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Training in implicit bias is broadly recognized as important in medical education and is mandated by some accrediting bodies. This study examined medical students' retention of concepts immediately following and one-year post participation in an implicit bias workshop.Study subjects were 272 third-year medical students who participated in workshops held between 2018-2020 that used the Implicit Associations Test (IAT) as a trigger for discussions in small groups. We developed a survey and administered it to students to capture their awareness of implicit bias pre-, post-, and one-year post-workshop attendance. Repeated Measures Analyses and independent-samples t-tests were used to examine for differences in responses on each of the seven survey items and a tabulated 7-item average of these seven items.Six of seven survey items and the tabulated 7-item average examined by Repeated Measures Analyses showed statistically significant increases between the pre-, post-, and one-year post-surveys (The findings support one-year retention of knowledge and attitudes gained from an implicit bias workshop and suggest similar retention at two years. Future educational interventions that train learners to recognize and manage implicit and explicit behaviors in clinical practice are needed.

Many metals present in trace concentrations in the oceans are sensitive to reduction and oxidation reactions (termed redox-sensitive trace metals or RSTMs) and can therefore be affected during intervals of expanded oceanic anoxia and euxinia (anoxic and sulfidic waters). These RSTMs are important micronutrients; and their availability plays a significant role in controlling metabolic pathways and therefore ecosystem structure. Understanding the links to ecosystem restructuring and potential collapse is important since past deoxygenation events are associated with biological turnover. The Early Jurassic Toarcian Oceanic Anoxic Event (T-OAE) was one such event. We focus on the RSTM molybdenum (Mo), important in the nitrogen cycle, from a basin transect where local redox conditions permit the tracking of the marine reservoir of Mo. Mo enrichments start to decline in the Pliensbachian, continue to decline in the early Toarcian, drop precipitously during the T-OAE interval, and remain low afterward before a protracted increase toward the initial values seen in the Pliensbachian. From a compilation of available data, we estimate that ∼41 Gt of Mo was buried during the T-OAE using a range of possible flux estimates. Given the known correlations of Mo with total organic carbon, the estimated burial of organic carbon during the T-OAE interval was ∼244,000 Gt. This requires a minimum of 3.25% of the ocean floor to be covered by euxinic waters. Finally, we suggest that the intervals traditionally classified as OAEs are associated with the greatest extent of euxinia. Published version

The split photodiode and the lateral effect photodiode are two popular detectors for measuring beam displacement. For small displacements of a Gaussian beam, which is the case of interest here, they are often seen as equivalent and used interchangeably, giving a signal proportional to the displacement. We show theoretically and experimentally that in the limit of low technical noise, where the signal to noise ratio is dominated by the shot noise of the light, the lateral effect photodiode produces a better signal to noise ratio than the split photodiode, owing to its optimum spatial detector response. This quantum advantage can be practically exploited in spite of the intrinsic thermal noise of the lateral effect photodiode.

Recent studies have reported that transcutaneous spinal stimulation (tSCS) may facilitate improved upper limb motor function in those with incomplete tetraplesia. However, little is known about how tSCS engages upper limb motor pools. This study aimed to explore the extent to which discrete upper limb motor pools can be selectively engaged via altering stimulus location and intensity. 14 participants with intact nervous systems completed two test visits, during which posterior root-muscle reflexes (PRMR) were evoked via a 3x3 cathode matrix applied over the cervicothoracic spine. An incremental recruitment curve at C7 vertebral level was initially performed to attain minimal threshold intensity (MTI) in each muscle. Paired pulses (1ms square monophasic with inter-pulse interval of 50ms) were subsequently delivered at a frequency of 0.25Hz at two intensities (MTI and [Formula: see text]) across all nine locations. in a random order. Evoked response to the 1

