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Competing Interests: None disclosed.

Type 1 Diabetes (T1D) is life-threatening without appropriate treatment. Though pediatric endocrinology care is limited in Rwanda, a decentralized health system allows access to local non-communicable disease (NCD) nurses through a network of 42 district hospitals. Recent rapid expansion of internet access in the country makes virtual diabetes education initiatives possible. We investigated whether Rwandan NCD nurses receiving diabetes education via online e-modules could make similar educational gains in insulin adjustment skills (IAS) compared to NCD nurses educated in a conference-style setting, and whether they would maintain equivalent competency at 1 year after education. We randomized 21 district hospitals and their NCD nurses to participate in a 1.5-day educational conference centered around care of type 1 diabetes (Group 1), while nurses from the remaining 21 hospitals (Group 2) received accommodation and access to equivalent educational materials in e-module form. Both groups were requested to review initial course materials at 4, 8, and 12 months. Ten-point IAS assessments were administered before and after education or review at each time point. Groups 1 and 2 had equal improvement after education (+2.0 vs. +2.0, p = 0.47) and equal final score at baseline (6.0 vs. 6.0, p = 0.74). However, both groups showed a diminishing improvement over time, so that any gains were lost by 4 months in Group 1 and 8 months in Group 2. Group 1 showed greater attrition in participation over time (19% vs 58% continued participation at one year, p = 0.002). Groups did not differ in subjective confidence in IAS after education. Both groups identified existing or potential access barriers to their respective educational method. While further modifications should be trialed to ensure equitable access and to maintain long-term engagement, online education is a feasible method to teach complex subspecialty skills to providers working in low-resource settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Importance: Smoking, a common lifestyle trait, is considered by many surgeons to be a major risk factor for postoperative complications. However, in the literature on local reconstruction, the association between smoking and the rate of postoperative complications after cutaneous tissue transfer is not well characterized., Objective: To study the outcomes of flaps and grafts used in Mohs micrographic surgery reconstruction with respect to smoking status and patient-specific and surgery-specific variables., Design, Setting, and Participants: This retrospective case-control study was conducted at a single tertiary referral center among 1008 patients who underwent Mohs reconstruction repaired by flap or graft between July 1, 2012, and June 30, 2016, and were selected via consecutive sampling. Cases with incomplete records or those in which a single flap or graft was used to repair multiple defects were excluded. Data analysis was performed from September 2017 to January 2018., Main Outcomes and Measures: Postoperative acute and long-term complications. Acute complications included postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention. Long-term complications included functional or cosmetic outcomes that prompted the patient to request or the surgeon to offer additional intervention., Results: Of the 1008 patients included in the study (396 women and 612 men), the median (SD) age was 70 (12) years (range, 21-90 years). A total of 128 patients (12.7%) were current smokers, 385 (38.2%) were former smokers, and 495 (49.1%) were never smokers. On multivariate logistic regression, current smoking (odds ratio [OR], 9.58; 95% CI, 3.63-25.3), former smoking (OR, 3.64; 95% CI, 1.41-9.38), larger defect size (OR, 2.25; 95% CI, 1.58-3.20), and the use of free cartilage graft (OR, 8.19; 95% CI, 2.02-33.1) were associated with increased risks of acute complications. For long-term complications, central face location (OR, 25.4; 95% CI, 6.16-106.5), use of interpolation flap or flap-graft combination (OR, 3.49; 95% CI, 1.81-6.74), larger flap size (OR, 1.42; 95% CI, 1.09-1.87), and basal cell carcinomas or other basaloid tumors (OR, 3.43; 95% CI, 1.03-11.5) were associated with an increased risk, whereas increased age (OR, 0.66 per 10-year interval; 95% CI, 0.54-0.80) was associated with decreased risk., Conclusions and Relevance: This study suggests that both current and former smokers are at increased risk for acute postsurgical complications but that smoking status is not associated with long-term complications. These findings may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling., Level of Evidence: 3.

Atrial fibrillation is the most common arrhythmia and ablation is becoming more prevalent as a treatment option. Appropriate treatment of atrial fibrillation mandates thromboembolic prophylaxis, and atrial fibrillation ablation periprocedural management of oral anticoagulation is paramount because of the unique susceptibility for thromboembolism that exists for a patient undergoing ablation. Uninterrupted warfarin therapy is the current standard approach for periprocedural atrial fibrillation anticoagulation. Novel oral anticoagulants, including direct thrombin and factor Xa inhibitors, are being used more frequently for thromboembolic prophylaxis in atrial fibrillation patients, but the best strategy for using novel oral anticoagulants in periprocedural anticoagulation is unknown. Optimal periprocedural anticoagulation management strategies with oral anticoagulants, limitations of using novel oral anticoagulants, and future directions in this field are discussed., (© 2014 Wiley Periodicals, Inc.)

The degradation kinetics of moricizine hydrochloride (1) were examined over a pH range of 0.6 to 6.0 at an ionic strength of 0.3 and 60 degrees C. The disappearance of intact 1 was followed by a stability-indicating HPLC assay. The degradation products, which had approximate solubilities of less than 100 micrograms/mL, precipitated in aqueous solution. The precipitate was collected for HPLC analysis and identification of degradation products. Degradation of 1 was catalyzed by acetate and phosphate buffers and was pH dependent, with the pH of the minimum rate constant located between 2.8 and 3.2. At pH 0.6-2.0, 1 degraded via amide hydrolysis to yield first ethyl (10H-phenothiazin-2-yl) carbamate (2), an amide hydrolysis product, which further oxidized in parallel to give ethyl (3-oxo-3H-phenothiazin-2-yl) carbamate (3), ethyl (10H-phenothiazin-2-yl) carbamate S-oxide (4), and diethyl (3,10'-bi-10H-phenothiazine-2,2'-diyl)bis(carbamate) (5), the dimer of the amide hydrolysis product. At pH 2.2-6.0, 1 degraded via a reverse Mannich reaction, to form the reverse Mannich product ethyl [10-(1-oxo-2-propenyl)-10H-phenothiazin-2-yl] carbamate (6), and by parallel reaction via the described amide hydrolysis pathway. The dimer of the amide hydrolysis product was not detectable at pH greater than 2.8. At pH greater than 4.0, the reverse Mannich product was the predominant degradation product. Degradation of 1 was subject to positive and negative kinetic salt effects at pH 1.0 and 4.0, respectively. Arrhenius plots determined at pH 1.0 and 6.0 were linear between 37 and 70 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)