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Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA.We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment.Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004).More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.

There is substantial variability in the reported incidence and outcomes of acute kidney injury (AKI). The extent to which this is attributable to differences in source populations versus methodological differences between studies is uncertain. We used 4 population-based datasets from Canada, Denmark, and the United Kingdom to measure the annual incidence and prognosis of AKI and acute kidney disease (AKD), using a homogenous analytical approach that incorporated KDIGO creatinine-based definitions and subsets of the AKI/AKD criteria. The cohorts included 7 million adults ≥18 years of age between 2011 and 2014; median age 59-68 years, 51.9-54.4% female sex. Age- and sex-standardised incidence rates for AKI or AKD were similar between regions and years; range 134.3-162.4 events/10,000 person years. Among patients who met either KDIGO 48-hour or 7-day AKI creatinine criteria, the standardised 1-year mortality was similar (30.4%-38.5%) across the cohorts, which was comparable to standardised 1-year mortality among patients who met AKI/AKD criteria using a baseline creatinine within 8-90 days prior (32.0%-37.4%). Standardised 1-year mortality was lower (21.0%-25.5% across cohorts) among patients with AKI/AKD ascertained using a baseline creatinine >90 days prior. These findings illustrate that the incidence and prognosis of AKI and AKD based on KDIGO criteria are consistent across 3 high-income countries when capture of laboratory tests is complete, creatinine-based definitions are implemented consistently within but not beyond a 90-day period, and adjustment is made for population age and sex. These approaches should be consistently applied to improve the generalizability and comparability of AKI research and clinical reporting.

Background Treating pain in the context of chronic kidney disease (CKD) is challenging because of altered pharmacokinetics and pharmacodynamics, with an increased risk of toxicity and drug adverse events in this population. The aims of this systematic review and meta-analysis were to assess the prevalence of analgesic use and establish the risk of analgesics-related adverse events, in patients with CKD. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Medline, Embase, CINAHL, and CENTRAL were searched until January 2021. Random-effects meta-analyses and meta-regression were conducted to pool and summarise prevalence data and measures of association between analgesic use and adverse events. Results Sixty-two studies relevant to the prevalence of analgesic use and 33 to analgesic-related adverse events were included, combining data on 2.3 and 3 million individuals, respectively. Pooled analyses found that 41% (95% confidence interval [CI], 35–48) of the CKD population regularly use analgesia. The annual period prevalence was estimated at 50% for opioids and 21% for nonsteroidal anti-inflammatory drugs (NSAID). Overall, 20% and 7% of patients with CKD are on chronic opioid or NSAID therapy, respectively. Opioid use was associated with an increased risk of death (1.61; 95% CI, 1.12–2.31; n= 7, I2= 91%), hospitalisation (1.38; 95% CI, 1.32–1.45; n=2, I2=0%), and fractures (1.51; 95% CI, 1.16–1.96; n=3, I2=54%). Conclusion High levels of analgesic consumption and related serious adverse outcomes were found in patients with CKD. Consideration needs to be given to how these patients are assessed and managed in order to minimise harms and improve outcomes. Clinical trial registration CRD42019156491 (PROSPERO).

Forest bathing is based upon a Japanese practice known as Shinrin–Yoku and is a nature-based therapy involving mindful walks through ancient woodland to reduce stress and anxiety. One proposed mechanism behind the effectiveness of Forest bathing is based on the potential mental and physical health benefits of the natural volatile organic compounds (NVOCs) that fill the forest understory. Surprisingly little is known about the concentrations and diversity of plant NVOCs in ambient air particularly in the UK and this study aims to increase that knowledge. Air samples were collected in July 2022 in a UK forest and compared with samples from a walled garden environment. The samples were collected over a 2 h time period and analysed using GC-MS and showed clear differences in the chemical composition of the air. This study revealed NVOCs including limonene, carvone, terpenes, terpenoids and sesquiterpenoids were present within a UK forest but were either not present or present at little to low levels in the control setting of a walled garden. This study also found that the typical 2 h duration of a Forest bathing session was a long enough sampling period to detect these NVOCs, indicating that Forest bathers could benefit from exposure to NVOCs.

