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Context: The COVID-19 pandemic resulted in a surge of critically ill patients that strained health care systems throughout New York City in March and April of 2020. At the peak of the crisis, consults for palliative care increased four- to sevenfold at NewYork-Presbyterian (NYP), an academic health care system with 10 campuses throughout New York City. We share our challenges, solutions, and lessons learned to help peer institutions meet increased palliative care demands during future crises and address pre-existing palliative care subspecialist shortages during nonpandemic times. Methods: In response to the increased demand, palliative care physician and administrative leadership at NYP piloted multiple creative care models to expand access to palliative care outpatient and inpatient services. The care models included virtual outpatient management of existing patients, embedded palliative care staff, education for providers, multidisciplinary family support, hospice units (which allowed for family visitation), and team expansion through training other disciplines (primarily psychiatry) and deploying an ePalliative Care service (staffed by out-of-state volunteers). Conclusion: Our comprehensive response successfully expanded the palliative care team's reach, and, at the height of the pandemic, allowed our teams to meet the increased demand for palliative care consults. We learned that flexibility and adaptability were critical to responding to a rapidly evolving crisis. Physician and family feedback and preliminary data suggest that virtual outpatient visits, embedded staff, hospice units, and team expansion through training other disciplines and deploying ePalliative Care services were impactful interventions.

Study Design: Modified Delphi study. Objective: The objective of this study was to establish expert consensus on the application of lateral lumbar interbody fusion (LLIF) by using the modified Delphi study. Methods: From June 2019 to March 2020, Members of the Chinese Study Group for Lateral Lumbar Spine Surgery were selected to collect expert feedback using the modified Delphi method where 65 spine surgeons from all over China agreed to participate. Four rounds were performed: 1 face-to-face meeting and 3 subsequent survey rounds. The consensus was achieved with ≥a 70.0% agreement for each question. The recommendation of grade A was defined as ≥90.0% of the agreement for each question. The recommendation of grade B was defined as 80.0-89.9% of the agreement for each question. The recommendation of grade C was defined as 70.0-79.9% of the agreement for each question. Results: A total of 65 experts formed a panelist group, and the number of questionnaires collected was 63, 59, and 62 in the 3 rounds. In total, 5 sections, 71 questions, and 382 items achieved consensus after the Delphi rounds including summary; preoperative evaluation; application at the lumbar spinal stenosis, lumbar disc herniation, lumbar spondylolisthesis, adult degenerative scoliosis, postoperative adjacent segmental degeneration, and revision surgery; complications; and postoperative follow-up evaluation of LLIF. Conclusion: The modified Delphi method was utilized to ascertain an expert consensus from the Chinese Study Group for Lateral Lumbar Spine Surgery to inform clinical decision-making in the application of LLIF. The salient grade A recommendations of the survey are enumerated.

According to Jewish law/ethics, continuous life-sustaining therapy may not be withdrawn after its introduction, unless the patient has improved and no longer has a medical indication for the treatment. We report the case of an 88-year-old Orthodox Jewish patient, on invasive mechanical ventilation, with severe anoxic brain injury after multiple cardiac arrests. Although the patient's son informed the palliative care team that his father did not want to be in pain or to linger in a vegetative state when terminally ill, the mechanical ventilation was keeping him alive with a poor neurological prognosis. Additionally, the patient had previously stated his wish to observe Orthodox Jewish principles regarding end-of-life care. After extensive discussion, the family Rabbi clarified that it would be acceptable to withdraw mechanical ventilation if there were a “reasonable expectation” he would breathe on his own for a “reasonable amount of time.” Thus, if the patient's death were to occur, it would not be an immediate consequence the normal ventilator weaning process. Following intermediation by the hospital Rabbi, the definition of what would be a “reasonable expectation” and “reasonable amount of time” was established by the family Rabbi as “over 50%” and “on the order of hours,” respectively. Following pulmonary consultation, the patient underwent palliative extubation and, 12 hours after the procedure, died comfortably surrounded by the family. In conclusion, the collaborative and interdisciplinary work among the family Rabbi, hospital Rabbi, and the various medical teams allowed the development of a plan that met all of the patient's personal and religious wishes and beliefs.

