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Introduction: This study discusses a tertiary trauma center's experience involving traumatic pancreatic injuries, focusing on identification, management, and complications, aiming to provide a valuable contribution to the literature on pancreatic trauma management., Methods: We conducted a five year (2019-2023) retrospective analysis utilizing trauma registry data to identified pancreatic injuries in tier 1 and 2 activations. Pancreatic Organ Injury Scaling (OIS) and overall injury severity (ISS) was assessed using AAST scoring. Data was stratified by mechanism, management, associated injuries, and outcomes., Results: Thirty-one patients suffering firearm (48.4 ​%), stabbing (16.1 ​%), or blunt injuries (35.5 ​%) were investigated. Firearms correlated with diaphragm (P ​= ​0.047), stomach (P ​= ​0.001) and intrabdominal injury count (P = 0.0042). Robust trends were found between OIS, ISS, complication, mortality and many alike., Conclusion: In penetrating injury, increasing ISS and number of intrabdominal injuries should heighten pancreatic trauma suspicion and lower the threshold for surgical exploration, particularly when involving the diaphragm, stomach, transverse colon or spleen., Competing Interests: Declaration of competing interest The authors declare no affiliations with or involvement in any organization or entity with any financial or personal interest in the subject matter of materials discussed in this manuscript. Additionally, no artificial intelligence (AI) or AI-assisted technologies were utilized in the writing of this manuscript or at any point while conducting the research discussed. All figures submitted were created by the authors who confirm these are original works and have not been published elsewhere., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction and Importance: Mazabraud's syndrome is a rare condition, describing the presence of fibrous bone dysplasia and intramuscular myxomas, with an incidence of 1:1,000,000. The aim of this article is to provide a review of the clinical presentation of Mazabraud's syndrome, including indications for surgical treatment, and follow-up strategies., Case Presentation: A 46-year-old woman presented with a 3-month history of a painless mass in the right gluteal region, she referred a rapid increase in the mass's volume in the 3 weeks prior to consultation. Physical examination revealed a solid, non-mobile mass adhered to the deep tissues of the right gluteal region. Magnetic resonance imaging (MRI) identified a probable intramuscular myxoma in the right gluteus, and incidentally evidenced an area suggestive of fibrous dysplasia in the left iliac bone. A total resection of the soft-tissue was performed, obtaining clear surgical margins. Pathology study confirmed the diagnosis of intramuscular myxoma. More than one year after surgical resection, the patient remains asymptomatic and has satisfactory results., Clinical Discussion: This case presented some unique features including a solitary myxoma, and contralateral fibrous dysplasia, surgical challenges included preoperative planning, as the myxoma was relatively large, and a careful resection to preserve the tumoral capsule, treatment included resection to attain clear margins, the sparing of healthy muscle proved to be valuable for a rapid postoperative recovery., Conclusion: The diagnosis of Mazabraud's syndrome can be overlooked given its very low incidence. Resection is warranted in symptomatic cases and because of the risk of late recurrence, long-term follow-up is required after surgery., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Research on traumatic brain injury (TBI) highlights the significance of counteracting its metabolic impact via exogenous fuels to support metabolism and diminish cellular damage. While ethyl pyruvate (EP) treatment shows promise in normalizing cellular metabolism and providing neuroprotection, there is a gap in understanding the precise metabolic pathways involved. Metabolomic analysis of the acute post-injury metabolic effects, with and without EP treatment, aims to deepen our knowledge by identifying and comparing the metabolite profiles, thereby illuminating the injury's effects and EP's therapeutic potential., Methods: In the current study, an untargeted metabolomics approach was used to reveal brain metabolism changes in rats 24 h after a controlled cortical impact (CCI) injury, with or without EP treatment. Using principal component analysis (PCA), volcano plots, Random Forest and pathway analysis we differentiated the brain metabolomes of CCI and sham injured animals treated with saline (Veh) or EP, identifying key metabolites and pathways affected by injury. Additionally, the effect of EP on the non-injured brain was also explored., Results: PCA showed a clear separation of the four study groups (sham-Veh, CCI-Veh, sham-EP, CCI-EP) based on injury. Following CCI injury (CCI-Veh), 109 metabolites belonging to the amino acid, carbohydrate, lipid, nucleotide, and xenobiotic families exhibited a twofold change at 24 h compared to the sham-Veh group, with 93 of these significantly increasing and 16 significantly decreasing (p < 0.05). CCI animals were treated with EP (CCI-EP) showed only 5 metabolites in the carbohydrate, amino acids, peptides, nucleotides, lipids, and xenobiotics super families that exhibited a twofold change, compared to the CCI-Veh group (p < 0.05). In the non-injured brain, EP treatment (sham-EP) resulted in a twofold change in 6 metabolites within the amino acid, peptide, nucleotide, and lipid super families compared to saline treated sham animals (sham-Veh, p < 0.05)., Conclusions: This study delineates the unique metabolic signatures resulting from a CCI injury and those related to EP treatment in both the injured and non-injured brain, underscoring the metabolic adaptations to brain injury and the effects of EP. Our analysis uncovers significant shifts in metabolites associated with inflammation, energy metabolism, and neuroprotection after injury, and demonstrates how EP intervention after injury alters metabolites associated with mitigating inflammation and oxidative damage., Competing Interests: Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

The successful team concept extends beyond the operating room and into many areas of hand surgery practice. Effective leadership is critical in creating highly effective teams. Evidence suggests that leadership skills can be learned and developed. The authors synthesize and translate findings from organizational psychology to provide insight and recommendations for clinical practice. Specifically, the role of broad emotional intelligence in leadership is explored. This includes self-awareness (eg, understanding one's strengths, challenges, behavioral tendencies, and emotional reactions), emotion regulation, managing others' emotions (eg, supporting others' needs, managing interpersonal conflict, and displaying empathy), and high-quality communication and establishing/maintaining boundaries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Rasmussen's encephalitis (RE) is a progressive inflammatory neurological process most commonly occurring in children characterized by drug-resistant focal epilepsy, hemiplegia, and cognitive decline, with brain atrophy and white matter changes typically localized to 1 hemisphere of the brain. Because the clinical course of RE is often indistinguishable from a variety of medical conditions, MRI has historically been the primary diagnostic tool. Here, we report both the clinical course and progression of neuroimaging findings of a 5-year-old female who had very subtle early cortical and white matter changes on MRI and was diagnosed with RE by correlating the clinical presentation, imaging, and electrographic findings., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

This mixed-methods study was conducted to explore the role of faith in mental health among Latino women (Latinas) during the COVID-19 pandemic. As part of a lifestyle study, surveys were administered to 89 participants during the 1st year of the pandemic. Specifically, a focus group was conducted with participants (n = 6) directly affected by COVID-19 (i.e., self or family member). The results showed inverse correlations between religiosity and both depression and anxiety, as well as positive correlations among religious practices, religious coping, and religiosity. Given these associations, future interventions should explore the role of faith in supporting individuals during difficult times., (© 2024. The Author(s).)