To determine the incidence and characteristics of ICU admissions in the Scottish population of patients treated with chronic kidney replacement therapy (KRT) over an 11-year period and determine factors associated with post-ICU admission mortality.Retrospective observational cohort study.We analyzed admissions to Scottish intensive care environments between January 1, 2009, and December 31, 2019.All patients receiving chronic KRT-including maintenance dialysis and kidney transplant-in Scotland.None.Descriptive statistics and factors associated with mortality using logistic regression and Cox proportional hazard models. From 10,657 unique individuals registered in the Scottish Renal Registry over the 11-year study period and alive as of January 1, 2009, 1,402 adult patients were identified as being admitted to a Scottish critical care setting. Between 2009 and 2019, admissions to ICU increased in a nonlinear manner driven by increases in admissions for renal causes and elective cardiac surgery. The ICU admission rate was higher among patients on chronic dialysis than in kidney transplant recipients (59.1 vs 19.9 per 1,000 person-years), but post-ICU mortality was similar (about 24% at 30 d and 40% at 1 year). Admissions for renal reasons were most common (20.9%) in patients undergoing chronic dialysis, whereas kidney transplant recipients were most frequently admitted for pneumonia (19.3%) or sepsis (12.8%). Adjusted Cox PH models showed that receiving invasive ventilation and vasoactive drugs was associated with an increased risk of death at 30 days post-ICU admission (HR, 1.75; 95% CI, 1.28-2.39 and 1.72; 95% CI, 1.28-2.31, respectively).With a growing population of kidney transplant recipients and the improved survival of patients on chronic dialysis, the number of ICU admissions is rising in the chronic KRT population. Mortality post-ICU admission is high for these patients.

Pain is a common but often undertreated symptom in patients with chronic kidney disease (CKD) with a much higher prevalence than in the general population. The aim of this systematic review was to synthesize all available quantitative evidence, in order to gain a better understanding of pain prevalence and pain types in patients with CKD. Four databases and the grey literature were searched until 15th January 2021. Random-effect meta-analyses were conducted with multiple subgroup analyses and meta-regressions to further explore the between-study heterogeneity. The quality of studies included was assessed using the Newcastle-Ottawa scale and the level of evidence was determined using the GRADE approach. One hundred sixteen studies reported data on 40,678 individuals. Results from meta-analyses yielded an overall prevalence of 60% (95% confidence interval 56-64) for pain, 48% (42-55) for chronic pain and 10% (6-15) for neuropathic pain. The prevalence of pain was lower among kidney transplant recipients 46% (37-56) compared with patients undergoing dialysis 63% (57-68) and those with non-dialysis CKD 63% (55-70). Musculoskeletal pain appeared to be the most common pain symptom among patients with CKD managed conservatively 42% (28-56) or receiving dialysis 45% (36-55) whilst abdominal pain was most prevalent in kidney transplant recipients 41% (7-86). Thus, all subgroups of patients with CKD suffer from a high burden of pain. Hence, greater awareness and recognition of this issue is vital to inform policy and service provision in this area.

Robust systematic approaches for the metabolic engineering of cell factories remain elusive. The available models for predicting phenotypical responses and mechanisms are incomplete, particularly within the context of compound toxicity that can be a significant impediment to achieving high yields of a target product. This study describes a Multi-Omic Based Production Strain Improvement (MOBpsi) strategy that is distinguished by integrated time-resolved systems analyses of fed-batch fermentations. As a case study, MOBpsi was applied to improve the performance of an Escherichia coli cell factory producing the commodity chemical styrene. Styrene can be bio-manufactured from phenylalanine via an engineered pathway comprised of the enzymes phenylalanine ammonia lyase and ferulic acid decarboxylase. The toxicity, hydrophobicity, and volatility of styrene combine to make bio-production challenging. Previous attempts to create styrene tolerant E. coli strains by targeted genetic interventions have met with modest success. Application of MOBpsi identified new potential targets for improving performance, resulting in two host strains (E. coli NST74ΔaaeA and NST74ΔaaeA cpxPo) with increased styrene production. The best performing re-engineered chassis, NST74ΔaaeA cpxPo, produced ∼3 × more styrene and exhibited increased viability in fed-batch fermentations. Thus, this case study demonstrates the utility of MOBpsi as a systematic tool for improving the bio-manufacturing of toxic chemicals.