Phosphorus is considered the ultimate limiting nutrient in the oceans over geological timescales. Phosphate (PO43-) availability consequently exerts control on the global carbon cycle and atmospheric/oceanic redox conditions over million-year timescales. Despite its importance, there are no established tools that can directly and continuously reconstruct oceanic phosphate concentrations through time. Here, we report a new approach to carbonate-associated phosphate (CAP) extraction and a series of experiment-based constraints for using CAP as a tool for reconstructing ancient oceanic phosphate concentrations. Experimental work shows that phosphate is incorporated into carbonate at various concentrations as a function of solution phosphate concentration, pH, temperature, and carbonate mineralogy. It is recommended here that in order to selectively extract CAP, carbonate sediments should be partially leached in order to avoid contamination from non-carbonate phases. Analyses of recent and ancient carbonates indicate that CAP values may shift during neomorphic aragonite-to-calcite transformations and secondary alteration. Diagenetic carbonate concretions in the organic- and phosphorus-rich Monterey Formation yield elevated CAP values that correlate with indicators of significant organic matter oxidation; however, this pattern was not observed for geologically young, weakly altered carbonates in the Marion Platform (north-eastern Australian shelf). These observations suggest CAP can yield reliable information on secular variation in oceanic phosphate concentrations and semi-quantitative reconstructions, if samples are characterised mineralogically and screened for secondary alteration.

Aim Extramedullary plasmacytoma are rare neoplasms, which mainly occur in the head and neck, the most common site being the nasal cavity or septum. Patients may present with epistaxis, nasal obstruction, or rhinorrhoea. Extension into the orbit is rare but can lead to visual disturbances. Method This case report pertains to a 69-year-old female patient who initially presented with a 6-week history of recurrent sinusitis, with left sided cheek pain and diplopia. Results A CT and MRI scan was performed, which showed opacification of the left maxillary, ethmoid and sphenoid sinuses with bony destruction of the medial and anterior maxillary walls and into the anterior soft tissues. The mass was completely obstructing the left nasal cavity extending into the inferomedial orbit. Staging CT scans also showed nodal disease in the neck. Biopsy with histology was positive for CD138, with diffuse proliferation of plasma cells of varying maturity and atypia. Additionally, mono IgG kappa was also positive as was CD45 suggestive of a lymphoid neoplasm. Bone marrow biopsy and PET scan confirmed there was no systemic involvement. Radiotherapy was initiated after the patient recovered from COVID -19. A repeat MRI scan 6 weeks post radiotherapy showed a partial response with reduction in the size of the tumour, resolution of the intra-orbital extension and disappearance of paraprotein. Conclusions This case report illustrates need for earlier consideration of EMP diagnostically to reduce the risk of conversion of the plasmacytoma to multiple myeloma, which is a known possibility and to ensure minimal delay in the commencement of treatment.

This report is the first output of Work Package 1: Diagnosis of the MYRIAD-EU project: Handbook of Multi-hazard, Multi-Risk Definitions and Concepts. The aim of the task was to (i) acknowledge the differences and promote consistency in understanding across subsequent work packages in the MYRIAD-EU project, (ii) improve the accessibility of our work to a broad array of stakeholders and (iii) strengthen consensus across the hazard and risk community through a common understanding of multi-hazard, multi-risk terminology and concepts. The work encompassed a mixed-methods approach, including internal consultations and data-generating exercises; literature reviews; external stakeholder engagement; adopting and building on a rich existing body of established glossaries. 140 terms are included in the glossary, 102 related to multi-hazard, multi-risk, disaster risk management and an additional 38 due to their relevance to the project, acknowledging the need for a common understanding amongst an interdisciplinary project consortium. We also include extended definitions related to concepts particularly of relevance to this project deliverable, including ‘multi-hazard’, ‘hazard interrelationships’, ‘multi-risk’ and ‘direct and indirect loss and risk’. Underpinned by a literature review and internal consultation, we include a specific section on indicators, how these might be applied within a multi-hazard and multi-risk context, and how existing indicators could be adapted to consider multi-risk management. We emphasise that there are a number of established glossaries that the project (and risk community) should make use of to strengthen the impact of the work we do, noting in our literature review a tendency in papers and reports to define words afresh. We conclude the report with a selection of key observations, including terminology matters – for all aspects of disaster risk management, for example communication, data collection, measuring progress and reporting against Sendai Framework targets. At the same time, we discuss when is it helpful to include ‘multi-‘ as a prefix, questioning whether part of the paradigm shift needed to successfully address complex challenges facing an interconnected world is through inherently seeing vulnerability, exposure and disaster risk through the lens of multiple, interrelated hazards. We emphasise that there is likely to be an evolution of the terminology throughout the project lifetime as terms are emerge or shift as the project evolves. Finally, we propose a roadmap for developing and testing draft multi-risk indicators in MYRIAD-EU. The WP1 team would like to acknowledge all the contributions of the consortium on this task and the feedback from the External Advisory Board, in particular the chair of the board Virginia Murray, Head of Global Disaster Risk Reduction at the UK Health Security Agency, and the contribution of Jenty Kirsch-Wood, Head of Global Risk Management and Reporting at UNDRR, for her reflections on the findings of this work.