Background Context: The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery., Purpose: The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron., Study Design: Retrospective chart review., Patient Sample: 8,565 elective and emergency spine surgery cases performed from 2013 to 2023 using our institution's database of longitudinally collected electronic medical record information., Outcomes Measures: Patient LOS, discharge disposition, and rate of 90-day readmission., Methods: Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables., Results: Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041)., Conclusions: This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Spruce beetle, Dendroctonus rufipennis (Kirby) (Coleoptera: Curculionidae), is the most destructive pest of mature spruce (Picea) in western North America. Recent outbreaks in Alaska and other western US states highlight the need for tools to protect Picea from D. rufipennis. The primary antiaggregation pheromone of D. rufipennis (3-methylcyclohex-2-en-1-one, MCH) and various combinations of potential repellents (1-octen-3-ol, exo-brevicomin, endo-brevicomin, ipsdienol, ipsenol, limonene, and verbenone) were tested for their ability to disrupt the response of D. rufipennis to attractant-baited multiple-funnel traps. Two assays were conducted on the Kenai Peninsula, Alaska, in June and July 2021. All treatments significantly reduced the mean number of D. rufipennis caught compared to the baited control. No other significant differences were observed among treatments. Informed by these and other data, tree protection studies were established in Lutz spruce, Picea × lutzii, on the Kenai Peninsula in 2022 and in Engelmann spruce, Pi. engelmannii, in the Uinta Mountains, Utah, in 2021. All experimental trees were baited with frontalin. Repellent treatments included MCH (SPLAT MCH, ISCA Inc., Riverside, CA, USA) and at least 1 additional repellent combination. In Alaska, all treatments significantly reduced colonization (strip attacks + mass attacks) and mortality of individually treated Pi. × lutzii and all Picea within 11.3-m radius of each treated Pi. × lutzii compared to the control. In Utah, all treatments except for SPLAT MCH + octenol significantly reduced colonization compared to the control. Only SPLAT MCH + Acer kairomone blend (AKB) and SPLAT MCH + octenol reduced Pi. engelmannii mortality compared to the control. SPLAT MCH + AKB and SPLAT MCH + acetophenone and green leaf volatiles (PLUS) were the most effective across both studies. The implications of these and other results to the development of an effective semiochemical repellent for D. rufipennis are discussed., (Published by Oxford University Press on behalf of Entomological Society of America 2024.)

Bonding and attachment are known to be critically important for the well-being of infants and children. Both bonding and attachment can begin before birth, which impacts fetal and infant brain development and may improve birth outcomes. Babies in the womb and preterm babies in the neonatal intensive care unit (NICU) can hear and respond to maternal voices with positive effects on physiologic stability, brain development, and language development. Supporting emotional connections before and after birth is the responsibility and the privilege of health-care providers who care for pregnant mothers and babies in the NICU., Competing Interests: Disclosure The author has no commercial or financial conflicts of interest, no funding sources, and no disclosures to make., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Caring for extremely preterm infants in the neonatal intensive care unit (NICU) is a multidisciplinary team effort. A clear understanding of roles for each member of the delivery team, anticipation of challenges, and standardized checklists support improved outcomes for this population. Physicians and nursing leaders are responsible for being role models and holding staff accountable for creating a unit culture of Neuroprotective Infant and Family-Centered Developmental Care. It is essential for parents to be included as part of the care team and babies to be acknowledged for their efforts in coping with the developmentally unexpected NICU environment., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest, no funding sources, and no disclosures to make., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Preterm babies who received 72 hours of breastfeeding practice before introducing a bottle had significantly higher rates of breastfeeding at the time of neonatal intensive care unit (NICU) discharge than did babies who were introduced to bottle-feeding with or before breastfeeding during the first 72 hours of oral feeding or babies who were primarily bottle-fed. There were no statistical differences in corrected gestational age (CGA) at birth, first oral feeding, or full oral feeds, in days from first to full oral feeds, or in CGA or days of life at NICU discharge., Competing Interests: Disclosure None of the authors has commercial or financial conflicts of interest or funding sources., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Methods: 30 male patients with primary inguinal hernias undergoing primary inguinal herniorrhaphy were prospectively recruited for ilioinguinal nerve resection and evaluation. Three samples of the resected ilioinguinal nerve (proximal, canal, and distal) were evaluated using Masson's trichrome stain to measure fascicle and total nerve cross-sectional area and detect changes in collagen., Results: The fascicle cross-sectional area in the canal segment was significantly decreased compared to the proximal control with a large effect size observed ( p = 0.016, η 2  = 0.16). There was no significant difference in the nerve cross-sectional area between locations, but there was a moderate to large effect size observed between locations ( p = 0.165, η 2  = 0.105). There was no significant difference in collagen content nor effect size observed between locations ( p = 0.99, η 2  = 1.503 × 10 -4 ). Interpretation . The decrease in the fascicle cross-sectional area within the inguinal canal further suggests that there is chronic pressure applied by hernia tissue consistent with axon degeneration. Collagen content is uniformly distributed along the length of the nerve. Further studies with larger samples are needed to confirm the observed effect of nerve location on the total nerve cross-sectional area and axon loss., Competing Interests: The authors declare that they have no conflicts of interest as outlined by the International Committee of Medical Journal Editors., (Copyright © 2024 Robert Wright et al.)

