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To assess the association between level of resident autonomy and operative times for appendectomies.A single center retrospective analysis of electronic medical record data of patients who underwent an appendectomy from 1/1/2017 to 12/31/2018. Medical record numbers s were matched with cases entered in the ACGME Resident Case Log system. Cases were stratified by resident role ("First Assistant," "Surgeon Junior," "Surgeon Chief," or "Teaching Assistant") and operative times were compared to cases without resident participation using student's t test.Maine Medical Center, Department of Surgery, Portland, Maine.Inclusion criteria: ≥5 years old, underwent appendectomy at a tertiary medical center during the study duration, and either had corresponding Case-log data or had no resident involvement. Patients who underwent appendectomy as part of a larger procedure were excluded.Six hundred eighty-eight patients met inclusion criteria, with residents participating in 574 (83.5%) cases. Overall mean operating time was 51 ± 21.5 minutes. Attending physicians without resident participation had the shortest OR times (43 ± 19.1 minutes). There was no difference in operating time between chief resident involvement and attending physicians without resident participation (45 ± 21; p = 0.43). Cases with residents involved as "First Assistant" (53 ± 18.6 minutes; p = 0.04) "Surgeon Junior" (52 ± 24.0 minutes; p0.001), or "Teaching Assistant" (57 ± 21.6 minutes; p0.001) were found to have longer operating times as compared to attending physicians operating without a resident.Operative times for appendectomies are impacted by resident role. Chief residents' operative times approach that of attendings when operating as Surgeon Chief, however they are significantly longer when operating as Teaching Assistant. Involvement of junior residents in any role lengthen operating times. This suggests that surgical education influences operating room efficiency.

Food environment research is increasingly gaining prominence in low- and middle-income countries (LMICs). However, in the absence of a systematic review of the literature, little is known about the emerging body of evidence from these settings. This systematic scoping review aims to address this gap. A systematic search of 6 databases was conducted in December 2017 and retrieved 920 records. In total, 70 peer-reviewed articles met the eligibility criteria and were included. Collectively, articles spanned 22 LMICs, including upper-middle-income countries (n = 49, 70%) and lower-middle-income countries (n = 18, 26%). No articles included low-income countries. Articles featured quantitative (n = 45, 64%), qualitative (n = 17, 24%), and mixed-method designs (n = 11, 8%). Studies analyzed the food environment at national, community, school, and household scales. Twenty-three articles (55%) assessed associations between food environment exposures and outcomes of interest, including diets (n = 14), nutrition status (n = 13), and health (n = 1). Food availability was associated with dietary outcomes at the community and school scales across multiple LMICs, although associations varied by vendor type. Evidence regarding associations between the food environment and nutrition and health outcomes was inconclusive. The paucity of evidence from high-quality studies is a severe limitation, highlighting the critical need for improved study designs and standardized methods and metrics. Future food environment research must address low-income and lower-middle-income countries, and include the full spectrum of dietary, nutrition, and health outcomes. Improving the quality of food environment research will be critical to the design of feasible, appropriate, and effective interventions to improve public health nutrition in LMICs.

Studies using transcranial direct current stimulation (tDCS) typically incorporate a fade‐in, short‐stimulation, fade‐out sham (placebo) protocol, which is assumed to be indistinct from a 10–30 min active protocol on the scalp. However, many studies report that participants can dissociate active stimulation from sham, even during low‐intensity 1 mA currents. We recently identified differences in the perception of an active (10 min of 1 mA) and a sham (20 s of 1 mA) protocol that lasted for 5 min after the cessation of sham. In the present study we assessed whether delivery of a higher‐intensity 2 mA current would exacerbate these differences. Two protocols were delivered to 32 adults in a double‐blinded, within‐subjects design (active: 10 min of 2 mA, and sham: 20 s of 2 mA), with the anode over the left primary motor cortex and the cathode on the right forehead. Participants were asked “Is the stimulation on?” and “How sure are you?” at 30 s intervals during and after stimulation. The differences between active and sham were more consistent and sustained during 2 mA than during 1 mA. We then quantified how well participants were able to track the presence and absence of stimulation (i.e. their sensitivity) during the experiment using cross‐correlations. Current strength was a good classifier of sensitivity during active tDCS, but exhibited only moderate specificity during sham. The accuracy of the end‐of‐study guess was no better than chance at predicting sensitivity. Our results indicate that the traditional end‐of‐study guess poorly reflects the sensitivity of participants to stimulation, and may not be a valid method of assessing sham blinding., We quantified how well participants were able to track the presence and absence of a tDCS current (i.e. their sensitivity), using cross‐correlations. Current strength was a good classifier of sensitivity (higher for 2mA than 1mA), but the accuracy of their end‐of‐study guess was no better than chance at predicting sensitivity. The traditional end‐of‐study guess method poorly reflects the sensitivity of participants to stimulation, and may not be a valid method of assessing sham blinding.

