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The article discusses the development of a crossover curriculum using paediatric cases to have internal medicine residents exposed to patients with chronic illnesses of childhood (CIC) during training in Great Britain in 2019. Topics covered include the learning objectives of seven interactive didactic sessions with topics like asthma with respiratory failure and sickle cell pain crisis. Also noted is the lesson on the value of cross-departmental engagement in enhancing resident education

Isolated segmental duodenal aganglionosis is an extremely rare condition. We report a case of megaduodenum due to an isolated aganglionic segment in the second part of the duodenum. A 60-year-old female presented with a history of off-and-on non-bilious vomiting and upper abdominal fullness after each meal. Investigations suggested that the stomach and the first part of the duodenum were grossly dilated. On exploration, a narrowed segment in the second part of the duodenum with gross dilation of the proximal duodenum and the stomach was found. Retrocolic duodenojejunostomy was done and a biopsy was taken from the narrowed duodenal segment. Histopathology examination revealed near-complete absence of the ganglion cells in the narrowed segment. [ABSTRACT FROM AUTHOR]

The article discusses the case of a female patient who was found to be in an unresponsive state, with a rapid and palpable pulse and pupils reactive to light.

The omnipresent microplastics (MPs) have gradually become a significant environmental problem due to its adverse consequences for ecological systems. MPs serve as substrates for biofilms colonization, which enhances adsorption of harmful contaminants on MPs surface in the aquatic ecosystem. The present study provides a critical discussion on the mechanism involved in MPs-biofilm formation, microbial colonization and the robust factors influencing the process in the aquatic ecosystem. Subsequently, the impact of MPs-biofilm on adsorption of inorganic and organic contaminants is explored. The ecological significance of MPs-biofilm associated pollutant complex for promoting greenhouse gases (GHGs) emissions from aquatic ecosystem is extensively discussed for understanding the climatic risk. Furthermore, the discussion is extended over ecotoxicological impact of MPs-biofilm on aquatic biodiversity and humans. The protective extracellular polymeric substances secreted by colonised bacteria over MPs during biofilm formation creates sticky MPs surface for heteroaggregates formation with swift adsorption of chemical compounds and microorganisms. MPs with functional aromatic groups facilitate the bacterial adhesion on the surface, but affect formation of biofilm. Alternatively, MPs-biofilm promotes the Mn and Fe hydrous oxides formation that can co-precipitate with heavy metal ions and facilitate in remediation measures. However, MPs biodegradation generates GHGs emission per unit mass, comparably more from freshwater than marine ecosystem. Considering the toxicity, MPs-biofilm induces the oxidative response in fishes, causing painful death and thus, destroys aquatic biodiversity. This study will be useful to address MPs-biofilm associated pollution scenario via trace, test and treat strategy involving future engineering research framework for ecological restoration., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Problem: Adolescents and young adults with chronic or rare conditions face unique risks to their physical, social and emotional development. Research suggests that peer support improves their quality of life and reduces social isolation. However, there is a paucity of current information considering multiple intervention formats., Eligibility Criteria: A targeted literature review was conducted to identify peer support interventions and assess their feasibility, acceptability and efficacy for this population. Searches were conducted in MEDLINE, Embase and American Psychological Association PsycINFO for records reporting peer support interventions in young adults with chronic or rare conditions. Data were extracted from relevant publications and qualitatively evaluated., Sample: Thirty studies were included, which assessed the use of peer support for young adults (aged 13-30 years) with chronic or rare conditions in Europe or North America., Results: Peer support interventions had positive effects on social positivity, psychosocial development and medical outcomes, though significance was not always demonstrated., Conclusions: Peer support can enhance care for young adults with chronic or rare conditions. Current literature suggests that once-weekly virtual interventions are the most feasible and acceptable for patients, leading to multifaceted improvements in their well-being., Implications: This study is one of the first to discuss in-person, virtual and hybrid peer-based interventions for young adults with chronic and rare conditions. While all formats improved social, psychological and medical outcomes, virtual formats may be most accessible to participants. Interventions should be made available to this population, and guidelines for optimal implementation of peer support are needed., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sneha Dave is the director and founder of Generation Patient and reports support for Generation Patient by grants from Arnold Ventures, the Helmsley Charitable Trust, the Commonwealth Fund, the Third Wave Fund and the Disability Inclusion Fund. Sandra C. Kim is an employee of Cleveland Clinic Children's Hospital, reports receipt of compensation for attending Imedex-Advances in IBD as a speaker/moderator and serves on the Board of Directors for the Crohn's and Colitis Foundation Northern Ohio chapter and Improve Care Now. Steph Beaver, Yasemin G. Hasimoglu, Isabel Katz, Hannah Luedke, Anastasia S. Yandulskaya are employees of Costello Medical. Niraj Sharma is an employee of Brigham and Women's Hospital, Boston Children's Hospital and Harvard Medical School. This study was completed on a pro bono basis by Costello Medical, Inc. All authors declare no other financial and non-financial relationships and activities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Microplastics generated from fragmentation of leftover plastics and industrial waste has reached in the remotely located Asian water tower (AWT) region, the 3rd pole of earth and origin site of several freshwater rivers. The accumulation of microplastics in AWT ecosystem has potential to alter the climatic condition contributing in global warming and disturbing the biodiversity structural dynamics. The present paper provides a comprehensive critical discussion over quantitative assessment of microplastics in different ecosystems (i.e. river, lakes, sediment and snow or glacier) of AWT. The hydrodynamic fate and transport of microplastics and their ecological impact on hydromorphology and biodiversity of AWT has been exemplified. Furthermore, key challenges, perspectives and research directions are identified to mitigate microplastics associated problems. During survey, the coloured polyethylene and polyurethane fibers are the predominant microplastics found in most areas of AWT. These bio-accumulated MPs alter the rhizospheric community structure and deteriorate nitrogen fixation process in plants. Significance in climate change, MPs pollution is enhancing the emissions of greenhouse gases (NH 3 by ∼34% and CH 4 by ∼9%), contributing in global warming. Considering the seriousness of MPs pollution, this review study can enlighten the pathways to investigate the effect of MPs and to develop monitoring tools and sustainable remediation technologies with feasible regulatory strategies maintaining the natural significance of AWT region., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Key Clinical Message: Although it is very uncommon, SLE may initially present with recurrent episodes of EM-like rash. Despite the various possibilities underlying their association, prompt identification, and treatment of SLE in patients presenting with EM is important to prevent death or serious organ damage., Abstract: Rowell's syndrome (RS) is an uncommon presentation of systemic lupus erythematosus (SLE) with erythema multiforme (EM)-like lesions associated with specific serological changes, including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA), positive rheumatoid factor, or anti-La antibodies in the serum. Our case, a 41-year-old male, presented with features of EM. Upon investigation, we identified underlying systemic lupus erythematosus, marking a rare instance of SLE presenting for the first time