Background: Race and sex differences are not consistently reported in the literature. Fundamentally, anatomical differences of cervical neuroforaminal dimensions (CNFD) amongst these groups would be important to know., Purpose: To establish normative radiographic morphometric measurements of CNFD and uncover the influence of patient sex, race, and ethnicity while also considering anthropometric characteristics., Study Design: Retrospective radiographic morphometric study., Patient Sample: A total of 1,000 patients between 18 and 35 years of age who were free of spinal pathology., Outcome Measures: Foraminal height, axial width, and area of cervical neural foramen., Methods: Cervical CTs were reviewed to measure CNFD, defined as follows: foraminal height, axial width, and area. Statistical analyses were performed to assess associations between CNFD, and patient height, weight, sex, race, and ethnicity., Results: CNFD measurements followed a bimodal distribution pattern moving caudally from C2-T1. Irrespective of disc level, cervical CNFD were as follows: left and right widths of 6.6±1.5 and 6.6±1.5 mm, heights of 9.4±2.4 and 9.4±3.2 mm, and areas of 60.0±19.5 and 60.6±20.7 mm 2 . Left and right foraminal width were highest at C2-C3 and lowest at C3-C4. Left and right foraminal height were highest at C7-T1 and C6-C7, respectively and lowest at C3-C4. Left and right foraminal areas were highest at C2-C3 and lowest at C3-C4. Significant differences were observed for all CNFD measurements across disc levels. CNFD did not vary based on laterality. Significant CNFD differences were observed with respect to patient sex, race, and ethnicity. Male height and area were larger compared to females. In contrast, female foraminal width was larger compared to males. The Asian cohort demonstrated the largest foraminal widths. White and Hispanic patients demonstrated the largest foraminal heights and areas. Black patients demonstrated the smallest foraminal widths, heights, and areas. Patient height and weight were only weakly correlated with CNFD measurements across all levels from C2-T1., Conclusions: This study describes 36,000 normative measurements of 12,000 foramina from C2-T1. CNFD measurements vary based on disc level, but not laterality. Contrasting left- versus right-sided neuroforamina of the same level may aid in determining the presence of unilateral stenosis. Patient sex, race, and ethnicity are associated with CNFD, while patient anthropometric factors are weakly correlated with CNFD., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Acute myeloid leukemia (AML) is a hematological malignancy that is characterized by an expansion of immature myeloid precursors. Despite therapeutic advances, the prognosis of AML patients remains poor and there is a need for the evaluation of promising therapeutic candidates to treat the disease. The objective of this study was to evaluate the efficacy of duocarmycin Stable A (DSA) in AML cells in vitro. We hypothesized that DSA would induce DNA damage in the form of DNA double-strand breaks (DSBs) and exert cytotoxic effects on AML cells within the picomolar range. Human AML cell lines Molm-14 and HL-60 were used to perform 3-(4,5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT), DNA DSBs, cell cycle, 5-ethynyl-2-deoxyuridine (EdU), colony formation unit (CFU), Annexin V, RNA sequencing and other assays described in this study. Our results showed that DSA induced DNA DSBs, induced cell cycle arrest at the G2M phase, reduced proliferation and increased apoptosis in AML cells. Additionally, RNA sequencing results showed that DSA regulates genes that are associated with cellular processes such as DNA repair, G2M checkpoint and apoptosis. These results suggest that DSA is efficacious in AML cells and is therefore a promising potential therapeutic candidate that can be further evaluated for the treatment of AML.

Glioblastoma multiforme (GBM) is a glioma and the most aggressive type of brain tumor with a dismal average survival time, despite the standard of care. One promising alternative therapy is boron neutron capture therapy (BNCT), which is a noninvasive therapy for treating locally invasive malignant tumors, such as glioma. BNCT involves boron-10 isotope capturing neutrons to form boron-11, which then releases radiation directly into tumor cells with minimal damage to healthy tissues. This therapy lacks clinically approved targeted blood-brain-barrier-permeating delivery vehicles for the central nervous system (CNS) entry of therapeutic boron-10. Gold nanoparticles (GNPs) are selective and effective drug-delivery vehicles because of their desirable properties, facile synthesis, and biocompatibility. This review discusses biomedical/therapeutic applications of GNPs as a drug delivery vehicle, with an emphasis on their potential for carrying therapeutic drugs, imaging agents, and GBM-targeting antibodies/peptides for treating glioma. The constraints of GNP therapeutic efficacy and biosafety are discussed.

Collecting duct carcinoma is an exceptionally rare and aggressive form of renal cell carcinoma (RCC), representing between 0.4 and 1.8% of RCC cases. The most commonly affected demographic are young African-American males. Here, we present a rare case of collecting duct RCC in a 22 year-old Caucasian female with final pathological staging of pT1aN1 who underwent robot-assisted right radical nephrectomy, with peri-hilar and para-aortic lymph node dissection. Given her node-positivity, adjunctive treatment is discussed., (© 2024 The Authors.)

Introduction: Exposure to smokers has been identified as a predictor of adolescent tobacco use. Conversely, adolescents who tend to be advocates against smoking may become less likely to initiate smoking themselves. Several digital tobacco prevention programs have been developed to include social strategies. This study aimed to identify (1) whether programs can motivate adolescents to become advocates against smoking, and (2) if being an advocate against smoking and exposure to friends who smoke can predict smoking while controlling for a program's effect., Methods: We conducted a non-prespecified secondary analysis using data from a randomized controlled trial (RCT) with 18-month follow-up. High schools were randomized to either receive ASPIRE or a tobacco education booklet. We conducted a cross-lagged linear path model to allow for reciprocal associations, estimating a two-time-points, three-variable panel model with logistic regression., Results: Receiving ASPIRE was associated with a lower likelihood of smoking, but it did not predict becoming an advocate against smoking or changing adolescents' proportion of friends who smoke. After controlling for the effect of ASPIRE, the study shows that adolescents who were advocates against smoking had a decreased risk of smoking by follow-up, and smoking at baseline significantly predicted having a higher proportion of friends who smoke at follow-up., Discussion: Being an advocate against smoking can be a key predictor of lower odds of smoking, even when controlling for an individual-based intervention. Future research can study the mechanisms and long-term effects of advocacy and incorporate social strategies that can leverage social networks for tobacco prevention., Competing Interests: 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., (© 2024 The Authors.)

Point-of-care ultrasound (POCUS) holds immense potential to manage critically deteriorating infants within the neonatal intensive care unit (NICU) and is increasingly used in neonatal clinical practice worldwide. Recent ultrasound-based protocols such as the Sonographic Assessment of liFe-threatening Emergencies-Revised (SAFE-R) and Crashing Neonate Protocol (CNP) offer step-by-step guidance for diagnosing and addressing reversible causes of cardiorespiratory collapse. Traditionally, pulseless electrical activity (PEA) has been diagnosed solely based on absent pulses on clinical examination, disregarding myocardial activity. However, integrating POCUS into resuscitation unveils the concept of pseudo-PEA, where cardiac motion activity is observed visually on the ultrasound but fails to generate a detectable pulse due to inadequate cardiac output. Paradoxically, existing neonatal resuscitation protocols lack directives for identifying and effectively leveraging pseudo-PEA insights in infants, limiting their potential to enhance outcomes. Pseudo-PEA is extensively described in adult literature owing to routine POCUS use in resuscitation. This review article comprehensively evaluates the adult pseudo-PEA literature to glean insights adaptable to neonatal care. Additionally, we propose a simple strategy to integrate POCUS during neonatal resuscitation, especially in infants who do not respond to routine measures., Conclusion: Pseudo-PDA is a newly recognized diagnosis in infants with the use of POCUS during resuscitation. This article highlights the importance of cross-disciplinary learning in tackling emerging challenges within neonatal medicine., What Is Known: • Point-of-Care ultrasound (POCUS) benefits adult cardiac arrest management, particularly in distinguishing true Pulseless Electrical Activity (PEA) from pseudo-PEA. • Pseudo-PEA is when myocardial motion can be seen on ultrasound but fails to generate palpable pulses or sustain circulation despite evident cardiac electrical activity., What Is New: • Discuss recognition and management of pseudo-PEA in infants. • A proposed algorithm to integrate POCUS into active neonatal cardiopulmonary resuscitation (CPR) procedures., (© 2023. The Author(s).)

