respectively to assess whether there is a clinical difference between two groups, or whether a cohort or patient has had a meaningful change in their FJS. Both values were greater than measurement error (MDC90), suggesting a real change. The PASS threshold for the postoperative FJS can be used as a marker of achieving patient satisfaction following THA. Cite this article: Bone Joint J 2021;103-B(12):1759–1765.

Occupational exposure assessments are dominated by small sample sizes and low spatial and temporal resolution with a focus on conducting Occupational Safety and Health Administration regulatory compliance sampling. However, this style of exposure assessment is likely to underestimate true exposures and their variability in sampled areas, and entirely fail to characterize exposures in unsampled areas. The American Industrial Hygiene Association (AIHA) has developed a more realistic system of exposure ratings based on estimating the 95th percentiles of the exposures that can be used to better represent exposure uncertainty and exposure variability for decision-making; however, the ratings can still fail to capture realistic exposure with small sample sizes. Therefore, low-cost sensor networks consisting of numerous lower-quality sensors have been used to measure occupational exposures at a high spatiotemporal scale. However, the sensors must be calibrated in the laboratory or field to a reference standard. Using data from carbon monoxide (CO) sensors deployed in a heavy equipment manufacturing facility for eight months from August 2017 to March 2018, we demonstrate that machine learning with probabilistic gradient boosted decision trees (GBDT) can model raw sensor readings to reference data highly accurately, entirely removing the need for laboratory calibration. Further, we indicate how the machine learning models can produce probabilistic hazard maps of the manufacturing floor, creating a visual tool for assessing facility-wide exposures. Additionally, the ability to have a fully modeled prediction distribution for each measurement enables the use of the AIHA exposure ratings, which provide an enhanced industrial decision-making framework as opposed to simply determining if a small number of measurements were above or below a pertinent occupational exposure limit. Lastly, we show how a probabilistic modeling exposure assessment with high spatiotemporal resolution data can prevent exposure misclassifications associated with traditional models that rely exclusively on mean or point predictions.

Avoiding catastrophic climate change requires rapid decarbonization and improved ecosystem stewardship at a planetary scale. The carbon released through the burning of fossil fuels would take millennia to regenerate on Earth. Though the timeframe of carbon recovery for ecosystems such as peatlands, mangroves and old-growth forests is shorter (centuries), this timeframe still exceeds the time we have remaining to avoid the worst impacts of global warming. There are some natural places that we cannot afford to lose due to their irreplaceable carbon reserves. Here we map ‘irrecoverable carbon’ globally to identify ecosystem carbon that remains within human purview to manage and, if lost, could not be recovered by mid-century, by when we need to reach net-zero emissions to avoid the worst climate impacts. Since 2010, agriculture, logging and wildfire have caused emissions of at least 4.0 Gt of irrecoverable carbon. The world’s remaining 139.1 ± 443.6 Gt of irrecoverable carbon faces risks from land-use conversion and climate change. These risks can be reduced through proactive protection and adaptive management. Currently, 23.0% of irrecoverable carbon is within protected areas and 33.6% is managed by Indigenous peoples and local communities. Half of Earth’s irrecoverable carbon is concentrated on just 3.3% of its land, highlighting opportunities for targeted efforts to increase global climate security. Avoiding catastrophic climate change requires that we avoid losing key natural carbon reserves. This study maps such irrecoverable carbon globally and finds a third of the remaining managed by Indigenous peoples and local communities and nearly a quarter in protected areas.

Background Children with inflammatory bowel disease [IBD] are disproportionally affected by recurrent Clostridioides difficile infection [rCDI]. Although faecal microbiota transplantation [FMT] has been used with good efficacy in adults with IBD, little is known about outcomes associated with FMT in paediatric IBD. Methods We performed a retrospective review of FMT at 20 paediatric centres in the USA from March 2012 to March 2020. Children with and without IBD were compared with determined differences in the efficacy of FMT for rCDI. In addition, children with IBD with and without a successful outcome were compared with determined predictors of success. Safety data and IBD-specific outcomes were obtained. Results A total of 396 paediatric patients, including 148 with IBD, were included. Children with IBD were no less likely to have a successful first FMT then the non-IBD affected cohort [76% vs 81%, p = 0.17]. Among children with IBD, patients were more likely to have a successful FMT if they received FMT with fresh stool [p = 0.03], were without diarrhoea prior to FMT [p = 0.03], or had a shorter time from rCDI diagnosis until FMT [p = 0.04]. Children with a failed FMT were more likely to have clinically active IBD post-FMT [p = 0.002] and 19 [13%] patients had an IBD-related hospitalisation in the 3-month follow-up. Conclusions Based on the findings from this large US multicentre cohort, the efficacy of FMT for the treatment of rCDI did not differ in children with IBD. Failed FMT among children with IBD was possibly related to the presence of clinically active IBD.