in communication networks, network virtualization can usually provide better capacity utilization and quality of service (QoS) than what can be achieved otherwise. Under this operation, once the capacity of a virtual optical network (VON) is allocated, it will be static for a certain period, for example, a service contract period. However, in reality, the actual traffic demand of a VON always fluctuates, which would lead to a mismatch between the capacity assigned and the actual traffic demand carried. This mismatch would further cause degradation of provisioned network services and inefficiency in assigned network capacity. To overcome this issue, we propose a new scheme, called spectrum trading (ST), to trade spectrum resources between VONs in the context of an elastic optical network (EON). The key idea is to allow different VONs to trade their spectrum resources according to their actual capacity requirement at different time instants. A VON with unused spectra can trade away its unused spectra to other VONs that are short of spectrum resources at that time. in exchange, it is rewarded with some credit for its contribution to the ST community, which it can then use later to obtain extra capacity, if needed. The trust-worthiness of the trading records between the VONs is ensured in a distributed fashion through a blockchain- assisted ledger that is updated whenever a new trade occurs. A software-defined control plane is also developed to enable spectrum trading with the support of the blockchain-assisted ledger. The performance of the ST scheme is evaluated and compared with the scenario without such trading. Results show that the proposed ST scheme is efficient in improving the QoS of each VON and significantly improves overall network capacity utilization.

BackgroundHispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy.ContextWe evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients.MethodA retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients.ResultsOf 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04).Significance of resultsSpanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.

Chordoma is a rare tumor of the skeletal system that is characterized by a high recurrence rate and treatment resistance. Given the common finding of immune dysregulation in chordoma, immunotherapy has emerged as potential treatment option. As an important immune checkpoint regulator, we evaluated cytotoxic T-lymphocyte antigen-4 (CTLA-4) expression and its prognostic significance for patients with chordoma of the spine. CTLA-4 expression was analyzed immunohistochemically in 32 chordoma tissues and 14 nucleus pulposus tissues to examine the specificity of CTLA-4 expression in chordoma. Univariate log-rank analysis was used to evaluate the association of CTLA-4 expression in tumor cells and tumor-infiltrating lymphocytes (TILs) with survival. Cox multivariate analysis was used to identify independent factors of survival. Positive CTLA-4 expression was observed in all of the TILs and tumor cell cytoplasm, and partial in the membrane or in both the membrane and nucleus, with a markedly higher positivity rate than that observed in normal nucleus tissues. Higher CTLA-4 expression in the tumor but not in TILs was significantly associated with shorter continuous disease-free survival (CDFS) and overall survival (OS). CTLA-4 expression in tumor cells and TILs were independent predictors for CDFS, whereas only tumor cell expression was a significant predictor of OS. Furthermore, the combination of CTLA-4 expression in the tumor and TILs had higher prognostic value. Targeting CTLA-4 may be a potential novel therapeutic strategy for chordoma patients.

Aims: To describe the real-world economic burden of patients with anaplastic lymphoma kinase-positive (ALK+) non-small cell lung cancer (NSCLC) treated with post-crizotinib, second-line ALK inhibit...

Climate change represents an unprecedented challenge to the world?s biosphere and to the global community. It also represents a unique challenge for plant health. Human activities and increased market globalization, coupled with rising temperatures, has led to a situation that is favourable to pest movement and establishment. This summary for policy makers drawn from the FAO scientific review on the impact of climate change on plant pests, and by extension, on plant health provides concrete recommendations for decision makers on how to address the impact of climate change on plant health. The evidence assessed strongly indicates that climate change has already expanded some pests? host range and geographical distribution, and may further increase the risk of pest introduction to new areas. Increased international cooperation and development of harmonized plant protection strategies are crucial to help countries successfully adapt their pest risk management measures to climate change.