Background: del Nido cardioplegia (DN) has been shown to be safe in adult patients undergoing isolated coronary artery bypass grafting with normal left ventricular ejection fraction. We sought to determine whether it was also safe in adult patients with diminished left ventricular function., Methods: All patients with preoperative left ventricular ejection fraction ≤ 40% undergoing isolated coronary artery bypass grafting between 1/1/2019 and 7/10/2022 were retrospectively analyzed. Off-pump and beating heart cases were excluded. Patients were divided by surgeon preference between conventional cardioplegia (CCP) and DN. Baseline and intraoperative characteristics and short-term postoperative outcomes were compared., Results: Six surgeons performed 829 isolated coronary artery bypass operations during the study. Two-hundred seventy-two met study criteria. Three surgeons used exclusively CCP for the duration of the study, two used exclusively DN and one switched from CCP to DN mid-way through. Group totals were: CCP n = 181 and DN n = 91. There were no significant differences in baseline characteristics including mean left ventricular ejection fraction (CCP 32.5 ± 7.4% vs. DN 33.4 ± 7.29%, p = 0.939). Other than a significant decrease in bypass time for DN (113.20 ± 37.2 vs. 122.43 ± 34.3 min, p = 0.043) there were no intergroup differences in urgency, number of grafts, ischemic time or incidence of blood transfusion. Postoperative outcomes between CCP and DN were similar including incidence of atrial fibrillation (12.2% vs. 8.8%, p = 0.403), intensive care length of stay (3.7 ± 2.3 vs. 4.3 ± 3.7 days, p = 0.886), total length of stay (5.7 ± 3.7 vs. 6.3 ± 4.4 days, p = 0.922) and 30-day mortality (3.85% vs. 1.10%, p = 0.205)., Conclusion: Compared to conventional cardioplegia, del Nido cardioplegia provides equivalent short-term outcomes in patients with low left ventricular ejection fraction undergoing isolated coronary artery bypass grafting., (© 2023. The Author(s).)

The frequency of dissolved oxygen depletion events (hypoxia) in coastal aquatic ecosystems has risen dramatically since the late 20th century, yet the causes and consequences of hypoxia for some culturally and economically important species remain poorly understood. In rivers, oxygen depletion can be caused by high densities of spawning Pacific salmon (Oncorhynchus spp.) consuming oxygen faster than can be replaced by reaeration. This process may be exacerbated when salmon densities are artificially inflated, such as when hatchery-origin salmon stray into rivers instead of returning to hatcheries. In Southeast Alaska, hatchery salmon production has increased rapidly since the 1970s, with over 553 million chum salmon (O. keta) and 64 million pink salmon (O. gorbuscha) released in 2021 alone. Straying is pervasive in streams with outlets <25 km from nearshore marine hatchery release sites. Using a previously ground-truthed mechanistic model of dissolved oxygen dynamics, we examined how water temperature and low-flow channel hydraulics contribute to hypoxia vulnerability. We then applied the model to predict hypoxia vulnerability for watersheds within 25 km of hatchery salmon release points, where straying salmon spawner densities are expected to be higher and promote dissolved oxygen depletion. Our model predicted that low-gradient stream reaches, regardless of water temperature, are the most prone to hypoxia due to low reaeration rates. Our spatial analysis determined that nearly 17,000 km of anadromous-accessible stream reaches are vulnerable to high densities of hatchery-origin salmon based on 2021 release sites. To our knowledge, this study is the first to map the spatial variation of hypoxia vulnerability in anadromous watersheds, identify habitat conditions most likely to promote hypoxia, and provide a repeatable analytical approach to identify hypoxia-prone stream reaches that can be updated as empirical data sets improve., 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 © 2023 Elsevier B.V. All rights reserved.)

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV., (© 2023. The Author(s).)

Introduction: Upper gastrointestinal (GI) bleeding in patients with roux-en-Y gastric bypass can be difficult to localize. Marginal ulcers are the most common cause, but a broad differential should be maintained in cases of severe bleeding, especially since the stomach and duodenum are not easily accessible by regular upper endoscopy., Presentation of Case: A 38-year-old female with Roux-en-Y gastric bypass presented with abdominal pain and hematochezia. Due to history of smoking and heavy use of ibuprofen, she was initially thought to have a bleeding marginal ulceration. Further investigation with computed tomographic (CT) angiography revealed a splenic artery pseudoaneurysm that had ruptured into a pancreatic pseudocyst, the gastric remnant and the peritoneum. The patient underwent successful treatment with trans-arterial embolization., Discussion: Splenic artery pseudoanerysms are rare but potentially lethal if unrecognized, particularly in patients with altered foregut anatomy. Their most likely origin is a nearby pancreatic pseudocyst, which erodes into the splenic artery by direct pressure and enzymatic digestion. Bleeding inside the pseudocyst is the most feared complication, resulting in massive intraperitoneal, extraperitoneal or endoluminal hemorrhage. Surgery is particularly challenging due to intense peripancreatic inflammation. Trans-Anterial embolization is the preferred treatment modality., Conclusion: Marginal ulcers continue to be the most common cause of GI bleeding in patients with Roux-en-Y anatomy, although high index of suspicion for alternative diagnosis should be maintained in cases of massive hemorrhage., Competing Interests: Declaration of competing interests 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 © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Traumatic brain injury (TBI) results from direct penetrating and indirect non-penetrating forces that alters brain functions, affecting millions of individuals annually. Primary injury following TBI is exacerbated by secondary brain injury; foremost is the deleterious inflammatory response. One therapeutic intervention being increasingly explored for TBI is hyperbaric oxygen therapy (HBOT), which is already approved clinically for treating open wounds. HBOT consists of 100% oxygen administration, usually between 1.5 and 3 atm and has been found to increase brain oxygenation levels after hypoxia in addition to decreasing levels of inflammation, apoptosis, intracranial pressure, and edema, reducing subsequent secondary injury. The following review examines recent preclinical and clinical studies on HBOT in the context of TBI with a focus on contributing mechanisms and clinical potential. Several preclinical studies have identified pathways, such as TLR4/NF-kB, that are affected by HBOT and contribute to its therapeutic effect. Thus far, the mechanisms mediating HBOT treatment have yet to be fully elucidated and are of interest to researchers. Nonetheless, multiple clinical studies presented in this review have examined the safety of HBOT and demonstrated the improved neurological function of TBI patients after HBOT, deeming it a promising avenue for treatment.

