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Elbow fractures are the most common pediatric fractures requiring operative treatment. Although recent reports have suggested that the COVID-19 pandemic has markedly reduced the incidence of pediatric fractures, no study has specifically evaluated the impact on pediatric elbow fractures. This study aimed to evaluate changes in the incidence, severity, and resource utilization for managing pediatric elbow fractures during the COVID-19 pandemic, compared with prepandemic years.A prepandemic (2007 to 2017) cohort and a COVID-19 pandemic period (March 2020 to March 2021) cohort of pediatric elbow injuries from a single tertiary hospital were retrospectively examined and compared. Exclusion criteria included outside treatment or lack of diagnosis by an orthopedist. Presentation information, injury patterns, transport, and treatment requirements were collected.Although the incidence of pediatric elbow fractures and rate of neurovascular injury were comparable, seasonal patterns were not sustained and the rate of fracture displacement was found to be significantly elevated in the COVID-19 period compared with nonpandemic years. Likewise, marked changes to where patients first presented (emergency department vs. Clinic), how the patients were transported, and the distance traveled for care were observed. Specifically, patients were more likely to present to the clinic, were more likely to self-transport instead of using emergency medical service transportation, and traveled a greater distance for care, on average. Aligning with these changes, the resources utilized for the treatment of pediatric elbow fracture markedly changed during the COVID-19 period. This study found that there was an increase in the overall number of surgeries performed, the total operative time required to treat elbow fractures, and the number of patients requiring admission during the COVID-19 period.These data provide a contrasting viewpoint to prior reports, illustrating that the incidence of elbow fractures remained consistent during the COVID-19 period, whereas the operative volume and need for hospital admission increased compared with years prior. Furthermore, this study demonstrated how the COVID-19 pandemic altered the interface between pediatric patients with elbow fractures and our institution regarding the location of presentation and transportation.Level III-retrospective cohort study.

Retrospective analysis on prospectively collected data.The aim of this study was to construct a clinical prediction model for 90-day mortality in elderly patients with traumatic spine injuries.Spine trauma in the elderly population is increasing. Comparing elderly spine trauma patients to younger patients with similar injuries proves challenging due to the extensive comorbidities and frailty found in the elderly. There is a paucity of evidence to predict survival of elderly patients following traumatic spinal injuries.All patients 65+ with spine trauma presenting to a level I trauma center from 2010 to 2019 were reviewed from a prospectively maintained trauma registry. Retrospective chart review was performed to record injury, frailty scores, comorbidities, presence of spinal cord injury, imaging evidence of sarcopenia and osteopenia, mortality, and complications. We preselected 13 variables for our multivariable logistic regression model: hypotension on admission, gender, marital status, age, max Abbreviated Injury Scale, Modified Frailty Index, surgical treatment, hematocrit, white blood count, spinal cord injury, closed head injury, injury level and presence of high energy mechanism. The performance of the prediction model was evaluated using a concordance index and calibration plot. The model was internally validated via bootstrap approach.Over the 9-year period, 1746 patients met inclusion criteria; 359 (20.6%) patients died within 90 days after presenting with spine trauma. The most important predictors for 90-day mortality were age, hypotension, closed head injury, max Abbreviated Injury Scale and hematocrit. There was an optimism-corrected C-index of 0.77. A calculator was created to predict a personalized mortality risk.The incidence of spine trauma in elderly patients continues to increase. Previous publications described preexisting conditions that imply increased mortality, but ours is the first to develop a predictive calculator. Prospective research is planned to externally validate this model to better determine its predictive value and utility in the clinical setting.

Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic autoinflammatory disease of the bone that typically occurs in children and adolescents. CRMO is characterized by recurrent periods of exacerbation and remission of symptomatic, osteolytic/sclerotic sterile bone lesions and is often a diagnosis of exclusion. Treatment consists of multimodal anti-inflammatory medication management by rheumatology and rarely involves surgery. This review summarizes the clinical presentation, pathophysiology, diagnosis, and management of this disease and highlights the role of the orthopedic surgeon. With increased familiarity with CRMO, clinicians will be able to diagnose and treat the condition in a more timely manner. [ Orthopedics . 2023;46(3):e149–e155.]

