Search

To identify patient factors associated with improper restraint usage and worse trauma outcomes for pediatric patients involved in motor vehicle collisions (MVCs).Retrospective study performed at a Level I pediatric trauma center for patients (≤18 yr) evaluated after MVC between 2008 and 2018. The Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) levels based on the patient's home address. Trauma registry data was correlated to ADI and used to analyze appropriate restraint usage by NSD. Proper restraint practices were defined based on national guidelines and state laws. Demographics and clinical outcomes were also analyzed. Chi-square analysis with Bonferroni corrections was used to assess the association of ADI, race, and ethnicity with proper restraint usage.Among 1152 patients included, approximately 50% were male, the median age was 7 years [IQR 4-10], and 53% were of Hispanic ethnicity. Hispanic patients comprised 73% of children in ADI quintile 5 (greatest NSD), yet only 26% of children in ADI quintile 1 (least NSD). No differences were observed across clinical data and outcomes. Hispanic children8 yr were significantly less likely to be in a car seat/booster seat compared to non-Hispanic children (OR 0.69, 95% CI 0.50-0.95, p = 0.025). Furthermore, those with greatest NSD (ADI quintile 5) had the largest proportion of unrestrained patients (21%, see Fig. 1).Hispanic children, especially those who require infant or booster seats (8 yr), and children living in areas with greater neighborhood socioeconomic disadvantage demonstrated poorer restraint practices. ADI can successfully identify high-risk groups for targeted injury prevention programs and improved compliance in the most vulnerable neighborhoods.Retrospective Study.

Idiopathic pulmonary fibrosis (IPF) is a progressive, often fatal form of interstitial lung disease (ILD) characterized by the absence of a known cause and usual interstitial pneumonitis (UIP) pattern on chest CT imaging and/or histopathology. Distinguishing UIP/IPF from other ILD subtypes is essential given different treatments and prognosis. Lung biopsy is necessary when noninvasive data are insufficient to render a confident diagnosis.Can we improve noninvasive diagnosis of UIP be improved by predicting ILD histopathology from CT scans by using deep learning?This study retrospectively identified a cohort of 1,239 patients in a multicenter database with pathologically proven ILD who had chest CT imaging. Each case was assigned a label based on histopathologic diagnosis (UIP or non-UIP). A custom deep learning model was trained to predict class labels from CT images (training set, n = 894) and was evaluated on a 198-patient test set. Separately, two subspecialty-trained radiologists manually labeled each CT scan in the test set according to the 2018 American Thoracic Society IPF guidelines. The performance of the model in predicting histopathologic class was compared against radiologists' performance by using area under the receiver-operating characteristic curve as the primary metric. Deep learning model reproducibility was compared against intra-rater and inter-rater radiologist reproducibility.For the entire cohort, mean patient age was 62 ± 12 years, and 605 patients were female (49%). Deep learning performance was superior to visual analysis in predicting histopathologic diagnosis (area under the receiver-operating characteristic curve, 0.87 vs 0.80, respectively; P .05). Deep learning model reproducibility was significantly greater than radiologist inter-rater and intra-rater reproducibility (95% CI for difference in Krippendorff's alpha did not include zero).Deep learning may be superior to visual assessment in predicting UIP/IPF histopathology from CT imaging and may serve as an alternative to invasive lung biopsy.

Objective To evaluate the efficacy of dexmedetomidine as an opioid-sparing agent in infants following open thoracic or abdominal operations. Methods Retrospective review of postoperative neonates who received IV acetaminophen with or without dexmedetomidine. The primary outcome was opioid dosage within the first ten postoperative days. Secondary outcomes included times to extubation, full feedings and discharge. Results 112 infants met inclusion criteria. Those managed with dexmedetomidine received 1.8-4.3 times more opioid on postoperative days 1-3, had longer times to extubation and trended towards longer lengths of hospital stay than infants who were not. Opioid was dosed >0.2 ME/kg on only 23% of days when the acetaminophen dose was >40 mg/kg/day and 10% of days when the acetaminophen dose was >45 mg/kg. Conclusion Dexmedetomidine may not be opioid sparing after major operations in neonates and its use delays recovery. IV acetaminophen dosed at 40 mg/kg/day or greater may yield the most substantial opioid-sparing effect.

