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Abstract In general, IBD increases arteriovenous thromboembolic events, though the association between UC and cerebrovascular complications remains inconclusive. Some studies suggest young women with UC have an increased risk of cerebrovascular accidents (CVA). The focus of this study was to characterize the rates, anatomic distribution, and risk factors for CVA in patients with UC. We developed a retrospective cohort of patients with UC at a single health care system from June 2010 to June 2015. Neuroimaging was used to document presence, location and type of stroke and traditional risk factors were considered. Prevalence of CVAs in patients with UC was compared to that of the general population of Minnesota (MN) and the United States (U.S.). A total of 2,183 UC patients were identified (1088 females [f-UC], 1095 males [m-UC]). The prevalence of CVA in UC patients (4.7%, 95% CI 3.9–5.6) was higher than in the U.S. (2.5–2.7%, p

One of the primary concerns associated with open fractures is the development of a fracture-related infection (FRI). To minimize the risk of developing an FRI and subsequent morbidity, prophylactic antibiotics should be administered to patients with open fractures as soon as possible. While the antibiotic recommendations for severe open fractures are somewhat debatable, the use of a cephalosporin remains a mainstay of prophylactic treatment. Though administration of prehospital antibiotics does represent an expansion of EMS responsibilities, there have been several other treatment expansions in the prehospital setting, such as the administration of tranexamic acid and the application of pelvic binders. The administration of antibiotics, specifically cefazolin, is inexpensive, technically simple, and does not require special storage. The following recommendations are supported by and represent consensus of the COT, OTA, ACEP, NAEMSP and NAEMT with regards to prehospital antibiotic prophylaxis for suspected fractures: In a responsive patient with no history of penicillin or cephalosporin allergy, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life threats. This intervention should not delay transport. In an obtunded patient, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life-threats. This intervention should not delay transport. In a responsive patient with a documented penicillin allergy, the administration by EMS of a 1st generation cephalosporin should be performed with close monitoring after the management of life-threats. This intervention should not delay transport. [ABSTRACT FROM AUTHOR]

Dilution of concentrated epinephrine prior to intravenous use during clinical emergencies can delay urgent interventions. The objective of this study was to determine whether diluted epinephrine remains stable and sterile over time in common hospital settings. Epinephrine samples were prepared by clinically relevant double dilution techniques. Samples were stored in 10-mL syringes and incubated under 1 of 4 simulated hospital environments with a mixture of lighting and temperature settings: 4°C/20°C, with or without fluorescent lighting. Samples were incubated for 0, 15, 30, 60, or 90 days. Capillary zonal electrophoresis was used to quantify the concentration of epinephrine and/or presence of any degradation products. All samples were tested for the presence of bacterial growth using blood agar cultures. Diluted epinephrine samples remained stable for up to 90 days in all 4 simulated clinical storage conditions. No bacterial colony-forming units were detected in any of the environmental samples regardless of incubation duration, light, or temperature conditions. Diluted epinephrine for anticipated clinical emergencies may remain clinically useful for up to 90 days, thus improving patient safety, access to medications, and overhead costs by reducing waste. [ABSTRACT FROM AUTHOR]

Equine rhinitis B virus is a lesser-known equine respiratory pathogen that is being detected with increasing frequency via a voluntary upper respiratory biosurveillance program in the United States. This program received 8684 nasal swab submissions during the years 2012–2023. The nasal swabs were submitted for qPCR testing for six common upper respiratory pathogens: Streptococcus equi subspecies equi (S. equi), equine influenza virus (EIV), equine herpesvirus type 1 (EHV-1), equine herpesvirus type 4 (EHV-4), equine rhinitis A virus (ERAV), and equine rhinitis B virus (ERBV). The overall ERBV qPCR-positivity rate was 5.08% (441/8684). ERBV was detected as a single pathogen in 291 cases (65.99% of positives, 291/441) and was detected as a coinfection with at least one other respiratory pathogen in 150 cases (34.01%, 150/441). Young horses, less than a year of age, with acute onset of fever and respiratory signs and horses used for competition are more likely to test qPCR-positive for ERBV. Horses with ERBV may present with fever, nasal discharge, ocular discharge, and/or cough. Coinfection is a common feature of ERBV infection and S. equi, EHV-4 and EIV were the most common pathogens coinfected with ERBV. This report provides important information regarding the clinical relevance of ERBV in the horse and begins investigating the impact of coinfection on clinical disease.

