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Yuefeng Hou,1 Leah P Griffin,2 Kari Ertmer,3 Stéphanie F Bernatchez,3 Tarja J Kärpänen,4 Maria Palka-Santini4 1 3M Health Care, 3M Company, Austin, TX, USA; 2 3M Health Care, 3M Company, San Antonio, TX, USA; 3 3M Health Care, 3M Company, St, Paul, MN, USA; 4 3M Health Care, 3M Deutschland GmbH, Neuss, GermanyCorrespondence: Yuefeng Hou, Email yhou@mmm.comPurpose: Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic.Methods: The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively.Results: The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group.Conclusion: This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.Keywords: comparative effectiveness, real world evidence, Premier Healthcare Database, inpatient, cohort study, central venous catheters

Molecular chains of two-coordinate carbon atoms (cumulenes) have long been targeted, due to interest in the electronic structure and applications of extended π-systems, and their relationship to the carbon allotrope, carbyne. While formal (isoelectronic) B═N for C═C substitution has been employed in two-dimensional (2-D) materials, unsaturated one-dimensional all-inorganic "molecular wires" are unknown. Here, we report high-yielding synthetic approaches to heterocumulenes containing a five-atom BNBNB chain, the geometric structure of which can be modified by choice of end group. The diamido-capped system is bent at the 2-/4-positions, and natural resonance theory calculations reveal significant contributions from B═N(:)-B≡N-B resonance forms featuring a lone pair at N (consistent with observed N-centered nucleophilicity). Molecular modification to generate a linear system best described by a B═N═B═N═B resonance structure involves chemical transformation of the capping groups (using B(C 5 F 5 ) 3 ) to enhance their π-acidity and conjugate the N-lone pairs.

Complexation of the green bismuthinidene (RBi) with two equivalents of a highly fluorinated aryl iodide at low temperature allows the crystallographic identification of an unstable red species that can be regarded as an intermediate in an overall Bi(I) → Bi(III) oxidation process. Both C-I bonds are orientated toward the filled 6p orbital of bismuth (Bi-I distances 3.44-3.52 Å), leading to an elongation of the C-I bonds by 0.05 and 0.07 Å. Density functional theory (DFT) calculations confirm that the Bi(I) center is indeed acting as an electron donor, establishing two strong and directional halogen bonds. The color change from green to red upon halogen bond formation is a consequence of the energetic stabilization of a Bi(I) lone pair by interactions with the sigma-holes of the halogen bond donors. Overall, this study presents the first structural proof of bismuth, and more generally of heavy organopnictogen(I) compounds, acting as halogen bond acceptors.

The synthesis of a series of isostructural organometallic complexes featuring Ae-Tr bonds (Ae = Be, Mg; Tr = Al, Ga, In) has been investigated, and their electronic structures probed by quantum chemical calculations. This systematic study allows for comparison, not only of the metal-metal bonding chemistries of the two lightest alkaline earth (Ae) elements, beryllium and magnesium, but also of the three triel (Tr) elements, aluminium, gallium, and indium. Computational analyses (NBO, QTAIM, EDA-NOCV) reveal that Be-Tr bonding is more covalent than Mg-Tr bonding. More strikingly, these calculations predict that the beryllium-indyl complex - featuring the first structurally characterised Be-In bond - should act as a source of nucleophilic beryllium. This has been confirmed experimentally by its reactivity towards methyl iodide, which yields the Be-Me functionality. By extension, the electrophilic character of the beryllium centre in the beryllium-gallyl complex contrasts with the umpoled, nucleophilic behaviour of the beryllium centre in both the -indyl and -aluminyl complexes., Competing Interests: The authors declare no competing interests., (This journal is © The Royal Society of Chemistry.)

By exploiting the electronic capabilities of the N-heterocyclic boryloxy (NHBO) ligand, we have synthesized "naked" acyclic gallyl [Ga{OB(NDippCH) 2 } 2 ] - and indyl [In{OB(NDippCH) 2 } 2 ] - anions (as their [K(2.2.2-crypt)] + salts) through K + abstraction from [KGa{OB(NDippCH) 2 } 2 ] and [KIn{OB(NDippCH) 2 } 2 ] using 2.2.2-crypt. These systems represent the first O-ligated gallyl/indyl systems, are ultimately accessed from cyclopentadienyl Ga I /In I precursors by substitution chemistry, and display nucleophilic reactivity which is strongly influenced by the presence (or otherwise) of the K + counterion., (© 2024 The Authors. Angewandte Chemie International Edition published by Wiley-VCH GmbH.)

Interspecific interactions, including predator-prey, intraguild predation (IGP) and competition, may drive distribution and habitat use of predator communities. However, elucidating the relative importance of these interactions in shaping predator distributions is challenging, especially in marine communities comprising highly mobile species. We used individual-based models (IBMs) to predict the habitat distributions of apex predators, intraguild (IG) prey and prey. We then used passive acoustic telemetry to test these predictions in a subtropical marine predator community consisting of eight elasmobranch (i.e. shark and ray) species in Bimini, The Bahamas. IBMs predicted that prey and IG prey will preferentially select habitats based on safety over resources (food), with stronger selection for safe habitat by smaller prey. Elasmobranch space-use patterns matched these predictions. Species with predator-prey and asymmetrical IGP (between apex and small mesopredators) interactions showed the clearest spatial separation, followed by asymmetrical IGP among apex and large mesopredators. Competitors showed greater spatial overlap although with finer-scale differences in microhabitat use. Our study suggests space-use patterns in elasmobranchs are at least partially driven by interspecific interactions, with stronger spatial separation occurring where interactions include predator-prey relationships or IGP., (© 2024 The Authors. Journal of Animal Ecology © 2024 British Ecological Society.)

Bimetallic compounds containing direct metal-group 13 element bonds have been shown to display unprecedented patterns of cooperative reactivity towards small molecules, which can be influenced by the identity of the group 13 element. In this context, we present here a systematic appraisal of group 13 metallo-ligands of the type [(NON)E] - (NON=4,5-bis(2,6-diisopropylanilido)-2,7-di-tert-butyl-9,9-dimethylxanthene) for E=Al, Ga and In, through a comparison of structural and spectroscopic parameters associated with the trans L or X ligands in linear d 10 complexes of the types LM{E(NON)} and XM'{E(NON)}. These studies are facilitated by convenient syntheses (from the In(I) precursor, InCp) of the potassium indyl species [{K(NON)In}⋅KCp] n (1) and [(18-crown-6) 2 K 2 Cp] [(NON)In] (1'), and lead to the first structural characterisation of Ag-In and Hg-E (E=Al, In) covalent bonds. The resulting structural, spectroscopic and quantum chemical probes of Ag/Hg complexes are consistent with markedly stronger σ-donor capabilities of the aluminyl ligand, [(NON)Al] - , over its gallium and indium counterparts., (© 2024 The Authors. Angewandte Chemie International Edition published by Wiley-VCH GmbH.)