Spinal cord injuries cause loss of muscle function and subsequently reduce independence. Therapeutic interventions such as transcutaneous spinal cord stimulation are increasingly being used to help improve motor functioning however, a comprehensive understanding of the biomechanical elements of movement may help optimize stimulation protocols. Twenty healthy participants completed five sit-to-stand (STS) transitions while initial knee angle and arm facilitation were altered. Electromyography (EMG) activation of four lower limb muscles and centre of pressure dynamics were recorded. Acute initial knee angles resulted in a change in duration of phases within the STS, and restrictive arm positioning caused the time to completion to increase (p=0.04). Muscle activation patterns across phases were compared and showed significant differences between phases in both the Tibialis Anterior and Rectus Femoris (p0.006). Acute initial knee angles were also found to significantly increase Biceps Femoris activation across multiple phases (p=0.034). Altering the starting position and limb movement result in vastly different temporal and muscular strategies to complete the STS. Thus, joint angle and upper limb facilitation should be considered when designing rehabilitative interventions for clinical cohorts.

Introduction The PowerFlow implantable apheresis intravenous port is a venous access device for therapeutic apheresis procedures. In this case review article, we identify key similarities and differences between apheresis PowerFlow ports and traditional ports. We also list strategies that emergency departments can implement to aid in correct port identification. Methods Using a case review format, we describe the clinical presentation of a 33-year-old female with neuromyelitis optica who was evaluated in the emergency department for an acute exacerbation. She had a history of outpatient apheresis procedures that made use of bilateral PowerFlow ports. Mistaken for a conventional port, the right PowerFlow port was accessed with a Huber needle rather than the appropriate catheter-over-needle device. On infusion of intravenous fluids, the patient experienced pain and swelling. Ultimately, the port malfunctioned and was eventually replaced. Results A subsequent root cause analysis identified opportunities for education and aids to improve port identification. To this end, strategies were implemented to appropriately identify the PowerFlow port using at least 2 of the following methods: (1) look in the patient’s chart for record of an implantable apheresis intravenous port; (2) check the port identification card, bracelet, or keychain issued at insertion; (3) palpate the port to look for the rounded top and hollow concave entry point; and (4) use x-ray or fluoroscopy to identify radiopaque port markers. Conclusion When a patient with a history of apheresis procedures presents with an implanted port, steps should be taken to ensure correct identification and access.

Cambrian–Devonian sedimentary rocks of the northern Canadian Cordillera record both the establishment and demise of the Great American Carbonate Bank, a widespread carbonate platform system that fringed the ancestral continental margins of North America (Laurentia). Here, we present a new examination of the deep-water Road River Group of the Richardson Mountains, Yukon, Canada, which was deposited in an intra-platformal embayment or seaway within the Great American Carbonate Bank called the Richardson trough. Eleven detailed stratigraphic sections through the Road River Group along the upper canyon of the Peel River are compiled and integrated with geological mapping, facies analysis, carbonate and organic carbon isotope chemostratigraphy, and new biostratigraphic results to formalize four new formations within the type area of the Richardson Mountains (Cronin, Mount Hare, Tetlit, and Vittrekwa). We recognize nine mixed carbonate and siliciclastic deep-water facies associations in the Road River Group and propose these strata were deposited in basin-floor to slope environments. New biostratigraphic data suggest the Road River Group spans the late Cambrian (Furongian) – Middle Devonian (Eifelian), and new chemostratigraphic data record multiple global carbon isotopic events, including the late Cambrian Steptoean positive carbon isotope excursion, the Late Ordovician Guttenberg excursion, the Silurian Aeronian, Valgu, Mulde (mid-Homerian), Ireviken (early Sheinwoodian), and Lau excursions, and the Early Devonian Klonk excursion. Together, these new data not only help clarify nomenclatural debate centered around the Road River Group, but also provide critical new sedimentological, biostratigraphic, and isotopic data for these widely distributed rocks of the northern Canadian Cordillera.