Fatigue damage in engineering structures is universal. The occurrence of fatigue cracks brings unpredictable hidden dangers to a structure in terms of safety and service performance. Traditional damage identification methods, such as power spectrum analysis, are mostly based on linear elasticity theory that cannot reflect the typical nonlinear characteristics of fatigue cracks and cannot meet the higher requirements of the signal analysis method put forward by current mass detection data. To solve this problem, a numerical model of a cantilever beam with a breathing crack is established in this study. A method for diagnosing fatigue damage is studied by combining bispectral analysis and a statistical normal cloud model, which characterize the nonlinear characteristics of the structure. This method can effectively describe the nonlinear characteristics of the structure and reasonably evaluate the degree of fatigue damage in the structure. The bispectrum-normal cloud model method proposed in this study overcomes the limitations of existing linear damage detection methods in nonlinear damage detection, and can improve the efficiency of signal analysis from a statistical point of view. It has good prospects for structural nonlinear damage assessment.

Background: Near-death awareness (NDA) refers to visions and dreams commonly experienced by terminally ill individuals within months to hours before death. Methods: A case report of a 68-year-old Jamaican male diagnosed with advanced cholangiocarcinoma, who experienced visions of his deceased mother during hospitalization. Results: This article discusses how to differentiate NDA from delirium, core components for determining decisional capacity, and how clinicians can use a cultural guide to optimize patient-centered care. Conclusion: Improved recognition of NDA may promote cultural humility/competency and help to differentiate NDA from an underlying medical/psychiatric condition. It may assist the clinician in understanding the significance of NDA and the comfort and meaning these experiences may hold for both the individual and their family.

In recent years, with the increasing number of women in advanced maternal age and standardized protocol of prenatal examination in China, more fetuses have been detected with scoliosis caused by hemivertebra (HV). The objective of this study was to obtain the responses of different populations on early detected scoliosis in fetuses caused by spinal hemivertebra through a multi-dimensional survey. A self-administered anonymous web and social media-based multi-dimensional online survey were conducted. Four short questionnaires concerning fetuses with scoliosis secondary to hemivertebra were sent to spine/orthopedic surgeons, obstetricians/ultrasonologists, scoliosis patients, and the non-medical general public separately. Survey items mainly included whether continue the pregnancy, the responses of different populations, whether they have knowledge of HV and what they wanted to know most about HV among the general public group, etc. All the questions were single choice questions, and additional responses could be added if needed. A total of 5586 respondents including 647 spine surgeons, 227 orthopaedic surgeons, 350 obstetricians, 54 ultrasonologists, 246 scoliosis patients and 4062 general public participated in the survey. 41.89% spine surgeons, 25.99% orthopedic surgeons, 6.57% obstetricians, 17.48% scoliosis patients and 19.23% general public chose to continue pregnancy and seek treatment after birth. 4.02% spine surgeons, 7.49% orthopedic surgeons, 3.71% obstetricians, 26.83% scoliosis patients and 14.28% non-medical general public suggested or chose to terminate the pregnancy. 54.10% spine surgeons, 66.52% orthopedic surgeons suggested explain the pros and cons to the parents and let them make their own choices.

Aim: Evaluate real-world patient preferences, experiences and outcomes (health-related quality of life [HRQoL]) from patients with anaplastic lymphoma kinase-positive (ALK+) non-small-cell lung cancer (NSCLC) utilizing the ALKConnect Patient Insight Network. Patients & methods: Demographics, disease history/status/treatment, patient preferences and HRQoL (MD Anderson Symptom Inventory lung cancer module, reported as symptom severity and interference) were evaluated for US adults with ALK+ NSCLC. Results: Among 104 patients (median age: 53.0 years, 67.3% female, 40.0% employed), HRQoL and 3-month delay in disease progression were important treatment attributes. Burdensome symptoms included fatigue and disturbed sleep. Symptoms interfered most with work and day-to-day activity. Higher HRQoL was associated with ALK tyrosine kinase inhibitor (TKI) treatment and employment. Conclusion: ALKConnect demonstrated that disease progression, HRQoL, fatigue/sleep, ALK TKIs and employment matter in ALK+ NSCLC.