Undergraduate and graduate education research has stratified study strategies from low-utility to high-utility with respect to durable learning. The purpose of this study was to determine the prevalence of these evidence-based learning strategies among surgery residents in preparation for the American Board of Surgery In-Training Examination (ABSITE).A 23-item survey was administered during individual interviews. It assessed whether they had a study plan, and the average length and frequency of their independent study, both during the year and the month prior to the ABSITE. Data were also collected on their primary resources and study strategies. Residents rated their usage of those strategies based on a 5-point Likert scale.Maine Medical Center, an academic tertiary care center located in Portland, ME.All residents in the Department of Surgery.Residents (n= 23) intensified their preparation for the ABSITE in the month prior to the exam compared to the remainder of the year, adopting study plans (87% vs 61%, p = 0.53) and increasing the time spent studying (median, 420 vs 120 minutes per week, p0.001). Primary resources used were textbooks (65%), ABSITE review books (26%) and online question banks (9%). All residents (100%) often or always used testing, but fewer residents often or always used spacing (24%), both considered high-utility strategies. Most residents (60%) often or always used highlighting, considered a low-utility strategy. There were no relationships between study strategies and ABSITE scores.All residents use self-testing as a study strategy. Most underuse spacing and overuse highlighting. Further research is needed to establish the relationship between these study strategies and ABSITE scores.

Summary The National Institute for Health and Care Excellence published guidelines for managing early-onset neonatal infections in 2012. It recommended provision for reporting blood cultures (BCs) with growth detected or not detected at 36 h. To determine if this was followed, a telephone survey was conducted amongst lead biomedical scientists based at microbiology laboratories (N = 209) in the UK. Overall, 202/209 responded and 139/202 had on-site facilities for BCs. BC results with growth detected or not detected at 36 h were available out-of-hours in 36/139 (26.6%) and 66/139 (47.5%) neonatal units, respectively. Early discontinuation of antibiotics should lead to improved antibiotic stewardship.

Summary Background Bronchiolitis is the most common reason for hospitalization in young children. In addition to respiratory syncytial virus (RSV), other viruses have been increasingly implicated. Guidance on testing has also changed. Aims To compare clinicopathological outcomes in young children admitted with bronchiolitis due to RSV in comparison with rhinovirus (RV), and identify associated risk/epidemiological factors. Methods Children aged less than two years admitted to hospital with a clinical diagnosis of bronchiolitis with positive results for either RSV or RV were included in this study. Polymerase-chain-reaction-negative cases using an extended respiratory virus panel served as a control group. Retrospective data were collected on sex, risk factors, respiratory support, intravenous fluids and antibiotics. Outcomes such as length of stay (LOS) and need for transfer to the high-dependency unit/paediatric intensive care unit were included. Findings Two hundred and twenty-seven out of 437 nasopharyngeal aspirate samples were positive for either RSV (N = 162) or RV (N = 65). The median age of cases was three months and 75% had at least one risk factor. Risk factors were higher in the RV group (P = 0.004). RV accounted for the majority of cases outside the RSV season (P

Enteroviral meningitis in infants and children commonly leads to hospital admission. Diagnosing viral meningitis can be difficult clinically. We examined the usefulness of enteroviral polymerase chain reaction (PCR) testing using cerebrospinal fluid (CSF) samples on clinical practice by comparing positive enteroviral CSF PCR cases (n = 39/136) to negative controls using both clinical outcomes and laboratory parameters. A positive result correlated with a reduced admission to high dependency unit, reduced the duration of antibiotics and a shorter length of stay (P .05). Adjusted CSF white cell count 5/μL correlated with positive PCR (P .05) but would have missed 32% of cases of enteroviral meningitis. Following these findings, an algorithm for the management of suspected viral meningitis has been introduced.

Non-invasive electrical stimulation methods are often used in experimental settings to investigate the possible modulation of antinociceptive mechanisms. Studies using transcranial direct current stimulation (tDCS) typically incorporate a fade-in, short-stimulation, fade-out sham (placebo) protocol, which is assumed to be indistinct from a 10-30min active protocol on the scalp. However, many studies report that participants can dissociate active stimulation from sham, even during low-intensity 1mA currents. In the present study we assessed whether delivery of a high-intensity 2mA current would exacerbate differences in the perception of active and sham protocols. Two protocols were delivered to 32 healthy, pain-free adults in a double-blinded, within-subjects design (active: 10min of 2mA, and sham: 20s of 2mA), with the anode over the left primary motor cortex and the cathode on the right forehead. Participants were asked “Is the stimulation on?” and “How sure are you?” at 30s intervals during and after stimulation. The differences between active and sham were more consistent and sustained during 2mA than during 1mA. We then quantified how well participants were able to track the presence and absence of stimulation (i.e. their sensitivity) during the experiment using cross-correlations. A good classifier of sensitivity during active tDCS was current strength, but exhibited only moderate specificity during sham. The accuracy of the end-of-study guess was no better than chance at predicting sensitivity. Our results from this methodological approach indicate that the traditional end-of-study guess poorly reflects the sensitivity of participants to stimulation, and may not be a valid method of assessing sham blinding. Further research should be carried out into inter-individual responses to sham-blinding and assessment methods in pain studies and the broader neurostimulation field. Wellcome Trust.