Introduction For over 30 years, the USNS Mercy hospital ship has provided surgical care on multiple humanitarian aid and disaster relief missions. During these missions, surgical support varies according to host nation needs, and the operative treatment of cancer patients remains controversial. We report the number of incidentally discovered surgical oncologic cases treated aboard the USNS Mercy on four missions and discuss challenges regarding oncologic care on these missions. Materials and Methods Between 2008 and 2016, operative cases and surgical pathology results from four multinational humanitarian missions were analyzed according to organ system, patient’s geographic location, and diagnosis. Primary outcomes were total number and proportion of malignant cases, analyzed yearly and over all four missions. Secondary outcomes were malignant diagnoses by organ system and host nation health capacities (based on indicators from the WHO). Results A total of 2,767 operations were performed during 18 port visits in 8 countries in Southeast Asia. In total, 1,193 pathology specimens (surgical biopsies, fine needle aspirations, etc.) were obtained. Overall malignancy rate across all organ systems was 9%. Yearly malignancy rates ranged from 2% to 13%. The highest malignancy rates were found in thyroid (33%), breast (20%), and parotid and salivary gland cases (19%). All host nations had operational strategies for cancer in place (n = 8, 100%), but few had national infrastructures to treat noncommunicable diseases (n = 2, 25%). Conclusions Despite current policies to screen out cancer patients on USNS Mercy missions, 9% of surgical biopsies were malignant. Cancer management during these missions presents a unique challenge because of limited resources for surgery, chemoradiotherapy, and follow-up care. Contingency plans must be considered to provide completion of care for these patients whose cancers are discovered incidentally. Furthermore, an understanding of host nation capabilities in relation to medical and surgical care is crucial to providing treatment in resource-limited areas.

BACKGROUND: There is a wide variation in radiation dose levels that can be used with chest CT in order to detect indeterminate pulmonary nodules. PURPOSE: To compare the performance of lower-radiation-dose chest CT with that of routine dose in the detection of indeterminate pulmonary nodules 5 mm or greater. MATERIALS AND METHODS: In this retrospective study, CT projection data from 83 routine-dose chest CT examinations performed in 83 patients (120 kV, 70 quality reference mAs [QRM]) were collected between November 2013 and April 2014. Reference indeterminate pulmonary nodules were identified by two nonreader thoracic radiologists. By using validated noise insertion, five lower-dose data sets were reconstructed with filtered back projection (FBP) or iterative reconstruction (IR; 30 QRM with FBP, 10 QRM with IR, 5 QRM with FBP, 5 QRM with IR, and 2.5 QRM with IR). Three thoracic radiologists circled pulmonary nodules, rating confidence that the nodule was a 5-mm-or-greater indeterminate pulmonary nodule, and graded image quality. Analysis was performed on a per-nodule basis by using jackknife alternative free-response receiver operating characteristic figure of merit (FOM) and noninferiority limit of −0.10. RESULTS: There were 66 indeterminate pulmonary nodules (mean size, 8.6 mm ± 3.4 [standard deviation]; 21 part-solid nodules) in 42 patients (mean age, 51 years ± 17; 21 men and 21 women). Compared with the FOM for routine-dose CT (size-specific dose estimate, 6.5 mGy ± 1.8; FOM, 0.86 [95% confidence interval: 0.80, 0.91]), FOM was noninferior for all lower-dose configurations except for 2.5 QRM with IR. The sensitivity for subsolid nodules at 70 QRM was 60% (range, 48%–72%) and was significantly worse at a dose of 5 QRM and lower, whether or not IR was used (P < .05). Diagnostic image quality decreased with decreasing dose (P < .001) and was better with IR at 5 QRM (P < .05). CONCLUSION: CT images reconstructed at dose levels down to 10 quality reference mAs (size-specific dose estimate, 0.9 mGy) had noninferior performance compared with routine dose in depicting pulmonary nodules. Iterative reconstruction improved subjective image quality but not performance at low dose levels.

Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Because of the variety of factors that can affect the decomposition process, it can be difficult to determine the post-mortem interval (PMI). The process is highly dependent on microbial activity, and volatile organic compounds (VOCs) are a by-product of this activity. Given both have been proposed to assist in PMI determination, a deeper understanding of this relationship is needed. The current study investigates the temporal evolution of the microbiome and VOC profile of a decomposing human analog (swine) in a controlled, indoor environment. Microbial communities and VOCs were sampled at six-time points, up to the active decay phase. Sampling locations included the abdominal area, anus, right ear canal, and right nostril. Bacterial communities were found to significantly change during decomposition (p-value < 0.001), and communities evolved differently based on sampling location. The families Moraxellaceae, Planococcaceae, Lactobacillaceae, and Staphylococcaceae drove these community shifts. From random forest analysis, the nostril sampling location was determined to be the best location to predict stage of decomposition. Individual VOCs exhibited large temporal shifts through decomposition stage in contrast to smaller shifts when evaluated based on functional groups. Finally, pairwise linear regression models between abdominal area bacteria and selected VOCs were assessed; Planococcaceae and Tissierellaceae were significantly correlated to indole. Overall, this study provides an exploratory analysis to support the connection between the microbiome, VOCs, and their relationship throughout decomposition.ImportanceThis research provides valuable insight into the complex process of decomposition, which is pertinent to forensic death investigations. The temporal evolution of both the microbiome and volatile organic compounds (VOCs) were characterized as a function of stage of decomposition and evaluated their interdependency upon one another. In turn, this information may assist in determining time since death, and fill a knowledge gap about VOC-bacteria associations during the decay process.