Sezary syndrome (SS) is an extremely rare form of cutaneous T-cell lymphoma (incidence 0.01 cases/100,000 person-years) associated with debilitating morbidity and poor overall prognosis.1,2 For patients with relapsed or treatment-refractory SS, traditional therapies are limited and predominantly palliative.1 Multiple prior single-center studies suggest allogeneic hematopoietic stem-cell transplantation (HSCT) with total-skin electron beam (TSEB) may offer durable remission to a subset of these patients.

Context: A paucity of literature describes the growing Chinese American community’s end-of-life (EOL) priorities and preferences. Objective: Develop a culturally-tailored advance care planning (ACP) tool to understand the EOL preferences of this underserved minority group. Methods: Informed by the Cultural Appropriateness Theory, the Chinese American Coalition for Compassionate Care (CACCC) developed Heart to Heart (HTH) Cards using a 3-step approach. First, CACCC created and refined a list of bilingual, culturally relevant EOL issues. Next, CACCC organized the EOL issues into a card deck. Finally, CACCC developed a unique playstyle of the cards—the HTH Café. From 2014-2019, CACCC recruited Chinese American volunteers and participants for HTH Cafés. Following each Café, participants completed an anonymous survey describing their sociodemographics, top 3 cards, and café evaluation. Results: The 54 HTH Cards were organized into 4 suits (spiritual, physical, financial/legal, and social). Each card displayed a culturally-tailored EOL issue in English and Chinese. Playstyles included one-on-one and group formats (ie. HTH Café). CACCC volunteers conducted 316 HTH Cafés for 2,267 Chinese American adults. Most participants were female (61.6%), between 18-50 years old (56.7%), lived in California (80.2%) and born in Asia (74.3%). The top priority (25.5%) was “If I’m going to die anyway, I don’t want to be kept alive by machines.” Participants thought the session was pleasant (99.5%) and expressed intent to complete advance directives (86.5%). Conclusion: HTH Cards represents the first, theory-driven, culturally-tailored ACP tool for Chinese Americans. More research is needed to establish its impact on ACP conversations and outcomes.

Background:Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.Aim:Examine the relationship between dementia, DNR timing, and end-of-life care intensity.Design:Observational cohort study.Setting/Participants:Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.Results:Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.Conclusions:Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

This chapter presents a review on the recent progress in transmission electron microscopy (TEM) studies of ferroelectric DWs in one of the most widely studied ferroelectric systems — BiFeO3 thin films. This system has been chosen representative for a much wider range of ferroelectric perovskites with functional DWs, due to its strong spontaneous polarization, coexistence of ferroelectricity, ferroelasticity and antiferromagnetism, and numerous functionalities at the DWs. Here, the chapter first briefly introduces the instrumentation, experimental procedures, imaging mechanisms, and analytical methods of the state-of-the-art TEM-based techniques. The application of these techniques to the study of DW structures and switching behaviors is demonstrated, with particular emphasis on the critical roles of interfaces and defects, and interplay between different types of DWs. The phenomena and mechanism discovered in the model system of BiFeO3 are also applicable to many other ferroelectric materials with similar DW structures. The results not only advance the fundamental understanding of static and dynamic properties of ferroelectric DWs, but also form the basis for designing of practical ferroelectric-DW-based devices.