Background Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. Methods The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database. Results Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. Conclusion Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Dermatologists diagnose and treat many immune-mediated inflammatory diseases (IMID). Understanding the inherent immune dysregulation of these diseases as well as the additional disruption that comes as a result of IMID treatments has been important during the COVID-19 pandemic. With vaccines becoming widely available, dermatologists need to be familiar with the risks and benefits of vaccination in these patients, particularly those taking biologics, in order to have informed discussions with their patients. In this review, we present the current evidence related to COVID-19 vaccine safety and efficacy in patients with IMID and review existing recommendations for vaccination against SARS-CoV-2. Given the current evidence, there is minimal concern that these patients are at any greater risk of harm from COVID-19 vaccination compared to healthy controls. For most, the benefit of avoiding severe COVID-19 through vaccination will outweigh the theoretical risk of these vaccines. A question that is still outstanding is whether patients on biologics will generate a sufficient immune response to the vaccine, which may be dependent on the specific biologic therapy and indication being treated. This underscores the importance of following patients with IMID after vaccination to determine the safety, efficacy, and duration of the vaccine in this population.

BackgroundThis study assessed the extent to which women's preconception binge drinking, tobacco use and cannabis use, reported prospectively in adolescence and young adulthood, predicted use of these substances during pregnancy and at 1 year postpartum.MethodsData were pooled from two intergenerational cohort studies: the Australian Temperament Project Generation 3 Study (395 mothers, 691 pregnancies) and the Victorian Intergenerational Health Cohort Study (398 mothers, 609 pregnancies). Alcohol, tobacco and cannabis use were assessed in adolescence (13–18 years), young adulthood (19–29 years) and at ages 29–35 years for those transitioning to parenthood. Exposures were weekly or more frequent preconception binge drinking (5 + drinks in one session), tobacco use and cannabis use. Outcomes were any alcohol, tobacco and cannabis use prior to awareness of the pregnancy, after awareness of pregnancy (up to and including the third trimester pregnancy) and at 1 year postpartum.ResultsFrequent preconception binge drinking, tobacco use and cannabis use across both adolescence and young adulthood were strong predictors of continued use post-conception, before and after awareness of the pregnancy and at 1 year postpartum. Substance use limited to young adulthood also predicted continued use post-conception.ConclusionsPersistent alcohol, tobacco use and cannabis use that starts in adolescence has a strong continuity into parenthood. Reducing substance use in the perinatal period requires action well before pregnancy, commencing in adolescence and continuing into the years before conception and throughout the perinatal period.

Objective: The aim of this systematic review was to determine the impact of topical oxygen therapy (TOT) on diabetic foot ulcer (DFU) healing. Method: Using systematic review methodology, we considered randomised controlled trials (RCTs), controlled trials, pilot studies and observational studies. The search was conducted in January 2019, using PubMed, CINAHL, Ovid, Cochrane, Web of Science and EMBASE databases. Data analysis was undertaken using RevMan and a narrative synthesis. The article titles were assessed by two authors independently, and the abstracts (when available) of the studies identified by the search strategy were screened for their eligibility, according to the inclusion and exclusion criteria. The full-text version of potentially relevant studies was obtained and two authors independently screened this against the inclusion criteria. Data were extracted using a predesigned extraction tool and all included studies were quality appraised using the Evidence-Based Librarianship checklist. Results: The search returned 565 records of which eight met the inclusion criteria. Of the included studies, three were set in single centre outpatient wound clinics, two studies were set in an outpatient wound care research clinic and three studies were multisite. Meta-analysis of four studies was undertaken. DFUs are >2 times more likely to heal with TOT than with standard care alone. The odds ratio (OR)=2.49 (95% confidence interval (CI): 1.59–3.90, p=0.00001). The remaining four studies also showed that using TOT increased healing rates. An included study reported that time to 50% DFU closure was significantly shorter in participants who received the TOT, mean 18.4 days versus 28.9 days in the sham therapy group (p=0.001). However, the validity of 65.5% of the eight studies was assessed as low. Conclusion: The findings suggest that TOT enhances healing for patients with hard-to-heal DFUs when used with standard care. The results from the trials reviewed also indicate a benefit for patients over standard care alone. However, the sample sizes in the studies were generally small, thus, more RCTs are warranted to further validate these findings. Declaration of interest: The authors have no conflicts of interest to declare.

Diabetic foot ulcers (DFUs) are deep tissue lesions associated with ischaemic, neuropathic, or combined neuroischaemic abnormalities and are a leading cause of morbidity and mortality. Of concern is that DFUs affect multiple areas of a person's functioning, including both physical and psychological distress. For example, inactivity due to a DFU can cause feelings of frustration, anger and guilt in patients. This distress has the potential to impair the immune response as well as impacting the quality of life (QoL).