The structure of coral-reef fish assemblages is affected by natural and anthropogenic factors such as the architectural complexity, benthic composition and physical characteristics of the habitat, fishing pressure and land-based input. The coral-reef ecosystem of South Kona, Hawai'i hosts diverse reef habitats with a relatively high live coral cover, but a limited number of studies have focused on the ecosystem or the fish assemblages. Here, we surveyed fish assemblages at 119 sites in South Kona in 2020 and 2021 and investigated the associations between the fish assemblages and environmental variables obtained from published Geographic Information System (GIS) layers, including depth, latitude, reef rugosity, housing density and benthic cover. The fish assemblages in South Kona were dominated by a relatively small number of widely occurring species. Multivariate analyses indicated that fish assemblage structure strongly correlated with depth, reefscape-level rugosity and sand cover individually, while the final parsimonious model included latitude, depth, housing density within 3-km of shore, chlorophyll-a concentration and sand cover. Univariate analysis revealed negative associations between housing density and fish species richness and abundance. Effects of environmental factors specific to fish trophic groups were also found. Reefscape-level rugosity had strong positive influences on the distributions of all herbivores (browsers, grazers and scrapers), while housing density had strong negative influences only on the abundance of browsers. Positive associations were also found between live coral cover and the presence of scrapers, as well as the abundance of corallivorous fish. This study intensively surveyed shallow coral reefs along the coastline of South Kona and was the most complete spatial survey on the reef fish assemblages to date. As it utilized GIS layers to assess large-scale patterns in the fish assemblages, future studies including in-situ environmental data may further reveal local-scale patterns and insights into factors affecting the structure of fish assemblages in Hawai'i.

Objective:. The objective of this study was to evaluate how much variation in postacute care (PAC) spending after traumatic hip fracture exists between hospitals, and to what degree this variation is explained by patient factors, hospital factors, PAC setting, and PAC intensity. Background:. Traumatic hip fracture is a common and costly event. This is particularly relevant given our aging population and that a substantial proportion of these patients are discharged to PAC settings. Methods:. It is a cross-sectional retrospective study. In a retrospective review using Medicare claims data between 2014 and 2019, we identified PAC payments within 90 days of hospitalization discharges and grouped hospitals into quintiles of PAC spending. The degree of variation present in PAC spending across hospital quintiles was evaluated after accounting for patient case-mix factors and hospital characteristics using multivariable regression models, adjusting for PAC setting choice by fixing the proportion of PAC discharge disposition across hospital quintiles, and adjusting for PAC intensity by fixing the amount of PAC spending across hospital quintiles. The study pool included 125,745 Medicare beneficiaries who underwent operative management for traumatic hip fracture in 2078 hospitals. The primary outcome was PAC spending within 90 days of discharge following hospitalization for traumatic hip fracture. Results:. Mean PAC spending varied widely between top versus bottom spending hospital quintiles ($31,831 vs $17,681). After price standardization, the difference between top versus bottom spending hospital quintiles was $8,964. Variation between hospitals decreased substantially after adjustment for PAC setting ($25,392 vs $21,274) or for PAC intensity ($25,082 vs $21,292) with little variation explained by patient or hospital factors. Conclusions:. There was significant variation in PAC payments after a traumatic hip fracture between the highest- and lowest-spending hospital quintiles. Most of this variation was explained by choice of PAC discharge setting and intensity of PAC spending, not patient or hospital characteristics. These findings suggest potential systems-level inefficiencies that can be targeted for intervention to improve the appropriateness and value of healthcare spending.