Background: In the neonatal intensive care unit (NICU), health outcome disparities exist between patients with limited English proficiency (LEP) and those proficient in English. Our objective was to investigate the communication experience of parents with LEP in the NICU to learn how to mitigate such health disparities., Methods: A certified bilingual provider conducted seventeen interviews of parents who identified Spanish as their preferred language and whose newborn was admitted to the NICU for ≥ 1 week. Interviews were conducted August 2020 - December 2021. Conventional content analysis utilizing an inductive open coding process was performed., Results: The experiences of Spanish speaking parents with LEP in the NICU can be characterized by 3 main themes: 1) Information accessibility 2) Perspectives about interpreters and 3) Emotional consequences., Conclusions: Our findings can inform neonatal quality initiatives to facilitate timely and good communication for NICU families with LEP., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Application of artificial intelligence (AI) has revolutionized the utilization of big data, especially in patient care. The potential of deep learning models to learn without a priori assumption, or without prior learning, to connect seemingly unrelated information mixes excitement alongside hesitation to fully understand AI's limitations. Bias, ranging from data collection and input to algorithm development to finally human review of algorithm output affects AI's application to clinical patient presents unique challenges that differ significantly from biases in traditional analyses. Algorithm fairness, a new field of research within AI, aims to mitigate bias by evaluating the data at the preprocessing stage, optimizing during algorithm development, and evaluating algorithm output at the postprocessing stage. As the field continues to develop, being cognizant of the inherent biases and limitations related to black box decision making, biased data sets agnostic to patient-level disparities, wide variation of present methodologies, and lack of common reporting standards will require ongoing research to provide transparency to AI and its applications., 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., (Published by Elsevier Inc.)

Objective . To propose a mathematical model for applying ionization detail (ID), the detailed spatial distribution of ionization along a particle track, to proton and ion beam radiotherapy treatment planning (RTP). Approach . Our model provides for selection of preferred ID parameters ( I p ) for RTP, that associate closest to biological effects. Cluster dose is proposed to bridge the large gap between nanoscopic I p and macroscopic RTP. Selection of I p is demonstrated using published cell survival measurements for protons through argon, comparing results for nineteen I p : N k , k = 2, 3, …, 10, the number of ionizations in clusters of k or more per particle, and F k , k = 1, 2, …, 10, the number of clusters of k or more per particle. We then describe application of the model to ID-based RTP and propose a path to clinical translation. Main results . The preferred I p were N 4 and F 5 for aerobic cells, N 5 and F 7 for hypoxic cells. Significant differences were found in cell survival for beams having the same LET or the preferred N k . Conversely, there was no significant difference for F 5 for aerobic cells and F 7 for hypoxic cells, regardless of ion beam atomic number or energy. Further, cells irradiated with the same cluster dose for these I p had the same cell survival. Based on these preliminary results and other compelling results in nanodosimetry, it is reasonable to assert that I p exist that are more closely associated with biological effects than current LET-based approaches and microdosimetric RBE-based models used in particle RTP. However, more biological variables such as cell line and cycle phase, as well as ion beam pulse structure and rate still need investigation. Significance . Our model provides a practical means to select preferred I p from radiobiological data, and to convert I p to the macroscopic cluster dose for particle RTP., (© 2023 Institute of Physics and Engineering in Medicine.)

Purpose: This study investigated the characteristics of patients presenting with the first-time seizure (FTS) and whether neurology follow-up occurred in a medically underserved area., Methods: A retrospective study of adults with a FTS discharged from the Emergency Department (ED) at Loma Linda University between January 1, 2017 and December 31, 2018 was performed. The primary outcome was days from the ED visit to the first neurology visit. Secondary outcomes included repeat ED visits, percentage of patients who had specialty assessment in one year, type of neurologist seen, and percentage lost to follow-up., Results: Of the 1327 patients screened, 753 encounters met criteria for manual review, and after exclusion criteria were applied, 66 unique encounters were eligible. Only 30% of FTS patients followed up with a neurologist. The median duration for neurology follow-up was 92 days (range=5-1180). After initial ED visit, 20% of follow-up patients were diagnosed with epilepsy within 189 days, and 20% of patients re-presented to the ED with recurrent seizures while awaiting their initial neurology appointment. Reasons for lack of follow-up included: referral issues, missed appointments, and shortage of available neurologists., Conclusion: This study highlights the significant treatment gap that a first-time seizure clinic (FTSC) could fill in underserved communities. FTSC may reduce the morbidity and mortality associated with untreated recurrent seizures., Competing Interests: Declaration of Competing Interest D. Goldenholz – is a scientific advisor for Magic Leap, Epilepsy AI and Eysz. He has funding from NIH NINDS K23NS124656. A. Cabrera, C. Jenkins, N. Baker, T. Losey, M. Estes, C. Casassa – Declaration of interest: None., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: Thoracoscopic and open approaches for the management of congenital lung malformations (CLM) has been debated. The aim of this study is to compare 30-day outcomes for non-emergent lobectomies in children., Methods: The National Surgical Quality Improvement Program-Pediatric database was queried for patients undergoing CLM resection from 2013 to 2020. Outcomes were compared by operative technique in an intention-to-treat model and then propensity matched., Results: 2157 patients met inclusion criteria and underwent non-emergent pulmonary lobectomy for CLM. The intended operative approach was thoracoscopic in 57.7% of patients. Patients in the open group compared to the thoracoscopic were more likely to be born premature, have chronic lung disease, require preoperative oxygen support, and be ventilator dependent. After propensity matching, there was no statistically significant difference in 30-day mortality, unplanned readmission, and other complications between the thoracoscopic and open groups. Thoracoscopic approach was associated with a shorter length of stay. The proportion of cases approached via thoracoscopy increased over time from 48.8% in 2013 to 69.9% in 2020., Conclusions: This large multicenter retrospective matched analysis demonstrates thoracoscopic lobectomy in children has similar favorable 30-day outcomes and shorter length of stay for the non-emergent management of CLM, compared to open thoracotomy., Level of Evidence: Level III., (© 2023. The Author(s).)

Nitric oxide (NO) is a gasotransmitter that avidly binds both free and heme-bound iron, forming relatively stable iron nitrosyl compounds (FeNOs). We have previously demonstrated that FeNOs are present in the human placenta and are elevated in preeclampsia and intrauterine growth restriction. The ability of NO to sequester iron raises the possibility of the NO-mediated disruption of iron homeostasis in the placenta. In this work, we tested whether exposure of placental syncytiotrophoblasts or villous tissue explants to sub-cytotoxic concentrations of NO would elicit the formation of FeNOs. Furthermore, we measured changes in the mRNA and protein expression levels of key iron regulatory genes in response to NO exposure. Ozone-based chemiluminescence was used to measure concentrations of NO and its metabolites. Our results showed a significant increase in FeNO levels in placental cells and explants treated with NO ( p < 0.0001). The mRNA and protein levels of HO-1 were significantly increased in both cultured syncytiotrophoblasts and villous tissue explants ( p < 0.01), and the mRNA levels of hepcidin and transferrin receptor were significantly increased in culture syncytiotrophoblasts and villous tissue explants, respectively, ( p < 0.01), while no changes were seen in the expression levels of divalent metal transporter-1 or ferroportin. These results suggest a potential role for NO in iron homeostasis in the human placenta and could be relevant for disorders of pregnancy such as fetal growth restriction and preeclampsia.

Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a "crashing" neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention.Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained "crashing" neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion., (© 2022. The Author(s).)