Objective To explore contraceptive decision making among recently pregnant patients with a history of opioid use disorder. Study Design We conducted semi-structured qualitative interviews, based on principles of the Ottawa Decision Support Framework, with 20 recently pregnant individuals diagnosed with opioid use disorder at a tertiary care medical center in Massachusetts. We audio-recorded the interviews and they were transcribed verbatim. We analyzed our interview data using inductive and deductive coding. Results Participants value the availability of barrier methods as a means of preventing both sexually transmitted infections and pregnancy. For some participants, housing instability makes storing contraceptive methods and managing personal hygiene related to bleeding patterns difficult. For others, housing instability impacts their overall fertility goals. Side effects including weight gain, interactions with mood stabilizing medications, concern regarding post-operative opioids, or intrinsic aspects of a method that serve as reminders of opioid use may be unacceptable given the risk of relapse. The relapsing and remitting arc of recovery make remembering important aspects of both short- and long-acting contraceptive method use difficult, yet participants offer strategies to aid in doing so. Conclusion When choosing a contraceptive method participants in our study exhibit similarities to individuals with other chronic medical conditions as well as motivations specific to opioid use disorder. Their contraceptive decisions are grounded in integrating a method into a chaotic life, preventing relapse, and protecting future fertility. Implications Our data highlight how lived experiences at the intersection of active opioid use disorder and recovery fundamentally shape the lens through which pregnancy-capable individuals with opioid use disorder view their contraceptive decisions.

Background Urinary tract infections from indwelling urinary catheters are amongst the most common healthcare acquired infection. Correct adherence to evidence-based guidelines has been shown to reduce these infections. There is limited Australian data on adherence to these guidelines. Aim To examine the prevalence of use of indwelling urinary catheters and identify the rate of adherence to evidence-based guidelines. Methods A cross-sectional study design using an audit tool was conducted at a major metropolitan teaching hospital (>600 beds) over 2-days in May 2019 in Western Australia. Findings Prevalence of use of indwelling urinary catheters (n = 67 of 522 patients, 12.8%) was low. There was good compliance with observed catheter care apart from securement of the catheter. There was poor compliance with documenting the planned date for catheter removal and daily perineal/penile hygiene (2.9%–18.6%). Discussion The observed care was generally compliant apart from securement. We attributed this to the possible lack of securement devices available on the general wards. Documentation was poorly completed at our centre and commonly reported in the literature. The introduction of prompting documentation using stickers may be useful in overcoming this shortfall in compliance. Conclusion This audit will allow us to target areas for improvement in catheter care and ensuring accurate and complete documentation. More research is needed in obtaining information around the evidence-based guidelines and relationship to clinical development of catheter associated urinary tract infection.

BACKGROUND Meeting psychological needs for autonomy, competence and relatedness as described by Self-Determination Theory (SDT) has been associated with increased well-being and job satisfaction in mental health staff and improved care outcomes for patients. AIMS The study investigated whether psychological need satisfaction predicted stress, turnover intention and job satisfaction in health care assistants (HCA) working in inpatient mental health hospitals in the United Kingdom including full time (FT) and temporary agency worker (TAW) staff. METHODS A cross-sectional survey explored need satisfaction between FT (n = 63) and TAW (n = 39) staff using the Work-Related Basic Need Satisfaction Scale. Multiple regression was used to explore whether satisfaction of the needs for autonomy, competence and relatedness predicted scores on measures of stress, job satisfaction and turnover intention. RESULTS Results were comparable between FT and TAW staff. Autonomy was the need least satisfied, a need which predicted self-reported job satisfaction, stress and turnover intention. Relatedness also predicted job satisfaction and turnover intention. CONCLUSIONS Recommendations are made to explore experiences of (and barriers to) autonomy and relatedness in inpatient HCA staff to target and improve autonomy and relatedness in this workforce. Implications of doing so are considered at a staffing, organisational and patient level.

Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand. This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013–7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE’s without RA vs 16.1 OE’s with RA from 48 to 72 h post-op, p 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE’s to 90 days, p 0.05). In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.

© 2020 The Authors. Oral Diseases published by Wiley Periodicals LLC.Objectives: Due to a worldwide increase in drug consumption, oral healthcare professionals are frequently confronted with patients using one or more drugs. A large number of drugs can be accompanied with adverse drug reactions in the orofacial region, amongst others of the tongue. This paper aims to give an overview of drugs that are known to be accompanied with tongue disorders. Materials and methods: The national drug information database for Dutch pharmacists, composed of scientific drug information, guidelines and summaries of product characteristics, was analysed for drug-induced tongue disorders. “MedDRA classification” and “Anatomical Therapeutic Chemical codes” were used to categorize the disorders. Results: The database comprises of 1645 drugs of which 121 (7.4%) are documented to be accompanied with tongue disorders as an adverse effect. Drug-induced tongue disorders are predominantly observed in the following drug categories: “nervous systems,” “anti-infectives for systemic use” and “alimentary tract and metabolism”. The most common drug-induced tongue disorders are glossitis, tongue oedema, tongue discoloration and burning tongue. Conclusion: Healthcare professionals are frequently confronted with drugs that can cause tongue disorders. The overview of drugs reported in this article supports clinicians in their awareness, diagnosis and treatment of drug-induced tongue disorders.