The recently described crustose calcifying red algal species Ramicrusta hawaiiensis, known only from mesophotic depths off Lehua Island, west of Kaua’i Island, was found in shallow benthic reef habitats (3-18 m deep) along the western coast of Hawai’i Island. Molecular and microscopy techniques were used for genetic confirmation and for detailed morphological and anatomical examination. Two independent benthic cover survey datasets collected from west Hawai’i Island were used to investigate temporal and geographic distribution of Ramicrusta. In both datasets, we report Ramicrusta at approximately 60% of the sites surveyed. Benthic cover for this alga varies among sites and among years and its presence in west Hawai’i is evident since at least 2003. These findings help to document Hawaiian coral reef ecosystem change and benthic community composition reshuffling. This study also emphasizes the critical importance of taxonomy and proper identification of macroalgal species to understand the potential for phase-shifts of dominant taxa in coral reef ecosystems after environmental disturbances and fluctuations in abiotic factors. In the last decade, members of the red algal order Peyssonneliales have increased in abundance and overgrown other benthic species in reef ecosystems in the Caribbean and tropical Pacific. The novel aspect of finding abundant Ramicrusta in much shallower water than originally described, the decadal presence of Ramicrusta, and its potential for competition with other benthic organisms make this research valuable to coral reef ecology and justify further investigation of Ramicrusta ecology and biology in the Hawaiian Islands and globally.

Objectives: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e‐Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. Methods: Following a registered protocol, a modified e‐Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. Results: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. Discussion: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care. [ABSTRACT FROM AUTHOR]

The Hawaiian Archipelago experienced a moderate bleaching event in 2019-the third major bleaching event over a 6-year period to impact the islands. In response, the Hawai'i Coral Bleaching Collaborative (HCBC) conducted 2,177 coral bleaching surveys across the Hawaiian Archipelago. The HCBC was established to coordinate bleaching monitoring efforts across the state between academic institutions, non-governmental organizations, and governmental agencies to facilitate data sharing and provide management recommendations. In 2019, the goals of this unique partnership were to: 1) assess the spatial and temporal patterns of thermal stress; 2) examine taxa-level patterns in bleaching susceptibility; 3) quantify spatial variation in bleaching extent; 4) compare 2019 patterns to those of prior bleaching events; 5) identify predictors of bleaching in 2019; and 6) explore site-specific management strategies to mitigate future bleaching events. Both acute thermal stress and bleaching in 2019 were less severe overall compared to the last major marine heatwave events in 2014 and 2015. Bleaching observed was highly site- and taxon-specific, driven by the susceptibility of remaining coral assemblages whose structure was likely shaped by previous bleaching and subsequent mortality. A suite of environmental and anthropogenic predictors was significantly correlated with observed bleaching in 2019. Acute environmental stressors, such as temperature and surface light, were equally important as previous conditions (e.g. historical thermal stress and historical bleaching) in accounting for variation in bleaching during the 2019 event. We found little evidence for acclimation by reefs to thermal stress in the main Hawaiian Islands. Moreover, our findings illustrate how detrimental effects of local anthropogenic stressors, such as tourism and urban run-off, may be exacerbated under high thermal stress. In light of the forecasted increase in severity and frequency of bleaching events, future mitigation of both local and global stressors is a high priority for the future of corals in Hawai'i.

Mangroves, seagrasses, and coral reefs interact in tropical regions throughout the world. These ecosystems exhibit strong synergies, as the health of each ecosystem supports the functioning of adjacent habitats. We present a global spatial analysis of mangrove, seagrass, and reef communities, identifying regions where these habitats co-occur. While only an estimated 18% of interaction zones are covered by protected areas, boundaries between mangroves, seagrasses, and reefs represent areas of high conservation efficiency, where benefits of conservation amplify synergistically as land-sea ecosystems are jointly managed. We discuss four types of conservation efficiencies in these coastal ecosystems: (1) increased resistance to disturbance through inter-ecosystem feedbacks, (2) high biodiversity within small geographic areas, (3) habitat portfolio effects giving rise to climate refugia, and (4) synergistic ecosystem services, where building one ecosystem service inherently increases others. Given these synergistic benefits, global campaigns to expand marine and terrestrial protection should focus on the tightly connective interface between mangroves, seagrasses, and reefs, in order to more efficiently build resilience within and between these habitats.