The homoleptic magnesium bis(aluminyl) compound Mg[Al(NON)] 2 (NON=4,5-bis(2,6-diisopropylanilido)-2,7-di-tert-butyl-9,9-dimethylxanthene) can be accessed from K 2 [Al(NON)] 2 and MgI 2 and shown to possess a non-linear geometry (∠Al-Mg-Al=164.8(1)°) primarily due to the influence of dispersion interactions. This compound acts a four-electron reservoir in the reductive de-fluorination of SF 6 , and reacts thermally with polar substrates such as MeI via nucleophilic attack through aluminium, consistent with the QT-AIM charges calculated for the metal centres, and a formal description as a Al(I)-Mg(II)-Al(I) trimetallic. On the other hand, under photolytic activation, the reaction with 1,5-cyclooctadiene leads to the stereo-selective generation of transannular cycloaddition products consistent with radical based chemistry, emphasizing the covalent nature of the Mg-Al bonds and a description as a Al(II)-Mg(0)-Al(II) synthon. Consistently, photolysis of Mg[Al(NON)] 2 in hexane in the absence of COD generates [Al(NON)] 2 together with magnesium metal., (© 2024 The Authors. Angewandte Chemie International Edition published by Wiley-VCH GmbH.)

The large steric profile of the N-heterocyclic boryloxy ligand, -OB(NDippCH) 2 , and its ability to stabilize the metal-centered HOMO, are exploited in the synthesis of the first example of a "naked" acyclic aluminyl complex, [K(2.2.2-crypt)][Al{OB(NDippCH) 2 } 2 ]. This system, which is formed by substitution at Al I (rather than reduction of Al III ), represents the first O-ligated aluminyl compound and is shown to be capable of hitherto unprecedented reversible single-site [4 + 1] cycloaddition of benzene. This chemistry and the unusual regioselectivity of the related cycloaddition of anthracene are shown to be highly dependent on the availability (or otherwise) of the K + countercation.

Background: Surgical site complications (SSCs) contribute to increased healthcare costs. Predictive analytics can aid in identifying high-risk patients and implementing optimization strategies. This study aimed to develop and validate a risk-assessment score for SSC-associated readmissions (SSC-ARs) in patients undergoing open spine surgery., Methods: The Premier Healthcare Database (PHD) of adult patients (n=157,664; 3,182 SSC-ARs) between January 2019 and September 2020 was used for retrospective data analysis to create an SSC risk score using mixed effects logistic regression modeling. Full and reduced models were developed using patient-, facility-, or procedure-related predictors. The full model used 37 predictors and the reduced used 19., Results: The reduced model exhibited fair discriminatory capability (C-statistic =74.12%) and demonstrated better model fit [Pearson chi-square/degrees of freedom (DF) =0.93] compared to the full model (C-statistic =74.56%; Pearson chi-square/DF =0.92). The risk scoring system, based on the reduced model, comprised the following factors: female (1 point), blood disorder [2], congestive heart failure [2], dementia [3], chronic pulmonary disease [2], rheumatic disease [3], hypertension [2], obesity [2], severe comorbidity [2], nicotine dependence [1], liver disease [2], paraplegia and hemiplegia [3], peripheral vascular disease [2], renal disease [2], cancer [1], diabetes [2], revision surgery [2], operative hours ≥5 [4], emergency/urgent surgery [2]. A final risk score (sum of the points for each surgery; range, 0-40) was validated using a 1,000-surgery random hold-out sample (C-statistic =85.16%)., Conclusions: The resulting SSC-AR risk score, composed of readily obtainable clinical information, could serve as a robust predictive tool for unplanned readmissions related to wound complications in the preoperative setting of open spine surgery., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-23-89/coif). K.B.M. is a paid consultant for 3M Health Care. He has personally received payment/honoraria for his assistance in writing this manuscript. Y.H., K.B., and L.P.G. are employees of 3M. The authors have no other conflicts of interest to declare., (2024 Journal of Spine Surgery. All rights reserved.)

Background: Septic arthritis of the shoulder is distinctly challenging to diagnose and treat. Guidelines for appropriate workup and management are limited and do not account for the variations in clinical presentation. The purpose of this study was to present a comprehensive and anatomically based classification system and treatment algorithm for septic arthritis of the native shoulder joint., Methods: A multicenter, retrospective analysis of all patients treated surgically for septic arthritis of the native shoulder joint was performed at 2 tertiary care academic institutions. Preoperative magnetic resonance imaging and operative reports were used to classify patients as having 1 of 3 infection subtypes: type I, confined to the glenohumeral joint; type II, extra-articular extension; or type III, concomitant osteomyelitis. On the basis of these clinical groupings of patients, the comorbidities, types of surgical management, and outcomes were analyzed., Results: Sixty-five shoulders in 64 patients met the inclusion criteria for the study. Of these infected shoulders, 9.2% had type I infections, 47.7% had type II, and 43.1% had type III. Age and the time between symptom onset and diagnosis were the only significant risk factors for the development of a more severe infection. Fifty-seven percent of shoulder aspirates revealed cell counts below the standard surgical cutoff of 50,000 cells/mL. On average, each patient required 2.2 surgical débridements to eradicate the infection. Infections recurred in 8 shoulders (12.3%). Body mass index was the only risk factor for recurrence of infection. Of the 64 patients, 1 (1.6%) died acutely of sepsis and multiorgan system failure., Conclusion: We propose a comprehensive system for the classification and management of spontaneous shoulder sepsis based on stage and anatomy. Preoperative magnetic resonance imaging can help determine the severity of disease and aid in surgical decision making. A systematic approach to septic arthritis of the shoulder as a unique entity from septic arthritis of other large peripheral joints may lead to more timely diagnosis and treatment and improve the overall prognosis., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Closed incision negative pressure therapy (ciNPT) has been adopted into practices of diverse surgical specialties to help reduce postsurgical complication risks. There are two primary commercially available systems that deliver ciNPT through different mechanisms. The purpose of this meta-analysis is to compare the potential effects of two different ciNPT systems on clinical outcomes following hip and knee arthroplasty. A systematic literature search was conducted to identify hip and knee arthroplasty studies comparing the incidence of surgical site infections (SSIs) and surgical site complications (SSCs) versus standard of care (SOC) following the use of two different ciNPT systems. Four meta-analyses were performed by calculating risk ratios (RR) to assess the effect of (1) ciNPT with foam dressing (ciNPT-F) versus SOC and (2) ciNPT with multilayer absorbent dressing (ciNPT-MLA) versus SOC. Comprehensive Meta-Analysis Version 3.0 (Biostat Inc., Englewood, NJ) software was used to perform the analyses. Twelve studies comparing ciNPT-F to SOC and six studies comparing ciNPT-MLAto SOC were analyzed. SSI rates were reported in seven of 12 studies involving ciNPT-F. In those, ciNPT-F significantly reduced the incidence of SSI (RR = .401, 95% confidence interval (CI) = .190, .844; p = .016). Across four of six studies that reported SSI rates, there was no significant difference in SSI rates between ciNPT-MLAvs SOC (RR = .580, 95% CI = .222, 1.513; p = .265). SSC rates were evaluated in eight of 12 ciNPT-F studies that reported SSC rates. This meta-analysis of the eight ciNPT-F studies showed significantly reduced SSC rates with ciNPT-F vs SOC (RR = .332, 95% CI = .236, .467; p < 0.001). For ciNPT-MLA, five of six studies reported SSC rates. In those, there was no significant difference in SSC rates between ciNPT-MLA vs SOC (RR = .798, 95% CI = .458, 1.398; p = .425). These meta-analyses results showed a significant reduction in SSI and SSC rates in the ciNPT-F group vs SOC and no difference in SSI and SSC rates in the ciNPT-MLA group vs SOC. The reasons for these observed differences were not evaluated as part of this study. Future controlled clinical studies comparing outcomes between different ciNPT systems over closed orthopedic incisions would help to validate these study results., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Cooper et al.)