The purpose of this study was to identify clinical and traffic factors that influence pediatric pedestrian versus automobile collisions (P-ACs) with an emphasis on health care disparities.A retrospective review was performed of pediatric (18 years or younger) P-ACs treated at a Level I pediatric trauma center from 2008 to 2018. Demographic, clinical, and traffic scene data were analyzed. Area deprivation index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) based on home addresses. Traffic scene data from the California Statewide Integrated Traffic Records System were matched to clinical records. Traffic safety was assessed by the streetlight coverage, the proximity of the collision to home addresses, and sidewalk coverage. Descriptive statistics and univariate analysis for key variables and outcomes were calculated using Kruskal-Wallis, Wilcoxon, χ 2 , or Fisher's exact tests. Statistical significance was attributed to p values of0.05.Among 770 patients, the majority were male (65%) and Hispanic (54%), with a median age of 8 years (interquartile range, 4-12 years). Hispanic patients were more likely to live in more disadvantaged neighborhoods than non-Hispanic patients (67% vs. 45%, p0.01). There were no differences in clinical characteristics or outcomes across ADI quintiles. Using the Statewide Integrated Traffic Records System (n = 272), patients with more NSD were more likely injured during dark streetlight conditions (15% vs. 4% least disadvantaged; p = 0.04) and within 0.5 miles from home ( p0.01). Pedestrian violations were common (65%). During after-school hours, 25% were pedestrian violations, compared with 12% driver violations ( p = 0.02).A larger proportion of Hispanic children injured in P-ACs lived in neighborhoods with more socioeconomic disadvantage. Hispanic ethnicity and NSD are each independently associated with P-ACs. Poor streetlight conditions and close proximity to home were associated with the most socioeconomically disadvantaged neighborhoods. This research may support targeted prevention programs to improve pedestrian safety in children.Prognostic/Epidemiological; Level IV.

Laparoscopic gastrostomy tube (GT) placement carries the risk of early tube dislodgement and is often modified with absorbable subcutaneously-tunneled transabdominal tacking sutures that can aid in tube replacement. However, these buried sutures may increase the risk of surgical site infection (SSI). This study sought to evaluate SSI rates associated with different types of transabdominal tacking sutures used in modified laparoscopic GT placement.A single-institution, retrospective review was performed of all patients ≤18 years-old undergoing modified laparoscopic GT placement between September 2016 and March 2020. Patients were stratified into three groups by suture type used, and the primary outcome was SSI within six weeks of surgery. Demographic and perioperative data were analyzed by chi-square or Fisher's exact test.A total of 113 modified laparoscopic GT placements were performed at a median age of 9 months (interquartile range 3 months to 3 years). Prophylactic antibiotic use was similar between groups. Eleven patients (10%) developed an SSI, and all were treated with antibiotics alone. No SSIs were observed with the use of poliglecaprone suture (n = 46), and higher SSI rates were observed with use of polyglactin (n = 17) and polydioxanone (n = 51) suture (18% polyglactin vs. 16% polydioxanone vs. 0% poliglecaprone, p0.05). No differences were observed in rates of early postoperative dislodgement, leakage, or granulation tissue.Absorbable braided and long-lasting monofilament transabdominal tacking sutures may increase risk of SSI following modified laparoscopic gastrostomy tube placement. In this cohort, the use of poliglecaprone (Monocryl) suture was associated with no SSIs and similar rates of postoperative dislodgement, leakage, and granulation tissue.Treatment Study, Level III.

There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries.Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage.Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage.Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Introduction Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Materials and Methods Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. Results A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician–gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Conclusions Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