Background In the United Kingdom, national guidance published in 2010 recommended the establishment of specialist teams to improve clinical pathways for patients presenting with malignancies of undefined primary origin (MUO) and cancer of unknown primary (CUP). This study sought to define outcomes of patients referred to a regional MUO/CUP service. Methods Data were collected prospectively on all patients (n = 1225) referred to a regional CUP team over a 10-year period. Patient demographics, clinical, pathological and outcome data were recorded and analysed. Results Confirmed CUP (cCUP) was diagnosed in 25% of patients. A primary metastatic cancer was identified in 36%, 5% were diagnosed with provisional CUP (pCUP), 27% retained the diagnosis of MUO and in 8% a non-cancer diagnosis was made. Median survival was low in all patients with a final malignant diagnosis: primary identified 9.0 months, cCUP 4.0 months, pCUP 1.5 months and MUO 1.5 months. Conclusions Patients presenting with MUO have poor outcomes irrespective of the final diagnosis. These patients need a patient-centred, streamlined, rapid diagnostic pathway. There are clear benefits to primary and secondary care teams having access to a dedicated, multidisciplinary MUO/CUP service, with clinical nurse specialists supporting the patients, to help facilitate this pathway and ensure early oncology review.

Beyond the spine-specific pathology, patient factors such as associated medical and psychosocial conditions, understanding of the treatment process, and the degree of patient activation-defined as the ability of the individual to utilize the available information and actively engage in making their healthcare decisions-can influence outcomes after posterolateral lumbar fusion (PLF) surgery. A retrospective observational cohort study of 177 patients undergoing PLF at a single institution was conducted. Patient demographics, medical and psychosocial risk factors, and outcomes were compared between patients who attended a nurse navigator-led group preoperative education course and those who did not. Patients attending the course were younger, more likely to undergo one-level fusion, less likely to undergo 5- or more-level fusion, and had less comorbidity burden as measured by the hierarchical condition categories score. No differences in psychosocial risk factors were observed between groups. Course attendees had a significantly shorter length of stay (2.12 vs. 2.60 days, p = .042) and decreased average hospital cost (U.S. $10,149 vs. U.S. $14,792, p < .001) than those who did not attend; no differences in other outcomes were observed. After controlling for differences in risk factors, patients enrolled in a preoperative education course demonstrated a statistically significant reduction in hospital cost (β=-4,143, p < .001). Preoperative education prior to PLF surgery may reduce hospital cost, possibly through increased patient activation. Given the relatively high prevalence of psychosocial risk factors in this and similar patient populations, optimizing patient activation and engagement is important to achieve high value care. Based on our findings, nurse navigator-led preoperative education appears to be valuable in this patient population and should be included in enhanced recovery protocols.

Pressure ulcers (PUs) have a profound impact on individuals, with studies demonstrating that compared with similarly aged persons, those living with a PU have a significantly lower quality of life. The aim of this study was to explore the impact of the Shanley Pressure Ulcer Prevention Programme (SPUPP) on older persons' knowledge of, and attitudes and behaviours towards, PU prevention. This was a multi-centre, open-label, randomised controlled trial. The population of interest was older persons living in the community who attended either a day care centre or a retirement group and were deemed to be at risk of PUs due to reduced mobility. Stratified random sampling was used to randomise based on days of attendance at day care centre/retirement group. Pretest and post-test were applied to the intervention and control groups. The SPUPP is a multimedia programme delivered using electronic media, hard copy materials, activities, and patient diaries and addresses the key tenets of PU prevention as described by the SKIN bundle. The programme contains five separate sessions delivered over 5 weeks. The impact of the SPUPP was assessed using the patient knowledge of and attitude and behaviour towards PU prevention instrument (KPUP). A total of 64 persons, 32 in each group, took part in the study. Of these, 75% (n = 48) were female, with a mean age of 81.9 years (SD: 5.56 years). Further, 68.8% (n = 44) were either overweight or obese and 40.6% (n = 26) were usually incontinent of urine. There were no differences between the intervention and control groups in mean scores during the pretest stage. However, at post-test, the mean scores for the intervention group were higher than the control group, 16.87 (SD: 1.88) versus 12.41 (SD: 3.21), respectively. For the post-test stage, mean differences between the two groups in favour of the intervention group (∆ = 4.46) were statistically significant, as t = 6.76, P = .0001, and equal variances were not assumed. The SPUPP impacted positively on knowledge scores of the participants and positively influenced attitudes and behaviours towards PU prevention. Thus, this research provides information regarding the potential to enhance patient involvement in PU prevention.

