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Category: Ankle; Arthroscopy Introduction/Purpose: A hypertrophic distal fascicle of the anterior tibiofibular ligament (ATiFLdf) is commonly encountered in patients with anterior ankle impingement. Repetitive snapping of the hypertrophic ATiFLdf has the potential to create osteochondral lesions (OCLs) at the lateral talar dome. However, the clinical manifestations of these OCLs in the setting of a hypertrophic ATiFLdf has not been described to date. The purpose of this retrospective review was to determine the prevalence of OCLs of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic ATiFLdf. In addition, we sought to evaluate the anatomy of the ATiFL to fully elucidate its role in creating chondral wear of the talus. Methods: Retrospective chart review identified 40 patients who underwent arthroscopy of the anterior ankle joint for the management of anterior ankle impingement. Pre-operative magnetic resonance imaging (MRI) scans were obtained and correlated with intra-operative arthroscopic findings. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, return to work data and return to sport data. Results: Thirty-two patients with a mean follow-up time of 29.3±10.4 months were included. The ATiFLdf was hypertrophic in 29 patients (90.6%), the mean thickness of which was 2.5±0.4 mm. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic ATiFLdf visualized during arthroscopy. The international cartilage repair society gradings of the lesions included: 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from pre-operative to post-operative (p< 0.001). No cases of syndesmotic instability were observed following resection of ATiFLdf. The mean post-operative Likert score was 4.1±0.4. There were 5 failures (15.6%) at a mean time of 9.0±4.7 months. Conclusion: This retrospective case series demonstrated that a hypertrophic ATiFLdf was closely associated with the development of an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, pre-operative MRI proved to demonstrate poor sensitivity for the detection of these OCLs. Suspicion should be raised for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf. Figure 1. (a) Hypertrophic ATiFLdf with associated OCL of the lateral talar dome; (b) Biter resecting hypertrophic ATiFLdf; (c) Resected hypertrophic ATiFLdf; (d) and (e) Hypertrophic ATiFLdf identified on coronal and axial MRI scans

Category: Sports; Other Introduction/Purpose: The purpose of this study was to assess outcomes following acute Achilles tendon ruptures (AATR) sustained by athletes participating in the Major League Soccer (MLS). Methods: Athletes participating in the MLS who sustained an AATR were identified using a publicly available database, match reports and injury reports. The years of inclusion was from 2008-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play (RTP), time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, assists, goals, passes, pass %, crosses, shots, shots on target and shot %. Results: Twenty-six athletes sustained an AATR in the MLS (0.008564 per 10,000 athlete-exposures). The mean age was 25.8±8.4 years and the mean BMI was 22.5±6.6kg/m 2 . There were 15 (57.7%) AATRs sustained by defensive players, 5 (19.2%) AATRs sustained by midfield players, 3 (11.6%) AATR sustained by forwards and 3 (11.6%) AATR sustained by goalkeepers. All athletes (100%) underwent surgical intervention. The mean number of games played prior to injury was 164.7±154.9. The RTP rate to the MLS was 73.1% at mean time of 11.1±5.5 months. The mean number of games missed due to injury was with 30.1±11.7 games. There was a statistically significant decrease in the mean number of games played, goals scored and shots taken following RTP. Conclusion: This current study found that AATRs were an uncommon injury in the MLS with an incidence of 0.008564 per 10,000 athlete-exposures. Sustaining an AATR was associated with a 73.1% return to play rate to the MLS at a mean time of 11.1 ± 5.5 months. There was a statistically significant deterioration in key performance metrics such as mean games played, goals scored and shots taken. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Sports; Other Introduction/Purpose: The purpose of this systematic review was to evaluate rates of return to play and levels of performance following acute Achilles tendon ruptures (AATR) in the National Football League (NFL). Additionally, we sought to determine the prevalence rates of AATR and identify any risk factors for the development of AATR. Methods: During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following treatment of acute Achilles tendon ruptures (AATR) in the NFL. Twelve studies were included. Results: In total, 676 players (698 Achilles) sustained an AATR in the NFL. The playing positions that sustained the highest rates of AATRs was linebackers (19.0%), wide receivers (11.9%) and running backs (9.0%). 139 AATRs (50.4%) occurred in the preseason, 135 AATRs (48.9%) occurred during the regular season and 2 AATRs (0.7%) occurred during a post-season game. Playing surface was not associated with an increased risk of AATR. The return to play rate was 66.2% at a weighted mean time of 10.9±1.3 months. The mean number of games played per season following AATR was 12.9 games and the weighted mean career length following AATR was 2.2 ± 0.8 seasons. Overall, player performance deteriorated significantly following AATR, as demonstrated by lower power rankings and position specific metrics. Conclusion: This systematic review found was that the proportion of athletes participating in the NFL who returned to play following AATR was 66.2%. Both the mean number of games played per season and the mean number of seasons played decreased significantly following AATR. Overall, player performance deteriorated following AATR, regardless of player position. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Ankle; Sports Introduction/Purpose: The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up. Methods: Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures. Results: Thirty-nine patients with a mean lesion size was 122.3±64.1 mm 2 and mean follow-up time of 138.9±16.9months were included. The mean FAOS scores improved from a preoperative score of 51.9±16.0 to 75.3±21.9 (p < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R2=0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9±5.2ms) compared to the superficial layer of the adjacent native cartilage (35.8±3.8ms) (p < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI. Conclusion: This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs.