as EM. Classical or true EM is precipitated by trigger factors such as infective agents like the herpes simplex virus, Mycoplasma pneumoniae, drugs like anticonvulsants, antibiotics, and non-steroid anti-inflammatory drugs, any underlying malignancy, or connective tissue disorders, and is not associated with any specific serological abnormalities. EM cases associated with LE lesions where an EM trigger factor is missing are considered an RS diagnostic criterion. In this case report, the importance of considering SLE in patients presenting initially with recurrent episodes of EM-like rash is emphasized. RS should be considered, especially when there is no evidence of triggering factors. Early diagnosis and prompt treatment of SLE are crucial to preventing death and irreversible organ damage., Competing Interests: The authors have no conflict of interest to declare., (© 2024 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Dolutegravir, the most recent antiretroviral drug with high efficacy, good tolerability, infrequent drug-drug interactions, and a favorable safety profile has not been reported in current literature as a cause of acquired sideroblastic anemia. Here, we present a 35-year-old male patient who was diagnosed with acquired sideroblastic anemia to Dolutegravir therapy., Competing Interests: The authors report no conflicts of interest., (© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Key Clinical Message: Pneumothorax and bronchopleural fistula (BPF) are potentially fatal complications that can occur in patients with COVID-19 pneumonia. Early detection, appropriate treatment, and consideration of surgical intervention are necessary for optimum outcomes., Introduction: Healthcare professionals face complex challenges as a result of the rare emergence of pneumothorax among the variety of COVID-19 complications, including severe viral pneumonia., Case History: A 57-year-old male with multiple comorbidities diagnosed with COVID-19 pneumonia was admitted to our center and exhibited bilateral crepitations. During hospitalization, the patient developed right-sided pneumothorax that persisted despite chest tube insertion was linked to the presence of BPF., Discussion: The occurrence of pneumothorax in COVID-19 patients is relatively rare risk factors for which are not yet fully understood, although smoking history may play a role. Conservative management is recommended for asymptomatic cases, while intercostal drainage is necessary for symptomatic patients. Surgical intervention may be required to manage the BPF in some instances., Conclusion: Pneumothorax and BPF are rare but potentially life-threatening complications in patients recovering from COVID-19 pneumonia. Early recognition, appropriate treatment, and consideration of surgical intervention are crucial for optimizing patient outcomes., Competing Interests: The authors have no conflict of interest to declare., (© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Key Clinical Message: Clinicians should consider central venous thrombosis (CVT) as a differential diagnosis in young adolescents with persistent headaches. It is essential to assess for concurrent CVT and dural arteriovenous fistula (DAVF), particularly in those with a history of CVT., Abstract: Cerebral venous thrombosis (CVT) and dural arteriovenous fistula (DAVF) are uncommon vascular disorders with diverse clinical presentations. The coexistence of CVT and DAVF is a rare but important association that may impact the management and prognosis of affected patients. Prothrombotic conditions generally ranging from acquired to genetic, oral contraceptives, malignancy, puerperium, infection, and head injury are the common risk factors for cerebral venous thrombosis. Here, we present a case of 18 years males who developed recurrent cerebral thrombosis on the background of the presence of an arteriovenous fistula., Competing Interests: The authors have no conflict of interest to declare., (© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Key Clinical Message: It is important for pregnant and breastfeeding women who adhere to a strict vegetarian diet to take appropriate steps to avoid vitamin B12 deficiency in their infants., Abstract: Vitamin B12 deficiency is rare during infancy. The initial symptoms of this deficiency are subtle and may include irritability, failure to thrive with a decline in growth rate, apathy, anorexia, refusal of solid foods, megaloblastic anemia, and developmental regression. The case presented here involves an 8-month-old male infant who showed neurological symptoms such as decreased activity, increased drowsiness, and reduced interaction with parents, which were ultimately linked to a deficiency of cobalamin (vitamin B12). Early recognition of this condition is critical because it is reversible. Therefore, pregnant and lactating women who follow a strict vegetarian diet should take necessary measures to prevent vitamin B12 deficiency in infants., Competing Interests: Authors' have no conflict of interest to declare., (© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Intestinal tuberculosis and Crohn's disease are chronic granulomatous diseases with similar clinical presentations and can mimic one another. Their treatment modalities are completely different; however, sometimes it is challenging to differentiate them. We report a case of a 51-year-old female presenting with abdominal pain and on-and-off diarrhea for 4 years with weight loss. Clinical symptoms along with multiple aphthous ulcers in the terminal ileum and negative tuberculin test favored the diagnosis of Crohn's disease. The patient did not respond to steroids. A repeat colonoscopy with acid-fast bacilli stain showed Mycobacterium tuberculosis . This case highlights that acid-fast bacilli culture and tuberculosis polymerase chain reaction to confirm or rule out the diagnosis of intestinal tuberculosis in all patients suspected of Crohn's disease., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Introduction: Mentorship increases trainee productivity, promotes career satisfaction and reduces burnout. Beginning in 2016, our Medicine-Paediatrics residency program developed and implemented a longitudinal mentorship curriculum among trainees. We report initial experiences with that program and discuss potential future directions., Curriculum Structure and Method of Implementation: We implemented and adapted a peer mentorship model and expanded it to include guest lectures and workshops centred around 13 core topics. Our expanded model included five longitudinal components: (1) peer mentorship; (2) virtual check-ins with residency leadership; (3) focussed didactics and workshops; (4) small-group dinners highlighting different career paths; and (5) dedicated faculty who pair residents with mentors based on common interests. We compared annual survey results on resident satisfaction with program mentorship, using chi-square and fisher's exact tests to assess statistically significant differences pre- (2012-2016) and post-intervention (2016-2020)., Results: We analysed 112 responses with annual response rate varying between 41.2% and 100%. Overall satisfaction with mentorship improved from 57.6% to 73.4% ( p  = .53), satisfaction with emotional support improved from 63.1% to 71.6% ( p  = .21), and satisfaction with career-specific mentorship improved from 48.5% to 59.5% ( p  = .70). Residents reported consistently high satisfaction with peer mentorship (77.8%-100%). The percent of residents reporting they had identified a career mentor increased from 60.0% in 2017 to 88.9% in 2019, which was sustained at 90.0% in 2020., Conclusion: We report our experience in implementing and adapting a mentorship curriculum for resident physicians in a single training program, including transitioning to a primarily online-based platform at the outset of the SARS-CoV-2 pandemic. Our results showed a trend towards improvement in resident satisfaction with overall and career-specific mentorship, as well as improved emotional support. Future work is needed using more objective outcome markers among a larger and more diverse group of residents. KEY MESSAGESAmong resident physicians in a single training program, a mix of mentor-mentee dyads, group-based peer mentoring and a structured curriculum has shown promise in improving resident-reported satisfaction with programmatic mentorshipWhile we attempted to adapt the mentorship curriculum to an online platform with the development of the SARS-CoV-2 pandemic, reported satisfaction in overall mentorship and emotional support decreased in comparison to the prior year, an important focus for future work.