Tropical and subtropical coastal flats are shallow regions of the marine environment at the intersection of land and sea. These regions provide myriad ecological goods and services, including recreational fisheries focused on flats-inhabiting fishes such as bonefish, tarpon, and permit. The cascading effects of climate change have the potential to negatively impact coastal flats around the globe and to reduce their ecological and economic value. In this paper, we consider how the combined effects of climate change, including extremes in temperature and precipitation regimes, sea level rise, and changes in nutrient dynamics, are causing rapid and potentially permanent changes to the structure and function of tropical and subtropical flats ecosystems. We then apply the available science on recreationally targeted fishes to reveal how these changes can cascade through layers of biological organization-from individuals, to populations, to communities-and ultimately impact the coastal systems that depend on them. We identify critical gaps in knowledge related to the extent and severity of these effects, and how such gaps influence the effectiveness of conservation, management, policy, and grassroots stewardship efforts., Competing Interests: Competing interestsAndy Danylchuk, Aaron Adams, and Steve Cooke are Guest Editors of this special issue, but they had no involvement in the peer review of this article and had no access to information regarding its peer review., (© The Author(s), under exclusive licence to Springer Nature B.V. 2022, corrected publication 2022Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Surgical site infection (SSI) after open spine surgery increases healthcare costs and patient morbidity. Predictive analytics using large databases can be used to develop prediction tools to aid surgeons in identifying high-risk patients and strategies for optimization. The purpose of this study was to develop and validate an SSI risk-assessment score for patients undergoing open spine surgery., Methods: The Premier Healthcare Database of adult open spine surgery patients ( n  = 157,664; 2,650 SSIs) was used to create an SSI risk scoring system using mixed effects logistic regression modeling. Full and reduced multilevel logistic regression models were developed using patient, surgery or facility predictors. The full model used 38 predictors and the reduced used 16 predictors. The resulting risk score was the sum of points assigned to 16 predictors., Results: The reduced model showed good discriminatory capability (C-statistic = 0.75) and good fit of the model ([Pearson Chi-square/DF] = 0.90, CAIC=25,517) compared to the full model (C-statistic = 0.75, [Pearson Chi-square/DF] =0.90, CAIC=25,578). The risk scoring system, based on the reduced model, included the following: female (5 points), hypertension (4), blood disorder (8), peripheral vascular disease (9), chronic pulmonary disease (6), rheumatic disease (16), obesity (12), nicotine dependence (5), Charlson Comorbidity Index (2 per point), revision surgery (14), number of ICD-10 procedures (1 per procedure), operative time (1 per hour), and emergency/urgent surgery (12). A final risk score as the sum of the points for each surgery was validated using a 1,000-surgery random hold-out (independent from the study cohort) sample (C-statistic = 0.77)., Conclusions: The resulting SSI risk score composed of readily obtainable clinical information could serve as a strong prediction tool for SSI in preoperative settings when open spine surgery is considered., Competing Interests: One or more authors declare potential competing financial interests or personal relationships as specified on required ICMJE-NASSJ Disclosure Forms., (© 2022 Published by Elsevier Ltd on behalf of North American Spine Society.)

Objectives: To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs)., Design: A retrospective cohort study., Setting: Large public level 1 trauma center., Patients: A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status., Intervention: DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application., Main Outcome Measurements: Operative rates of DRF, total hospital charges, and length of stay., Results: Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention., Conclusions: This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care., Level of Evidence: Prognostic Level III., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Introduction: Although NPWTi-d has been associated with improved patient outcomes compared with NPWT alone, questions remain regarding the timing of NPWTi-d initiation., Objective: This study examined the effect of the timing of NPWTi-d initiation on patient outcomes and costs., Methods: A retrospective analysis was conducted utilizing a national, all-payer hospital database and included patients who received NPWTi-d in 2019. A matched cohort of 514 patients who received either early (within 1 day of NPWT application) or late (within 2-7 days of NPWT application) NPWTi-d initiation was created using propensity scoring. Differences in clinical outcomes and costs were compared using Wilcoxon rank sum, chi-square, and t tests., Results: Early NPWTi-d initiation was associated with significantly shorter NPWT duration (7.0 vs. 11.4 days; P <.0001) and inpatient stay (13.4 vs. 16.3 days; P <.0001) compared with late NPWTi-d initiation. Early NPWTi-d initiation was also associated with fewer debridements, OR visits during hospitalization, days until final OR procedure, and wound-related readmissions. Patients with early NPWTi-d initiation had a $10 877 lower mean cost of index admission (P <.0001), which included lower NPWT costs., Conclusion: Study data suggest that in these patients with wounds, early NPWTi-d initiation helped improve patient outcomes and reduced care costs.