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is one of the key tobacco-specific nitrosamines that plays an important role in human lung carcinogenesis. However, repeated inhalation toxicity data on NNK, which is more directly relevant to cigarette smoking, are currently limited. In the present study, the subacute inhalation toxicity of NNK was evaluated in Sprague Dawley rats. Both sexes (9–10 weeks age; 16 rats/sex/group) were exposed by nose-only inhalation to air, vehicle control (75% propylene glycol), or 0.8, 3.2, 12.5, or 50 mg/kg body weight (BW)/day of NNK (NNK aerosol concentrations: 0, 0, 0.03, 0.11, 0.41, or 1.65 mg/L air) for 1 h/day for 14 consecutive days. Toxicity was evaluated by assessing body and organ weights; food consumption; clinical pathology; histopathology observations; blood, urine, and tissue levels of NNK, its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and their glucuronides (reported as total NNK, tNNK, and total NNAL, tNNAL, respectively); O6-methylguanine DNA adduct formation; and blood and bone marrow micronucleus frequency. Whether the subacute inhalation toxicity of NNK followed Haber’s Rule was also determined using additional animals exposed 4 h/day. The results showed that NNK exposure caused multiple significant adverse effects, with the most sensitive endpoint being non-neoplastic histopathological lesions in the nose. The lowest-observed-adverse-effect level (LOAEL) was 0.8 mg/kg BW/day or 0.03 mg/L air for 1 h/day for both sexes. An assessment of Haber’s Rule indicated that 14-day inhalation exposure to the same dose at a lower concentration of NNK aerosol for a longer time (4 h daily) resulted in greater adverse effects than exposure to a higher concentration of NNK aerosol for a shorter time (1 h daily).

Background and ObjectivesEpilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children and adolescents with epilepsy.MethodsIn 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible. Our aim statement was to decrease the number of ED visits, per 1000 established patients with epilepsy, from 13.03 to 11.6, by December 2019 and sustain for 1 year.ResultsWe successfully decreased ED visits for seizure-related care in patients with epilepsy from 13.03% to 10.2% per 1,000 patients, which resulted in a centerline shift.DiscussionUsing QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.

Background Pressure ulcer (PU) development begins with an inflammatory response, arising due to pressure and shear forces causing changes to the cytoskeletal structure of cells. Thus, pain, synonymous with inflammation, may be an indicator of PU development. Aim To explore the role of pain as an indicator of PU development and to determine how this pain was measured. Method We searched PUBMED, CINAHL, SCOPUS, Cochrane, and EMBASE databases. A total of 879 records were returned, with eight satisfying the inclusion criteria. Narrative data synthesis was undertaken. The quality of studies was assessed using the evidence-based librarianship (EBL) checklist. Results The studies were conducted between 2000 and 2019, and 75% (n = 6) employed a cross-sectional design. The mean sample size was 760 participants (SD = 703). Of the included studies, 87.5% (n = 7) identified that pain was associated with PU development. The most frequent pain assessment tool was the numeric rating scale (37.5%; n = 3). Using the EBL checklist, 62.5% (n = 5) of the studies scored ≥75%, reflecting validity. Linking evidence to action Pain is associated with PU development; however, further research is required to validate these findings and assess the characteristics associated with pain as a symptom preceding PU development.

Many long-term survivors of childhood cancer (LTSCC), individuals at least 5 years post-diagnosis or 2 years post-treatment, experience late- and long-term effects from their treatments, including pain. Yet, pain is poorly understood among LTSCC. The current study aimed to (1a) describe rates and multiple dimensions of pain; (1b) identify patterns of chronic pain; and (2) test correlates of chronic pain in LTSCC. Survivors (n = 140; 48.6% male, Mage = 17.3 years (range = 8–25)) were recruited from across Canada. Between 2017 and 2019, participants completed the Pain Questionnaire, Pain Catastrophizing Scale, Pediatric Quality of Life Inventory, Patient-Reported Outcome Measurement Information System (PROMIS)–Pain Interference, Anxiety, and Depression scales, Child Posttraumatic Stress Scale, the Posttraumatic Stress Disorder Checklist for the DSM-V, and the Cancer Worry Scale. Twenty-six percent of LTSCC reported experiencing chronic pain. Exploratory cluster analysis showed 20% of survivors had moderate to severe chronic pain based on measures of pain intensity and interference. The combination of higher posttraumatic stress symptoms, older current age, more pain catastrophizing, and sex (being female) significantly predicted the presence of chronic pain in logistic regression, χ2 (4, N = 107) = 28.10, p < .001. Higher pain catastrophizing (OR = 1.09; 95% CI = 1.02–1.16), older current age (OR = 1.20; 95% CI = 1.07–1.34), and higher posttraumatic stress (OR = 1.92; 95% CI = 1.01–3.63) were significant predictors of chronic pain. LTSCC should be screened for the presence and magnitude of chronic pain during long-term follow-up visits so appropriate interventions can be offered and implemented. Future research should investigate pain interventions tailored for this population. Findings support regular screening for the presence and magnitude of chronic pain in survivors of childhood cancer in long-term follow-up care.

