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Introduction The surge of SARS-CoV-2-virus infected (COVID-19) patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC in early March 2020. Upon the arrival of military medical assets to the Javits Convention Center in NYC, the planned mission to care for non-SARS-CoV-2 patients was immediately changed to manage patients with (SARS-CoV-2)COVID-19 and their comorbid conditions. Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the Javits New York Medical Station (JNYMS) from April 2020. Methods The data review reported aggregated summary statistics and participant observations collected by N.Y. State and U.S. military officials. Results During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2-positive patients were transferred from NYC hospitals to the JNYMS. At its peak, the JNYMS accepted 119 patients in a single day, had a maximum census of 453, and had a peak intensive care unit census of 35. The median length of stay was 4.6 days (interquartile range: 3.1-6.9 days). A total of 103 patients were transferred back to local hospitals, and there were 6 deaths, with an overall mortality rate of 0.6% (95% CI, 0.3-1.2). Discussion and Conclusions This is the first report of the care provided at the JNYMS. Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1,000 SARS-CoV-2 patients with varying degrees of illness in a 1-month period. This was the largest field hospital mobilization in the U.S. medical history in response to a non-wartime pandemic. Its success with huge patient throughput including disposition and low mortality relieved critical overcrowding and supply deficiencies throughout NYC hospitals. The downstream impact likely saved additional hundreds of lives and reduced stress on the system during this healthcare crisis.

Objectives Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy. Methods From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff. Results Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001). Conclusions Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.

Combinatorial synthesis and high-throughput characterization of a Ni-Ti-Co thin film materials library are reported for exploration of reversible martensitic transformation. The library was prepared by magnetron co-sputtering, annealed in vacuum at 500 °C without atmospheric exposure, and evaluated for shape memory behavior as an indicator of transformation. Composition, structure, and transformation behavior of the 177 pads in the library were characterized using high-throughput wavelength dispersive spectroscopy (WDS), X-ray photoelectron spectroscopy (XPS), X-ray diffraction (XRD), and four-point probe temperature-dependent resistance (R(T)) measurements. A new, expanded composition space having phase transformation with low thermal hysteresis and Co > 10 at. % is found. Unsupervised machine learning methods of hierarchical clustering were employed to streamline data processing of the large XRD and XPS data sets. Through cluster analysis of XRD data, we identified and mapped the constituent structural phases. Composition-structure-property maps for the ternary system are made to correlate the functional properties to the local microstructure and composition of the Ni-Ti-Co thin film library.

Purpose To establish the magnetic resonance imaging (MRI) and operative incidence of ramp lesions in a consecutive group of patients who had undergone anterior cruciate ligament reconstruction (ACLR) and to propose a graded radiologic classification that seeks to define key preoperative features that most strongly correlate with arthroscopically confirmed ramp lesions. Methods After retrospective review, all consecutive patients who underwent ACLR with preoperative MRI over a 16-month period were included in the study. Diagnostic arthroscopy with direct visualization of the posteromedial compartment was used to establish the true incidence of ramp lesions. Three radiologists, blinded to the surgical findings, independently analyzed the MRI scans of all patients and classified the signal intensity at the posterior meniscocapsular junction using 4 criteria (type 1, diffuse increased signal equal to adjacent femoral cartilage; type 2, diffuse increased signal greater than cartilage; type 3, diffuse increased signal plus full-height linear fluid-signal cleft; and type 4, full-height fluid-signal meniscocapsular separation). Interobserver reliability, in addition to sensitivity, specificity, and positive and negative predictive values, was calculated. Results Of the 93 patients included (mean age, 26.7 years), 11 (11.8%) were confirmed to have ramp lesions on arthroscopy. Inter-rater reliability for the MRI diagnosis of the positive ramp lesions was good, at 0.75. Type 3 criteria were the most accurate, producing average sensitivity and specificity values of 85% and 82%, respectively. Conclusions Ramp lesions are not infrequently encountered in ACLR and, if not recognized at the time of surgery, may contribute to inferior outcomes. MRI is an effective method of preoperative assessment, and the presence of type 3 changes should be used as criteria for radiologically definitive ramp lesion diagnosis. Clinical Relevance This study highlights the incidence of meniscal ramp lesions encountered in ACLR surgery and the effectiveness of MRI as a preoperative imaging modality.