Movement of fishes in the aquatic realm is fundamental to their ecology and survival. Movement can be driven by a variety of biological, physiological and environmental factors occurring across all spatial and temporal scales. The intrinsic capacity of movement to impact fish individually (e.g., foraging) with potential knock-on effects throughout the ecosystem (e.g., food web dynamics) has garnered considerable interest in the field of movement ecology. The advancement of technology in recent decades, in combination with ever-growing threats to freshwater and marine systems, has further spurred empirical research and theoretical considerations. Given the rapid expansion within the field of movement ecology and its significant role in informing management and conservation efforts, a contemporary and multidisciplinary review about the various components influencing movement is outstanding. Using an established conceptual framework for movement ecology as a guide (i.e., Nathan et al., 2008: 19052), we synthesized the environmental and individual factors that affect the movement of fishes. Specifically, internal (e.g., energy acquisition, endocrinology, and homeostasis) and external (biotic and abiotic) environmental elements are discussed, as well as the different processes that influence individual-level (or population) decisions, such as navigation cues, motion capacity, propagation characteristics and group behaviours. In addition to environmental drivers and individual movement factors, we also explored how associated strategies help survival by optimizing physiological and other biological states. Next, we identified how movement ecology is increasingly being incorporated into management and conservation by highlighting the inherent benefits that spatio-temporal fish behaviour imbues into policy, regulatory, and remediation planning. Finally, we considered the future of movement ecology by evaluating ongoing technological innovations and both the challenges and opportunities that these advancements create for scientists and managers. As aquatic ecosystems continue to face alarming climate (and other human-driven) issues that impact animal movements, the comprehensive and multidisciplinary assessment of movement ecology will be instrumental in developing plans to guide research and promote sustainability measures for aquatic resources., (© 2022 Fisheries Society of the British Isles.)

Homologation of carbon monoxide is central to the heterogeneous Fischer-Tropsch process for the production of hydrocarbon fuels. C-C bond formation has been modeled by homogeneous systems, with [C n O n ] 2- fragments ( n = 2-6) formed by two-electron reduction being commonly encountered. Here, we show that four- or six-electron reduction of CO can be accomplished by the use of anionic aluminum(I) ("aluminyl") compounds to give both topologically linear and branched C 4 /C 6 chains. We show that the mechanism for homologation relies on the highly electron-rich nature of the aluminyl reagent and on an unusual mode of interaction of the CO molecule, which behaves primarily as a Z-type ligand in initial adduct formation. The formation of [C 6 O 6 ] 4- from [C 4 O 4 ] 4- shows for the first time a solution-phase CO homologation process that brings about chain branching via complete C-O bond cleavage, while a comparison of the linear [C 4 O 4 ] 4- system with the [C 4 O 4 ] 6- congener formed under more reducing conditions models the net conversion of C-O bonds to C-C bonds in the presence of additional reductants.

Interspecific interactions can play an essential role in shaping wildlife populations and communities. To date, assessments of interspecific interactions, and more specifically predator-prey dynamics, in aquatic systems over broad spatial and temporal scales (i.e., hundreds of kilometers and multiple years) are rare due to constraints on our abilities to measure effectively at those scales. We applied new methods to identify space-use overlap and potential predation risk to Atlantic tarpon (Megalops atlanticus) and permit (Trachinotus falcatus) from two known predators, great hammerhead (Sphyrna mokarran) and bull (Carcharhinus leucas) sharks, over a 3-year period using acoustic telemetry in the coastal region of the Florida Keys (USA). By examining spatiotemporal overlap, as well as the timing and order of arrival at specific locations compared to random chance, we show that potential predation risk from great hammerhead and bull sharks to Atlantic tarpon and permit are heterogeneous across the Florida Keys. Additionally, we find that predator encounter rates with these game fishes are elevated at specific locations and times, including a prespawning aggregation site in the case of Atlantic tarpon. Further, using machine learning algorithms, we identify environmental variability in overlap between predators and their potential prey, including location, habitat, time of year, lunar cycle, depth, and water temperature. These predator-prey landscapes provide insights into fundamental ecosystem function and biological conservation, especially in the context of emerging fishery-related depredation issues in coastal marine ecosystems., (© 2022 The Ecological Society of America.)

An economic model was developed to estimate the cost of negative pressure wound therapy with instillation and dwelling of a topical wound solution vs control therapies. Economic model inputs were means derived from the results of a recently published systematic review and meta-analysis of 13 comparative studies of negative pressure wound therapy with instillation. Means across studies comprising complex acute and chronic wounds for negative pressure wound therapy-instillation vs control (negative pressure wound therapy without instillation, gauze dressings, or gentamicin polymethylmethacrylate beads) groups were 1.77 vs 2.69 operating room visits (P = .008) and 9.88 vs 21.80 therapy days (P = .02), respectively. These inputs plus hospital cost data were used to model costs for the United States, Germany, and the United Kingdom. For the United States, Germany, and United Kingdom, respectively, economic model estimates of total potential per patient savings were $33 338, €8467, and £5626 for negative pressure wound therapy-instillation group vs control, based on assumed number of OR visits during therapy, cost of therapy system, and length of therapy. Model results showed an overall potential cost-savings with negative pressure wound therapy-instillation vs control, based on fewer OR visits and shorter therapy duration as reported in the published systematic review and meta-analysis., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

We report on the reversible uptake of carbon dioxide by dimetallynes featuring ancillary hemi-labile pincer ligands. Insertion into the Ge-Ge/Sn-Sn bonds yields species containing an E(CO 2 )E unit, with the mode of ligation of the CO 2 fragment determined crystallographically being found to be dependent on the identity of the Group 14 element. The thermodynamics of CO 2 uptake/loss can be established through VT NMR (ΔH°=+24.6(2.3) kJ mol -1 , ΔS°=+64.9(3.8) J mol -1  K -1 , ΔG° 298 =+5.3(1.9) kJ mol -1 for the loss of CO 2 in the Ge case), and the chemical consequences of reversibility demonstrated by thermodynamically-controlled exchange reactions., (© 2022 Wiley-VCH GmbH.)

Objectives: In the outpatient setting, combining remote therapy monitoring (RTM) with negative pressure wound therapy (NPWT) can support improved adherence to prescribed therapy. A recent study reported that patients receiving NPWT with RTM required fewer therapy days than patients receiving NPWT alone, possibly reducing costs of care. Our objective was to determine whether RTM reduced 90-day costs in patients undergoing NPWT., Study Design: We conducted a retrospective cohort study of patients receiving NPWT with or without RTM in the postacute setting., Methods: Patients beginning NPWT between March 2018 and May 2019 were included. Payer claims data were collected and analyzed with t test for continuous variables and χ2 test for categorical variables. Multiple regressions were performed to control for confounding variables., Results: Of the 1105 patients included the study, 675 (61%) received RTM and 430 (39%) did not. RTM patients were significantly older (P < .0001), had more ulcers (P = .0004), and had higher Charlson Comorbidity Index (CCI) scores (P < .0001). The unadjusted mean 90-day wound-related cost was not significantly higher for non-RTM patients than for RTM patients (P = .0799). After controlling for differences in age, payer type, CCI score, and wound type, there was a significant reduction in 90-day wound-related costs in the RTM group compared with the non-RTM group ($11,119 vs $14,752; P = .0131). The RTM group had higher NPWT costs ($3757 vs $3289; P = .0035) but lower wound-related non-NPWT costs ($7361 vs $11,462; P = .0045)., Conclusions: This study demonstrated the value of RTM in supporting NPWT adherence and decreasing the costs of wound care in these patients.