BACKGROUND: Traumatic lumbosacral instability is a rare but potentially devastating injury. These injuries are frequently associated with neurologic injury and often result in long-term disability. Despite their severity, radiographic findings can be subtle, and multiple reports exist in which these injuries were not recognized on initial imaging. Transverse process fractures, high-energy mechanisms, and other injury features have been suggested as indications for advanced imaging, which has a high degree of sensitivity in detecting unstable injuries. CASE PRESENTATION: A 21-year-old man presented to our level I trauma center after being ejected in a rollover motor vehicle collision. He sustained multiple injuries, including multiple lumbar transverse process fractures and a unilateral superior articular facet fracture of S1. PRIMARY OUTCOMES: Initial supine computed tomography (CT) images showed no displacement of the fracture and no listhesis or instability. Subsequent upright imaging in a brace, however, demonstrated significant displacement of the fracture with dislocation of the contralateral L5-S1 facet joint and significant anterolisthesis. The patient underwent open posterior reduction and stabilization of L4-S1 followed by L5-S1 anterior lumbar interbody fusion. The patient demonstrated excellent alignment on postoperative imaging. At 3 months postoperatively, he had returned to work, was ambulating without assistance, and reported minimal back discomfort and no lower extremity pain, numbness, or weakness. CONCLUSION: This case serves as a warning that supine CT imaging alone may not be sufficient to rule out unstable lumbar spine injuries, such as traumatic L5-S1 instability, and that upright radiographs in these potentially unstable injuries may represent a hazard to patients. Fractures involving the pedicle, pars, or facet joints as well as multiple transverse process fractures and/or a high-energy mechanism of injury should all raise suspicion of instability and warrant additional imaging. CLINICAL RELEVANCE: This article provides guidance on approaching treatment for patients with potential traumatic lumbosacral instability. LEVEL OF EVIDENCE: 5.

Contrast-induced nephropathy (CIN) is a major complication of imaging in patients with chronic kidney disease (CKD). The publication of an academic randomized controlled trial (RCT; n = 83) reporting oral (N)-acetylcysteine (NAC) to reduce CIN led to 70 clinical trials, 23 systematic reviews, and 2 large RCTs showing no benefit. However, no mechanistic studies were conducted to determine how NAC might work; proposed mechanisms included renal artery vasodilatation and antioxidant boosting. We evaluated the proposed mechanisms of NAC action in participants with healthy and diseased kidneys. Four substudies were performed. Two randomized, double-blind, placebo-controlled, three-period crossover studies (n = 8) assessed the effect of oral and intravenous (i.v.) NAC in healthy kidneys in the presence/absence of iso-osmolar contrast (iodixanol). A third crossover study in patients with CKD stage III (CKD3) (n = 8) assessed the effect of oral and i.v. NAC without contrast. A three-arm randomized, double-blind, placebo-controlled parallel-group study, recruiting patients with CKD3 (n = 66) undergoing coronary angiography, assessed the effect of oral and i.v. NAC in the presence of contrast. We recorded systemic (blood pressure and heart rate) and renal (renal blood flow (RBF) and glomerular filtration rate (GFR)) hemodynamics, and antioxidant status, plus biomarkers of renal injury in patients with CKD3 undergoing angiography. Primary outcome for all studies was RBF over 8 hours after the start of i.v. NAC/placebo. NAC at doses used in previous trials of renal prophylaxis was essentially undetectable in plasma after oral administration. In healthy volunteers, i.v. NAC, but not oral NAC, increased blood pressure (mean area under the curve (AUC) mean arterial pressure (MAP): mean difference 29 h⋅mmHg, P = 0.019 vs. placebo), heart rate (28 h⋅bpm, P 0.001), and RBF (714 h⋅mL/min, 8.0% increase, P = 0.006). Renal vasodilatation also occurred in the presence of contrast (RBF 917 h⋅mL/min, 12% increase, P = 0.005). In patients with CKD3 without contrast, only a rise in heart rate (34 h⋅bpm, P = 0.010) and RBF (288 h⋅mL/min, 6.0% increase, P = 0.001) occurred with i.v. NAC, with no significant effect on blood pressure (MAP rise 26 h⋅mmHg, P = 0.156). Oral NAC showed no effect. In patients with CKD3 receiving contrast, i.v. NAC increased blood pressure (MAP rise 52 h⋅mmHg, P = 0.008) but had no effect on RBF (151 h⋅mL/min, 3.0% increase, P = 0.470), GFR (29 h⋅mL/min/1.73m², P = 0.122), or markers of renal injury. Neither i.v. nor oral NAC affected plasma antioxidant status. We found oral NAC to be poorly absorbed and have no reno-protective effects. Intravenous, not oral, NAC caused renal artery vasodilatation in healthy volunteers but offered no protection to patients with CKD3 at risk of CIN. These findings emphasize the importance of mechanistic clinical studies before progressing to RCTs for novel interventions. Thousands were recruited to academic clinical trials without the necessary mechanistic studies being performed to confirm the approach had any chance of working.