The purpose of this study was to analyze a nationwide database of malpractice lawsuits involving pediatric surgical patients to identify contributing factors in liability claims.Using the CRICO (Controlled Risk Insurance Company Strategies' Comparative Benchmarking System) database, malpractice claims involving patients ≤18 y old were reviewed from 2008 to 2017. Data were analyzed using descriptive statistics and logistic regression.Of the 844 claims, 76% of the patients were older than age 5. While the average total indemnity paid was $544,325, cases with claimants1-year-old accounted for 24% of the total indemnity paid, with an average of $1,135,240 per claimant. The most frequently named responsible services were Orthopedics (34%), General Surgery (15%), and Otolaryngology (11%). Fracture or dislocation, appendectomy, skin/breast surgery, arthroscopy, and tonsillectomy/adenoidectomy were among the frequently involved procedures for the cohort of cases. The most common contributing factors for the top procedures involve issues surrounding patient assessment, technical performance, and communication. Cases with a contributing factor of failure to appreciate and reconcile relevant sign/symptom/test results were associated with a higher likelihood of payment (OR 6.6, P 0.05). Issues surrounding the selection of therapy also led to an increased likelihood of an indemnity payment (OR 2.8, P 0.05).Malpractice claims related to pediatric surgical procedures involve a wide range of specialties. Patient evaluations, technical performance, and communication are modifiable factors to improve surgical care in children. The contributing factors assigned to each procedure may represent an opportunity for focused improvement to improve patient outcomes.

Background Older aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes. Methods Using a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2. Results Extremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins. Conclusions Assessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.

BACKGROUND Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

We report our in-house R&D efforts of designing and developing key integrated photonic devices and technologies for a chip-scale optical oscillator and/or clock. This would provide precision sources to RF-photonic systems. It could also be the basic building block for a photonic technology to provide positioning, navigation, and timing as well as 5G networks. Recently, optical frequency comb (OFC)-based timing systems have been demonstrated for ultra-precision time transfer. Our goal is to develop a semiconductor-based, integrated photonic chip to reduce the size, weight, and power consumption, and cost of these systems. Our approach is to use a self-referenced interferometric locking circuit to provide short-term stabilization to a micro-resonator-based OFC. For long-term stabilization, we use an epsilon-near-zero (ENZ) metamaterial to design an environment-insensitive cavity/resonator, thereby enabling a chip-scale optical long-holdover clock.

To evaluate the efficacy of dexmedetomidine as an opioid-sparing agent in infants following open thoracic or abdominal operations.Retrospective review of postoperative neonates who received IV acetaminophen with or without dexmedetomidine. The primary outcome was opioid dosage within the first ten postoperative days. Secondary outcomes included times to extubation, full feedings and discharge.112 infants met inclusion criteria. Those managed with dexmedetomidine received 1.8-4.3 times more opioid on postoperative days 1-3, had longer times to extubation and trended towards longer lengths of hospital stay than infants who were not. Opioid was dosed0.2 ME/kg on only 23% of days when the acetaminophen dose was40 mg/kg/day and 10% of days when the acetaminophen dose was45 mg/kg.Dexmedetomidine may not be opioid sparing after major operations in neonates and its use delays recovery. IV acetaminophen dosed at 40 mg/kg/day or greater may yield the most substantial opioid-sparing effect.

The purpose of this study was to evaluate the characteristics of neonates with congenital diaphragmatic hernia (CDH) undergoing enteral access procedures (gastrostomy or jejunostomy) during their initial hospitalization, and establish a clinical scoring system based on these characteristics.Data were obtained from the multicenter, multinational CDH Study Group database (CDHSG Registry) between 2007 and 2019. Patients were randomly partitioned into model-derivation and validation subsets. Weighted scores were assigned to risk factors based on their calculated β-coefficients after logistic regression.Of 4537 total patients, 597 (13%) underwent gastrostomy or jejunostomy tube placement. In the derivation subset, factors independently associated with an increased risk for enteral access included oxygen requirement at 30-days, chromosomal abnormalities, gastroesophageal reflux, major cardiac anomalies, ECMO requirement, liver herniation, and increased defect size. Based on the devised scoring system, patients could be stratified into very low (0-4 points;10% risk), low (5-6 points; 10-20% risk), intermediate (7-9 points; 30-60% risk), and high risk (≥10 points; 70% risk) groups for enteral access.This study identifies risk factors associated with enteral access procedures in neonates with congenital diaphragmatic hernia and establishes a novel scoring system that may be used to guide clinical decision making in those with poor oral feeding.Prognosis study.

Background: Surgical care is an important, yet often neglected component of child health in LMICs. This study examines the potential impact of scaling up surgical care at first-level hospital in LMICs on the first 8000 days of life. Methods: Epidemiological data from the Global Burden of Disease (GBD) 2019 Study and a counterfactual method developed for the Disease Control Priorities; 3rd Edition (DCP3) were used to estimate the number of avertable deaths in the under 20-year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. Findings: An estimated 314 609 (95% UI, 239 619-402 005) deaths per year in the under 20-year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the avertable deaths are in the under-five year age group (80·9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of avertable deaths after age 5 years. Sixty-one percent of the avertable deaths occur in lower-middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. Interpretation: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 8000 days of life. Funding: None to declare. Declaration of Interest: None to declare.