Lyonia ovalifolia (angeri) is a deciduous tree whose shoot and leaves are toxic. Its chemical constituents include grayanane diterpenoids, lyoniol A, and other toxic compounds. Young children might consume it intentionally or unintentionally, with subsequent adverse health outcomes and even mortality depending on the amount ingested. We present a case of an adolescent girl who developed poisoning on ingestion of angeri leaves., Competing Interests: The authors have no conflict of interest to declare., (© 2022 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Objectives: Simultaneous intracranial EEG and functional MRI (icEEG-fMRI) recordings in humans, whereby EEG is recorded from electrodes implanted inside the cranium during fMRI scanning, were made possible following safety studies on test phantoms and our specification of a rigorous data acquisition protocol. In parallel with this work, other investigations in our laboratory revealed the damage caused by the EEG electrode implantation procedure at the cellular level. The purpose of this report is to further explore the safety of performing MRI, including simultaneous icEEG-fMRI data acquisitions, in the presence of implanted intra-cranial EEG electrodes, by presenting some histopathological and heat-shock immunopositive labeling observations in surgical tissue samples from patients who underwent the scanning procedure., Methods: We performed histopathology and heat shock protein expression analyses on surgical tissue samples from nine patients who had been implanted with icEEG electrodes. Three patients underwent icEEG-fMRI and structural MRI (sMRI); three underwent sMRI only, all at similar time points after icEEG implantation; and three who did not undergo functional or sMRI with icEEG electrodes., Results: The histopathological findings from the three patients who underwent icEEG-fMRI were similar to those who did not, in that they showed no evidence of additional damage in the vicinity of the electrodes, compared to cases who had no MRI with implanted icEEG electrodes. This finding was similar to our observations in patients who only underwent sMRI with implanted icEEG electrodes., Conclusion: This work provides unique evidence on the safety of functional MRI in the presence of implanted EEG electrodes. In the cases studied, icEEG-fMRI performed in accordance with our protocol based on low-SAR (≤0.1 W/kg) sequences at 1.5T using a head-transmit RF coil, did not result in measurable additional damage to the brain tissue in the vicinity of implanted electrodes. Furthermore, while one cannot generalize the results of this study beyond the specific electrode implantation and scanning conditions described herein, we submit that our approach is a useful framework for the post-hoc safety assessment of MR scanning with brain implants., (Copyright © 2022. Published by Elsevier Inc.)