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The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured.Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured.Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury-of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P0.05) or anterior (17/45, 37.8%, P0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone.Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs.Level IV, case series.

Introduction We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. Methods We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. Results Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on “Health Equity and Social Justice” and only two mentioned “Social and Environmental Determinants of Health.” Only 22% (n = 4) were available as open-access. Conclusion Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Objectives/hypothesis To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach. Study design Retrospective cohort study. Methods Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative). Results Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications. Conclusions Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery. Level of evidence Level 4 Laryngoscope, 2021.

Studies on the TSH receptor (TSHR) have numerous practical applications in vitro and in vivo. For example human monoclonal autoantibodies (MAbs) to the TSHR are useful reagents for in vitro diagnostics. Measurement of TSHR autoantibodies (TRAbs) is helpful in diagnosis and management of autoimmune thyroid disease. Currently available highly sensitive and specific assays to measure TRAbs use the human TSHR MAb M22 instead of the TSH. Furthermore, preparations of the human TSHR MAb M22 are useful as the World Health Organisation International Standard for thyroid stimulating antibody and for calibration of the assays for measuring TRAbs. Preparations of thermostabilised TSHR extracellular domain have recently become available and this is likely to have an impact on improvements in specificity testing for TRAb assays. In addition the stable TSHR preparations have practical application for specific immunoadsorption of patient serum TRAbs. Human TSHR MAbs also have promising prospects as new therapeutics. Autoantibodies with TSHR antagonistic activities are “natural” inhibitors of TSHR stimulation and are expected to be helpful in controlling TSHR activity in patients with Graves’ disease, Graves’ ophthalmopathy and thyroid cancer.

Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures.Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children's hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon.The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT.The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT.Level IV: retrospective case series.

Background The causal nature of the observed associations between serum lipids and apolipoproteins and kidney function are unclear. Methods Using two-sample and multivariable Mendelian randomization (MR), we examined the causal effects of serum lipids and apolipoproteins on kidney function, indicated by the glomerular-filtration rate estimated using creatinine (eGFRcrea) or cystatin C (eGFRcys) and the urinary albumin-to-creatinine ratio (UACR). We obtained lipid- and apolipoprotein-associated genetic variants from the Global Lipids Genetics Consortium (n = 331 368) and UK Biobank (n = 441 016), respectively, and kidney-function markers from the Trøndelag Health Study (HUNT; n = 69 736) and UK Biobank (n = 464 207). The reverse causal direction was examined using variants associated with kidney-function markers selected from recent genome-wide association studies. Results There were no strong associations between genetically predicted lipid and apolipoprotein levels with kidney-function markers. Some, but inconsistent, evidence suggested a weak association of higher genetically predicted atherogenic lipid levels [indicated by low-density lipoprotein cholesterol (LDL-C), triglycerides and apolipoprotein B] with increased eGFR and UACR. For high-density lipoprotein cholesterol (HDL-C), results differed between eGFRcrea and eGFRcys, but neither analysis suggested substantial effects. We found no clear evidence of a reverse causal effect of eGFR on lipid or apolipoprotein traits, but higher UACR was associated with higher LDL-C, triglyceride and apolipoprotein B levels. Conclusion Our MR estimates suggest that serum lipid and apolipoprotein levels do not cause substantial changes in kidney function. A possible weak effect of higher atherogenic lipids on increased eGFR and UACR warrants further investigation. Processes leading to higher UACR may lead to more atherogenic lipid levels.