Molecular clips hold the potential of self-association and the ability to form host–guest complexes. Here we describe the synthesis of a 1,2-dimethoxyphenyl terminated glycoluril molecular clip (2) that binds with smaller solvent molecules by π⋯H–C and C=O⋯H–O non-covalent interactions. We obtained single crystals of 2 and 2 + CH2Cl2, CH3OH, CH3CN, and DMF solvents complexed within the clip. These solvents always form two π⋯H–C interactions between the aromatic rings in the clip, and CH3OH formed an additional C=O⋯H–O hydrogen bond with the glycoluril carbonyl group. Based on single crystal data we found that π⋯H–C interactions of 2 + CH2Cl2 are stronger than 2 + CH3CN and 2 + DMF, due to the presence of stronger electron withdrawing groups in CH2Cl2, which lead to a decrease in dihedral angle of two glycoluril aromatic planes. We also investigated the non-covalent interaction energies of these solvent molecules with 2 using computational methods. Several solvent adducts of a glycoluril derivative have been isolated and characterized by single crystal X-ray diffraction, revealing two common pi⋯H–C non-covalent bonds within the molecular clip.

A palladium-tellurium binary alloy nanomaterial was synthesized by a one-pot reaction of bis(4-methoxyphenyltelluro)methane [(4-CH3O-C6H4Te)2CH2](1) and allylpalladium (II)chloride dimer [(η3-C3H5)2Pd2(μ-Cl2)] (2) in 1:1 ratio using methylene chloride as solvent at ambient conditions. In addition to the Pd20Te7 alloy nanomaterial (3) generated, a palliadum (II) tellurolate complex [PdC1(μ-TeC6H4-OCH3)Te(C6H4-OCH3)2]2 (6), and other organic and organotellurim compounds were isolated as byproducts using column chromatography. The palladium-tellurium binary alloy nanomaterial and other byproducts from the reaction were characterized by powder X-ray diffraction (PXRD), NMR, GC-MS, transmission electron microscopy (TEM), and single crystal X-ray diffractions (XRD) methods. The palladium-tellurium binary alloy nanomaterial was obtained as single-phase Pd20Te7 nanorods, under mild conditions. TEM results indicated that the nanorods are less than 15 nm in diameter and range from 40 to 200 nm in length. A nanomaterial mixture was isolated with two binary-phases Pd20Te7 and Pd10Te3 when benzene was used as solvent. Compound 6 was successfully tested for catalytic activity for the Heck Reaction and produced a mixture of PdTe2 with Pd13Te3 nanomaterials as byproducts.

Rationale and Objectives This study aims to estimate observer performance for a range of dose levels for common computed tomography (CT) examinations (detection of liver metastases or pulmonary nodules, and cause of neurologic deficit) to prioritize noninferior dose levels for further analysis. Materials and Methods Using CT data from 131 examinations (abdominal CT, 44; chest CT, 44; head CT, 43), CT images corresponding to 4%–100% of the routine clinical dose were reconstructed with filtered back projection or iterative reconstruction. Radiologists evaluated CT images, marking specified targets, providing confidence scores, and grading image quality. Noninferiority was assessed using reference standards, reader agreement rules, and jackknife alternative free-response receiver operating characteristic figures of merit. Reader agreement required that a majority of readers at lower dose identify target lesions seen by the majority of readers at routine dose. Results Reader agreement identified dose levels lower than 50% and 4% to have inadequate performance for detection of hepatic metastases and pulmonary nodules, respectively, but could not exclude any low dose levels for head CT. Estimated differences in jackknife alternative free-response receiver operating characteristic figures of merit between routine and lower dose configurations found that only the lowest dose configurations tested (ie, 30%, 4%, and 10% of routine dose levels for abdominal, chest, and head CT examinations, respectively) did not meet criteria for noninferiority. At lower doses, subjective image quality declined before observer performance. Iterative reconstruction was only beneficial when filtered back projection did not result in noninferior performance. Conclusion Opportunity exists for substantial radiation dose reduction using existing CT technology for common diagnostic tasks.