Ablation sits far along on the spectrum of atrial fibrillation therapy, where its indications and potential efficacy call for careful consideration.

Countries around the world introduced strict restrictions on movement and activities known as 'lockdowns' to restrict the spread of the novel coronavirus disease (COVID-19) from the end of 2019. A sudden improvement in air quality was observed globally as a result of these lockdowns. To provide insight into the changes in air pollution levels in response to the COVID-19 restrictions we have compared surface air quality data in Delhi during four phases of lockdown and the first phase of the restriction easing period (25 March to 30 June 2020) with data from a baseline period (2018-2019). Simultaneously, short-term exposure of PM 2.5 and O 3 attributed premature mortality were calculated to understand the health benefit of the change in air quality. Ground-level observations in Delhi showed that concentrations of PM 10 , PM 2.5 and NO 2 dropped substantially in 2020 during the overall study period compared with the same period in previous years, with average reductions of ~49%, ~39%, and ~39%, respectively. An overall lower reduction in O 3 of ~19% was observed for Delhi. A slight increase in O 3 was found in Delhi's industrial and traffic regions. The highest peak of the diurnal variation decreased substantially for all the pollutants at every phase. The decrease in PM 2.5 and O 3 concentrations in 2020, prevented 904 total premature deaths, a 60% improvement when compared to the figures for 2018-2019. The restrictions on human activities during the lockdown have reduced anthropogenic emissions and subsequently improved air quality and human health in one of the most polluted cities in the world. Implications : I am submitting herewith the manuscript entitled "Unprecedented Reduction in Air Pollution and Corresponding Short-term Premature Mortality Associated with COVID-19 Forced Confinement in Delhi, India" for potential publishing in your journal.The novelty of this research lies in: (1) we utilized ground-level air quality data in Delhi during four phases of lockdown and the first phase of unlocking period (25 th March to 30 th June) for 2020 as well as data from the baseline period (2018-2019) to provide an early insight into the changes in air pollution levels in response to the COVID-19 pandemic, (2) Chatarize the change of diurnal variation of the pollutants and (3) we assess the health risk due to PM 2.5 and O 3 . Results from ground-level observations in Delhi showed that concentrations of PM 10 , PM 2.5 and NO 2 substantially dropped in 2020 during the overall study period compared to the similar period in previous years, with an average reduction of ~49%, ~39%, and ~39%, respectively. In the case of O 3 , the overall reduction was observed as ~19% in Delhi, while a slight increase was found in industrial and traffic regions. And consequently, the highest peak of the diurnal variation decreased substantially for all the pollutants. The health impact assessment of the changes in air quality indicated that 904 short-term premature deaths (~60%) were prevented due to the decline in PM 2.5 and O 3 concentrations in the study period. The restrictions on human activities during the lockdown have reduced the anthropogenic emissions and subsequently improved air quality and human health in one of the most polluted cities in the world.

Introduction: Medical students are positioned to observe, document, and explore opportunities to improve patient safety and quality in their institutions. Medical schools are introducing quality improvement (QI) knowledge and skills in the preclinical classrooms, yet few provide opportunities to apply these tools in the clinical setting., Methods: Clerkship students participated in two 1-hour sessions, organized in groups of 12-15 students, led by faculty with QI expertise. The sessions in the module introduced core concepts in QI and patient safety, while drawing on students' own clinical experiences. Students identified a system failure they encountered in their own clinical setting/practice and analyzed contributing factors using the 5 Whys Tool. We evaluated the efficacy of the two-session module with a pre- and postsurvey of students' self-reported change in knowledge, skills, and attitudes. Surveys also assessed students' satisfaction with module content and format. Faculty perspectives were solicited by email., Results: In April-May 2019, 59 students at a large US medical school participated. Of students, 73% and 53% completed pre- and postsurveys, respectively. All students submitted a report of an identified systems failure and their analysis of contributing factors. Students' self-rated knowledge and skills increased significantly. Students preferred active engagement compared to passive learning. Students and faculty identified areas for future module improvement., Discussion: The educational program was well received and increased students' knowledge and confidence in core concepts of QI and safety. The module addressed the requirement for graduating students to identify safety incidents and contribute to a culture of QI., (© 2021 Gheihman et al.)