Objective Medical errors affect trainees. Existing curricula emphasize tenets of patient safety but rarely address the impact of medical errors on health care providers, particularly at the undergraduate level. The authors developed an interactive session exploring the professional and personal effects of medical errors for 300 second-year medical students. Methods The session utilized case-based learning, small group discussion, and video vignettes. Physicians in multiple specialties were interviewed, sharing narrative accounts of their experience with medical errors and adverse events. Discussions were facilitated by local physicians, who delivered content and shared personal anecdotes. Surveys using a 5-point Likert scale were conducted before and after the session. Results Pre- and post-test surveys resulted in 91 responses in 2016 and 174 in 2017. In 2016, results showed significant change in student responses by 0.34 units (SD 0.35 units; p < 0.001). Two survey items addressing student awareness and three items addressing confidence were significant. The domains assessing students’ attitudes and knowledge regarding medical errors were not significant. In 2017, the overall mean change was 0.33 with a lower standard error, 0.03 (p < 0.001), showing significance in both years the session was delivered. Conclusion A 1-h, small-group session increased medical students’ understanding of the impact of medical errors and adverse events on providers and the supportive resources available. Recruitment of local faculty to facilitate discussions and share personal anecdotes enhanced the success of the session.

IntroductionNeurogenic thoracic outlet syndrome (NTOS) is a rare and sometimes overlooked cause of upper limb pain, weakness and disability and presents to a range of different healthcare professionals. Here we present a case of severe NTOS with characteristic clinical, radiological and electroclinical findings.HistoryA 16 year old right-handed female presented with a two year history of progressive symptoms affecting her left hand. Initially she noticed weakness affecting initially the 4thand 5thleft digits which progressed to involve the whole hand. She described a burning sensation affecting the medial aspect of her left forearm at night.ExaminationExamination of the left arm revealed decreased bulk of the thenar, hypothenar and inter- ossei intrinsic muscles of the hand, power diminished to grade 4 in the left ADM, APB, FDIO and to grade 4+ in left EDC, and altered sensation in the T1 dermatome.InvestigationsA lordotic chest radiograph revealed bilaterally elongated C7 transverse processes, a finding confirmed on retrospective review of the brachial plexus MRI, which also revealed bilateral grade 1 cervical ribs and increased signal on STIR sequence of the left C8 and T1 nerve roots. Nerve conduction studies revealed electroclinical evidence of a left lower trunk brachial plexopathy.OutcomeThe patients neuropathic pain responded to low dose gabapentin. She was assessed at the Peripheral Nerve Injuries Unit at RNOH Stanmore and recently underwent successful left thoracic outlet decompression.hamish.morrison@nhs.net

Objective The incidence of lymph node metastases (LNM) in squamous cell carcinoma of the lip is modest (8%), making it challenging to identify patients that may benefit from elective pathologic staging evaluation of the neck. We evaluated predictors of LNM in patients with lip cancer in order to potentially refine selection of patients for pathologic staging evaluation of the neck. Study design Retrospective cohort study. Subjects Clinically N0 patients with squamous cell carcinoma of the lip that underwent definitive surgical resection and pathologic evaluation of lymph node metastases in the National Cancer Data Base from 2006 to 2013. Methods Multivariable binomial logistic-regression was used to assess the relationship between occult pathologic lymph node metastasis and potential preoperative predictors including; patient demographics, T-stage, location, and pathologic details. Results Among 786 patients the overall rate of LNM was 12.1%. Patients were more likely to have LNM with T2 (odds ratio (OR) 2.05; (95% confidence interval (CI) 1.19–3.54) or T3–4 (OR 2.36; CI 1.32–4.22) moderately differentiated (OR 2.65; CI 1.30–5.38) or poorly differentiated (OR 4.37; CI 1.97–9.71), or involvement of the mucosal surface (OR 1.82; CI 1.09–3.03). We created a prediction model based on proportional odd ratios from multivariant binomial logistic-regression analysis from statistically significant factors; incorporating T2–4, moderate/poorly differentiated, or mucosal site. Conclusion Our prediction model found that patients with two or more risk factors were the best candidates for elective pathologic nodal evaluation.