Rationale and Objectives The study aimed to determine whether the addition of the Fleischner Society guidelines to chest computed tomography (CT) reports identifying incidental pulmonary nodules affects follow-up care. Patients and Methods Beginning in 2008, a template containing the Fleischner Society guidelines was added at the interpreting radiologist's discretion to chest CT reports describing incidental solid pulmonary nodules at our institution. The records of all medical centers in Olmsted county were used to capture the complete medical history of local patients >35 years old diagnosed with a pulmonary nodule from April 1, 2008 to October 1, 2011. Patients with a history of cancer or previously diagnosed nodule, or who died before follow-up, were excluded. Patients were categorized according to whether they did (“template group”) or did not (“control group”) have the template added. Nodule size and smoking history were used to determine recommended follow-up care. Differences in follow-up were compared between groups using Pearson's chi-square test. Results A total of 510 patients (276 in the template group, 234 in the control group) were included in the study. Only 198 patients (39%) received their recommended follow-up care. Template group patients were significantly more likely to receive recommended follow-up care compared to control group patients (45% vs 31%, P = .0014). Most patients whose management did not adhere to Fleischner Society guidelines did not receive a recommended follow-up chest CT (210 out of 312, 67%). Conclusions The addition of the Fleischner Society guidelines to chest CT reports significantly increases the likelihood of receiving recommended follow-up care for patients with incidental pulmonary nodules. Additional education is needed to improve appropriate guideline utilization by radiologists and adherence by ordering providers.

We have selectively synthesized and characterized several aliphatic internal imine isomers which show selectivity towards various transition metal ions with large shifts in the UV–Vis and OFF-ON switching of fluorescence in solution. The stoichiometry with different transition metals has been determined to be 1:1, with the 1,2-ethlenediamine dimer showing the best selectivity towards Hg(II). Selectivity in different solvent media and the varying kinetics of transition metal binding with the macrocycle has been presented along with the crystallography of the ligands and their metal complexes.

Amyloid-associated cystic lung disease is rare. It can be associated with collagen vascular disease (CVD). We aimed to describe the clinical, radiology, and pathology findings of this entity.We reviewed the records of subjects having biopsy-proven pulmonary amyloidosis with cystic lung disease demonstrated at high-resolution computed tomography (HRCT). Demographic characteristics, association with CVD and lymphoproliferative disorders, pulmonary function, and pathology results were reviewed. HRCT appearance was analyzed for number, size, distribution, and morphology of cysts and nodules.Twenty-one subjects (13 female, eight male; median age, 61 years) with cystic pulmonary amyloidosis were identified. The most common pulmonary function patterns were normal (42%) and obstructive (32%). The most common associated CVD was Sjögren syndrome (10 of 12). Nine subjects had no CVD. Cysts tended to be multiple (≥ 10 in 14 of 21, 67%), round (21 of 21, 100%), or lobulated (20 of 21, 95%); thin-walled (2 mm in 17 of 21, 81%); and of small (1 cm in 21 of 21, 100%) to moderate (1-2 cm in 17 of 21, 81%) size. Peribronchovascular (19 of 21, 90%) and subpleural (19 of 21, 90%) cysts were typically present. Seventeen (81%) subjects had lung nodules, which tended to be numerous (≥ 10 in 10 of 17, 59%; 4-9 in six of 17, 35%). At least one calcified nodule was present in 14 of 17 subjects (82%). Pulmonary mucosa-associated lymphoid tissue lymphoma (MALToma) was diagnosed in seven subjects (33%).Amyloid-associated cystic lung disease can occur with or without underlying CVD. Cystic lesions in the lung are commonly numerous, often are peribronchovascular or subpleural, and are frequently associated with nodular lesions that are often calcified. MALToma was a relatively frequent association.

Uniform Fe3O4 nanoparticles (NPs) with an average crystallite size of 12 nm were rapidly prepared using a sonochemical route. These NPs were subsequently coated with a crown ether-functionalized polypyrrole polymer. The morphology, structure, and composition of the coated and uncoated NPs were characterized by elemental analyses, transmission electronic microscopy, X-ray powder diffraction, and Fourier transform infrared spectroscopy. The resultant nanocomposites possess the magnetism of Fe3O4 NPs that make for easy separation by an external magnetic field and show the ability to remove Cu(II) from aqueous solution.

The aim of the study was to assess whether magnetic resonance imaging (MRI) characteristics can distinguish benign from malignant part-solid pulmonary nodules and predict the aggressiveness of the latter. We also sought to compare MRI-derived parameters with morphologic and physiological values derived from conventional examinations such as computed tomography and positron emission tomography/computed tomography.This was an institutional review board-approved pilot study of 28 participants (23 women, mean age 73.5±13.8 y) with 32 biopsy-proven lesions. 3-T unenhanced pulmonary MRI examinations were performed with regions of interest drawn around lesions for T1, T2, T2*, and diffusion-weighted sequences. Apparent diffusion coefficient (ADC) and T2* values were calculated. Two weeks later the regions of interest were redrawn. MRI parameters were compared with lesion pathology, maximal standard uptake value (SUVmax), and Hounsfield units (HU). MRI lesion visibility was correlated with solid component size and the percentage of solid component. Intraobserver and interobserver agreements were determined.Only ADC values correlated with malignancy (P0.05). ADC≥1.28 μm/ms predicted malignancy with 83.3% sensitivity (area under the curve 0.79). ADC and T2* correlated with adenocarcinoma subtypes (P0.05). No MRI parameters predicted tumor differentiation (P0.11). SUVmax did not correlate with any MRI parameters (P0.56). Visibility on T1-weighted images correlated with the percentage of solid components (P0.03). T1 and T2 values showed significant correlation with HU measurements of the entire nodule (P0.001 and P0.024, respectively) and HU measurements of solid components (P=0.031 and 0.008, respectively).3 T MRI with quantitative ADC values demonstrated potential for discriminating benign part-solid pulmonary nodules from malignant lesions. ADC and T2* values correlated with adenocarcinoma subtypes. No MRI parameters correlated with SUVmax. T1 and T2 values showed significant correlation with HU measurements of the entire nodule and of the solid components.