Objectives: Simultaneous intracranial EEG and functional MRI (icEEG-fMRI) can be used to map the haemodynamic (BOLD) changes associated with the generation of IEDs. Unlike scalp EEG-fMRI, in most patients who undergo icEEG-fMRI, IEDs recorded intracranially are numerous and show variability in terms of field amplitude and morphology. Therefore, visual marking can be highly subjective and time consuming. In this study, we applied an automated spike classification algorithm, Wave_clus (WC), to IEDs marked visually on icEEG data acquired during simultaneous fMRI acquisition. The motivation of this work is to determine whether using a potentially more consistent and unbiased automated approach can produce more biologically meaningful BOLD patterns compared to the BOLD patterns obtained based on the conventional, visual classification., Methods: We analysed simultaneous icEEG-fMRI data from eight patients with severe drug resistant epilepsy, and who subsequently underwent resective surgery that resulted in a good outcome: confirmed epileptogenic zone (EZ). For each patient two fMRI analyses were performed: one based on the conventional visual IED classification and the other based on the automated classification. We used the concordance of the IED-related BOLD maps with the confirmed EZ as an indication of their biological meaning, which we compared for the automated and visual classifications for all IED originating in the EZ., Results: Across the group, the visual and automated classifications resulted in 32 and 24 EZ IED classes respectively, for which 75% vs 83% of the corresponding BOLD maps were concordant. At the single-subject level, the BOLD maps for the automated approach had greater concordance in four patients, and less concordance in one patient, compared to those obtained using the conventional visual classification, and equal concordance for three remaining patients. These differences did not reach statistical significance., Conclusion: We found automated IED classification on icEEG data recorded during fMRI to be feasible and to result in IED-related BOLD maps that may contain similar or greater biological meaning compared to the conventional approach in the majority of the cases studied. We anticipate that this approach will help to gain significant new insights into the brain networks associated with IEDs and in relation to postsurgical outcome., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities., Objective: To investigate inequalities in YAs' insurance coverage pre- (2000-2010) and post-federal health reforms (dependent coverage expansion, 2010-2013, and Medicaid/Marketplace expansions, 2014-2016), among a nationally representative sample., Design: A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19-25) compared to adolescents (ages 13-18) and older YA (ages 26-30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics., Participants: Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000-2016 National Health Interview Survey., Main Measures: Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics., Key Results: An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities., Conclusion: While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.

The quantification of brain dynamics is essential to its understanding. However, the brain is a system operating on multiple time scales, and characterization of dynamics across time scales remains a challenge. One framework to study such dynamics is that of fractal geometry; and currently there exist several methods for the study of brain dynamics using fractal geometry. We aim to highlight some of the practical challenges of applying fractal geometry to brain dynamics-and as a putative feature for machine learning applications, and propose solutions to enable its wider use in neuroscience. Using intracranially recorded electroencephalogram (EEG) and simulated data, we compared monofractal and multifractal methods with regards to their sensitivity to signal variance. We found that both monofractal and multifractal properties correlate closely with signal variance, thus not being a useful feature of the signal. However, after applying an epoch-wise standardization procedure to the signal, we found that multifractal measures could offer non-redundant information compared to signal variance, power (in different frequency bands) and other established EEG signal measures. We also compared different multifractal estimation methods to each other in terms of reliability, and we found that the Chhabra-Jensen algorithm performed best. Finally, we investigated the impact of sampling frequency and epoch length on the estimation of multifractal properties. Using epileptic seizures as an example event in the EEG, we show that there may be an optimal time scale (i.e., combination of sampling frequency and epoch length) for detecting temporal changes in multifractal properties around seizures. The practical issues we highlighted and our suggested solutions should help in developing robust methods for the application of fractal geometry in EEG signals. Our analyses and observations also aid the theoretical understanding of the multifractal properties of the brain and might provide grounds for new discoveries in the study of brain signals. These could be crucial for the understanding of neurological function and for the developments of new treatments.