Malnutrition in all its forms currently affects one in three people globally and is considered one of the greatest public health challenges of our time. Low- and middle-income countries (LMICs) are increasingly facing a double burden of malnutrition that includes undernutrition, as well as increasing overweight, obesity and diet related non-communicable diseases. The role of food environments in shaping transitioning diets and the double burden of malnutrition in LMICs is increasingly gaining policy attention. However, food environment research to date has predominantly been undertaken in response to obesity and associated diet-related non-communicable diseases in high-income countries (HICs). Empirical research in LMICs is in its infancy. There is a need to create a cohesive research agenda to facilitate food environment research and inform action across the globe, particularly with regard to LMICs. In this paper, we address three fundamental questions: First, how can the food environment be defined and conceptualised in a way that captures the key dimensions that shape food acquisition and consumption globally? Second, how can existing knowledge and evidence from HICs be leveraged to accelerate food environment research in LMICs? Third, what are the main challenges and opportunities in doing so? We conduct a brief synthesis of the food environment literature in order to frame our critical perspectives, and introduce a new definition and conceptual framework that includes external and personal domains and dimensions within the wider food environment construct. We conclude with a discussion on the implications for future research in LMICs.

Pediatric surgeons have the privilege to care for patients at every stage of human development, from the fetus to the fully developed young adult. As such, we must cultivate and advance an all-encompassing knowledge base ranging from obstetrics to pediatrics to adult medicine and surgery. This unique, sweeping perspective on human disease requires an equally broad approach to research, which in our field is as vast and varied as it is stimulating.

A 36-week-2-day-old male infant was admitted to the neonatal unit with respiratory distress, hypoglycaemia and suspected early onset neonatal sepsis for respiratory support, monitoring and intravenous antibiotics. His initial C-reactive protein was 12 mg/L, this increased to 66 mg/L at 24 hours. Blood cultures at 48 hours confirmed Neisseria meningitidis serogroup B. As the isolate was sensitive to benzylpenicillin the same antibiotic was continued for a total of 7 days. His mother remained asymptomatic but was monitored closely. Ciprofloxacin chemoprophylaxis was given to close family contacts. Neisseria meningitidis causing early onset neonatal sepsis is extremely rare and neonates may have minimal symptoms at presentation. A table reviewing all documented cases of early onset neonatal sepsis caused by Neisseria meningitidis over a 102-year time period is included. There is need for early identification and initiation of empirical antibiotic therapy pending confirmation and sensitivities.

There has been increasing interest in associations between neighborhood food environments and cardiovascular risk factors. However, results from high-income countries remain inconsistent, and there has been limited research from low- and middle-income countries. We conducted a cross-sectional analysis of the third wave follow-up of the Andhra Pradesh children and parents study (APCAPS) (n = 5764, median age 28.8 years) in south India. We examined associations between the neighborhood availability (vendor density per km2 within 400 m and 1600 m buffers of households) and accessibility (distance from the household to the nearest vendor) of fruit/vegetable and highly processed/take-away food vendors with 11 cardiovascular risk factors, including adiposity measures, glucose-insulin, blood pressure, and lipid profile. In fully adjusted models, higher density of fruit/vegetable vendors within 400 m of participant households was associated with lower systolic blood pressure [−0.09 mmHg, 95% confidence interval (CI): −0.17, −0.02] and diastolic blood pressure (−0.10 mmHg, 95% CI: −0.17, −0.04). Higher density of highly processed/take-away food vendors within 400 m of participant households was associated with higher Body Mass Index (0.01 Kg/m2, 95% CI: 0.00, 0.01), waist circumference (0.22 mm, 95% CI: 0.05, 0.39), systolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.06), and diastolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.05). However, within 1600 m buffer, only association with blood pressure remained robust. No associations were found for between neighborhood accessibility and cardiovascular risk factors. Lower density of fruit/vegetable vendors, and higher density of highly processed/take-away food vendors were associated with adverse cardiovascular risk profiles. Public health policies regarding neighborhood food environments should be encouraged in south India and other rural communities in south Asia., Highlights • Greater density of healthy food vendors was associated with lower blood pressure. • Greater density of unhealthy food vendors was associated with higher blood pressure. • Greater density of unhealthy food vendors was associated with higher adiposity. • Public health policies modifying neighborhood food environments should be encouraged.