Objectives: To examine the incidence of surgical site complications associated with pronation-abduction ankle fracture-dislocations with an open medial tension wound., Design: Retrospective case series., Setting: Accredited Level-1 trauma center., Patients/participants: Forty-eight open pronation-abduction ankle fracture-dislocations with medial tension failure wounds treated at our institution from 2014 to 2016., Intervention: Immediate irrigation and debridement along with surgical stabilization of open ankle fracture-dislocation., Main Outcome Measures: The primary outcome measure was deep surgical site infection. Secondary outcome measures included other surgical site complications and adverse radiographic events., Results: A total of 5 patients (10.4%) developed a deep surgical site infection requiring additional surgical debridement. One of the patients with a deep surgical site infection required a below-knee amputation as a result of sepsis. Adverse radiographic outcomes included 3 fibular nonunions (6.3%), 3 implant failures related to syndesmotic fixations (6.3%), one periimplant fracture (2.1%), and postoperative collapse of the tibial plafond in 3 patients (6.3%)., Conclusions: Open pronation-abduction ankle fracture-dislocations with medial tension failure wounds remain a challenging and potentially devastating injury. Our study suggests that with appropriate surgical debridement, early stabilization, and primary wound closure, acceptable outcomes with a relatively low risk of surgical site complications can be achieved., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: B. A. Zelle has consulted for KCI Inc. USA and DepuySynthes and received compensation. B. A. Zelle has also received speaker fees from AO North America. B. A. Zelle has received research grants from DepuySynthes, KCI Inc. USA, Department of Defense, and the Orthopaedic Trauma Association. B. A. Zelle has received educational grants from COTA, Smith and Nephew Inc. and Arthrex. He serves on the editorial board of International Orthopaedics, Journal of Bone and Joint Surgery, Journal of Orthopaedic Trauma, and Patient Safety in Surgery. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Macro- and micronutrients play important roles in the biological wound-healing pathway. Although deficiencies may potentially affect orthopaedic trauma patient outcomes, data on nutritional deficiencies in orthopaedic trauma patients remain limited in the literature. The purpose of this study was to (1) evaluate the prevalence of macro- and micronutrient deficiencies in orthopaedic trauma patients with lower extremity fractures and (2) evaluate the impact of such deficiencies on surgical site complications. This retrospective study identified 867 patients with lower extremity fractures treated with surgical fixation from 2019 to 2020. Data recorded included albumin, prealbumin, protein, vitamins A/C/D, magnesium, phosphorus, transferrin and zinc, as well as wound complications. Nutritional deficiencies were found for prealbumin, albumin and transferrin at 50.5%, 23.4% and 48.5%, respectively. Furthermore, a high prevalence of micronutrient deficiencies (vitamin A, 35.4%; vitamin C, 54.4%; vitamin D, 75.4%; and zinc, 56.5%) was observed. We also recorded a statistically significant difference in wound complications in patients who were deficient in prealbumin (21.6% vs. 6.6%, p = 0.0142) and vitamin C (56.8% vs. 28.6%, p = 0.0236). Our study outlines the prevalence of nutritional deficiencies in an orthopaedic trauma population and identifies areas for possible targeted supplementation to decrease wound complications.

We present a novel approach for constructing chains of Group 14 metal atoms linked by unsupported metal-metal bonds that exploits hemilabile ligands to generate unsaturated metal sites. The formation/nature of catenated species (oligo-dimetallynes) can be controlled by the use of (acidic/basic) "protecting groups" and through variation of the ligand scaffold. Reduction of Ar NiPr2 GeCl (Ar NiPr2 =2,6-( i Pr 2 NCH 2 ) 2 C 6 H 3 )-featuring hemilabile N i Pr 2 donors-yields (Ar NiPr2 Ge) 4 (2), which contains a tetrameric Ge 4 chain. 2 represents a novel type of a linear homo-catenated Ge I compound featuring unsupported E-E bonds. Trapping experiments reveal that a key structural component is the central two-way Ge=Ge donor-acceptor bond: reactions with IMe 4 and W(CO) 5 (NMe 3 ) give the base- or acid-stabilized digermynes (Ar NiPr2 Ge(IMe 4 )) 2 (4) and (Ar NiPr2 Ge{W(CO) 5 }) 2 (5), respectively. The use of smaller N-donors leads to stronger Ge-N interactions and quenching of catenation behaviour: reduction of Ar NEt2 GeCl gives the digermyne (Ar NEt2 Ge) 2 , while the unsymmetrical system Ar NEt2 GeGeAr NiPr2 dimerizes to give tetranuclear (Ar NEt2 GeGeAr NiPr2 ) 2 through aggregation at the N i Pr 2 -ligated Ge I centres., (© 2021 The Authors. Angewandte Chemie International Edition published by Wiley-VCH GmbH.)

Objective: To examine the impact of insurance status on access to orthopaedic care and incidence of surgical site complications in patients with closed unstable ankle fractures., Design: Retrospective chart review., Setting: Certified Level-1 urban trauma center and county facility., Participants: Four hundred eighty-nine patients with closed unstable ankle fractures undergoing open reduction and internal fixation between 2014 and 2016., Intervention: Open reduction and internal fixation of unstable ankle fracture., Main Outcome Measures: Time from injury to presentation, time from injury to surgery, rate of surgical site infections, and loss to follow-up., Results: A total of 489 patients (70.5% uninsured vs. 29.5% insured) were enrolled. Uninsured patients were more likely to be present to an outside hospital first (P = 0.004). Time from injury to presentation at our hospital was significantly longer in uninsured patients (4.5 ± 7.6 days vs. 2.3 ± 5.5 days, P < 0.001). Time from injury to surgery was significantly longer in uninsured patient (9.4 ± 8.5 days vs. 7.3 ± 9.1 days, P < 0.001). Uninsured patients were more likely to be lost to postoperative follow-up care (P = 0.002). A logistic regression analysis demonstrated that delayed surgical timing was directly associated with an increased risk of postoperative surgical site infection (P = 0.002)., Conclusions: Uninsured patients with ankle fractures requiring surgery experience significant barriers regarding access to health care. Delay of surgical management significantly increases the risk of surgical site infections in closed unstable ankle fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: B. A. Zelle has consulted for KCI Inc USA and DePuy Synthes and received compensation. B. A. Zelle has also received speaker fees from AO North America. B. A. Zelle has received research grants from DePuy Synthes, KCI, Department of Defense, and the Orthopaedic Trauma Association. B. A. Zelle has received educational grants from Smith & Nephew Inc and Arthrex. He serves on the editorial board of International Orthopaedics, Journal of Bone and Joint Surgery, Journal of Orthopaedic Trauma, and Patient Safety in Surgery. None of these activities are related to the content of this article. The remaining authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures., Methods: Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication., Results: The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups., Conclusion: The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

Purpose: To evaluate if income status affects the timing of presentation to orthopaedic care, surgical treatment, or continuity of care following a closed ankle fracture., Methods: Th is retrospective study identified 434 patients with closed ankle fractures treated with operative fixation from 2014 to 2016. Median income data were extracted using the patients' ZIP codes and data from the U.S. Census Bureau., Results: Lower-income patients presented to the hospital and received surgical treatment significantly later than others. They were also more often uninsured and nonadherent with postoperative weightbearing precautions. Additionally, these patients less frequently sought care on the day of their injury, and they had both shorter inpatient stays and duration of overall follow-up in comparison with others., Conclusion: Socioeconomic status is a vital consideration for improving patient access to acute orthopaedic surgical care. Lower-income patients are more susceptible to multiple time-sensitive delays in their care, and these patients frequently encounter difficulties maintaining appropriate follow-up carex.