BACKGROUND Displaced pediatric supracondylar humeral fractures (SCHFs) are stabilized after reduction by smooth pins. Although some SCHFs are biomechanically stable after lateral-only entry pinning (lateral pinning), an additional medial entry pin (cross-pinning) confers superior stabilization in some SCHFs. There is a recognized risk of iatrogenic ulnar nerve injury with medial entry pinning. The best existing evidence has estimated an iatrogenic ulnar nerve injury rate of approximately 3.4% in cross-pinning. In similar studies, the rate of iatrogenic nerve injury (all nerves) in lateral pinning is estimated at 1.9%. This study aimed to use a large, single-center, single-technique (mini-open) retrospective case series to determine the rate of iatrogenic ulnar nerve injury in cross-pinning. METHODS Patients undergoing percutaneous cross-pinning via the mini-open technique for SCHFs from 2007 to 2017 were retrospectively reviewed. Injury characteristics, operative variables, fixation technique, and complications, such as iatrogenic nerve injury, were recorded. Patients who underwent operative treatment at another hospital, had no postoperative follow-up, or died due to polytrauma were excluded. RESULTS In this study, 698 patients undergoing cross-pinning during the study period were identified. Patients treated with cross-pinning had severe fractures, including a total of 198 preoperative neurovascular injuries (28.4%), 32 patients (4.6%) with skin tenting, and 19 patients (2.7%) with open fractures. Iatrogenic nerve injury was reported in 3 cases (0.43%), all of which affected the ulnar nerve. In 2 of 3 cases of iatrogenic nerve injury, the ulnar nerve symptoms resolved at a mean follow-up of 15 weeks. CONCLUSIONS The mini-open approach for medial pin insertion is safer than previous estimates. Here, in the largest single-center study of cross-pinning for SCHFs, the iatrogenic ulnar nerve injury rate of 0.43% was nearly 10 times lower than estimated rates from recent meta-analyses. Considering all nerves, the iatrogenic injury rate for this cross-pinning cohort was also lower than the estimated iatrogenic nerve injury rate for lateral pinning. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

This study asked whether interindividual variation in maximum and standard aerobic metabolic rates of the Gulf killifish, Fundulus grandis, correlates with gill morphology and cardiac mitochondrial bioenergetics, traits reflecting critical steps in the O2 transport cascade from the environment to the tissues. Maximum metabolic rate (MMR) was positively related to body mass, total gill filament length and myocardial oxygen consumption during maximum oxidative phosphorylation (multiple R2=0.836). Standard metabolic rate (SMR) was positively related to body mass, total gill filament length and myocardial oxygen consumption during maximum electron transport system activity (multiple R2=0.717). After controlling for body mass, individuals with longer gill filaments, summed over all gill arches, or greater cardiac respiratory capacity had higher whole-animal metabolic rates. The overall model fit and the explanatory power of individual predictor variables were better for MMR than for SMR, suggesting that gill morphology and myocardial bioenergetics are more important in determining active rather than resting metabolism. After accounting for body mass, heart ventricle mass was not related to variation in MMR or SMR, indicating that the quality of the heart (i.e. the capacity for mitochondrial metabolism) was more influential than heart size. Finally, the myocardial oxygen consumption required to offset the dissipation of the transmembrane proton gradient in the absence of ATP synthesis was not correlated with either MMR or SMR. The results support the idea that interindividual variation in aerobic metabolism, particularly MMR, is associated with variation in specific steps in the O2 transport cascade.

Introduction:Double aortic arch is a rare congenital malformation of the aortic arch that most frequently presents in childhood. Early surgical intervention typically yields excellent outcomes.Objectives:To describe aortotracheal fistula as a rare, yet serious complication of vascular ring and subsequent aortic aneurysm in an adult patient.Methods:Clinical history, as well as radiographic and endoscopic imaging were obtained to describe the development, diagnosis, and clinical course of this patient’s aortotracheal fistula. Additionally, follow up data was obtained to document the healing of this fistula after surgical repair.Results:We describe a case of a 46-year-old male with DiGeorge Syndrome and a double aortic arch, repaired in childhood, which developed into an aortotracheal fistula after tracheostomy placement as an adult.Conclusions:This case demonstrates that dangerous complications of a double aortic arch can persist into adulthood, even after surgical repair in infancy. Each patient’s unique anatomy must be considered when thinking about airway management and prevention of complications of this rare congenital anomaly.