An oligothiophene chromophore RingBDT(T3A)2 has been synthesized, where BDT is benzo[1,2-b:4,5-b′]dithiophene, Ring is a 1,12-dodecylenedioxy cyclic side chain on the benzene of BDT, T3 is 2,2′:5′,2′′-terthiophene, and A is an electron acceptor. In single crystals, the immediate precursor of RingBDT(T3A)2 formed π-dimers and the ring prevented further π-stacking of the dimers. A differential scanning calorimetry study showed that BDT(T3A)2, the ringless analog with two 2-ethylhexyloxy side chains on BDT, crystallized quickly from its melt upon cooling, while crystallization of RingBDT(T3A)2 melt upon cooling was slow and incomplete. Interestingly, RingBDT(T3A)2 solid crystallized fast at ∼110 °C upon heating, but its thin films (200 nm) remained amorphous after annealing at 80 °C. Despite the amorphous nature, the hole mobility of RingBDT(T3A)2 films (1.52 × 10−3 cm2 V−1 s−1) was 144% higher than that of the highly crystalline BDT(T3A)2 films (200–80 nm). Solar cells were fabricated from blends of the chromophores and phenyl-C61-butyric acid methyl ester (PC60BM). Thermal annealing at 100 °C for 10 minutes enhanced chromophore π–π interaction, and improved device fill factor and efficiency for the RingBDT(T3A)2 blend solar cells, while retaining the amorphous nature of blend. In stark contrast, thermal annealing under the same conditions caused the efficiency of BDT(T3A)2 cell efficiency to drop by 82%. This study demonstrates the effectiveness of using a macrocyclic side chain as a strategy for developing amorphous molecular semiconducting materials with improved mobility and morphological stability.

A new aza-crown ether anthraquinone-coupled chemosensor ( 2 ) has been synthesized and employed for the selective fluorescence detection of Mg(II) in the nanomolar range with limited interference by Ca(II) ion. The binding stoichiometry for the chemosensor with Mg(II) is found to be 2:1, and the binding constant was determined to be 2.9×10 9 M −2 and 5.1×10 9 M −2 in acetonitrile and DMSO, respectively. The chemosensor also shows negligible fluorescence enhancement from other alkali, alkaline earth, and transition metals. Chemosensor 2 has been used in the bioimaging of Mg(II) in embryonic mouse fibroblast NIH3T3 cells at both native concentrations and cells incubated with excess Mg(II). The chemosensor can access Mg(II) ions in both the cytoplasm and nucleus of the cells. The corrected total cell fluorescence is also calculated to confirm the uptake of the chemosensor in living cells.

A new mechanism for the fluorescence detection of metal cations in solution is introduced involving a unique keto–enol tautomerization. Reduction of 1,8-anthraquinone-18-crown-5 yields the doubly reduced secondary alcohol, 2. Compound 2 acts as a chemodosimeter for Al(III) ions producing a strong blue emission due to the formation of the anthracene fluorophore, 3, via dehydration of the internal secondary alcohol in DMSO/aqueous solution. The enol form is not the most thermodynamically stable form under these conditions however and slowly converts to the keto form 4. Reduction of 1 with Fe/AcOH or the reaction of 2 with HCl directly yields compound 4, the keto tautomer of 3, which also produces the same blue emission in more polar solvents. Competition studies reveal that compound 2 produces a blue emission exclusively in the presence of the strong Lewis acidic Al(III) ion and at relatively low pH.