Information on ecological systems often comes from diverse sources with varied levels of complexity, bias, and uncertainty. Accordingly, analytical techniques continue to evolve that address these challenges to reveal the characteristics of ecological systems and inform conservation actions. We applied multiple statistical learning algorithms (i.e., machine learning) with a range of information sources including fish tracking data, environmental data, and visual surveys to identify potential spawning aggregation sites for a marine fish species, permit (Trachinotus falcatus), in the Florida Keys. Recognizing the potential complementarity and some level of uncertainty in each information source, we applied supervised (classic and conditional random forests; RF) and unsupervised (fuzzy k-means; FKM) algorithms. The two RF models had similar predictive performance, but generated different predictor variable importance structures and spawning site predictions. Unsupervised clustering using FKM identified unique site groupings that were similar to the likely spawning sites identified with RF. The conservation of aggregate spawning fish species depends heavily on the protection of key spawning sites; many of these potential sites were identified here for permit in the Florida Keys, which consisted of relatively deep-water natural and artificial reefs with high mean permit residency periods. The application of multiple machine learning algorithms enabled the integration of diverse information sources to develop models of an ecological system. Faced with increasingly complex and diverse data sources, ecologists, and conservation practitioners should find increasing value in machine learning algorithms, which we discuss here and provide resources to increase accessibility.

We used acoustic telemetry to quantify permit Trachinotus falcatus habitat use and connectivity in proximity to the Florida Keys, USA, and assessed these patterns relative to current habitat and fisheries management practices. From March 2017 to June 2018, 45 permit tagged within 16 km of the lower Florida Keys were detected at stationary acoustic receivers throughout the south Florida region, the majority of which remained within the Special Permit Zone, where more extensive fisheries harvest regulations are implemented. There was a high level of connectivity between nearshore flats (i.e., <3 m water depth) and the Florida reef tract (FRT; 15-40 m water depth), with 75% of individuals detected in both habitats. These locations probably function primarily as foraging and spawning habitats, respectively. Permit occupancy on the FRT peaked during the months of March-September, with the highest number of individuals occurring there in April and May. Specific sites on the FRT were identified as potentially important spawning locations, as they attracted a high proportion of individuals that exhibited frequent visits with high residency durations. There were also significant positive relationships between seasonal habitat-use metrics on the FRT and an empirical permit gonadosomatic index. Large aggregations of permit at spawning sites on the FRT are potentially vulnerable to the effects of fishing (including predation during catch and release) at a critical point in their life cycle. These data on permit space use and movement, coupled with knowledge of stressors on their ecology, provide insights for implementing science-based strategic management plans., (© 2019 The Fisheries Society of the British Isles.)

Background: Closed incision negative pressure therapy (ciNPT) is an emerging approach to managing closed incisions of patients at risk of postoperative complications. There are primarily 2 different commercially available ciNPT systems. Both systems consist of a single-use, battery-powered device and foam- or gauze-based peel-and-place dressing designed for closed incisions. These systems vary in design, and there are no data comparing outcomes between the 2 systems., Methods: We performed 2 separate meta-analyses to compare surgical site infection (SSI) rates postuse of (1) ciNPT with foam dressing (FOAM) versus conventional dressings and (2) ciNPT with multilayer absorbent dressing (MLA) versus conventional dressings., Results: Seven articles and 2 abstracts met inclusion criteria in the FOAM group (n = 489) versus the control group (n = 489) in meta-analysis 1; 7 articles and 1 abstract met inclusion criteria in the MLA group (n = 532) versus the control group (n = 540) in meta-analysis 2. Meta-analysis 1 showed that patients in the control group were 3.17 times more likely to develop an SSI compared with patients in the FOAM group [weighted mean odds ratios of FOAM group versus control group was 3.17 ( P < 0.0001) with the 95% confidence intervals of 2.17-4.65]. Meta-analysis 2 showed no significant difference in SSI rates between patients in the MLA group and patients in the control group [weighted mean odds ratios of MLA group versus control group was 1.70 ( P = 0.08) with the 95% confidence intervals of 0.94-3.08]., Conclusions: Comparing outcomes of two different ciNPT systems with a common comparator (conventional dressings) may provide an interim basis for comparing ciNPT systems until further comparative evidence is available. More comparative research is required to determine outcomes in clinical practice., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Since the 1970s, the magnitude of turtle cold-stun strandings have increased dramatically within the northwestern Atlantic. Here, we examine oceanic, atmospheric, and biological factors that may affect the increasing trend of cold-stunned Kemp's ridleys in Cape Cod Bay, Massachusetts, United States of America. Using machine learning and Bayesian inference modeling techniques, we demonstrate higher cold-stunning years occur when the Gulf of Maine has warmer sea surface temperatures in late October through early November. Surprisingly, hatchling numbers in Mexico, a proxy for population abundance, was not identified as an important factor. Further, using our Bayesian count model and forecasted sea surface temperature projections, we predict more than 2,300 Kemp's ridley turtles may cold-stun annually by 2031 as sea surface temperatures continue to increase within the Gulf of Maine. We suggest warmer sea surface temperatures may have modified the northerly distribution of Kemp's ridleys and act as an ecological bridge between the Gulf Stream and nearshore waters. While cold-stunning may currently account for a minor proportion of juvenile mortality, we recommend continuing efforts to rehabilitate cold-stunned individuals to maintain population resiliency for this critically endangered species in the face of a changing climate and continuing anthropogenic threats., Competing Interests: The authors have declared that no competing interests exist.