The maintenance of health (homeostasis) and the occurrence of disease such as chronic obstructive pulmonary disease (COPD) are acquired through nature-nurture interactions. The inherited genotype of a person is responsible for producing a deficiency of enzymes called anti-proteases, such as alpha-1 antitrypsin, which protect lung tissue—or for producing an excess of enzymes, such as proteases, which destroy lung tissue. Smoking is discussed in this paper, since it is a major risk factor in the development of COPD, a condition affecting 3 million people in the UK. Research into genetics is beginning to indicate that smoking behaviour may be linked to some form of genetic disposition. Such an association would help health professionals deliver a more patient-centred smoking cessation service. This paper argues that the nurse, in this educator role, can only be considered a partial agent of homeostatic control with patients who have COPD, due to the progressive nature of this disease.

Background: The Personal Care Participation Assessment and Resource Tool (PC-PART), formerly the Handicap Assessment and Resource Tool (HART), assesses the domains of clothing, hygiene, nutrition, mobility, safety, residence and supports. Aim: To examine the interrater reliability of the PC-PART in a rehabilitation setting. Methods: Assessments made by the researcher were compared to the interdisciplinary rehabilitation team. The research and standard assessments occurred within three working days. Raters were blind to each other's scores. Sample participants were a consecutive case-series of rehabilitation clients with varied diagnoses, activity limitations and participation restrictions. Of 66 consecutive patients seen during the a priori determined enrolment period, 25 were included in the study (nine males and 16 females, aged 44–85 years). The remaining 41 patients did not meet the inclusion criteria. Conclusion: The PC-PART has good interrater reliability. Clinicians, administrators and researchers can be reassured about this aspect of the validity of the tool.

Congenital bleeding disorders comprise a heterogeneous group of diseases that reflect abnormalities of blood vessels, coagulation proteins and platelets. Studies of these diseases, many of which are rare and several of which result in a mild bleeding diathesis only, have significantly increased our understanding of normal haemostasis. Two lessons have been learned. First, quantitative abnormalities of coagulation proteins and platelets are an important, but not the only, cause of significant haemorrhage; some cases of inherited bleeding disorders reflect synthesis of a dysfunctional coagulation protein or production of abnormal platelets. Diagnostic tests that reflect qualitative abnormalities are therefore important in the evaluation of selected patients with inherited bleeding disorders. Second, in occasional patients the inherited disorder is complex and reflects combined abnormalities of coagulation proteins alone or in association with platelet disorders. In clinical practice it is useful to distinguish disorders that cause significant clinical bleeding from those that cause few or no symptoms. Examples of the former include severe deficiencies of factors VIII and IX, and the homozygous forms of factor II, V, VII, X, XI, XIII, fibrinogen and von Willebrand factor. Comparable platelet disorders include the inherited thrombocytopenias with platelet counts less than 20 x 10(9) litre-1 and the homozygous forms of Bernard-Soulier syndrome and Glanzmann's thrombasthenia. The most frequently encountered mild haemostatic abnormalities include type I von Willebrand's disease, the platelet storage pool deficiency syndromes and the mild and moderate forms of haemophilia A and B; occasionally heterozygous or homozygous forms of the rarer coagulation disorders, e.g. factor XI deficiency, may present with a mild bleeding diathesis. Finally, some disorders are entirely asymptomatic, e.g. factor XII deficiency and deficiencies of other contact coagulation factors. Management of patients with inherited bleeding disorders should reflect knowledge of the specific disorder to be treated plus careful consideration of the clinical circumstance for which therapy is proposed. In all cases, once a decision to treat has been made, the safest efficacious therapy should be given (for example DDAVP in the treatment of patients with mild haemophilia A or type I von Willebrand's disease). Although blood products are now much safer and the risk of blood transmitted viral infections is low, there still remains a risk that transfusion of any blood product may be associated with serious side-effects. As a result, therapy should be given only after careful consideration of the risk: benefit ratio and not merely to treat an abnormal laboratory result.(ABSTRACT TRUNCATED AT 400 WORDS)

Following gonadectomy, male mice of a C57 Black strain show decreased weight gains and females show increased weight gains relative to intact controls. A similar sex difference results from a single injection of goldthioglucose, and after 100 days, female mice overtake the weight gains of the males. It is suggested that these differences are in part due to the drug causing a functional gonadectomy. This is discussed in the light of experiments on the interaction between gonadectomy and goldthioglucose.