Racist and sexist power hierarchies endure in the US under the guise of fake news. The authors engage in the Black feminist tradition of truth-telling and centre the experiences of Black women in t...

Over the past two decades, the U.S. Geological Survey (USGS) National Earthquake Information Center (NEIC) has overcome many operational challenges. These range from minor disruptions, such as power outages, to significant operational changes, including system reconfiguration to handle unique earthquake sequences and the need to handle distributed work during a pandemic. Our ability to overcome crises is built on the development and implementation of a continuity of operations plan, well-designed infrastructure, adaptive software systems, experienced staff, and extensive collaboration. The NEIC does not operate in a vacuum but benefits from contributions of United States and international seismic networks. Similarly, the overall resilience of earthquake monitoring in the United States and around the globe benefits from the NEIC’s role as the national center for the Advanced National Seismic System (ANSS). Here, we highlight significant adaptations the NEIC has made in the face of crises. We discuss the COVID-19 pandemic, which represents the most significant operational crisis to impact the NEIC. The NEIC has maintained continuous operations during the ongoing COVID-19 pandemic by shifting from a fully onsite operations center to a distributed hybrid of onsite and telework staffing. We then discuss cases in which the NEIC has supported regional monitoring in the face of significant crises. In 2018, the NEIC assisted the Hawaiian Volcano Observatory with the Kīlauea volcano eruption by responding to large events, implementing contingency monitoring procedures, and calculating moment magnitudes for the low-frequency caldera collapses. Impacts of a crisis extend beyond the immediate response and often require a significant postevent assessment and a rebuilding phase. After the 2017 Hurricane Maria, the NEIC, the USGS National Strong-Motion Program, and the USGS Albuquerque Seismological Laboratory worked with the Puerto Rico Seismic Network and the Puerto Rico Strong-Motion program to assess, plan, and implement upgrades at sites that experienced storm damage.

Despite poor graft integration among some patients that undergo an anterior cruciate ligament (ACL) reconstruction, there has been little consideration of the bone quality into which the ACL femoral tunnel is drilled and the graft is placed. Bone mineral density of the knee decreases following ACL injury. However, trabecular and cortical architecture differences between injured and non-injured femoral ACL entheses have not been reported. We hypothesize that injured femoral ACL entheses will show significantly less cortical and trabecular mass compared with non-injured controls. Femoral ACL enthesis explants from 54 female patients (13-25 years) were collected during ACL reconstructive surgery. Control explants (n = 12) were collected from seven donors (18-36 years). Injured (I) femoral explants differed from those of non-injured (NI) controls with significantly less (p ≤ 0.001) cortical volumetric bone mineral density (vBMD) (NI: 736.1-867.6 mg/cm3 ; I: 451.2-891.9 mg/cm3 ), relative bone volume (BV/TV) (NI: 0.674-0.867; I: 0.401-0.792) and porosity (Ct.Po) (NI: 0.133-0.326; I: 0.209-0.600). Injured explants showed significantly less trabecular vBMD (p = 0.013) but not trabecular BV/TV (p = 0.314), thickness (p = 0.412), or separation (p = 0.828). We found significantly less cortical bone within injured femoral entheses compared to NI controls. Lower cortical and trabecular bone mass within patient femoral ACL entheses may help explain poor ACL graft osseointegration outcomes in the young and may be a contributor to the osteolytic phenomenon that often occurs within the graft tunnel following ACL reconstruction.

This study investigates agreement between ventilation and perfusion for lung cancer patients undergoing radiotherapy. Ventilation-perfusion scans of nineteen patients with stage III lung cancer from a prospective protocol were compared using voxel-wise Spearman correlation- coefficients. The presented results show in about 25% of patients, ventilation and perfusion exhibit lower agreement.

Aims The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time. Methods A study of 2,393 TKAs was performed in 2,393 patients. Patient demographics, comorbidities, OKS, EuroQol five-dimension score (EQ-5D), and Forgotten Joint Score (FJS) were collected preoperatively and one year postoperatively. Overall patient satisfaction with their TKA was assessed at one year. Patients with VTE within six months of surgery were identified retrospectively and compared with those without. Results A total of 37 patients (1.5%) suffered a VTE and were significantly more likely to have associated comorbidities of stroke (p = 0.026), vascular disease (p = 0.026), and kidney disease (p = 0.026), but less likely to have diabetes (p = 0.046). In an unadjusted analysis, patients suffering a VTE had a significantly worse postoperative OKS (difference in mean (DIM) 4.8 (95% confidence interval (CI) 1.6 to 8.0); p = 0.004) and EQ-5D (DIM 0.146 (95% CI 0.059 to 0.233); p = 0.001) compared with patients without a VTE. After adjusting for confounding variables VTE remained a significant independent predictor associated with a worse postoperative OKS (DIM -5.4 (95% CI -8.4 to -2.4); p < 0.001), and EQ-5D score (DIM-0.169 (95% CI -0.251 to -0.087); p < 0.001). VTE was not independently associated with overall satisfaction after TKA (odds ratio 0.89 (95% CI 0.35 to 2.07); p = 0.717). Conclusion Patients who had a VTE within six months of their TKA had clinically significantly worse knee-specific outcome (OKS) and general health (EQ-5D) scores one year postoperatively, but the overall satisfaction with their TKA was similar to those patients who did not have a VTE. Cite this article: Bone Joint J 2021;103-B(7):1254–1260.