Background: This study examined trends in inpatient charges for primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), hemiarthroplasty (HA), and revision total shoulder arthroplasty (revTSA) over the past decade. Methods: The New York Statewide Planning and Research Cooperative System was queried for patients undergoing primary aTSA, rTSA, HA, and revTSA from 2010 to 2020 using International Classification of Diseases procedure codes. The primary outcome measured was total charges per encounter. Secondary outcomes included accommodation and ancillary charges, charges covered by insurance, and facility volume. Ancillary charges were defined as fees for diagnostic and therapeutic services and accommodation charges were defined as fees associated with room and board. Subgroup analysis was performed to assess differences between high- and low-volume centers. Results: During the study period, 46,044 shoulder arthroplasty cases were performed: 18,653 aTSA, 4002 HA, 19,253 rTSA, and 4136 revTSA. An exponential increase in rTSA (2428%) and considerable decrease in HA (83.9%) volumes were observed during this period. Total charges were the highest for rTSA and revTSA and the lowest for aTSA. Subgroup analysis of revTSA by indication revealed that total charges were the highest for periprosthetic fractures. For aTSA, rTSA, and HA, high-volume centers achieved significantly lower total charges compared to low-volume centers. Over the study period, total inpatient charges increased by 57.2%, 38.4%, 102.4%, and 68.4% for aTSA, rTSA, HA, and revTSA, outpacing the inflation rate of 18.7%. Conclusion: Total inpatient charges for all arthroplasty types increased dramatically from 2010 to 2020, outpacing inflation rates, but high-volume centers demonstrated greater success at mitigating charge increases compared to low-volume centers.

Abstract Background Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial. Methods This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH. Discussion Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