Engineering geology has an important role to play in sustainable development. This is due to the unique perspective that engineering geologists have of the interfaces between: science and engineering; the natural and built environments; the past, present and future. This paper examines the role of engineering geology in delivering the United Nations Sustainable Development Goals (SDGs) and demonstrates that there is a strong link between the knowledge, skills and activities of engineering geologists and the delivery of all 17 goals. The study includes a detailed evaluation of all 169 SDG targets and highlights the key impact areas where engineering geologists already contribute to sustainable development, as well as identifying opportunities for contributions to be strengthened. It is hoped that this paper will empower engineering geologists to confidently communicate the value of their role, act responsibly and exert their influence to drive positive outcomes in terms of sustainable development in everything that they do. Supplementary material : Mapping exercise of typical engineering geology knowledge, skills and activities against all 169 SDG targets and related indicators is available at https://doi.org/10.6084/m9.figshare.c.5778817 Thematic collection: This article is part of the Sustainability in Engineering Geology & Hydrogeology collection available at: https://www.lyellcollection.org/cc/sustainability-in-engineering-geology-and-hydrogeology

Treatment results for patients with newly diagnosed FMS-like tyrosine kinase 3 (FLT3)-mutated (FLT3mut+) acute myeloid leukemia (AML) ineligible for intensive chemotherapy are disappointing. This multicenter, open-label, phase 3 trial randomized (2:1) untreated adults with FLT3mut+ AML ineligible for intensive induction chemotherapy to receive gilteritinib (120 mg/d orally) and azacitidine (GIL + AZA) or azacitidine (AZA) alone. The primary end point was overall survival (OS). At the interim analysis (August 26, 2020), a total of 123 patients were randomized to treatment (GIL + AZA, n = 74; AZA, n = 49). Subsequent AML therapy, including FLT3 inhibitors, was received by 20.3% (GIL + AZA) and 44.9% (AZA) of patients. Median OS was 9.82 (GIL + AZA) and 8.87 (AZA) months (hazard ratio, 0.916; 95% CI, 0.529-1.585; P = .753). The study was closed based on the protocol-specified boundary for futility. Median event-free survival was 0.03 month in both arms. Event-free survival defined by using composite complete remission (CRc) was 4.53 months for GIL + AZA and 0.03 month for AZA (hazard ratio, 0.686; 95% CI, 0.433-1.087; P = .156). CRc rates were 58.1% (GIL + AZA) and 26.5% (AZA) (difference, 31.4%; 95% CI, 13.1-49.7; P < .001). Adverse event (AE) rates were similar for GIL + AZA (100%) and AZA (95.7%); grade ≥3 AEs were 95.9% and 89.4%, respectively. Common AEs with GIL + AZA included pyrexia (47.9%) and diarrhea (38.4%). Gilteritinib steady-state trough concentrations did not differ between GIL + AZA and gilteritinib. GIL + AZA resulted in significantly higher CRc rates, although similar OS compared with AZA. Results support the safety/tolerability and clinical activity of upfront therapy with GIL + AZA in older/unfit patients with FLT3mut+ AML. This trial was registered at www.clinicaltrials.gov as #NCT02752035.