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

Background and Objectives: The transition from pediatric to adult health care is a vulnerable period for youth with special health care needs. Although successful transitions are recognized as critical for improving adult outcomes and reducing health care utilization and cost, an educational gap in health care transitions for physicians persists. Our aim with this project was to develop a national health care transition residency curriculum for primary care physicians, using an expert-based, consensus-building process., Methods: Medical professionals with expertise in health care transition were recruited to participate in a survey to assist in the development of a health care transition curriculum for primary care physicians. By using a modified Delphi process, curricular goals and objectives were drafted, and participants rated the importance of each objective, feasibility of developing activities for objectives, and appropriateness of objectives for specified learners. Mean and SDs for each response and percent rating for the appropriateness of each objective were calculated., Results: Fifty-six of 246 possible respondents participated in round 1 of ratings and 36 (64%) participated in the second round. Five goals with 32 associated objectives were identified. Twenty-five of the 32 objectives (78%) were rated as being appropriate for "proficient" learners, with 7 objectives rated as "expert." Three objectives were added to map onto the Got Transition guidelines., Conclusions: The identified goals and objectives provide the foundation and structure for future curriculum development, facilitating the sharing of curricular activities and evaluation tools across programs by faculty with a range of expertise., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Paper devices have many advantages over other microfluidic devices. The paper substrate, from cellulose to glass fiber, is an inexpensive substrate that can be readily modified to suit a variety of applications. Milli- to micro-scale patterns can be designed to create a fast, cost-effective device that uses small amounts of reagents and samples. Finally, well-established chemical and biological methods can be adapted to paper to yield a portable device that can be used in resource-limited areas (e.g., field work). Altogether, the paper devices have grown into reliable analytical devices for screening low quality pharmaceuticals. This review article presents fabrication processes, detection techniques, and applications of paper microfluidic devices toward pharmaceutical screening., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Youth with special health care needs (YSHCN) require assistance from their pediatricians to transition to adult care. There are few data on what transition resources pediatricians have. In this article we discuss whether care coordination and/or comprehensive electronic health record (CEHR) implementation are associated with improved transition processes., Methods: Using the American Academy of Pediatrics Periodic Survey #79, we report whether practices generated written transition plans, assisted in finding adult providers, and discussed confidentiality issues. Descriptive statistics and a logistic regression model were done to evaluate whether CEHR, care coordination, or practice and physician characteristics were associated with improved transition planning., Results: Transition planning support in practices is low. Pediatricians with any care coordinator report more written transition plans for YSHCN (23% vs 6%; P < .001), assistance identifying adult providers (59% vs 39%; P < .001), and discussing confidentiality issues (50% vs 33%; P < .001). Pediatricians with a CEHR compared with those without are more likely to report written transition plans for YSHCN (24% vs 12%; P < .05) and discussing confidentiality issues (51% vs 39%; P < .05). In the logistic regression model, having care coordination (adjusted odds ratio, 11.1; 95% confidence interval, 5.9-21.3) and CEHR (adjusted odds ratio, 2.6; 95% confidence interval, 1.5-5.0) were independently associated with higher odds of having a written transition plan., Conclusions: Only 1 in 5 pediatricians have a transition coordinator in their practice and just 15% have a CEHR, even as these resources are associated with improved transition processes for YSHCN. Policy decisions should be made to help practices with supports, such as care coordination and electronic health record implementation, to improve transitions to adulthood., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To validate the application of an automated neuronal spike classification algorithm, Wave&#95;clus (WC), on interictal epileptiform discharges (IED) obtained from human intracranial EEG (icEEG) data., Method: Five 10-min segments of icEEG recorded in 5 patients were used. WC and three expert EEG reviewers independently classified one hundred IED events into IED classes or non-IEDs. First, we determined whether WC-human agreement variability falls within inter-reviewer agreement variability by calculating the variation of information for each classifier pair and quantifying the overlap between all WC-reviewer and all reviewer-reviewer pairs. Second, we compared WC and EEG reviewers' spike identification and individual spike class labels visually and quantitatively., Results: The overlap between all WC-human pairs and all human pairs was >80% for 3/5 patients and >58% for the other 2 patients demonstrating WC falling within inter-human variation. The average sensitivity of spike marking for WC was 91% and >87% for all three EEG reviewers. Finally, there was a strong visual and quantitative similarity between WC and EEG reviewers., Conclusions: WC performance is indistinguishable to that of EEG reviewers' suggesting it could be a valid clinical tool for the assessment of IEDs., Significance: WC can be used to provide quantitative analysis of epileptic spikes., (Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Importance: There is a lack of agreement on what constitutes successful outcomes for the process of health care transition (HCT) among adolescent and young adults with special health care needs., Objective: To present HCT outcomes identified by a Delphi process with an interdisciplinary group of participants., Design, Setting, and Participants: A Delphi method involving 3 stages was deployed to refine a list of HCT outcomes. This 18-month study (from January 5, 2013, of stage 1 to July 3, 2014, of stage 3) included an initial literature search, expert interviews, and then 2 waves of a web-based survey. On this survey, 93 participants from outpatient, community-based, and primary care clinics rated the importance of the top HCT outcomes identified by the Delphi process. Analyses were performed from July 5, 2014, to December 5, 2014., Exposures: Health care transition outcomes of adolescents and young adults with special health care needs., Main Outcomes and Measures: Importance ratings of identified HCT outcomes rated on a Likert scale from 1 (not important) to 9 (very important)., Results: The 2 waves of surveys included 117 and 93 participants as the list of outcomes was refined. Transition outcomes were refined by the 3 waves of the Delphi process, with quality of life being the highest-rated outcome with broad agreement. The 10 final outcomes identified included individual outcomes (quality of life, understanding the characteristics of conditions and complications, knowledge of medication, self-management, adherence to medication, and understanding health insurance), health services outcomes (attending medical appointments, having a medical home, and avoidance of unnecessary hospitalization), and a social outcome (having a social network). Participants indicated that different outcomes were likely needed for individuals with cognitive disabilities., Conclusions and Relevance: Quality of life is an important construct relevant to HCT. Future research should identify valid measures associated with each outcome and further explore the role that quality of life plays in the HCT process. Achieving consensus is a critical step toward the development of reliable and objective comparisons of HCT outcomes across clinical conditions and care delivery locations.