IntroductionThere is no consensus as to what specifically constitutes head and neck cancer radiotherapy quality assurance (HNC RT QA). The aims of this study are to (1) describe the RT QA processes used in the TROG 12.01 study, (2) review the RT QA processes undertaken for all patients with loco-regional failure (LRF), and (3) provide prospective data to propose a consensus statement regarding the minimal components and optimal timing of HNC RT QA.Materials and methodsAll patients undergoing RT QA in the original TROG 12.01 study were included in this substudy. All participating sites completed IMRT credentialling and a clinical benchmark case. Real-time (pre-treatment) RT QA was performed for the first patient of each treating radiation oncologist, and for one in five of subsequent patients. Protocol violations were deemed major if they related to contour and/or dose of gross tumour volume (GTV), high dose planning target volume (PTVhd), or critical organs of risk (spinal cord, mandible, and brachial plexus).ResultsThirty HNROs from 15 institutions accrued 182 patients. There were 28 clinical benchmark cases, 27 pre-treatment RT QA cases, and 38 post-treatment cases. Comprehensive RT QA was performed in 65/182 (36%) treated patients. Major protocol violations were found in 5/28 benchmark cases, 5/27 pre-treatment cases, and 6/38 post-treatment cases. An independent review of all nine LRF cases showed major protocol violations in four of nine cases.ConclusionOnly pre-treatment RT QA can improve patient outcomes. The minimal components of RT QA in HNC are GTVs, PTVhd, and critical organs at risk. What constitutes major dosimetric violations needs to be harmonised.

Abstract Introduction Adjuvant radiotherapy is an established component in the management of metastatic cutaneous squamous cell carcinoma (SCC) involving the parotid gland. Radiotherapy technique, dose and volumes are seldom described sufficiently to allow close examination. We report our treatment outcomes and focus on treatment‐related factors that affect outcomes in this cohort. Methods We performed a retrospective review of patients with metastatic cutaneous SCCs who underwent parotidectomy with or without ipsilateral neck dissection. All patients received adjuvant radiotherapy. Demographics, clinical data and treatment details were collected from an intuitional electronic database. Individual patient‐level radiotherapy technique, volumes and doses were reviewed. Results Between July 2008 and July 2018, 60 patients met our inclusion criteria. Median follow‐up duration was 32.7 months. The mean age was 66.4 years. The majority of patients (49 patients) received full neck irradiation. The 2‐year and 5‐year loco‐regional failure‐free survival was 87% (95% confidence interval (CI): 0.74–0.93) and 71% (95% CI: 0.52, 0.83), respectively. The 2‐year and 5‐year overall survival was 76% (95% CI: 0.62, 0.85) and 60% (95% CI: 0.45, 0.72), respectively. There were 15 cases of loco‐regional failures, with 6 cases with dermal involvement. Lymphovascular invasion (LVI) was associated with higher loco‐regional failure (hazard ratio: 8.43, 95% CI: 1.85–38.39, P = 0.005) and cancer‐specific mortality (hazard ratio: 5.40, 95% CI: 1.40–20.87, P = 0.015). Treatment technique, intensity‐modulated radiation therapy (IMRT) vs 3D conformal radiotherapy (3D CRT), bolus use, perineural invasion (PNI) and surgical margins were not significantly associated with loco‐regional failure. Conclusion We demonstrated high loco‐regional control rates with routine use of comprehensive adjuvant radiotherapy. The presence of LVI was identified as a strong predictor for recurrence. Further analysis will help to define optimal radiation dose and techniques.

Measurement(s) Antibody Binding Technology Type(s) AlphaSeq Factor Type(s) Antibody sequence Sample Characteristic - Organism Homo sapiens

Abstract Introduction Optical three‐dimensional scanning devices can produce geometrically accurate, high‐resolution models of patients suitable for clinical use. This article describes the use of a metrology‐grade structured light scanner for the design and production of radiotherapy medical devices and synthetic water‐equivalent computer tomography images. Methods Following commissioning of the device by scanning objects of known properties, 173 scans were performed on 26 volunteers, with observations of subjects and operators collected. Results The fit of devices produced using these scans was assessed, and a workflow for the design of complex devices using a treatment planning system was identified. Conclusions Recommendations are provided on the use of the device within a radiation oncology department.