Purpose: With the COVID-19 pandemic, in-person fellowship interviews were curtailed, leading candidates to seek information from other resources. Our main purposes were (1) to determine what information recent participants in the match needed to evaluate programs and (2) to assess which of these were available online., Methods: A focus group of ten recent graduates/applicants identified information that was important in choosing a fellowship program. In August 2020 and December 2021, websites belonging to the American Pediatric Surgical Association (APSA) and individual programs were assessed., Results: Recent applicants identified 55 pieces of information considered important to their decision making. Of 57 pediatric surgery fellowships, 98% were listed on APSA's website. Program descriptions on APSA's website listed on average 60% of program information desired by applicants. All listed fellowship director, accreditation status, faculty list, and current fellow(s). Other descriptors frequently noted were alumni (95%), graduate's board performance (83%), ECMO exposure (77%), and curriculum (70%). Information desired but less frequently available were fellow case logs (63%), trauma center designation (53%), burn center designation (40%), research opportunities (30%), candidate interview assistance (25%), and supplemental fellowships (12%). There were 7% of program descriptions that were not updated for at least a year., Conclusions: APSA and individual program websites were complimentary. Websites often lacked data that applicants sought to inform their rank list. To best adapt to the evolving virtual interview paradigm, we suggest reporting key information on a central APSA website with more nuanced information available via links to program specific websites., Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00104-w., (© The Author(s) 2023.)

Acute pancreatitis (AP) leads to a variety of complications, such as local or systemic inflammatory responses as well as organ failure. While choledocholithiasis and alcohol abuse are two of the most common causes of AP, hypertriglyceridemia causes AP with an incidence rate between 2 and 5%. The management of hypertriglyceridemia-induced pancreatitis (HTGIP) is focused on the lowering of triglyceride (TG) levels, and the efficacy of therapies for the management of HTGIP may vary based on the hypertriglyceridemia etiology. The aim of this article is to report a case of a 43-year-old female with a history of familial hypertriglyceridemia and without diabetes who was admitted for acute pancreatitis with a TG level elevated to 4,435 mg/dL. The patient was treated with a combination of insulin, heparin, atorvastatin, and omega-3-acid ethyl esters, and her TG level was reduced to 880 mg/dL after 9 days of therapy. Despite the successful treatment of the patient, standardization of the approach for the treatment of HTGIP is needed. Future research should aim to identify the appropriateness of insulin therapy specifically in patients without diabetes presenting with hypertriglyceridemia and the dosing associated with optimal safety., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2022 Luis Tolento Cortes et al.)

Aim: To evaluate the use of low-dose naltrexone (LDN) as a broad-spectrum analgesic. Methods: Retrospective cohort study from a single pain management practice using data from 2014 to 2020. Thirty-six patients using LDN for ≥2 months were matched to 42 controls. Pain scores were assessed at initial visit and at most recent/final documented visit using a 10-point scale. Results: Cases reported significantly greater pain reduction (-37.8%) than controls (-4.3%; p < 0.001). Whole sample multivariate modeling predicts 33% pain reduction with LDN, with number needed to treat (for 50% pain reduction) of 3.2. Patients with neuropathic pain appeared to benefit even more than those with 'nociceptive'/inflammatory pain. Conclusion: LDN is effective in a variety of chronic pain states, likely mediated by TLR-4 antagonism.

Multiciliated cells (MCCs) in the brain reside in the ependyma and the choroid plexus (CP) epithelia. The CP secretes cerebrospinal fluid that circulates within the ventricular system, driven by ependymal cilia movement. Tumors of the CP are rare primary brain neoplasms mostly found in children. CP tumors exist in three forms: CP papilloma (CPP), atypical CPP, and CP carcinoma (CPC). Though CPP and atypical CPP are generally benign and can be resolved by surgery, CPC is a particularly aggressive and little understood cancer with a poor survival rate and a tendency for recurrence and metastasis. In contrast to MCCs in the CP epithelia, CPCs in humans are characterized by solitary cilia, frequent TP53 mutations, and disturbances to multiciliogenesis program directed by the GMNC-MCIDAS transcriptional network. GMNC and MCIDAS are early transcriptional regulators of MCC fate differentiation in diverse tissues. Consistently, components of the GMNC-MCIDAS transcriptional program are expressed during CP development and required for multiciliation in the CP, while CPC driven by deletion of Trp53 and Rb1 in mice exhibits multiciliation defects consequent to deficiencies in the GMNC-MCIDAS program. Previous studies revealed that abnormal NOTCH pathway activation leads to CPP. Here we show that combined defects in NOTCH and Sonic Hedgehog signaling in mice generates tumors that are similar to CPC in humans. NOTCH-driven CP tumors are monociliated, and disruption of the NOTCH complex restores multiciliation and decreases tumor growth. NOTCH suppresses multiciliation in tumor cells by inhibiting the expression of GMNC and MCIDAS, while Gmnc-Mcidas overexpression rescues multiciliation defects and suppresses tumor cell proliferation. Taken together, these findings indicate that reactivation of the GMNC-MCIDAS multiciliogenesis program is critical for inhibiting tumorigenesis in the CP, and it may have therapeutic implications for the treatment of CPC., (© 2022. The Author(s).)

Background: The psychosocial burden of having a chronic disease can be substantial for adolescents with childhood-onset systemic lupus erythematosus (cSLE). Current literature is scarce on interventions that can improve psychosocial outcomes for this population. Therapeutic recreation camps have been proposed as a beneficial experience for chronically ill pediatric populations. However, their effective components have not been well characterized in patients with cSLE. In this study, we sought to understand the various components of the camp experience for adolescents with cSLE from both the patient and parent perspective., Methods: We recruited patients with cSLE who had participated in one or more annual, weekend-long recreational lupus camp(s) near Dallas, Texas. Semi-structured in-depth telephone interviews were conducted from March-June 2020 with both the patients and parents. Questions focused on overall patient experience, psychosocial impact of camp participation, coping skills gained, and opportunities to prepare for the transition from pediatric to adult care. Interviews were coded and analyzed using inductive thematic analysis., Results: We interviewed 9 current and former campers (ages 16-24), including a current camp counselor, and 3 of their parents separately. Reported benefits included a positive impact on social support through peer bonding, opportunities to develop coping mechanisms through structured activities and peer/medical staff interactions, opportunities for education about the cSLE disease experience, improved adherence through peer modeling, overall increase in self-efficacy, and better parental insight into the patient experience. Participants also provided suggestions for expansion and improvement in program development to optimize educational opportunities for both campers and parents. In addition, they advocated for longitudinal social support and community building., Conclusions: In this qualitative study, in which cSLE patients and their parents reflected on their experiences with therapeutic recreation camps, we found several perceived benefits impacting the patient and parent experience. Participants expressed a desire for more educational opportunities that could contribute to their successful transition from pediatric to adult care. Further studies are needed to demonstrate the effects of therapeutic recreation camps on the psychosocial health of this population., (© 2022. The Author(s).)