Conservation of aquatic resources is hampered by our limited knowledge of biological diversity and its distribution. Due to challenges with detection of rare or difficult to sample species, and the expansion of genetic technologies, fisheries professionals are supplementing traditional biodiversity field studies with emerging environmental DNA (eDNA) techniques. eDNA is generally evaluated with qPCR (primer- and probe-mediated single species detection), single-gene metabarcoding (PCR primer-mediated diversity analysis) or the emerging technique of multi-gene metagenomics (PCR independent diversity analysis). In each case, techniques are dependent on sequence databases for primer design and/or taxonomic assignment of recovered sequence data. Current reference databases contain limited mitochondrial genome information and are reliant on specific gene fragments, such as COI, which are not always suited for qPCR and metabarcoding marker design needs. To facilitate primer design and enhance taxonomic resolution for eDNA approaches, we describe a suite of order and/or family-specific long-range PCR primers sufficient for sequencing complete mitochondrial genomes. While the intent was to obtain mitochondrial genome data for freshwater fish, primers were designed on sequence alignments from all available species (including marine), and should be broadly applicable within their respective taxonomic group. We have sequenced 205 complete mitochondrial genomes representing 65 species/subspecies from 9 fish families, including novel genomes from 28 species not represented in GenBank at the time of submission. Continued expansion of species representation in mitochondrial genome databases will help move biodiversity assessment from single-gene metabarcoding approaches to multi-gene metagenomics and provide a valuable resource for eDNA applications, molecular ecology and phylogenetics.

In recent years, a great deal of attention has been given to the passive detection of fissile material by detecting spontaneously emitted neutrons. Neutron detection schemes generally rely on low-density detection media with high neutron-gamma discrimination capability. However, such detectors generally suffer from low efficiency for high energy (>1.00 MeV) neutrons and usually are constructed with moderating material built into the detector package to compensate for that. But when the source is highly shielded by hydrogenous materials, the moderating material surrounding the detector actually decreases the detector efficiency (Rees and Czirr, 2012). This problem is further compounded if the source is shielded with borated material, significantly reducing the number of emerging neutrons. We have built, tested, and modeled a simple neutron detector that uses a large block of plastic scintillator fitted with a removable cadmium foil. This detector is sensitive to fission gammas, gammas emitted from neutron capture in shielding, gammas emitted from neutron capture in the plastic scintillator, and gammas produced by neutron capture in the cadmium foil. We demonstrate that by applying suitable data analysis, we can detect a shielded californium source with a very small chance of false positives from typical gamma sources . When boron is added to the shielding, we also use the 477 keV gammas emitted when neutrons capture in boron. This process is enhanced by using an auxiliary NaI gamma detector . Although the detection method flies in the face of currently promoted detectors, it is a simple technique that could be applied to a variety of detection applications.

Background Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR). Methods Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization. Results Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures. Conclusion Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources. Level of evidence Level III-Retrospective comparative study.

Two rounds of genome duplication (GD) in the ancestor of vertebrates, followed by additional GD during the evolution of ray-finned fishes (Actinopterygii), expanded certain gene families, including those encoding the hypoxia inducible transcription factor (HIF). The present study analyzed Actinopterygian genomes for duplicates of HIFα, the subunit that confers oxygen-dependent gene regulation. In contrast to tetrapod vertebrates that retain three HIFα genes from the ancestral vertebrate GD, four HIFα forms were found in the genomes of primitive Actinopterygians (spotted gar and Asian arowana). All four forms have been retained in zebrafish and related species (Otocephala) and salmonids and their sister taxa (northern pike) but one of them (HIF4α) was lost during the evolution of more derived fishes (Neoteleostei). In addition, the current analyses confirm that Otocephala retain duplicates of HIF1α and HIF2α from the teleost-specific GD, provide new evidence of salmonid-specific duplicates of HIF1α, HIF2α, and HIF3α, and reveal a broad distribution of a truncated form of HIF2α in salmonids and Neoteleostei. This study delivers a comprehensive view of HIFα evolution in the ray-finned fishes, highlights the need for a consistent nomenclature, and suggests avenues for future research on this critical transcription factor.