BACKGROUND: Surgical site infection (SSI) is a common postoperative concern. PURPOSE: To provide an in-depth understanding of the lived experience and quality of life (QoL) of individuals with SSI. METHODS: A systematic search for published studies that explored the impact of SSI on QoL among adult patients (older than 18 years) who had undergone any type of surgery was performed in June 2020. The search included but was not limited to MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane databases using the terms “surgical site infection” OR “hospital-acquired infection” OR “nosocomial infection” OR “wound site infection” OR “surgical wound site infection” AND “Quality of Life” OR “Life quality” OR “Health-Related Quality of Life” OR “Life Style” OR “QOL” OR “HRQoL” OR “Short-form questionnaire 36” OR “Questionnaire SF-36” OR “SF-36.” All quantitative and qualitative study designs were included; no language or date of publication restrictions were imposed. The Critical Appraisal Skills Program Qualitative Checklist was used to assess the methodological quality of the included studies. Study author, date, setting, sample size, population, and design and type of surgery as well as QoL instrument scores were extracted. A narrative thematic synthesis, which comprised the physical, psychological, social, economic, and spiritual effects as well as the health care worker–patient relationship, was undertaken for qualitative studies. Outcome measures were collected and assessed using a range of established health QoL instruments and reported in terms of QoL for quantitative studies. In addition, the type of QoL instrument employed within the studies was elucidated for comparing the scores of the instruments. RESULTS: A total of 696 publications were found; 690 were eliminated, leaving 4 quantitative and 2 qualitative studies conducted between 2002 and 2018 that met the inclusion criteria. The total number of participants in the assessed studies was 785. The mean sample size for the included studies was 131 participants (SD = 192.5; median, 95). Thematic synthesis showed 6 overarching themes: physical, psychological, social, spiritual, and economic effects of SSI as well as the health care worker–patient relationship. Short Form-36 was used to assess QoL in 3 of the 4 quantitative studies; these studies showed that there were decrements in scores of Short Form-36. CONCLUSION: Although this systematic review included heterogeneous groups of patients who underwent different surgical procedures and completed different QoL assessment tools, patients with SSI experienced low QoL, with limitations in physical, social, and psychological functioning. The health care worker–patient relationship was predominantly perceived negatively. Further prospective research is warranted.

Using health-related goals to direct care could improve quality and reduce cost of medical care; however, the effect of these goals for patients with spinal pathologies is not well understood. The purpose of this study was to describe patient-reported goals by provider type and to evaluate the effect of patient-provider goal awareness on patient satisfaction and treatment pathway.A pilot program was instituted in which all new or existing patients scheduled with either a single spine surgeon or a nonsurgical spine nurse practitioner were asked to complete a paper survey instrument regarding their goals of care before their visit. The patient goals were then discussed between the provider and the patient. Univariate and multivariate analyses were performed to evaluate relationships between patient goals, provider seen, diagnosis, and treatment recommendations.There were 703 respondents to the survey, of whom 416 were included for subgroup analysis. Patient-reported goals varied by provider type. When examining rates of recommended interventions by patient goals, notable differences were observed for 7 of the 13 goal categories. Significant differences in intervention recommendations by provider type existed for physical therapy, medications, MRI, and surgery (all P0.001). After controlling for other variables, seeing a surgeon, thoracolumbar pathology, and goals of "return to activity or social events I enjoy," and "learn about spine surgery" were significant independent predictors of recommendation for surgery (all odds ratio3 and P0.05). This model generated an area under the curve of 0.923 (95% confidence interval, 0.861 to 0.986), indicating outstanding discrimination in predicting recommendation for surgery. Patient satisfaction scores rose from 91.5% to 92.2%, but this difference was not statistically significant (P = 0.782).Specific patient-reported goals vary by provider type and are associated with specific diagnosis and treatment recommendations. Goal-directed care may improve the design of treatment pathways and the overall patient experience.

Highlights Abstract Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient’s body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG.