Abstract Optical devices capable of suppressing diffraction nature of light are of great technological importance to many nanophotonic applications. One important technique to achieve diffractionless optics is to exploit field canalization effect. However, current technological platforms based on metamaterial structures typically suffer from strict loss-confinement trade-off, or lack dynamic reconfigurability over device operations. Here we report an integrated canalization platform that can alleviate this performance trade-off. It is found that by leveraging material absorption of anisotropic 2D materials, the dispersion of this class of materials can flatten without increasing propagation losses and compromising confinement. The realization of such plasmon canalization can be considered using black phosphorus (BP), where topological transition from elliptic to hyperbolic curves can be induced by dynamically leveraging material absorption of BP. At the transition point, BP film can support long range, deeply subwavelength, near-diffractionless field propagation, exhibiting diffraction angle of 5.5°, propagation distance of 10λspp, and λspp

Purpose: The purpose of the study was to evaluate, as a pilot trial, safety and tolerability of CAM-101 10% and 30% topical ophthalmic fibrinogen-depleted human platelet lysate (FD hPL) solution in patients with dry eye disease (DED) secondary to graft-versus-host disease (GvHD) after 6 weeks of treatment. Design: A phase I/II, pilot, prospective, multicenter, randomized, double-masked clinical trial. Participants: Patients with DED secondary to GvHD. Methods: Sixty-four adult patients were stratified by “symptom severity” (Ocular Surface Disease Index [OSDI], ocular discomfort Visual Analog Scale (VAS), ocular symptom frequency, and use of artificial tears) and then randomized 1:1:1 to CAM-101 (FD hPL) at 10% or 30% concentration or an electrolyte (Plasma-Lyte A) vehicle control, 1 drop in both eyes, 4 times daily, for 42 days. After 42 days, control patients were offered 42 days of open-label treatment with 30% FD hPL. Main Outcome Measures: Primary outcome safety measures were ocular and systemic adverse events and the number of patients in each group with clinically significant change from normal to abnormal in any ocular findings. Secondary outcomes were changes from baseline to day 42 in ocular discomfort, OSDI, fluorescein corneal staining, and lissamine green conjunctival staining relative to the vehicle control. The ocular symptom frequency was assessed on a 100-point VAS. Results: FD hPL 10% and 30% were safe and well tolerated. Relative to the vehicle control, significant decreases from baseline to day 42 were seen in the FD hPL 30% group with regard to ocular discomfort (mean decrease = −18.04; P = 0.018), frequency of burning/stinging (−20.23; P = 0.022), eye discomfort (−32.97; P < 0.001), eye dryness (−21.61; P = 0.020), pain (−15.12; P = 0.044), photophobia (−24.33; P = 0.0125), and grittiness (−20.08; P = 0.0185). Decreases were also seen for itching and foreign body sensation, though not statistically significant. Improvements were seen in tear breakup time (mean increase = 1.30 seconds; P = 0.082) and the investigator’s global evaluation 4-point scale (mean decrease = −0.86; P = 0.026). Corneal fluorescein staining was not improved. The OSDI had a mean decrease of −8.88 compared to the vehicle, although not statistically significant. Conclusions: Fibrinogen-depleted human platelet lysate appears to be well tolerated, with no significant toxicity at concentrations of 10% and 30%. These initial data suggest some efficacy, especially for subjective outcome measures relative to baseline assessments and treatment with the vehicle, but larger studies are needed to confirm these effects.

Abstract Desmoplasia is characteristic of pancreatic ductal adenocarcinoma (PDAC), which exhibits 5‐year survival rates of 3%. Desmoplasia presents physical and biochemical barriers that contribute to treatment resistance, yet depleting the stroma alone is unsuccessful and even detrimental to patient outcomes. This study is the first demonstration of targeted photoactivable multi‐inhibitor liposomes (TPMILs) that induce both photodynamic and chemotherapeutic tumor insult, while simultaneously remediating desmoplasia in orthotopic PDAC. TPMILs targeted with cetuximab (anti‐EGFR mAb) contain lipidated benzoporphyrin derivative (BPD‐PC) photosensitizer and irinotecan. The desmoplastic tumors comprise human PDAC cells and patient‐derived cancer‐associated fibroblasts. Upon photoactivation, the TPMILs induce 90% tumor growth inhibition at only 8.1% of the patient equivalent dose of nanoliposomal irinotecan (nal‐IRI). Without EGFR targeting, PMIL photoactivation is ineffective. TPMIL photoactivation is also sixfold more effective at inhibiting tumor growth than a cocktail of Visudyne‐photodynamic therapy (PDT) and nal‐IRI, and also doubles survival and extends progression‐free survival by greater than fivefold. Second harmonic generation imaging reveals that TPMIL photoactivation reduces collagen density by >90% and increases collagen nonalignment by >103‐fold. Collagen nonalignment correlates with a reduction in tumor burden and survival. This single‐construct phototoxic, chemotherapeutic, and desmoplasia‐remediating regimen offers unprecedented opportunities to substantially extend survival in patients with otherwise dismal prognoses.