Background/Purpose: Non-accidental trauma (NAT) remains a major cause of morbidity and mortality in childhood, with fractures serving as the second most common presenting sign of abuse. Conventionally, elbow fractures are more frequently associated with accidental trauma than NAT. We hypothesized that elbow fractures in non-early ambulatory children are at risk of a NAT mechanism. Methods:Patients were identified using an institutional database of pediatric elbow fractures at a large, tertiary pediatric hospital between 2007 and 2017. A diagnosis of NAT was established if a physician specializing in Child Abuse Pediatrics confirmed that the trauma was the result of NAT by their clinical judgement, if custody of the child was altered as a result of the case, or if legal documentation of criminal investigation secondary to the case was found. Results:Of 4,608 elbow fractures in the database, 21 were confirmed to be caused by NAT. Fifteen (71%) of the patients were male with a median age of 0.7 years-old and a range between 0.1 and 10.4 years (Table 1). Of the 21 elbow fractures associated with NAT, there were 11 supracondylar (further subclassified as 3 Gartland I, 3 Gartland II, 1 Gartland IIIa, 1 Metaphyseal-Diaphyseal Junction fracture and 3 unspecified), 5 lateral condyle, 4 humeral shaft fractures involving the elbow and 1 radial head fracture. Of the 21 patients identified, 12 (57%) were found to have bruising inconsistent with the mechanism given or unrelated to the injury, while 11 (52%) had additional fractures or healing fractures identified. Seventeen (81%) injuries were determined to be inconsistent with mechanism of injury described or did not specify mechanism. Among all the patients presenting with an elbow fracture under the age of 1 over a 10-year span, 33% were determined to have suffered NAT (12/36). Patients between 1 and 2 and older than 2 presenting with elbow fractures had injuries caused by NAT 1% (3/221) and 0.1% (6/4350) of the time respectively. Conclusion:While elbow fractures are rarely considered a result of NAT in most age groups, a high degree of clinical suspicion should be maintained for elbow fractures in children under one. For comparison, in children under one year presenting with femur fractures, widely considered to be pathognomonic of child abuse, 16-35% are the result of NAT. An overwhelming majority of patients with elbow fractures resulting from NAT presented with additional bruising and injuries. However, a minority did not, and suspicion is only raised as a result of the mechanism provided. Thus, it is imperative that medical personal who encounter pediatric injuries understand the natural history of these injuries and vigilantly evaluate for their common signs in order to identify possible NAT.

Background Autoimmune Polyglandular Syndrome type 1 (APS-1) is a rare recessive inherited disease, caused by AutoImmune Regulator (AIRE) gene mutations and characterized by three major manifestations: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CH) and Addison’s disease (AD). Methods Autoimmune conditions and associated autoantibodies (Abs) were analyzed in 158 Italian patients (103 females and 55 males; F/M 1.9/1) at the onset and during a follow-up of 23.7 ± 15.1 years. AIRE mutations were determined. Results The prevalence of APS-1 was 2.6 cases/million (range 0.5–17 in different regions). At the onset 93% of patients presented with one or more components of the classical triad and 7% with other components. At the end of follow-up, 86.1% had CH, 77.2% AD, 74.7% CMC, 49.5% premature menopause, 29.7% autoimmune intestinal dysfunction, 27.8% autoimmune thyroid diseases, 25.9% autoimmune gastritis/pernicious anemia, 25.3% ectodermal dystrophy, 24% alopecia, 21.5% autoimmune hepatitis, 17% vitiligo, 13.3% cholelithiasis, 5.7% connective diseases, 4.4% asplenia, 2.5% celiac disease and 13.9% cancer. Overall, 991 diseases (6.3 diseases/patient) were found. Interferon-ω Abs (IFNωAbs) were positive in 91.1% of patients. Overall mortality was 14.6%. The AIRE mutation R139X was found in 21.3% of tested alleles, R257X in 11.8%, W78R in 11.4%, C322fsX372 in 8.8%, T16M in 6.2%, R203X in 4%, and A21V in 2.9%. Less frequent mutations were present in 12.9%, very rare in 9.6% while no mutations in 11% of the cases. Conclusions In Italy, APS-1 is a rare disorder presenting with the three major manifestations and associated with different AIRE gene mutations. IFNωAbs are markers of APS-1 and other organ-specific autoantibodies are markers of clinical, subclinical or potential autoimmune conditions.