PURPOSE To demonstrate a case of spontaneous resolution of submacular heavy liquid. METHODS This is a case report analyzing consecutive data and optical coherence tomography scans of a patient who underwent revisional retinal detachment surgery with pars plana vitrectomy using perfluorocarbon liquid (PFCL) as an adjunct. Postoperatively submacular PFCL bubbles were noted, and after an only partially successful surgical attempt to remove them, the residual PFCL bubbles were monitored over the course of several months. The primary outcome measure was the anatomical appearance and size of the PFCL bubbles on optical coherence tomography. The secondary outcome measure was the functional outcome based on the best-corrected visual acuity. RESULTS We present a case of retained submacular PFCL after complex retinal detachment repair, which could only partially be removed surgically. However, the remaining PFCL droplets resolved spontaneously over several months, with partial anatomical restoration of the retinal layers and improvement in visual acuity. CONCLUSION We hypothesize that the PFCL bubble was resorbed presumably by the retinal pigment epithelium.

INTRODUCTION Selenium is an essential micronutrient that must be supplemented in infants and young children on exclusive parenteral nutrition (PN). We examined selenium status and clinical factors associated with a deficiency in infants on PN. METHODS This was a retrospective cohort study of pediatric patients receiving PN with routine monitoring of selenium status. Deficiency was diagnosed using age-based norms of plasma selenium status. Associations between selenium deficiency and the following clinical factors were examined: birthweight status: extremely low birthweight (ELBW) versus very low birthweight (VLBW) versus low birthweight (LBW) versus normal birthweight (NBW), serum albumin status, presence of cholestasis, and co-administration of enteral feeds. RESULTS A total of 42 infants were included with gestational age [median (interquartile range)] 28 weeks (25,34). The prevalence of selenium deficiency was 80% and the prevalence of albumin deficiency was 87.5%. The odds of selenium deficiency were higher in ELBW infants (odds ratio = 17.84, 95% confidence interval [4.04-78.72], P

In 2004, Robert Stake published a provocative article that asked: “How Far Dare an Evaluator Go Toward Saving the World?” This question raises the issue of what role evaluators’ values play in the conduct of evaluations. Following review of Stake’s premises, I present value statements from a diverse group of 40 evaluators working with philanthropic foundations. The results update and revise Stake’s list of “six advocacies common in evaluation.” The findings capture changes in evaluation language and substantive concerns over the last 15 years regarding evaluators’ values and engagement. The conclusion affirms Stake’s original overarching principle. In closing, I offer an additional concern toward saving the world not on Stake’s list or that of the evaluators sampled: global sustainability and environmental justice in the face of the global pandemic and climate emergency. This process of inquiry generated a facilitation tool for use by evaluators, presented here, to support reflective practice about evaluators’ values.

Aim To explore gender differences in older adults’ perceptions about preventing falls. Background Falls are a major problem for older adults and health care systems and a challenge to the aging population. Consideration of older adults’ perceptions of fall prevention is needed to increase their engagement in evidence-based prevention strategies. Method A qualitative analysis of secondary data was performed. Results Three major themes emerged: We’ve Seen It, Women Are Caregivers, and Men Are Analyzing Risks and Modifying Behaviors. The men and women in this study shared information about falls and fall prevention in alignment with traditional role expectations. The women learned about falling through their roles as caregivers and prevented falls by controlling extrinsic risk factors indoors such as holding onto handrails on stairs or making home modifications. The men demonstrated an analytical approach to reducing risk such as employing improved safety measures during outdoors activities as a responsibility to maintain independence. Implications The different perceptions of men and women influence what they do to engage in fall prevention. Health care professionals need to consider gender differences and take an individualized approach that includes allowing older adults to share their experiences, acknowledging their successful fall prevention behaviors, and validating and addressing their concerns.

Objective The ability of people to infer intentions from movement of other vessels was investigated. Across three levels of variability in movements in the path of computer-controlled ships, participants attempted to determine which entity was hostile. Background Detection of hostile intentions through spatial movements of vessels is important in an array of real-world scenarios. This experiment sought to determine baseline abilities of humans to do so. Methods Participants selected a discrete movement direction of their ship. Six other ships’ locations then updated. A single entity displayed one of two hostile behaviors: shadowing, which involved mirroring the participant’s vessel’s movements; and hunting, which involved closing in on the participant’s vessel. Trials allowed up to 35 moves before identifying the hostile ship and its behavior. Uncertainty was introduced through adding variability to ships’ movements such that their path was 0%, 25%, or 50% random. Results Even with no variability in the ships’ movements, accurate detection was low, identifying the hostile entity about 60% of the time. Variability in the paths decreased detection. Detection of hunting was strongly degraded by distance between ownship and the hostile ship, but shadowing was not. Strategies employing different directions of movement across the trial, but also featuring some runs of consecutive movements, facilitated detection. Conclusions Early identification of threats based on movement characteristics alone is likely to be difficult, but particularly so when adversaries employ some level of uncertainty to mask their intentions. These findings highlight the need to develop decision aids to support human performance.

For decades critics have categorised John Gay's Trivia: or The Art of Walking the Streets of London as a mock Georgic deriving its main characteristics and themes from Juvenal's Third Satire and Vi...