Abstract This study investigates the medium-scale traveling ionospheric disturbances (MSTIDs) statistically at the low-latitude equatorial ionization anomaly (EIA) region in the northern hemisphere. We apply the automatic detection algorithm including the three-dimensional fast Fourier transform (3-D FFT) and support vector machine (SVM) on total electron content (TEC) observations, derived from a network of ground-based global navigation satellite system (GNSS) receivers in Taiwan (14.5° N geomagnetic latitude; 32.5° inclination), to identify MSTID from other waves or irregularity features. The obtained results are analyzed statistically to examine the behavior of low-latitude MSTIDs. Statistical results indicate the following characteristics. First, the southward (equatorward) MSTIDs are observed almost every day during 0800–2100 LT in Spring and Winter. At midnight, southward MSTIDs are more discernible in Summer and majority of them are propagating from Japan to Taiwan. Second, northward (poleward) MSTIDs are more frequently detected during 1200–2100 LT in Spring and Summer with the secondary peak of occurrence between day of year (DOY) 100–140 during 0000–0300 LT. The characteristics of the MSTIDs are interpreted with additional observations from radio occultation (RO) soundings of FORMOSAT-3/COSMIC as well as modeled atmospheric waves from the high-resolution Whole Atmosphere Community Climate Model (WACCM) suggesting that the nighttime MSTIDs in Summer is likely connected to the atmospheric gravity waves (AGWs).

Abstract Background Patients with unresectable advanced cutaneous squamous cell carcinoma (cSCC) are generally treated with palliative intent. Immune checkpoint blockade has significant activity in the palliative setting in patients with recurrent or metastatic cSCC. This single arm phase 2 prospective study aims to investigate the combination of curative intent chemoradiation and durvalumab (anti-PD-L1 checkpoint inhibitor) for this patient cohort. Methods Patients with unresectable locally and or regionally advanced pathologically confirmed cSCC (stage III-IVa) deemed fit for CRIO by consensus of the Multidisciplinary meeting will be eligible. In the first stage of a two-stage minimax design, we aim to recruit a total of 15 patients. If fewer than 7 patients achieved a complete response in the first stage, we will conclude the treatment is not more effective than standard treatment. The co-primary endpoints of CRIO are the safety of treatment (acute and late toxicities) and the rate of complete response. Secondary endpoints would include overall survival, progression free survival, and locoregional control. Translational research endpoints including biomarkers (CD73, CD39, PD-1, PD-L1) will also be explored utilising multiplex immunohistochemistry on tumour biopsy samples obtained prior to commencing treatment and during treatment (week 2). In addition, the utility of CXCR-4 PET/CT scan will be explored. Discussion CRIO is a novel trial evaluating the combination of curative intent chemoradiotherapy with concurrent and adjuvant durvalumab for patients with unresectable stage III-IVa cSCC. Trial registration: Trial registered with the Australian New Zealand Clinical Trial Registry (ACTRN12618001573246)