Conniella apterygia is redescribed from re-examination of the holotype, two paratypes, and six additional specimens. The genus is closely allied to Cirrhilabrus, sharing similarities in general morphological and meristic details, but is separated from Cirrhilabrus and most other labrid fishes in lacking pelvic fins and a pelvic girdle. Recent molecular phylogenetic studies have provided strong evidence for the deep nesting of Conniella within Cirrhilabrus, contradicting its generic validity and suggesting that the loss of pelvic elements is autapomorphic. Consequently, the species is redescribed and assigned to the genus Cirrhilabrus, as Cirrhilabrus apterygia new combination. The pelvic morphologies of related cirrhilabrin labrids are discussed, and a new synapomorphy is identified for Paracheilinus.

A growing body of evidence suggests that the deep oceans during the early Paleozoic Era were widely oxygen deficient, despite evidence for increased marine oxygenation during the Neoproterozoic. However, the temporal and geographic extents and dynamics of reducing marine conditions within these oceans are not well understood. Here, we investigate marine redox history during the Drumian through the earliest Jiangshanian International Stages of the Cambrian Period, using concentrations of redox-sensitive metals (vanadium, uranium, and molybdenum), iron speciation, and Mo isotope stratigraphy of the Alum Shale Formation of Scandinavia. These data suggest a major perturbation occurred in trace metal cycling during the later Cambrian Period that was linked to a transient change in marine redox conditions coincident with the well-known Steptoean Positive Isotope Excursion or SPICE. The δ98Mo measurements of the Alum shale show systematic variations during the interval that contains the SPICE which are broadly consistent with a transient expansion of sulfidic, reducing marine environments — indicating a significant exacerbation of an already-common condition during the Cambrian Period. Additionally, iron speciation data record a local transition from predominantly anoxic, ferruginous (Fe+2 containing) to anoxic, euxinic (sulfide containing) water column conditions near the initiation of the SPICE. Trace metal abundances, however, appear to decline well before the start of the SPICE, suggesting an earlier initiation of the global expansion of reducing environments. More broadly, our data and modeling support the notion that significant portions of the oceans remained oxygen deficient throughout the later portion of the Cambrian, and that these oceans were also prone to transient intervals of more reducing conditions similar to the Oceanic Anoxic Events of the Mesozoic.

INTRODUCTION AND OBJECTIVE:Sacral neuromodulation is an effective treatment for refractory overactive bladder. Based on standard culture, about 25% of explanted stimulators have been shown to be co...

INTRODUCTION AND OBJECTIVE:Evaluate whether inflatable penile prosthesis (IPP) after radical cystectomy (RC) is associated with higher complication rates compared to IPP for other etiologies of ere...

INTRODUCTION AND OBJECTIVE:The pulse width (PW) parameter in sacral neuromodulation (SNM) is understudied, with no evidence-based guidance available on alternative PW for bladder indications. The a...

INTRODUCTION AND OBJECTIVE:Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common. Per the American Urologic Association guidelines, there are two prostate size-independe...

Improved medical care throughout childhood and adolescence has enabled patients with complex urological abnormalities to live longer into adulthood. These patients are now at risk of developing common, age-related, urological conditions. This review aims to review existing data and make recommendations in areas where expert opinion is currently lacking METHODS: This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the ICUD and SIU at the 2018 SIU annual conference in Seoul, South Korea.BPH may present differently in patients with neurogenic bladder. Thorough assessment of neurological status, bladder and sphincter function is required before offering any bladder outlet surgery. Prostate specific antigen screening should be offered to men aged 50-69 with neurogenic bladders if they have good life expectancy. Multi-parametric MRI and transperineal biopsy would be the investigations of choice if feasible. Surgery for localized disease should only be done by surgeons with the relevant expertise. Bladder cancer in this patient group is more likely to present at a later stage and have a worse prognosis. Parenthood is achievable for most, but often requires assistance with conception. Pregnant women who have had previous urogenital reconstructive surgery should be managed in appropriate obstetric units with the involvement of a reconstructive urologist.Most evidence regarding complex urogenital abnormalities comes from the pediatric population. Evidence regarding common, age-related urological issues is generally from the 'normal' adult population. As patients with complex congenital urological conditions live longer, more data will become available to assess the long-term benefits of intervention.