Coral reefs are undergoing changes caused by coastal development, resource use, and climate change. The extent and rate of reef change demand robust and spatially explicit monitoring to support management and conservation decision-making. We developed and demonstrated an airborne-assisted approach to design and upscale field surveys of reef fish over an ecologically complex reef ecosystem along Hawai‘i Island. We also determined the minimal set of mapped variables, mapped reef strata, and field survey sites needed to meet three goals: (i) increase field survey efficiency, (ii) reduce field sampling costs, and (iii) ensure field sampling is geostatistically robust for upscaling to regional estimates of reef fish composition. Variability in reef habitat was best described by a combination of water depth, live coral and macroalgal cover, fine-scale reef rugosity, reef curvature, and latitude as a proxy for a regional climate-ecosystem gradient. In combination, these factors yielded 18 distinct reef habitats, or strata, throughout the study region, which subsequently required 117 field survey sites to quantify fish diversity and biomass with minimal uncertainty. The distribution of field sites was proportional to stratum size and the variation in benthic habitat properties within each stratum. Upscaled maps of reef survey data indicated that fish diversity is spatially more uniform than fish biomass, which was lowest in embayments and near land-based access points. Decreasing the number of field sites from 117 to 45 and 75 sites for diversity and biomass, respectively, resulted in a manageable increase of statistical uncertainty, but would still yield actionable trend data over time for the 60 km reef study region on Hawai‘i Island. Our findings suggest that high-resolution benthic mapping can be combined with stratified-random field sampling to generate spatially explicit estimates of fish diversity and biomass. Future expansions of the methodology can also incorporate temporal shifts in benthic composition to drive continuously evolving fish monitoring for sampling and upscaling. Doing so reduces field-based labor and costs while increasing the geostatistical power and ecological representativeness of field work.

As human development continues to encroach into natural habitats, artificial light at night (ALAN) has increasingly become a concern for wildlife. Nocturnal animals are especially vulnerable to ALAN, as the physiology and behavior of nocturnal species have evolved under conditions associated with predictably dark environments. Studies exposing amphibians to constant bright light provide evidence for changes to normal metabolism, growth, and behavior, but few of these studies have used treatments of dim ALAN comparable to that found in affected habitats. Eastern red-backed salamanders, Plethodon cinereus, use their tails for fat storage and communication, are capable of tail autotomy as an antipredator mechanism, and can regenerate the tail in its entirety. We examined the effect of different, ecologically-relevant intensities of ALAN on the rate of tail regeneration in adult P. cinereus. We hypothesized that ALAN would increase tail regeneration rates such that salamanders exposed to higher levels of light at night would regenerate tails faster than those exposed to lower light levels. In a controlled laboratory setting, we exposed salamanders (N = 76) in test chambers to nocturnal illuminations of 0.0001 lx (no ALAN, natural nocturnal illumination dark control), 0.01 lx (weak ALAN), 1 lx (moderate ALAN), or 100 lx (bright ALAN, equal to dim daytime and our day lighting treatment) for a period of 90 d immediately following tail autotomy. In addition, because these salamanders eat mostly live, moving prey, we investigated the impact of ALAN on the behavior of prey (Drosophila virilis) fed to the salamanders in our laboratory trials, which could alter feeding and regeneration rates in salamanders. We predicted that prey consumption would not be affected by ALAN and measured both prey consumption and prey behavior (activity) to examine the potential influence on regeneration. For tail regeneration, we found a non-monotonic response to ALAN, with salamanders exposed to nocturnal illuminations 0.1 lx and 100 lx regenerating tails significantly slower than salamanders in the 0.0001 lx or 1 lx treatments. Prey consumption did not differ among light treatments; however, fruit fly activity increased with increasing ALAN. These results suggest that ALAN influences regeneration rates, but the rate of regeneration is not dose-dependent and is not explained easily by prey consumption or movement of prey. We suggest that tail regeneration in these salamanders may involve a complex mechanism of altered gene expression and/or modulation of hormonal activity (corticosterone, melatonin, serotonin, and/or prolactin) at different intensities of nocturnal lighting.