Intra-articular entrapment of the medial collateral ligament (MCL) is a rare but recognised complication of traumatic injury to the posteromedial corner (PMC) of the knee. Considering the MCL is the most commonly injured ligament of the knee this complication is extremely rare with only a handful of cases describing MCL entrapment following distal avulsion of the MCL. We present the first known case of MCL entrapment following proximal avulsion of the MCL and posterior oblique ligament (POL) with the mid-substance of the MCL becoming entrapped in the joint, lying on the superior surface of the medial meniscus and extending up into the intercondylar notch. In addition, the medial patellar retinaculum was also entrapped in the medial aspect of the medial patellofemoral joint. MCL entrapment is best treated with expeditious surgical intervention and it is therefore crucial that the MRI findings are not overlooked. Details of the clinical assessment, MRI and operative findings are presented with a literature review of MCL entrapment.

The American Academy of Pediatrics has created recommendations for health appraisal and preparation of young people before participation in day, resident, or family camps and to guide health and safety practices at camp. These recommendations are intended for parents and families, primary health care providers, and camp administration and health center staff. Although camps have diverse environments, there are general guidelines that apply to all situations and specific recommendations that are appropriate under special conditions. This policy statement has been reviewed and is supported by the American Camp Association and Association of Camp Nursing.

The last few decades have seen rapid development in computational and theoretical tools for simulating, fabricating, and characterizing material systems. In this report, the potential of surface characterization by x-ray photoelectron spectroscopy (XPS) to provide rapid elemental and chemical state information is presented. The development of the group analysis array functionality is significant for facilitating processing and display of large datasets in the application of XPS analysis to combinatorial materials discovery. We demonstrate that group array analysis provides a more detailed understanding of the chemical distribution across a Ni-Ti-Co combinatorial thin-film materials library.

We study the recently introduced 'critically coupled' model of magnetic Skyrmions, generalising it to thin films with curved geometry. The model feels keenly the extrinsic geometry of the film in three-dimensional space. We find exact Skyrmion solutions on spherical, conical and cylindrical thin films. Axially symmetric solutions on cylindrical films are described by kinks tunnelling between 'vacua'. For the model defined on general compact thin films, we prove the existence of energy minimising multi-Skyrmion solutions and construct the (resolved) moduli space of these solutions., Comment: 27 pages, 4 figures. v2: title changed, references added, figures improved, minor corrections made; version accepted for publication

MRI is an excellent diagnostic tool in the imaging of sports-related musculoskeletal pathology; however, standard slice thickness acquisitions can lack the spatial resolution to accurately define and characterise osseous abnormalities. Standard MRI sequences may be supplemented with CT to reduce diagnostic uncertainty. We provide a clinical perspective, in the form of pictorial review, on the potential applications of 3D MRI sequences, specifically using volumetric interpolated breath-hold examination in the characterisation of various musculoskeletal osseous pathologies. The potential to negate the requirement for CT in a young radiation sensitive cohort is a clinically significant concept and suggests the requirement for further studies comparing the performance of volumetric MRI to CT.

The American Academy of Pediatrics recommends that specific guidelines be established for health appraisals of young people before participation in day and resident camps. Camp guidelines should include reference to health maintenance, storage and administration of medication, and emergency medical services. Although camps have diverse environments, there are general guidelines that apply to all situations and specific recommendations that are appropriate under special conditions. This policy statement has been reviewed and is supported by the American Camp Association.