Flexible ligands often have multiple binding modes or bound conformations that differ by rotation of a portion of the molecule around internal rotatable bonds. Knowledge of these binding modes is important for understanding the interactions stabilizing the ligand in the binding pocket, and other studies indicate it is important for calculating accurate binding affinities. In this work, we use a hybrid molecular dynamics (MD)/non-equilibrium candidate Monte Carlo (NCMC) method to sample the different binding modes of several flexible ligands and also to estimate the population distribution of the modes. The NCMC move proposal is divided into three parts. The flexible part of the ligand is alchemically turned off by decreasing the electrostatics and steric interactions gradually, followed by rotating the rotatable bond by a random angle and then slowly turning the ligand back on to its fully interacting state. The alchemical steps prior to and after the move proposal help the surrounding protein and water atoms in the binding pocket relax around the proposed ligand conformation and increase move acceptance rates. The protein-ligand system is propagated using classical MD in between the NCMC proposals. Using this MD/NCMC method, we were able to correctly reproduce the different binding modes of inhibitors binding to two kinase targets – c-Jun N-terminal kinase-1 and cyclin-dependent kinase 2 – at a much lower computational cost compared to conventional MD and umbrella sampling. This method is available as a part of the BLUES software package.

The Paleocene‐Eocene Thermal Maximum is marked by a prominent negative carbon‐isotope excursion, reflecting the injection of thousands of gigatons of isotopically light carbon into the atmosphere. The sources of the isotopically light carbon remain poorly constrained. Utilizing a multiproxy geochemical analysis (osmium isotopes, mercury, sulfur, and platinum group elements) of two Paleocene‐Eocene boundary records, we present evidence that a comet impact and major volcanic activity likely contributed to the environmental perturbations during the Paleocene‐Eocene interval. Additionally, Earth system model simulations indicate that stratospheric sulfate aerosols, commensurate with the impact magnitude, were likely to have caused transient cooling and reduced precipitation. Plain Language Summary The Paleocene‐Eocene Thermal Maximum (~55.9 Ma) records a period of climate warming associated with the injection of thousands of gigatons of carbon into the atmosphere. However, the sources of the carbon are still unclear. Our study uses geochemical data (osmium isotopes, mercury, sulfur, and platinum group elements) of two North Atlantic Ocean drill cores across the Paleocene‐Eocene interval to suggest that both a comet impact and large‐scale volcanism occurred at that time. The comet is estimated to be small (~3.3 km diameter) with ~0.4 Gt carbon and thus cannot be responsible for the Paleocene‐Eocene Thermal Maximum. However, climate modeling suggests that the comet impact might have caused transient cooling and reduced precipitation.

Aims: To evaluate the distribution of dental caries using the DMFT index (Decayed, Missing, Filled Teeth) and Significant Caries Index (SiC) in 12-year old children of Chandigarh. To comparatively analyze the risk factors between the two groups - ‘SiC index group’ and ‘least DMFT group’ and to determine if the WHO Health goals have been achieved for the population. Methods: The examination for dental caries was done as per the WHO recommendations on 495 children. DMFT, SiC values and the oral health behaviours were recorded and the risk predictors for caries identified on logistic regression analysis. Results: The prevalence of dental caries was 74.1%. The mean DMFT was 2.93 ± 2.57 (0-12) and the mean SiC was 5.76 ± 1.89 (4-12). The odds of being in the SiC group were lesser with ≥ once a day tooth cleaning (OR:0.644, CI:0.109 - 3.822, p-value 0.628) and higher with ≤ once a day sugar intake (OR:1.286; CI:0.782-2.115, p-value 0.322), ≤ once a day fruit intake (OR: 1.485; CI:0.820 - 2.691, p-value 0.192), in boys (OR:1.175;CI:0.748 - 1.847, p - value 0.484) and in the lower strata (OR:2.578; CI:1.187 - 5.598, p-value 0.017). Conclusion: The study confirmed an unequal distribution of dental caries and aims to focus on the more susceptible lower strata and reduction of the D component of DMFT. The WHO Health Goals for 2000 were achieved for the population, but the Goals for 2015 were yet to be met. The study also highlights the need to strive to attain the WHO Health Goals for 2020.