Purpose: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients., Methods: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression., Results: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively., Conclusions: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort., Methods: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC., Results: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002)., Conclusion: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL., Level of Evidence: 2B., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Sildenafil is the drug of choice for neonatal pulmonary hypertension in developing countries where inhaled nitric oxide is not available. Available as oral and intravenous preparation - no study has been done in the past to compare the two forms. Each has its own benefits - but requires comparison in terms of efficacy and safety. This study was done to compare the efficacy of oral versus intravenous (IV) sildenafil in infants with mild to moderate pulmonary hypertension., Methods: An open labelled randomized trial was conducted in a neonatal intensive care unit of urban tertiary hospital in western India between February 2019 to December 2020. Infants born after 34 weeks of gestation with Pulmonary arterial pressure (PAP) > 25 mm Hg measured by echocardiography, within 72 h of birth, were enrolled for the study. Participants were randomly assigned to receive sildenafil either orally or by intravenous route. Primary outcome was the time taken for PAP to decrease below 25 mm Hg. Secondary outcomes were time taken for oxygenation index to decrease by 25%, duration of invasive and non-invasive mechanical ventilation, nasal oxygen, hospital stay, time to achieve full feeds, mortality, and side effects., Results: Forty patients were enrolled. The baseline characteristics of neonates in both groups were similar except for APGAR scores at 1 min and 5 min, with oral group having lower score [MEDIAN (IQR) 5.00 (4.00- 7.00) and 7.00 (6.00- 8.00)] compared to IV group [MEDIAN (IQR) 7.00 (6.00-8.00) and 9.00 (8.00-9.00)] respectively. Time taken for PAP to decrease below 25 mm was not statistically different between the oral and intravenous groups. Systemic hypotension occurred in 4 neonates of the intravenous group but none in the oral group., Conclusion: Oral and intravenous sildenafil had equal efficacy at reducing PAP in neonatal pulmonary hypertension, albeit intravenous sildenafil use was associated with a greater complication rate., Trial Registration: Trial was registered in the clinical trials registry of India [ CTRI/2019/04/018781 ][25/04/2019]., (© 2022. The Author(s).)

Semi-aquatic north-temperate reptiles experience challenging environmental conditions for thermoregulation on both seasonal and daily bases. We studied the thermal biology of north-temperate Northern Water Snakes (Nerodia sipedon) in central Michigan by remote radiotelemetry monitoring of snake body temperature (T b ) using surgically implanted thermally-sensitive radio-transmitters and by measuring operative temperatures (T e ) across a range of microhabitats using biophysical models. Our goals included evaluation of thermoregulatory capabilities at a locality that we viewed to be a fine-grained thermal environment, seasonal variations in patterns of thermoregulation, and the effects of sex on thermoregulation. During summer, snakes showed diel T b cycling apparently using the open Sphagnum mat for late morning warming and shuttling among different microhabitats until early evening when a monotonic decline in T b ensued and continued through the early morning hours. Snakes attained T b within their laboratory-determined preferred body temperature range (T set  = 28-33 °C) mostly during late afternoon and with average percentages of T b values for individual snakes within T set range when permitted by operative temperatures (E x ) between 68 and 70% of the time depending on method of measurement. Relatively high investment in thermoregulation when thermal conditions were poor occurred only during September but declined thereafter as snakes prepared to overwinter. We did not detect differences in thermoregulation among reproductive females, non-reproductive females, and males. Relative to a population of N. sipedon at a higher latitude in Ontario our snakes showed a relatively high T set range and thermoregulated more effectively, particularly during the daylight hours. It remains unclear how much inter-population variation in thermoregulation is due to potential adaptations to latitude, to habitat differences, or variations in methodologies., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Sedation management of trauma patients after damage control laparotomy (DCL) has not been optimized. We evaluated if shorter sedation exposure was associated with increased proportion of delirium-free/coma-free (DF/CF-ICU) days and change in time to definitive fascial closure (DFC)., Methods: We reviewed trauma DCL patients at an ACS-verified level I center over 5 years as shorter (SE) or longer than median (LE) sedation exposure. We compared demographics, injury patterns, hemodynamic parameters, and injury severity between groups. We calculated the propensity for each patient to achieve DFC using age, gender, ISS, red blood cell transfusion, bowel discontinuity, abdominal vascular injury, and time to first takeback; we then determined the effect of sedation exposure on rate of DFC by multivariate Cox regression, adjusted for propensity to achieve DFC. We used linear regression adjusted for age, ISS, head-AIS, bowel discontinuity, and vascular injury to determine the effect of sedation exposure on the proportion of DF/CF-ICU days., Results: 65 patients (33.8% penetrating) had mean age 41.8 ± 16.0, ISS 27.1 ± 14.2, Head-AIS 1.2 ± 1.6 and median sedation exposure of 2.2 [IQR 0.78, 7.3] days (35 SE and 30 LE). Pattern and severity of solid organ injuries and proportion of small and large bowel and vascular injuries were similar between groups. LE had more abdominal sepsis (23.3% vs 0%, p = 0.003) and enterocutaneous fistula (16.7% vs 0%, p = 0.016), and more ventilator (17.3 ± 12.7 vs 6.1 ± 6.8, p < 0.001), ICU (20.8 ± 14.2 vs 7.2 ± 7.6, p < 0.001), and hospital days (29.6 ± 19.6 vs 13.9 ± 9.0, p < 0.001). DFC was achieved more rapidly in the SE group (2.0 ± 1.5 days vs 3.9 ± 3.7 days [unadjusted], p = 0.023) and SE had a higher proportion of unadjusted DF/CF-ICU days (33.0 ± 32.0% vs 18.1 ± 16.4%, p = 0.020). SE was associated with an increased proportion of adjusted DF/CF-ICU days by multivariate linear regression (13.1% [95% CI 1.4-24.8%], p = 0.029) and with faster adjusted rate of DFC by multivariate Cox regression (RR 2.28 [95% CI 1.25-4.15, p = 0.007])., Conclusions: Shorter sedation exposure is associated with increased proportion of DF/CF-ICU days and more rapid DFC after DCL for trauma., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: We report the first ante-mortem diagnosis of hemorrhagic pericardial effusion in hereditary hemorrhagic telangiectasia resulting in constriction; the case also demonstrates the unusual but well-described complication of right-sided heart failure requiring extracorporeal membrane oxygenation (ECMO) support after pericardiectomy., Case Presentation: A previously healthy 48 year old man with a strong family history of Osler-Weber-Rendu disease presented to our institution with signs and symptoms of advance heart failure. His workup demonstrated a thickened pericardium and constrictive physiology. He was brought to the operating room where old clot and inflamed tissue were appreciated in the pericardial space and he underwent complete pericardiectomy under cardiopulmonary bypass. Separation from bypass, hampered by the development of right ventricular dysfunction and profound vasoplegia, required significant pressor and inotropic support. The right heart dysfunction and vasoplegia worsened in the early postoperative period requiring a week of ECMO after which his right ventricle recovered and he was successfully de-cannulated., Conclusion: Given the poor outcome of severe postoperative right ventricular failure after pericardiectomy, with high central venous pressure, a low gradient between central venous and pulmonary artery pressures and high vasopressor requirements, ECMO should be instituted promptly., (© 2022. The Author(s).)