Despite many positive benefits of ecotourism, increased human encounters with wildlife may have detrimental effects on wild animals. As charismatic megafauna, nesting and foraging sea turtles are increasingly the focus of ecotourism activities. The purpose of our study was to quantify the behavioral responses of immature green turtles (Chelonia mydas) to disturbance by snorkelers, and to investigate whether turtles have individual-level responses to snorkeler disturbance. Using a standardized disturbance stimulus in the field, we recorded turtle behaviors pre- and post-disturbance by snorkelers. Ninety percent of turtles disturbed by snorkeler (n = 192) initiated their flights at distances of ≤3 m. Using principal component analysis, we identified two distinct turtle personality types, 'bold' and 'timid', based upon 145 encounters of 19 individually identified turtles and five disturbance response variables. There was significant intra-individual repeatability in behavioral responses to disturbance, but bolder turtles had more behavioral plasticity and less consistent responses than more timid individuals. Bolder individuals with reduced evasion responses might be at a higher risk of shark predation, while more timid turtles might have greater energetic consequences due to non-lethal predator effects and repeated snorkeler disturbance. Over the longer term, a turtle population with a mix of bold and timid individuals may promote more resilient populations. We recommend that snorkelers maintain >3 m distance from immature green turtles when snorkeling, and that ecotourism activities be temporally and spatially stratified. Further, turtle watching guidelines need to be communicated to both tour operators and independent snorkelers to reduce the disturbance of turtles.

Introduction: Muscle cramping is a common symptom in amyotrophic lateral sclerosis (ALS) that lacks efficacious treatment. The natural history of this symptom is unknown, which hampers efforts to design optimal clinical trials., Methods: We surveyed early stage ALS patients about their experience with cramps each month by phone for up to 21 months., Results: Cramps developed in 95% of patients over the course of their disease. The number of cramps experienced by an individual varied widely from month-to-month and trended lower after the first year of illness (P = 0.26). Those with limb-onset and age >60 years had more cramps than bulbar-onset (P < 0.0001) and younger patients (P < 0.0001)., Conclusions: The high variability of the number of cramps experienced suggests that clinical trials will need to use crossover designs or large numbers of participants, even when the treatment effect is substantial., (© 2015 Wiley Periodicals, Inc.)

Introduction: Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies., Methods: One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment., Results: The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005)., Conclusions: Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36., (© 2015 Wiley Periodicals, Inc.)

Background: Treatment-related symptoms and decreased health-related quality of life (HRQoL) frequently occur during chemotherapy for breast cancer. Although research findings suggest that yoga can reduce symptoms and Improve HRQoL after treatment, potential benefits of yoga during chemotherapy have received minimal attention., Objective: To estimate accrual, adherence, study retention, and preliminary efficacy of a yoga intervention compared with an active control group for breast cancer patients during chemotherapy., Methods: Women with stage I-III breast cancer were recruited from 3 community cancer clinics and randomized to 10 weeks of gentle yoga or wellness education. Depressive symptoms, fatigue, sleep, and HRQoL were assessed at baseline, mid-intervention (Week 5), and after intervention (Week 10)., Results: 40 women aged 29-83 years (median, 48 years; 88% white) were randomized to yoga (n = 22) or wellness education (n = 18). The groups did not differ significantly on baseline characteristics, adherence, or study retention. Participant feedback was positive and comparable between groups. Meaningful within-group differences were identified For sleep adequacy and quantity in yoga participants and for somnolence in wellness-education participants., Limitations: Small sample size and lack of a usual-care control group., Conclusions: This study established Feasibility of a community-based randomized trial of yoga and an active comparison group for women undergoing chemotherapy for breast cancer. Preliminary efficacy estimates suggest that yoga improves sleep adequacy Symptom severity and interference remained stable during chemotherapy for the yoga group and snowed a trend toward increasing in the control group. The study highlighted obstacles to multisite yoga research during cancer treatment., Funding/sponsorship: National Cancer Institute (3U10 CA081851, PI; Shaw; R25 CA122061, PI: Avis); Translational Science Institute, Wake Forest School of Medicine.

Background: Young adulthood (age 18 to 35) is a high-risk period for unhealthy weight gain. Few studies have recruited for prevention of weight gain, particularly in young adults. This paper describes the recruitment protocol used in the Study of Novel Approaches to Prevention (SNAP)., Methods: We conducted extensive formative work to inform recruitment methods and message development. We worked with a professional marketing firm to synthesize major themes and subsequently develop age-appropriate messages for recruitment. A variety of approaches and channels were used across two clinical centers to recruit young adults who were normal or overweight (body mass index (BMI) 21 to 30 kg/m2) for a 3-year intervention designed to prevent weight gain. We tracked recruitment methods, yields, and costs by method. Logistic regression was used to identify recruitment methods that had the highest relative yield for subgroups of interest with covariate adjustments for clinic., Results: The final sample of 599 participants (27% minority, 22% male) was recruited over a 19-month period of sustained efforts. About 10% of those who initially expressed interest via a screening website were randomized. The most common reason for ineligibility was already being obese (BMI >30 kg/m2). The top two methods for recruitment were mass mailing followed by email; together they were cited by 62% of those recruited. Television, radio, paid print advertising, flyers and community events each yielded fewer than 10% of study participants. Email was the most cost-effective method per study participant recruited., Conclusions: These findings can guide future efforts to recruit young adults and for trials targeting weight gain prevention., Trial Registration: ClinicalTrials.gov NCT01183689 (registered 13 August 2010).

Introduction: Nerve cross-sectional area reference values have been reported for many nerves, but there have been few studies in pediatric and geriatric populations. This study was conducted to determine the influence of age on nerve cross-sectional area., Methods: Thirty-two children (3 months to 16 years) and 20 geriatric adults (67-92 years) without known neurologic conditions underwent bilateral ultrasound to measure the area of the following nerves: median at the wrist and forearm; ulnar at the wrist and elbow; radial in the spiral groove; sciatic in the distal thigh; fibular at the knee; tibial at the knee and ankle; and sural at the ankle., Results: In general, nerve cross-sectional area increased with age. Nerve size correlated most closely with age, but a correlation was also seen with body mass index., Conclusions: Nerve cross-sectional area increases with age, which is important to note when using ultrasound to evaluate children and geriatric patients., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction: Nerve and muscle ultrasound has been studied in several conditions, but validity and reliability have not been assessed systematically., Methods: Nerve cross-sectional area and muscle thickness were measured ultrasonographically at several sites in 4 cadavers, which were then dissected, and actual measurements were obtained. To assess intrarater and interrater reliability, between 3 and 5 ultrasonographers, with varying experience levels, made repeated measurements on healthy volunteers., Results: Correlation coefficients for nerve and muscle validity were >0.968 (P < 0.001), and for intrarater reliability were >0.901 (P < 0.001) for still and real-time images. Correlation coefficients for interrater reliability were more varied, but for still images they were all significant at the P < 0.001 (0.542-0.998) level, and for real-time images they were significant at the P < 0.05 level for half the sites (0.243-0.981)., Conclusion: Overall, nerve and muscle ultrasound is a valid and reliable diagnostic imaging technique., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction: Intensive care unit acquired weakness (ICU-AW) results from a complex mixture of nerve and muscle pathology, and early identification is challenging. This pilot study was designed to examine the ultrasonographic changes that occur in muscles during ICU hospitalization., Methods: Patients admitted to the ICU for acute respiratory failure were enrolled prospectively and underwent serial muscle ultrasound for thickness and gray-scale assessment of the tibialis anterior, rectus femoris, abductor digiti minimi, biceps, and diaphragm muscles over 14 days., Results: Sixteen participants were enrolled. The tibialis anterior (P = 0.001) and rectus femoris (P = 0.041) had significant decreases in gray-scale standard deviation when analyzed over 14 days. No muscles showed significant changes in thickness., Conclusions: Ultrasound is an informative technique for assessing muscles of patients in the ICU, and lower extremity muscles demonstrated increased homogeneity during ICU stays. This technique should be examined further for diagnosing and tracking those with ICU-AW., (Copyright © 2012 Wiley Periodicals, Inc.)