Aromatic endoperoxides serve as important intermediate species toward generating singlet state oxygen, which is key to photodynamic therapy applications. Gaining insights for fine-tuning endoperoxide stability and degree of oxygen-oxygen bond activation is of fundamental and practical interest for the chemical and medicinal communities. We report here that 9,10-bisperfluorooctyl-anthracene, upon exposing to light and air, is almost quantitatively converted to 9,10-bisperfluorooctyl-anthracene endoperoxide (compound 1) at room temperature. 1H NMR spectra and the X-ray crystal structure revealed that the resulting compound 1 is stable at room temperature without further decomposition. The crystal structure analysis showed that the compound 1 is stabilized by F···O intramolecular interactions along with F···F, F···H and F···C intermolecular interactions. DFT calculations further indicate that the degree of oxygen-oxygen bond activation in anthracene endoperoxides, reflected as changes of O O, C O bond distances, may not solely depend on the electronic effect of substituents at the 9,10- positions. This uncertainty warrants further investigation both experimentally and computationally.

PURPOSE The aim of this study was to evaluate the ability of computer-aided detection (CAD) and human readers to detect pulmonary nodules ≥5 mm using 100 kV ultra-low-dose computed tomography (ULDCT) utilizing a tin filter. MATERIALS AND METHODS After informed consent, 55 patients prospectively underwent standard-dose chest CT (SDCT) using 120 kV followed by ULDCT using 100 kV/tin. Reference nodules ≥5 mm were identified by a thoracic radiologist using SDCT. Four thoracic radiologists marked detected nodules on SDCT and ULDCT examinations using a dedicated computer workstation. After a 6-month memory extinction, readers were shown the same ULDCT cases with all CAD markings as well as their original detections, and characterized CAD detections as true positive or false positive. RESULTS Volume CT Dose index (CTDIvol) for SDCT and ULDCT were 5.3±2 and 0.4±0.2 mGy (P

We theoretically investigate the feasibility of transmitting a frequency signal in an interstice of the data channels in a commercial wavelength division multiplexed optical fiber communications system. The frequency signal will be impaired by neighboring data channels due to cross-phase modulation (XPM). We calculate the Allan deviation of the phase noise resulting from XPM using typical commercial system parameters as the averaging time varies. We find that the instability added by this effect is comparable to experimentally observed instabilities in research networks suggesting that frequency transfer over commercial networks without occupying an entire data channel should be feasible.

Dansylamide derivatives of an 1,8-anthraquinone-18-crown-5 anthracenone macrocycle have been synthesized by acid catalyzed nucleophilic substitution followed by reduction with sodium borohydride to yield new fluorosensors, 2 and 3, as characterized by elemental analyses, 1H and 13C NMR, ESI–MS, and X-ray crystallography. The optical properties of 2 and 3 were investigated with various metal cations and found to be selective for Pb(II) ion. Substantial ON-OFF quenching of the dansylamide fluorescence was observed after addition of Pb(II). Competition studies with other metal ions were conducted with Pb(II) and ESI–MS, UV/Vis and NMR titrations were carried out to determine a 1:1 binding stoichiometry and association constants with Pb(II) (7.5 × 103 M−1) and compared to fluorescence quenching of the free dansylamide fluorophore (80 M−1). While Pb(II) binding is reversible, as determined by addition of EDTA in an aqueous solution, cations with higher oxidation potentials quench fluorescence via a different mechanism involving oxidation of the macrocycle in a chemodosimeter type response.

1,2-Bis(9-anthracenyl)ethyne was synthesized and a new crystal polymorph was discovered. The previously reported structure was completely planar with a torsional angle between the two anthracenyl rings of 0.0°, whereas the new polymorph had a torsional angle of 66.6°. The new polymorph also stacks differently between molecules and has greater π–electron overlap. In solution, the spectroscopic characteristics of both polymorphs were identical, but in the solid-state, results of red-shifted spectra for the co-planar polymorph indicate a strikingly simple example of the effect on UV–vis and fluorescence spectra of extending π-conjugation wrapped up in one molecule with two polymorphs. It was also determined that the co-planar polymorph is favored with rapid crystallization, whereas the twisted polymorph prefers slow crystallization. This may indicate that the co-planar polymorph is kinetically favored and the twisted polymorph is thermodynamically favored.

The reaction of the Ph2As− anion with 1,8-bis(2-bromoethoxy)anthracene-9,10-dione in 2:1 ratio generates 1,8-bis(2-diphenylarsinoethoxy)anthracene-9,10-dione (L1). L1 and 1,8-bis(2-phenylselenoethoxy)anthraquinone (L2) reacted with bis(benzonitrile)palladium(II) chloride in 1:1 ratio yielding Pd(L1)Cl2 (1) and Pd(L2)Cl2 (2). X-ray structures of 1 and 2 revealed that L1 and L2 chelate with Pd(II) and form a convex square planar geometry. The catalytic properties of both Pd(II) complexes in the Heck reaction was investigated, and the results show that compound 2 acts as a better catalyst than 1. The redox behavior of L1, 1 and 2 versus Ag/AgCl are also explored.