This study investigated the preparedness and views of patients with perinatally acquired HIV and their family caregivers about transitioning to adult medical care. Fifteen participants (ages 15-24 years) with perinatally acquired HIV and eight family caregivers participated in structured interviews. All interviews were recorded and analyzed for themes using qualitative research methodology. Three major themes emerged: (a) perceived lack of readiness for transition, (b) fear of change and anxiety about entering the adult health care system, and (c) burgeoning personal responsibility that comes with age. Participants also offered suggestions to improve the transition experience, including starting the process early with specific guidelines. All patients and family caregivers wanted early knowledge about transition; these individuals could be an important resource to find potential solutions to guide the transition process. Clinical outcomes must be assessed in patients undergoing transition to determine the effect on management of medical disease, and protocols must be developed., (Copyright © 2014 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined. Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success. In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes., (Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Survey of adult-centered hospitalist perspectives on caring for adults with chronic diseases of childhood onset (CDoCO) to investigate comfort level and identify targets of future educational and policy intervention., Methods: We developed an on-line survey for adult-centered hospitalists based on a prior outpatient survey and introduced it to the Society of Hospital Medicine membership via e-mail. Consent was implied by completing the survey., Results: Of all respondents, 60% saw 5 or more adults with CDoCO over a 6-month period. Among internal medicine respondents, 40% did not feel comfortable caring for this population, with lack of familiarity with the literature, lack of training in CDoCO, coordinating with multiple specialists, and lack of training in adolescent development and behavior ranked as the most significant barriers to care., Conclusion: The steadily growing population of adults with CDoCO and their high inpatient utilization have lead to increased care by adult-centered hospitalists, many of whom do not feel comfortable caring for them. Educational initiatives aimed at increasing medical knowledge base for common issues, training in adolescent development, increased care coordination, and access to address psychosocial issues would improve hospitalist comfort and patient care for this vulnerable population., (© 2013 Society of Hospital Medicine.)

The aim of this study was to formulate and evaluate microencapsulated controlled release preparations of a highly water/soluble drug, salbutamol sulphate by (water in oil) in oil emulsion technique using ethyl cellulose as the retardant material. Various processing and formulation parameters such as drug/polymer ratio, stirring speed, volume of processing medium were optimized to maximize the entrapment. The release of salbutamol sulphate from ethyl cellulose microsphere was compared and possible release mechanism proposed. Microspheres were prepared by water in oil emulsion technique using acetonitrile/dichloromethane (1:1 ratio) solvent system. Span 80 was used as the dispersing agent and n-hexane was added to harden the microspheres. The prepared microspheres were characterized for their micromeritic properties and drug loading, as well as compatibility by infrared spectroscopy, differential scanning calorimetry (DSC), X-ray powder diffractometry and scanning electron microscopy (SEM). The in-vitro release studies were carried out in phosphate buffer at pH 7.4. The prepared microspheres were white, free flowing and spherical in shape. The drug-loaded microspheres showed 55.7 - 76.6 % of entrapment and release was extended up to 10 h. Various processing and formulation parameters such as drug/polymer ratio, stirring speed, volume of processing medium, etc. significantly affect the drug release from the microspheres. The best/fit release kinetics was achieved with Higuchi plot followed by zero order and first order. The release of salbutamol sulphate was influenced by altering the drug to polymer ratio and the drug release was found to be diffusion controlled.