Patients with panniculus morbidus have an abdominal panniculus that becomes a pathologic entity, associated with the development of candidal intertrigo, dermatitis, lymphedema, and ischemic panniculitis. Panniculectomy is a standard treatment for this problem. The objective of this study was to determine risk factors for complications associated with panniculectomy surgery to lower the complication rate. We performed a retrospective chart review of patients who underwent panniculectomy between 1999 and 2007 by looking at data related to surgical complications, comorbidities, age, and gender. In 563 patients, we recorded the incidence of the following complications: wound-related (infection, dehiscence, and/or necrosis), hematoma/seroma, respiratory distress, blood transfusions, deep venous thrombosis or pulmonary embolism, and death. Overall, 34.3% of patients suffered at least 1 complication. In patients with wound complications specifically, there was a significantly higher body mass index versus those with no wound complications (43.7% vs. 30.7%, P < 0.0001). Smokers also had a higher rate of wound complications (40.5% vs. 19.5%, P < 0.0001).

Introduction: High-resolution ultrasound has been used to evaluate several neuromuscular conditions, but it has only been used on a limited basis in amyotrophic lateral sclerosis (ALS) patients. It has not been used to assess their peripheral nerves. This study was designed to use neuromuscular ultrasound to investigate nerve cross-sectional area and muscle thickness in ALS., Methods: Twenty individuals with ALS and 20 matched controls underwent neuromuscular ultrasound to measure the cross-sectional area of their median and sural nerves and the thickness of their biceps/brachialis muscle complex., Results: The cross-sectional area of the median nerve in the mid-arm was smaller in the ALS group than in controls (10.5 mm(2) vs. 12.7 mm(2) , P = 0.0023), but no difference was seen in the sural nerve (4.5 mm(2) vs. 5.0 mm(2) , P = 0.1927). The ALS group also had thinner biceps/brachialis than controls (2.1 cm vs. 2.9 cm, P = 0.0007)., Conclusions: Neuromuscular ultrasound demonstrates nerve and muscle atrophy in ALS and should be further explored as a disease biomarker., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: The effectiveness and benefits of regionalized trauma care are well substantiated; however, the effectiveness of regionalized burn care and potential benefits of burn center verification have not been fully validated., Study Design: This was a retrospective study of all acute burn admissions using a statewide discharge database from October 1, 2000, to September 30, 2007. Demographics, referral patterns, care practices, and outcomes were compared between 2 American Burn Association (ABA)-verified burn centers (VBCs) and the remaining 107 nonburn centers (NBCs) in North Carolina., Results: Overall, 6,873 adult burn patients required admission, with 79% of them meeting ABA burn center referral criteria. Of the 5,402 patients meeting ABA referral criteria, 43% were admitted to an NBC, and 25% of all NBC patients had burn operations. Burns admitted to NBCs tended to involve the hand/wrist and lower extremities. Older patients with comorbidities/concomitant trauma were more likely to be admitted to NBCs (p < 0.0001); however, larger burns were more likely to be admitted to a VBC (p < 0.0001). More NBC patients were discharged to nursing homes (p < 0.0001). Patients with Medicare were more likely to be admitted to NBCs (p < 0.0001), and uninsured patients or those with Workman's Compensation insurance were more likely to be admitted to VBCs (p < 0.0001), and payer status remained a significant predictor of treatment at a VBC on regression analysis., Conclusions: This is the most comprehensive study of its kind and demonstrates that ABA burn center referral criteria are not always used for effective regionalized burn care or to ensure the best possible outcomes. Even with establishment of the burn center verification process, the mere presence of a VBC is insufficient for effective regionalized care. A greater emphasis is needed on the development of burn care systems., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Effective communication is critical to providing quality health care and can be affected by a number of modifiable organizational factors. The authors performed a prospective multisite validation study of an organizational communication climate assessment tool in 13 geographically and ethnically diverse health care organizations. Communication climate was measured across 9 discrete domains. Patient and staff surveys with matched items in each domain were developed using a national consensus process, which then underwent psychometric field testing and assessment of domain coherence. The authors found meaningful within-site and between-site performance score variability in all domains. In multivariable models, most communication domains were significant predictors of patient-reported quality of care and trust. The authors conclude that these assessment tools provide a valid empirical assessment of organizational communication climate in 9 domains. Assessment results may be useful to track organizational performance, to benchmark, and to inform tailored quality improvement interventions.

Background: During the pitching motion, velocity is generated by the upper extremity kinetic chain on internal rotation of the shoulder and trunk translational/rotational motion. This generation of power places significant forces and torques on the elbow and shoulder. Elbow valgus torque and shoulder rotational torque are theoretically linked to elbow injury., Hypothesis: Pitchers experiencing higher levels of elbow valgus torque and shoulder external rotation torque throughout the pitching motion are more likely to suffer elbow injury than pitchers with lower levels of torque., Study Design: Cohort study; Level of evidence, 3., Methods: With an established biomechanical analysis model, 23 professional baseball pitchers were videotaped during spring training games and followed prospectively for the next 3 seasons for elbow injury. A mixed statistical model using differences of least squares means and analysis of variance was used to analyze the association between elbow injury and torque levels throughout the pitching motion as well as at each major event within the pitching motion., Results: There were overall statistical trends relating elbow injury with both higher elbow valgus torque (P = .0547) and higher shoulder external rotation torque (P = .0548) throughout the entire pitching motion. More importantly, there was an individual significant correlation of elbow injury with both higher elbow valgus torque (P = .0130) and higher shoulder external rotation torque (P = .0018) at the late cocking phase (pitching event of maximum external rotation of the shoulder)., Conclusion: This study provides information that supports existing theories about how and why certain injuries occur during the throwing motion in baseball. The late cocking phase appears to be the critical point in the pitching motion, where higher levels of torque at the shoulder and elbow can result in increased risk of injury. Manipulation of pitching mechanics to alter these torque levels or using these measures to identify pitchers at risk may help decrease injury rates.