Design: A retrospective analysis of all anesthetic records at our institution over a two-year period was performed. Setting . Operating room cases under balanced anesthesia. Patients . All patients with ASA class I or II, who did not have trauma or were initially admitted to ICU, aged 18-65, without preexisting cardiac, renal, or pulmonary disease. Patients were divided into three groups: those acutely positive for methamphetamine within 48 hours of surgery ( n  = 137), those positive for methamphetamine between 48 hours and 7 days of surgery ( n  = 69), and randomly selected controls who were negative for methamphetamine within 7 days of surgery ( n  = 159). Measurements . Intraoperative hemodynamic instability was defined as either a drop of more than 40% in MAP for greater than 5 minutes or requirement for significant amount of vasopressors. Main Results . Among the patients who were acutely positive for methamphetamine within 24 hours, 31.4% met the criteria for hemodynamic instability within the first hour of general anesthesia, compared to 26.1% of the subacutely positive patients and 6.3% of controls ( p < 0.0001). This was despite lower doses of anesthetic medications in the acutely and subacutely positive groups., Conclusion: Patients who present to the operating room with a positive urine drug screen for amphetamines within 2 days of surgery are at increased risk of hemodynamic instability. Postponing surgery up to 7 days somewhat decreases this risk, but not to the levels of patients who do not use methamphetamines., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Keyvan M. Safdari et al.)

Medical education conferences offer practical workshops to facilitate physicians' lifelong learning. Little is known about integration of workshop material after conferences. We sought to evaluate the application of workshop content focused on scholarly publication preparation. We developed an email survey to examine participants' progress preparing a publication in 2019, administered 4, 9, and 15 months post-conference. The survey included scaled items and open-ended questions. Thirty-three participants attended the workshop. Participants continued to develop their projects, but noted time, adequate evaluations, and no writing partners as barriers. Following up with workshop participants offers insights into effective application of workshop content., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s) under exclusive licence to International Association of Medical Science Educators 2022.)

Creation of a small baby program requires special resources and multidisciplinary engagement. Such a program has the potential to improve patient care, parent and staff satisfaction, collaboration and communication. We have described benefits, challenges, and practical approaches to creating and maintaining a small baby program that could be a model for the development of special programs for other sub-populations within in the NICU., (© 2021. The Author(s).)

Climate change is shifting forest tree species distributions across elevational and latitudinal gradients, and these changes are often pronounced at ecotones where species meet their climatic bounds and are replaced by other species. Using an extensive ecotone composed of lower-montane white fir (Abies concolor var. lowiana) and upper-montane red fir (Abies magnifica var. magnifica) in the central Sierra Nevada range of California, USA, we (1) examined how the demographics of the ecotone have responded to recent climate using a field observational study and a historical dataset, (2) quantified climate drivers across species life stages using contemporary demographic data, and (3) tested the potential impacts of future climate on species-specific seedling survival and growth in a fully factorial growth chamber experiment that varied temperature, growing season length, and water availability. A re-examination of the ecotone midpoint after 35 yr suggested a reduction in A. concolor sapling and tree densities and a rise in A. magnifica proportional dominance between surveys. Seedling abundances across the ecotone indicated that A. magnifica tends to dominate the regeneration layer and currently forms an important component of the seedling community at elevations below those where A. magnifica saplings or trees begin to co-dominate stands. Observational and experimental assessments suggest that temperature and precipitation serve as important drivers, differentiating A. concolor vs. A. magnifica distributions, and are primary stressors at the seedling stage. Seedlings of both species were adversely affected by experimental climate treatments, although A. concolor exhibited greater survival and a more conservative growth strategy under extreme climatic stress than A. magnifica. Projections indicate that historical climate conditions will rise by an amount greater than the ecotone's current elevational extent by the end of the 21st century. Differential drivers of species abundances suggest that the projected climate will expand conditions that promote A. concolor abundance and impede A. magnifica abundance across the ecotone; however, disturbance activity and microclimatic conditions will also influence regeneration and overstory tree dynamics. Our study demonstrates the importance of quantifying species-specific responses to climate and indicates that widespread regeneration failure may be one possible consequence in which species exhibit strong sensitivity to projected climate conditions., (© 2021 Ecological Society of America. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Several unsuccessful attempts have been made to reach a cross-disciplinary consensus on issues fundamental to the field of eating disorders in the United States (U.S.). In January 2020, 25 prominent clinicians, academicians, researchers, persons with lived experience, and thought leaders in the U.S. eating disorders community gathered at the Legacy of Hope Summit to try again. This paper articulates the points on which they reached a consensus. It also: (1) outlines strategies for implementing those recommendations; (2) identifies likely obstacles to their implementation; and (3) charts a course for successfully navigating and overcoming those challenges., Methods: Iterative and consensual processes were employed throughout the Summit and the development of this manuscript., Results: The conclusion of the Summit culminated in several consensus points, including: (1) Eating disorder outcomes and prevention efforts can be improved by implementing creative health education initiatives that focus on societal perceptions, early detection, and timely, effective intervention; (2) Such initiatives should be geared toward parents/guardians, families, other caretakers, and frontline healthcare providers in order to maximize impact; (3) Those afflicted with eating disorders, their loved ones, and the eating disorders community as a whole would benefit from greater accessibility to affordable, quality care, as well as greater transparency and accountability on the part of in-hospital, residential, and outpatient health care providers with respect to their qualifications, methodologies, and standardized outcomes; (4) Those with lived experience with eating disorders, their loved ones, health care providers, and the eating disorders community as a whole, also would benefit from the establishment and maintenance of treatment program accreditation, professional credentialing, and treatment type and levels of care guidelines; and (5) The establishment and implementation of effective, empirically/evidence-based standards of care requires research across a diverse range of populations, adequate private and government funding, and the free exchange of ideas and information among all who share a commitment to understanding, treating, and, ultimately, markedly diminishing the negative impact of eating disorders., Conclusions: Widespread uptake and implementation of these recommendations has the potential to unify and advance the eating disorders field and ultimately improve the lives of those affected. A cross-disciplinary group of eating disorder professionals, thought leaders, and persons with lived experience have come together and reached a consensus on issues that are fundamental to the battle against the life-threatening and life-altering illnesses that are eating spectrum disorders. Those issues include: (1) the need for early detection, intervention, prevention, and evidenced-based standards of care; (2) the critical need to make specialized care more accessible and affordable to all those in need; (3) the importance of developing uniform, evidenced-based standards of care; (4) the need for funding and conducting eating spectrum disorder research; and (5) the indispensability of advocacy, education, and legislation where these illnesses are concerned. During the consensus process, the authors also arrived at strategies for implementing their recommendations, identified likely obstacles to their implementation, and charted a course for successfully navigating and overcoming those challenges. Above all else, the authors demonstrated that consensus in the field of eating spectrum disorders is possible and achievable and, in doing so, lit a torch of hope that is certain to light the path forward for years to come., (© 2021. The Author(s).)