Background Little is known about real-world treatment and outcomes of patients with anaplastic lymphoma kinase-positive (ALK+) advanced non-small cell lung cancer (NSCLC). Patients and Methods This retrospective study of the Flatiron Health EHR-derived deidentified database included patients with a lung cancer diagnosis and confirmed advanced NSCLC who received ALK tyrosine kinase inhibitor (TKI) therapy (January 1, 2011, through June 30, 2018). Patient characteristics and treatment patterns were characterized. Real-world progression-free survival (rwPFS) and time to discontinuation were calculated using the Kaplan-Meier method. Results First-line ALK TKI therapy was administered to 581 patients (27.5% had brain metastasis on or prior to initiation) and second-line ALK TKI therapy to 254 patients post crizotinib (45.7% had brain metastasis on or prior to second-line ALK TKI initiation). Crizotinib (84.6%; n = 492) was the most commonly administered first-line ALK TKI therapy. For second-line ALK TKI post crizotinib (n = 254), 49.6% received ceritinib, 41.7% received alectinib, 5.9% received crizotinib retreatment, and 2.8% received brigatinib. Median (95% confidence interval [CI]) rwPFS was 7.47 (6.48–8.32) months for first-line and 7.30 (5.72–8.42) months for second-line ALK TKI. Median (95% CI) rwPFS was significantly longer among first-line ALK TKI patients without than with brain metastasis (8.52 [7.57–10.59] vs. 4.97 [3.75–5.99] months; p Conclusion Median rwPFS in patients with advanced ALK+ NSCLC was

Introduction The treatment landscape for anaplastic lymphoma kinase (ALK)-positive non–small-cell lung cancer (NSCLC) primarily involves ALK-directed tyrosine kinase inhibitors (TKIs). Although therapy with immune checkpoint inhibitors (ICIs) is a treatment option in NSCLC, the efficacy of ICI is inconclusive in ALK-positive NSCLC as a result of limited data. This retrospective real-world study sought to describe the characteristics of ALK-positive NSCLC patients treated with ICI and to assesses treatment outcomes in US oncology practices. Patients and Methods This analysis used the Flatiron Health electronic health record–derived deidentified database and included adult (18 years and older) ALK-positive advanced NSCLC patients with receipt of one or more ICIs after January 1, 2015. Median time to ICI discontinuation and real-world progression-free survival (rwPFS) were estimated by Kaplan-Meier methods. Results Of 83 patients with ALK-positive NSCLC treated with ICIs, 50.6% (n = 42) received ICI without a prior ALK TKI. Median time to ICI discontinuation was 2.17 months (95% confidence interval, 1.41, 3.32). The median rwPFS was 2.34 months (95% confidence interval, 1.55, 3.09); in patients who received an ICI without prior ALK TKI, it was 3.9 months, and in patients who received ICI therapy after an ALK TKI, it was 1.5 months. Conclusions Real-world effectiveness (rwPFS) of ICIs in ALK-positive NSCLC patients, whether provided before or after TKIs, was limited, underscoring the relative lack of efficacy of ICI in this patient population, particularly compared to approved ALK TKIs.

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

ObjectiveTo characterize the safety and effectiveness during one surgeon’s initial phases of performing a Midline lumbar fusion by freehand technique based on perioperative parameters.MethodsThe first 90 consecutive patients underwent single level MIDLF, utilized a consistent technique, performed by one surgeon were retrospectively studied. A piecewise regression analysis was performed to evaluate the operation duration based on case number, and to estimate the breakpoint. The early learning period and the late steady phase was divided according to the case number of the breakpoint. Perioperative parameters and clinical data of 2 groups were compared then to elucidate if improvement in operative duration was accompanied by better patient prognosis.ResultsThe inflectional asymptote of the surgeon’s learning curve for MIDLF was achieved at the 40th case. The demographics parameters were similar between the early group of 40 patients and the latter 50. Average surgical time, intraoperative blood loss, length of incision, duration of drainage, postoperative drainage and post-operative hospitalization were significantly less in the late cohort (p.05), and lateral cortical breach was observed in 35/360 cases (24 vs.11, P.05). The overall complication incidence decreased alone with the learning curve, and statistical difference was achieved. Furthermore, there was no difference in clinical improvement between the two groups.ConclusionsOur result indicated that technical proficiency in MIDLF was achieved after 40 surgeries. And it is effective to significantly improve the patients’ functional status and relief the pain during one surgeon’s learning process of MIDLF in the treatment of lumbar degenerative disease, even in the initial phase. As the surgeon gains surgical proficiency and familiarity with MIDLF procedure, potential complications could be minimized. Furthermore, our results provided evidence to the excellent performance as an alternative option to traditional pedicle screw fixation.