Background: We have recently shown that atrial fibrillation is associated with an increase in sympathetic nerve activity (SNA) compared with sinus rhythm. It remains unclear, however, whether these findings are true at various rates and whether the magnitude of sympathoexcitation is related to the degree of irregularity., Objective: To determine the role of irregularity in mediating the SNA changes at various pacing rates. Univariate analysis showed that as the irregularity increased, SBP increased (r = 0.44, P < .001) but that MAP and DBP did not change significantly., Methods: Using custom-made software, atrioventricular sequential pacing with predetermined rates (100, 120, and 140 bpm) and irregularities (standard deviation = 0%, 5%, 15%, and 25% of mean cycle length) was performed in 23 patients referred for electrophysiologic evaluation. Pacing at each rate/irregularity was performed for 2 minutes, with 2 minutes of recovery in between. Systolic, diastolic, and mean arterial blood pressure (SBP, DBP, and MAP), central venous pressure (CVP), and SNA were measured at baseline and during pacing., Results: Univariate analysis showed that as the irregularity increased, SBP increased (r = 0.44, P < .001 but that MAP and DBP did not change significantly. A significant correlation was found between the pacing irregularity and SNA, with greater sympathoexcitation noted at greater degrees of irregularity (r = 0.2, P = .04). A five-variable linear model using DBP, MAP, CVP, and degree of pacing irregularity to predict SNA was highly statistically significant (r = 0.46, P < .001). After controlling for hemodynamic changes, for every 1% increase in irregularity, there was a 6.1% increase in SNA., Conclusion: We have shown that greater degrees of irregularity cause greater sympathoexcitation and that the effects of irregular pacing on SNA are independent of the hemodynamic changes.

Objectives: The aim of the present study was to evaluate in a prospective randomized fashion the electrophysiologic effects of acute biventricular (BV) pacing. We hypothesized that (1) the local coupling interval in the left ventricle in response to right-sided ventricular premature beats is prolonged when BV pacing is applied during the drive train compared with right ventricular (RV) pacing, and (2) BV programmed electrical stimulation (PES) decreases the induction of ventricular arrhythmias compared with standard RV-PES, regardless of the presence of intraventricular conduction delay., Background: Previous studies have suggested that BV pacing might decrease the frequency of ventricular arrhythmias; however, the mechanism of arrhythmia suppression remains unclear., Methods: Eighteen patients with coronary artery disease were randomized to RV-PES or BV-PES with a repeat study using the other pacing mode. The RV effective refractory periods were measured during RV-PES and BV-PES. In addition, the local LV S(1)-S(2) coupling interval was measured at 600/450 ms and 400/350 ms during RV-PES and BV-PES., Results: BV-PES had no effect on RV effective refractory periods. On the other hand, the local LV S(1)-S(2) coupling intervals increased significantly during BV-PES compared with RV-PES (P < .0001). Ventricular tachycardia was induced in six patients using RV-PES but in only one patient with BV-PES (RR = 83%, P = .01). No difference was observed in the induction of ventricular fibrillation., Conclusions: BV-PES significantly reduced the induction of ventricular tachycardia compared to RV-PES, with no significant effect on ventricular fibrillation induction. Our findings may help explain the reduced incidence of ventricular arrhythmias noted with chronic BV pacing.

We report a case of a 39-year-old human immunodeficiency virus (HIV)--negative male who presented with a progressively increasing swelling in the left hypochondrium. He did not manifest fever or toxaemic symptoms. Computerised tomographic scan (CT scan) of the abdomen revealed an abscess in the anterior wall and multiple splenic abscesses. Fine needle aspiration from the abscesses in the anterior abdominal wall and the spleen confirmed the diagnosis of tuberculosis as the aetiology. The patient responded well to antituberculosis treatment and the abscesses regressed considerably.

A 28-year-old, lactating lady presented to us with left-sided breast abscess and lymph node enlargement in the left axillary region for the past one and a half months. Investigations revealed the breast abscess and axillary lymphadenopathy were tubercular in origin. The patient was put on standard four-drug anti-tubercular treatment (rifampicin, isoniazid, ethambutol and pyrazinamide). The patient did not respond to the intensive four-drug therapy, which was continued for three months. The culture isolate of the breast abscess grew M. tuberculosis, which was resistant to isoniazid, rifampicin and streptomycin. The patient was then retreated with a regimen comprising--kanamycin, ofloxacin, ethionamide para-amino salicyclic acid (PAS), pyrazinamide and isoniazid, from which the patient benefited and recovered.

Tuberculosis is said to be one of the commonest opportunistic infection in patients with HIV/ AIDS. A study was carried out to study the clinical, bacteriological and radiological features of HIV/TB patients. Over a period of two years, a total of 301 tuberculosis patients were suspected to have HIV/AIDS co-infection, and upon testing, 42 patients were found to be HIV seropositive. Most of the study patients were manual labourers followed by truck drivers. Sexual (heterosexual) route was found to be the major risk factor for HIV/AIDS. The most common symptom in these patients was cough and expectoration, followed by fever and weight loss. Acid-fast bacilli (AFB) smear positivity was found in 21.4% patients. On chest skiagram, infiltrative lesions were commonly seen in 61.9% patients. Extra-pulmonary tubercular manifestations were seen in 45.6% of HIV/TB cases.

A 15-year-old girl presented with a history of cough, fever for five months and breathlessness of two days duration. Her chest roentgenogram showed bilateral miliary shadows with a left sided pneumothorax. Shortly afterwards, she developed a pneumothorax on the other side also. She was managed with intercostal tube drainage on both sides and antitubercular treatment. She made an uneventful recovery.