In modern medical practice, there is an ever-increasing rise in litigation. A strong emphasis is placed on good record keeping as an integral part of patient care and the clinician legal defence. This commentary describes the potential flaws and vulnerabilities in the radiologist record keeping and the potential implications for patient care.

In today's science education reform efforts, teachers are being asked to teach with different materials, and in different ways than they themselves were taught or learned to teach. This chemistry course will provide future teachers with the solid underpinning needed to understand chemical concepts, and an experience base from which they can draw upon in their teaching. This course was designed jointly by university chemistry instructors, students, and practicing teachers. It uses hands-on, learner-centered, and inquiry-based pedagogies to promote deeper learning. The course offers strong chemical content and provides students with a model of effective science teaching. Students define, design, and carry out investigations of real-world issues. There is a focus on the human side of science through inclusion of historical, cultural, and environmental perspectives. This project produced a model of effective chemistry teaching that is applicable to any undergraduate non-majors or majors chemistry course. The ...

6 beta-[(1-Substituted-4-pyridinio)amino]penam-3-carboxylates and 7 beta-[(1-substituted-4-pyridinio)amino]ceph-3-em-4-carboxylates have been found to be interesting new classes of antibacterial beta-lactams, readily available by SN2 Ar coupling of fluoro-substituted quaternized pyridines and appropriate amino lactam carboxylic acids. Compared to penicillin G, the penam 12c exhibited a spectrum extended to Gram-negative species, such as Escherichia, Shigella, Klebsiella and Enterobacter, offset by a loss of potency against Gram-positive species. Excluding Pseudomonas, many examples of the cephems showed excellent activity against the above Gram-negative organisms, and in some cases, such as 15i, the spectrum included good performance against the staphylococci and streptococci. With Serratia and many Proteus species, there was an adverse inoculum and medium effect which was not observed in the good Gram-positive reach of the cephem series.

Reaction of methyl 2,3-anhydro-5- O -trityl-β- d -ribofuranoside ( 4 ) with methyl-magnesium chloride gave a mixture of methyl 3-chloro-3-deoxy-5- O -trityl-β- d -xylofuranoside ( 5 ) and methyl 3-deoxy-3- C -methyl-5- O -trityl-α- d -xylofuranoside ( 6 ). Removal of the trityl group from 6 gave methyl 3-deoxy-3- C -methyl-β- d -xylofuranoside ( 9 ), which, on treatment with p -nitrobenzoyl chloride, gave methyl 3-deoxy-3- C -methyl-2,5-di- O -( p -nitrobenzoyl)-β- d -xylofuranoside ( 10 ). The glycosyl chloride ( 15 ) derived from 10 reacted with 6-(benzamido)chloromercuripurine to give 6-(benzamido)-9-[3-deoxy-3- C -methyl-2,5-di- O -( p -nitrobenzoyl)- d -xylofuranosyl]purine ( 16 ). Alkaline methanolysis of 16 produced 9-(3-deoxy-3- C -methyl-α- d -xylofuranosyl)-adenine (α- 1 ) and 9-(3-deoxy-3- C -methyl-β- d -xylofuranosyl)adenine (β- 1 ) in the ratio of 1:4. Treatment of 6 with benzoyl chloride gave methyl 2- O -benzoyl-3-deoxy-3- C -methyl-5- O -trityl-β- d -xylofuranoside ( 17 ). The trityl group was removed from 17 to give methyl 2- O -benzoyl-3-deoxy-3- C -methyl-β- d -xylofuranoside ( 18 ), which was converted into methyl 2,5-di- O -benzoyl-3-deoxy-3- C -methyl-β- d -xylofuranoside ( 19 ). When the glycosyl halide ( 20 ) obtained from 19 reacted with 6-(benzamido)chloromercuripurine, 6-(benzamido)-9-(2,5-di- O -benzoyl-3-deoxy-3- C -methyl- d -xylofuranosyl)-purine ( 21 ) was produced. Ammonolysis of 21 gave α- 1 and β- 1 in the ratio of 1:16.