This present investigation aimed to explore the role and clinical significance of miR-132 in the pathogenesis of osteoarthritis. Twenty osteoarthritis patients and 20 healthy volunteers were enrolled in the present study. The synovial tissues and plasma of the patients and controls were collected and RT-qPCR was performed to determine the expression level of miR-132. In addition the osteoarthritis patient-derived fibroblast-like synoviocytes were isolated, cultured, transfected with miR-132 inhibitors and the proliferation and apoptosis of the cells was determined using MTT assay as well flowcytometry. Finally, the relationship between miR-132 and sirtuin1 in osteoarthritis was evaluated. miR-132 expression was significantly increased in both synovial tissues and plasma of osteoarthritis patients and results of receiver operating characteristic curve showed that both synovial and plasma miR-132 could serve as potential diagnostic biomarker for osteoarthritis with high sensitivity and specificity. Moreover, miR-132 inhibitors significantly inhibited the proliferation and promoted apoptosis of osteoarthritis patients-derived fibroblast-like synoviocytes. Finally, the expression of miR-132 and sirtuin1 was negatively correlated in osteoarthritis and sirtuin1 was confirmed to be a direct target of miR-132. miR-132 was up-regulated in osteoarthritis and miR-132 might promote the development of osteoarthritis through regulating the proliferation and apoptosis of osteoarthritis patients-derived fibroblast-like synoviocytes via targeting sirtuin1.

Retrospective cohort study. Retrospective comparison of radiographic and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in surgical treatment of Lenke 5 curves. ASF and PSF are used for treatment of Lenke 5 curves in patients with adolescent idiopathic scoliosis (AIS). Currently, no consensus exists for optimal surgical treatment of Lenke 5 curves. Patients with Lenke 5 curves treated with either ASF or PSF were prospectively enrolled in a multicenter database and then retrospectively reviewed. Demographic data, perioperative measures, radiographic data, and SRS-22R scores were collected and compared for statistical significance. A total of 149 patients were included in the study; 51 underwent PSF and 98 underwent ASF. There was no difference in demographics between groups. The PSF group was fused one level longer than the ASF group (5.9 levels PSF, 4.6 levels ASF, p < .0001). The PSF group had shorter operative times (223 minutes PSF, 297 minutes ASF; p < .0001) and a higher proportion of patients who received a postoperative blood transfusion (45% vs. 5%, p < .0001). PSF patients had longer hospital stays (6.1d PSF vs. 5d ASF, p = .031). The ASF group had larger preoperative major curve (48.2° ASF, 44.2° PSF; p < .01). Coronal balance, thoracolumbar/lumbar Cobb angle, shoulder height, trunk shift, and overall sagittal balance were not different between groups at two-year follow-up. Curve correction at two-year follow-up was similar between groups (66% ASF vs. 62% PSF). There were no significant differences in clinical outcomes or complication rates between groups. There is no difference in radiographic or clinical outcomes in patients treated with ASF or PSF for Lenke 5 curves. ASF may save a fusion level, but has longer operative time than PSF. Ultimately, the risks and benefits of each approach merit consideration by surgeon and patient. Level II.

The subgroup of young patients with non-small-cell lung cancer (NSCLC) is poorly understood. We retrospectively studied the clinical characteristics, gene mutations, and outcomes of patients with NSCLC (aged ≤ 40 years). Of the 7494 patients with lung cancer diagnosed from February 2001 to October 2016, 252 aged ≤ 40 years showed NSCLC. We divided their cases into non-squamous cell carcinoma and squamous cell carcinoma groups according to their histology results. Of the 252 young NSCLC patients, 173 (69%) patients had stage IIIB or IV, and 196 (78%) had never smoked. The four most common metastases were intrapulmonary lesions, pleura, bone, and brain. Among patients with adenocarcinoma, 29 (40%, n = 73) harbored epidermal growth factor receptor (EGFR) mutations, 25 (34%, n = 74) harbored anaplastic lymphoma kinase (ALK) translations, and 1 (14%, n = 7) harbored ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) translations. The median progression-free survival (PFS) and overall survival (OS) were 3.3 and 27.6 months for patients receiving chemotherapy (n = 65), and 12.1 and 33.6 months for patients receiving EGFR tyrosine kinase inhibitors (TKIs) (n = 13), respectively. Patients receiving crizotinib had a median PFS time of 21.9 months (n = 8). Young patients are associated with an increased likelihood of gene mutations and can receive a better prognosis when patients harboring gene mutations are treated with EGFR-TKIs or ALK inhibitors.