Background Increased time to operative intervention is associated with a greater risk of mortality and complications in adults with a hip fracture. This study sought to determine factors associated with timeliness of operation in elderly patients presenting with an isolated hip fracture and the influence of surgical delay on outcomes.Methods Trauma quality collaborative data (July 2016 to June 2019) were analyzed. Inclusion criteria were patients ≥65 years with an injury mechanism of fall, Abbreviated Injury Scale (AIS) 2005 diagnosis of hip fracture, and AIS extremity ≤3. Exclusion criteria included AIS in other body regions >1 and non-operative management. We examined the association of demographic, hospital, injury presentation, and comorbidity factors on a surgical delay >48 hours and patient outcomes using multivariable regression analysis.Results 10 182 patients fit our study criteria out of 212 620 patients. Mean age was 82.7±8.6 years and 68.7% were female. Delay in operation >48 hours occurred in 965 (9.5%) of patients. Factors that significantly increased mortality or discharge to hospice were increased age, male gender, emergency department hypotension, functionally dependent health status (FDHS), advanced directive, liver disease, angina, and congestive heart failure (CHF). Delay >48 hours was associated with increased mortality or discharge to hospice (OR 1.52; 95% CI 1.13 to 2.06; p48 hours were male gender, FDHS, CHF, chronic renal failure, and advanced directive. Admission to the orthopedic surgery service was associated with less incidence of delay >48 hours (OR 0.43; 95% CI 0.29 to 0.64; p48 hours was associated with increased mortality. The only measured modifiable characteristic that reduced delay to operative intervention was admission to the orthopedic surgery service.Level of evidence III.

Background: The novel coronavirus disease (COVID-19) has afflicted millions of people worldwide since its first case was reported in December 2019. Personal protective equipment (PPE) has been tailored accordingly, but as of April 2020, close to 10 000 health care workers in the United States have contracted COVID-19 despite wearing recommended PPE. As such, standard guidelines for PPE may be inadequate for the health care worker performing high-risk aerosolizing procedures such as endotracheal intubation. In this brief technical report, we describe the integration of an orthopedic hood cover as an item for full barrier protection against COVID-19 transmission. Technical Description: The Coronavirus Airway Task Force at Virginia Commonwealth University Medical Center approved this initiative and went live with the full barrier suit during the last week of March 2020. The PPE described in this report includes a Stryker T4 Hood, normally used in conjunction with the Stryker Steri-Shield T4 Helmet. Instead of the helmet, the hood is secured to the head via a baseball cap and binder clip. This head covering apparatus is to be used as an accessory to other PPE items that include an N95 mask, waterproof gown, and disposable gloves. The motor ventilation system is not used in order to prevent airborne viral entry into the hood. Discussion: An advantage of the full barrier suit is an additional layer of droplet protection during intubation. The most notable disadvantage is the absence of a ventilation system within the hood covering. Conclusion: Modification of existing PPE may provide protection for health care workers during high-risk aerosolizing procedures such as endotracheal intubation. Although the integration of this medical equipment meets the immediate needs of an escalating crisis, further innovation is on the horizon. More research is needed to confirm the safety of modified PPE.

Background: Music has emerged as a well-received medical intervention. Patients may be uncomfortable during total joint replacement, which can result in high sedation requirements. These requirements place elderly patients at risk for delirium. This study compares the effect of noise-cancellation versus music medicine on sedation requirements, pain, and opioid consumption during elective total knee replacement. Methods: This prospective, double-blinded, randomized clinical trial was conducted at Virginia Commonwealth University Medical Center between July 2018 and July 2019. All participants underwent primary total knee arthroplasty with a combined spinal-epidural as their primary anesthetic and received noise-cancelling, wireless headphones. Patients in the control group received the noise-cancellation feature only, while patients in the experimental group were permitted to listen to music of their choice. Patients signaled a request for sedation by squeezing a noise-making rubber hippopotamus toy. The primary outcomes included whether sedation was requested by the participant, the number of sedation demand doses requested, and the amount of propofol sedation administered during the procedure. Secondary outcomes included postoperative pain scores, total opioid consumption, and time to first opioid request. Results: Seventy-one percent (n = 36) of patients agreed to participate in the study. Forty-four percent of participants in the noise-cancellation group and 19% of participants in the music group requested sedation ( P = .25). The median propofol consumption was not different between groups (0 [0-6.7] µg/kg/min vs 0 [0-0] µg/kg/min, P = .101 for noise cancellation vs music, respectively). Pain scores and opioid consumption were not different between groups. Discussion: To date, this is the first study to use Bluetooth communication, noise-cancellation, and an Internet-based music streaming service to determine whether this technology has an impact on outcomes during major orthopedic surgery. Conclusion: As an isolated intervention, the benefits of music in a complex operating room environment may be overstated. However, music integration with noise-reduction technology and patient-controlled sedation may lead to a safer and more satisfying anesthetic. More research is needed to determine the nonpharmacologic interventions that will produce positive outcomes for the geriatric population.