While comorbidity between coronary heart disease (CHD) and depression is evident, it is unclear whether the two diseases have shared underlying mechanisms. We performed a range of analyses in 367,703 unrelated middle-aged participants of European ancestry from UK Biobank, a population-based cohort study, to assess whether comorbidity is primarily due to genetic or environmental factors, and to test whether cardiovascular risk factors and CHD are likely to be causally related to depression using Mendelian randomization. We showed family history of heart disease was associated with a 20% increase in depression risk (95% confidence interval [CI] 16–24%, p

Funder: The Darwin Trust of Edinburgh, Funder: National Institute of Health [grant number R01 HL136528], BACKGROUND: We conducted a Mendelian randomisation (MR) study to investigate whether physical activity (PA) causes a reduction of colorectal cancer risk and to understand the contributions of effects mediated through changes in body fat. METHODS: Common genetic variants associated with self-reported moderate-to-vigorous PA (MVPA), acceleration vector magnitude PA (AMPA) and sedentary time were used as instrumental variables. To control for confounding effects of obesity, we included instrumental variables for body mass index (BMI), body fat percentage, waist circumference and arm, trunk and leg fat ratios. We analysed the effect of these instrumental variables in a colorectal cancer genome-wide association study comprising 31,197 cases and 61,770 controls of European ancestry by applying two-sample and multivariable MR study designs. RESULTS: We found decreased colorectal cancer risk for genetically represented measures of MVPA and AMPA that were additional to effects mediated through genetic measures of obesity. Odds ratio and 95% confidence interval (CI) per standard deviation increase in MVPA and AMPA was 0.56 (0.31, 1.01) and 0.60 (0.41, 0.88), respectively. No association has been found between sedentary time and colorectal cancer risk. The proportion of effect mediated through BMI was 2% (95% CI: 0, 14) and 32% (95% CI: 12, 46) for MVPA and AMPA, respectively. CONCLUSION: These findings provide strong evidence to reinforce public health measures on preventing colorectal cancer that promote PA at a population level regardless of body fatness.

Imazapyr is a herbicide that can be used in irrigation canals to control a range of aquatic weed species, however, its residual nature, combined with its phytotoxicity to crops at low concentrations, means that the water in canals must be carefully managed following imazapyr application. Residues of the herbicide imazapyr (isopropylamine salt) in irrigation water were analysed and modelled after application to irrigation canals in south-eastern Australia. A treatment program to control delta arrowhead (sagittaria, Sagittaria platyphylla (Engelm.) J.G. Sm.) in over 400 km of irrigation canals was enacted by applying imazapyr to dewatered canals during winter. Following imazapyr application, canals were left dewatered for a period (up to eight weeks) and then refilled. After refilling, canals were ponded for a period (up to 28 days) to allow degradation of imazapyr in the water via photolysis. Upon refilling canals, ~650 water samples containing imazapyr were collected across the treatment area and data modelled to measure the extent of water contamination and to guide efforts to reduce the subsequent irrigation hazard to crops. Modelled data demonstrates that imazapyr behaviour in irrigation water following canal refilling was predictable when 1) amount of imazapyr applied, 2) the dewatered period following herbicide application, 3) the water ponding period, and 4) solar exposure during water ponding were taken into account. Minimising the amount applied (g imazapyr per km of canal) and maximising the time between spraying and refilling (dewatered period) reduced the initial concentration in the water following canal refilling. The amount of imazapyr in the canal water following refilling was reduced by half for every 16 days (confidence interval = 10 &ndash, 38 days) that the canal remained dewatered after imazapyr application. Imazapyr dissipation during the ponding period following canal refilling occurred at a rate that depended on solar exposure. Dissipation did not occur when solar exposure was &lt, 8.5 MJ m&minus, 2. However, when solar exposure was &gt, 10 MJ m&minus, 2, imazapyr concentration in the water reduced by half for every 4.4 days of ponding period (confidence interval = 2.9&ndash, 9.5 days). Our two models, combined with local climate data on solar exposure, can be used by canal managers to determine the optimal time to refill canals so that imazapyr dissipation is maximised, and thus risk of damaging irrigated crops is minimised.