Purpose This study asked whether pregnancy, a risk factor for dry eye disease associated with both chronic, immune-mediated- and autoimmune etiologies, augments development of clusters of coordinately functioning cells (CCFC) that may be precursors to pathological lacrimal gland infiltrates. Methods Lacrimal glands were from six virgin- and six term-pregnant rabbits of the same age and environmental exposure history. Seventy-two immune response-related gene transcripts were assayed by real time RT-PCR. Principal component (PC) analysis identified transcript signatures of CCFC contributing negative ( ⊖ ) or positive ( ⊕ ) PC loadings and determined gland PC projections, which reflect levels of CCFC development. Results Three CCFC were of interest as potential precursors to pathological infiltrates. CCFC 1 ⊖ was suggestive of an ectopic lymphoid structure with resting T cells and B cells. CCFC 1 ⊕ was suggestive of an immune-mediated infiltrate with T H 1 cells and mature, cytotoxic B cells. CCFC 2 ⊖ was suggestive of an ectopic lymphoid structure with activated T cells, mature B cells, germinal center, and plasmacytes. CCFC 4 ⊖ and CCFC 5 ⊖ also included plasmacytes. Pregnancy augmented CCFC 1 ⊖ in some glands; augmented CCFC 1 ⊕ in others; and augmented CCFC 2 ⊖ , CCFC 4 ⊖ , and CCFC 5 ⊖ different combinations. Conclusions Potential precursors of pathological infiltrates form in the lacrimal glands by the time of sexual maturity. Pregnancy augments lacrimal gland plasmacyte populations, and it can augment development of potential precursors to either chronic, immune-mediated infiltrates or autoimmune infiltrates of various phenotypes. Systemic and strictly local, probabilistic phenomena interact with pregnancy to determine which combinatorial phenotypes are favored.

Genetically modified food has always been a hot issue in the field of food safety. In order to realize the detection of genetically modified materials, a bionic recognition model of a multi-weight vector neural network is proposed by combining a multi-weight vector neural network with terahertz time domain spectroscopy. In this paper, for each class of samples, 50 samples are randomly selected as the training set, a multiweight vector neural network bionic recognition model is established, and 50 samples are selected as the first test set to verify the recognition rate. Other dissimilar samples are used as the second test set to verify their misjudgment rate. The experimental results show that the model can effectively identify transgenic materials with similar spectral characteristics. The model proposed in this paper provides a new method for the detection and identification of genetically modified organisms.

The health risks presented by noxious vehicle emissions inside tunnels has been amplified due to the increasing use of roadway tunnels. Particularly, for adjacent roadway tunnels, vehicular emissions from the upstream tunnel can further deteriorate the air quality within the following tunnels. A scale vehicle tunnel model was designed to experimentally modelled the airflow and pollutants dispersion in contiguous roadway tunnels. The channelling effect on pollutants dispersion between adjacent roadway tunnels was studied, and factors such as ventilation speed, open road section length, traffic condition (e.g. car free, car running and traffic congestion) were considered. Pollutants mass flow rate ratio between downstream and upstream tunnels was calculated to evaluate the variation of the entrained pollutants amount. For the car free condition, pollutant can be easily entrained into the downwind tunnel when the gap distance between roadway tunnels decreased. For the car running condition with fixed tunnel gap distance, the traffic speed variation barely changed the pollutants mass flow rate ratio. Furthermore, evident influences on pollutants concentration were observed from continuous congestion and partial congestion. Lastly, numerical simulation using computational fluid dynamics approach was conducted for the car free scenario, and reasonably good agreements were found for pollutants concentration ratio compared with the experimental data. The results yielded from this study further quantified the relationships among different influential factors on the pollutants dispersion between roadway tunnels, and can contribute to an improved tunnel ventilation system design, especially for the downstream tunnel.

Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS). Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions. Results: Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC. Conclusion: There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.

Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or “possibly” provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p

PURPOSE: The origin of blood in glaucoma-related disc hemorrhages (DH) remains unknown. A prior clinic-based study of primary open-angle glaucoma (POAG)-related DH showed that they had grayscale pixel intensities more similar to blood from retinal macroaneurysms and adjacent retinal arterioles than to blood from retinal vein occlusions or adjacent retinal venules, suggesting an arterial source. Here we assessed the densitometric profile of DH from fundus photographs in the Ocular Hypertension Treatment Study (OHTS). DESIGN: Retrospective cross-sectional study of prospectively collected images. METHODS: Stereo disc photographs of 161 DH events from 83 OHTS participants (mean age (standard deviation (SD)): 65.6 (9.2) years; 46.6% female; 13.0% black race) were imported into ImageJ to measure densitometry differences (adjacent arterioles minus DH (ΔA) or venules minus DH (ΔV)). Their size as percentage of disc area, ratio of length to midpoint width, and location relative to the disc margin were also analyzed. We performed t-tests to compare ΔA and ΔV, analysis of variance to compare ΔA and ΔV across DH recurrent events, and multivariable linear regression to identify determinants of ΔA and ΔV. RESULTS: Mean (SD) ΔA and ΔV were −2.2 (8.7) and −11.4 (9.7) pixel intensity units, respectively (P

Background Critical illness increases the risk for poor mental health outcomes among both patients and their informal caregivers, especially their surrogate decision-makers. Surrogates who must make life-and-death medical decisions on behalf of incapacitated patients may experience additional distress. EMPOWER (Enhancing & Mobilizing the POtential for Wellness & Emotional Resilience) is a novel cognitive-behavioral, acceptance-based intervention delivered in the intensive care unit (ICU) setting to surrogate decision-makers designed to improve both patients’ quality of life and death and dying as well as surrogates’ mental health. Methods Clinician stakeholder and surrogate participant feedback (n = 15), as well as results from an open trial (n = 10), will be used to refine the intervention, which will then be evaluated through a multisite randomized controlled trial (RCT) (n = 60) to examine clinical superiority to usual care. Feasibility, tolerability, and acceptability of the intervention will be evaluated through self-report assessments. Hierarchical linear modeling will be used to adjust for clustering within interventionists to determine the effect of EMPOWER on surrogate differences in the primary outcome, peritraumatic stress. Secondary outcomes will include symptoms of post-traumatic stress disorder, prolonged grief disorder, and experiential avoidance. Exploratory outcomes will include symptoms of anxiety, depression, and decision regret, all measured at 1 and 3 months from post-intervention assessment. Linear regression models will examine the effects of assignment to EMPOWER versus the enhanced usual care group on patient quality of life or quality of death and intensity of care the patient received during the indexed ICU stay assessed at the time of the post-intervention assessment. Participant exit interviews will be conducted at the 3-month assessment time point and will be analyzed using qualitative thematic data analysis methods. Discussion The EMPOWER study is unique in its application of evidence-based psychotherapy targeting peritraumatic stress to improve patient and caregiver outcomes in the setting of critical illness. The experimental intervention will be strengthened through the input of a variety of ICU stakeholders, including behavioral health clinicians, physicians, bereaved informal caregivers, and open trial participants. Results of the RCT will be submitted for publication in a peer-reviewed journal and serve as preliminary data for a larger, multisite RCT grant application. Trial registration ClinicalTrials.gov, NCT03276559. Retrospectively registered on 8 September 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3515-0) contains supplementary material, which is available to authorized users.

Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values