Abstract Background Postoperative delirium is common in older adults, especially in those patients undergoing spine surgery, in whom it is estimated to occur in > 30% of patients. Although previously thought to be transient, it is now recognized that delirium is associated with both short- and long-term complications. Optimizing the depth of anesthesia may represent a modifiable strategy for delirium prevention. However, previous studies have generally not focused on reducing the depth of anesthesia beyond levels consistent with general anesthesia. Additionally, the results of prior studies have been conflicting. The primary aim of this study is to determine whether reduced depth of anesthesia using spinal anesthesia reduces the incidence of delirium after lumbar fusion surgery compared with general anesthesia. Methods This single-center randomized controlled trial is enrolling 218 older adults undergoing lumbar fusion surgery. Patients are randomized to reduced depth of anesthesia in the context of spinal anesthesia with targeted sedation using processed electroencephalogram monitoring versus general anesthesia without processed electroencephalogram monitoring. All patients are evaluated for delirium using the Confusion Assessment Method for 3 days after surgery or until discharge and undergo assessments of cognition, function, health-related quality of life, and pain at 3- and 12-months after surgery. The primary outcome is any occurrence of delirium. The main secondary outcome is change in the Mini-Mental Status Examination (or telephone equivalent) at 3-months after surgery. Discussion Delirium is an important complication after surgery in older adults. The results of this study will examine whether reduced depth of anesthesia using spinal anesthesia with targeted depth of sedation represents a modifiable intervention to reduce the incidence of delirium and other long-term outcomes. The results of this study will be presented at national meetings and published in peer-reviewed journals with the goal of improving perioperative outcomes for older adults. Trial registration Clinicaltrials.gov, NCT03133845. This study was submitted to Clinicaltrials.gov on October 23, 2015; however, it was not formally registered until April 28, 2017 due to formatting requirements from the registry, so the formal registration is retrospective.

Abstract These human-patient simulation scenarios give participants the opportunity to experience, treat, and receive feedback on their care of patients who are experiencing an acute uncal herniation. The scenarios allow participants to apply elements of effective teamwork such as sound communication style, workload distribution, and patient assessment and reassessment, in caring for these unstable simulated patients. This resource contains two simulation scenarios. One scenario occurs in the operating room when the patient is about to be anesthetized for a craniotomy. The second scenario occurs in the post-anesthesia care unit 2 hours postcraniotomy. In both scenarios all machinery, airway devices, and medications are made available to learners. The scenarios have been used for MS4 students, anesthesiology residents, and board-certified anesthesiologists for CME for maintenance of certification in anesthesiology. They have been very effective in generating discussion and understanding in the debriefing phase among the residents and faculty. MS4 come to understand that anesthesiology involves critical care medicine.

Introduction: Previous studies have shown that relative clause (RC) attachment preferences vary across languages, often influenced by factors like morphosyntactic agreement (e.g., number and gender). Mandarin Chinese, with its limited inflectional morphemes compared to Indo-European languages, provides a distinct context for examining this. This study explores relative clause attachment ambiguity in Mandarin by manipulating classifier-noun agreement. Method: This study conducted two self-paced reading experiments to investigate the influence of an initial classifier on comprehenders' anticipation of its associated noun and the impact of this prediction on RC attachment preferences in Mandarin Chinese. Results: Experiment 1 revealed a significant effect of classifier-noun agreement in offliine comprehension: there was an increase in selecting the high-attachment noun (NPhigh) as the RC attachment site when the classifier agreed with NPhigh, whereas there was a decrease in selecting NPhigh when the classifier agreed with the low-attachment noun (NPlow). Online processing results supported this effect, showing that classifiers guide comprehenders' expectations by pre-activating semantic features of the upcoming noun, thus modulating RC attachment preferences. Experiment 2 introduced semantic compatibility between the RC and potential attachment nouns as an additional disambiguating cue, revealing a reliable prediction effect for the upcoming noun. Although the classifier's prediction effect was diminished, it remained influential in this condition. Discussion: This study highlights the complexity of relative clause attachment in Mandarin, demonstrating the significant predictive roles of classifier-noun agreement and semantic compatibility. [ABSTRACT FROM AUTHOR]