World Heritage status for selected sites in Areas Beyond National Jurisdiction is under active consideration, and the Costa Rica Thermal Dome in the eastern tropical Pacific Ocean is a feasible candidate site. A scientific expedition to the area in April 2017 added to biological baseline data but also confirmed presence of microplastics in the water column. National and regional efforts are being made by Central American countries to strengthen mechanisms for integrated ocean management, educate coastal communities and give early consideration to potential future threats such as ocean fertilisation. This paper concludes that to achieve World Heritage status for this iconic site requires an entity to both propose the area and report on its status. Bringing into force the Antigua Convention, a Regional Seas Convention for the Eastern Tropical Pacific, would provide an appropriate platform for Central American governments to enact protective measures.

The capacity of fishes to tolerate low oxygen (hypoxia) through behavioral and physiological adjustments varies among species in a fashion that correlates with oxygen availability in their natural habitats. Less is known about variation in hypoxia tolerance within a species, but it is expressly this interindividual variation that will determine which individuals will survive during severe hypoxia. Here, we measured aquatic surface respiration (ASR) and loss of equilibrium (LOE), two common indexes of hypoxia tolerance of fishes, in gulf killifish, Fundulus grandis, subjected to multiple trials of a highly reproducible hypoxia protocol over a period of 6-8 wk. The time and [Formula: see text] at the first occurrence of ASR and the time and [Formula: see text] at LOE differed significantly among individuals in a repeatable fashion. This interindividual variation in ASR and LOE was significantly correlated with general body and gill morphology. The time to ASR was shorter and the [Formula: see text] at ASR was higher for fish with greater mass. After correcting for mass, fish with longer or more numerous gill filaments had longer times to ASR or LOE, respectively. Fish in better condition factor (heavier for their length) had lower [Formula: see text] at LOE. Repeatable interindividual variation in hypoxia tolerance, if genetically based, could influence the capacity of species to adapt as their habitats become increasingly threatened by aquatic hypoxia.

Background/Purpose: Non-accidental trauma (NAT) remains a major cause of morbidity and mortality in childhood, with fractures serving as the second most common presenting sign of abuse. Conventionally, elbow fractures are more frequently associated with accidental trauma than NAT. We hypothesized that elbow fractures in non-early ambulatory children are at risk of a NAT mechanism. Methods:Patients were identified using an institutional database of pediatric elbow fractures at a large, tertiary pediatric hospital between 2007 and 2017. A diagnosis of NAT was established if a physician specializing in Child Abuse Pediatrics confirmed that the trauma was the result of NAT by their clinical judgement, if custody of the child was altered as a result of the case, or if legal documentation of criminal investigation secondary to the case was found. Results:Of 4,608 elbow fractures in the database, 21 were confirmed to be caused by NAT. Fifteen (71%) of the patients were male with a median age of 0.7 years-old and a range between 0.1 and 10.4 years (Table 1). Of the 21 elbow fractures associated with NAT, there were 11 supracondylar (further subclassified as 3 Gartland I, 3 Gartland II, 1 Gartland IIIa, 1 Metaphyseal-Diaphyseal Junction fracture and 3 unspecified), 5 lateral condyle, 4 humeral shaft fractures involving the elbow and 1 radial head fracture. Of the 21 patients identified, 12 (57%) were found to have bruising inconsistent with the mechanism given or unrelated to the injury, while 11 (52%) had additional fractures or healing fractures identified. Seventeen (81%) injuries were determined to be inconsistent with mechanism of injury described or did not specify mechanism. Among all the patients presenting with an elbow fracture under the age of 1 over a 10-year span, 33% were determined to have suffered NAT (12/36). Patients between 1 and 2 and older than 2 presenting with elbow fractures had injuries caused by NAT 1% (3/221) and 0.1% (6/4350) of the time respectively. Conclusion:While elbow fractures are rarely considered a result of NAT in most age groups, a high degree of clinical suspicion should be maintained for elbow fractures in children under one. For comparison, in children under one year presenting with femur fractures, widely considered to be pathognomonic of child abuse, 16-35% are the result of NAT. An overwhelming majority of patients with elbow fractures resulting from NAT presented with additional bruising and injuries. However, a minority did not, and suspicion is only raised as a result of the mechanism provided. Thus, it is imperative that medical personal who encounter pediatric injuries understand the natural history of these injuries and vigilantly evaluate for their common signs in order to identify possible NAT.