Graphical Abstract, Background Automated acute kidney injury (AKI) electronic alerts (e-alerts) are rule-based warnings triggered by changes in creatinine and are intended to facilitate earlier detection in AKI. We assessed the impact of the introduction in the Tayside region of UK in April 2015 of automated AKI e-alerts with an accompanying education programme. Methods Interrupted time-series analysis using segmented regression was performed involving all adults with AKI aged ≥18 years who had a serum creatinine measured between 1 April 2013 and 31 March 2017. Analysis evaluated associations of AKI e-alert introduction on rate and severity (Stages 2–3) of AKI as well as mortality and occupied hospital bed days per patient per month in the population with AKI. Results There were 32 320 episodes of AKI during the observation period. Implementation of e-alerts had no effect on the rate of any AKI [incidence rate ratio (IRR) 0.996, 95% confidence interval (CI) 0.991 to 1.001, P = 0.086] or on the rate of severe AKI (IRR 0.995, 95% CI 0.990 to 1.000, P = 0.061). Subgroup analysis found no impact on the rate or severity of AKI in hospital or in the community. Thirty-day mortality following AKI did not improve (IRR 0.998, 95% CI 0.987 to 1.009, P = 0.688). There was a slight reduction in occupied bed days (β-coefficient −0.059, 95% CI −0.094 to −0.025, P = 0.002). Conclusions Introduction of automated AKI e-alerts was not associated with a change in the rate, severity or mortality associated with AKI, but there was a small reduction in occupied hospital bed days.

Objective This qualitative study aimed to explore sun protection barriers and enablers in secondary schools in Victoria. Methods Five focus groups were conducted with nominated Health or Physical Education (PE) Coordinators (or other staff representatives) from schools in metropolitan and regional Victoria. Discussions were audio-recorded, transcribed and coded thematically. Results Participants identified the need for regulatory influences that included minimum standards for sun protection policy, training and shade in the built environment. Participants perceived that sun protection is not always acknowledged to be a duty of care in secondary schools. A crowded health and well-being curriculum, a focus on fostering independence, and challenges overcoming peer norms were perceived to be important contextual influences. At an organisational level, strong leadership and a united approach among staff were identified as critical ingredients for successful policy implementation and organisational change. Several potentially effective strategies were proposed, including increased shade, leveraging from student leaders, normalising sun protection practices and prioritising staff role modelling. Conclusions A cultural shift is required for many schools to accept and act on sun protection as a duty of care. A comprehensive approach that includes regulatory action, healthy school policies and leading by example may help protect students and staff from harmful UV exposure during school hours. SO WHAT?: Without regulatory support, strong leadership is required to implement and enforce sun protection practices within schools. Health promotion programs could assist schools to trial and evaluate the sun protection strategies that involve student-led solutions, role modelling and increasing shade.

Background Patients who survive an episode of acute kidney injury (AKI) are more likely to have further episodes of AKI. AKI is associated with increased mortality, with a further increase with recurrent episodes. It is not clear whether this is due to AKI or as a result of other patient characteristics. The aim of this study was to establish whether recurrence of AKI is an independent risk factor for mortality or if excess mortality is explained by other factors. Methods This observational cohort study included adult people from the Tayside region of Scotland, with an episode of AKI between 1 January 2009 and 31 December 2009. AKI was defined using the creatinine-based Kidney Disease: Improving Global Outcomes definition. Associations between recurrent AKI and mortality were examined using a Cox proportional hazards model. Results Survival was worse in the group identified to have recurrent AKI compared with those with a single episode of AKI [hazard ratio = 1.49, 95% confidence interval (CI) 1.37–1.63; P Conclusions Recurrent AKI is associated with increased mortality. After adjusting for patient characteristics, the increase in mortality is independently associated with recurrent AKI and is not solely explained by other risk factors.

Selected β-amino acids, such as β-aminobutyric acid (BABA) and R-β-homoserine (RBH), can prime plants for resistance against a broad spectrum of diseases. Here, we describe a genome-wide screen of fully annotated Arabidopsis thaliana T-DNA insertion lines for impaired in RBH-induced immunity (iri) mutants against the downy mildew pathogen Hyaloperonospora arabidopsidis, yielding 104 lines that were partially affected and four lines that were completely impaired in RBH-induced resistance (IR). We confirmed the iri1-1 mutant phenotype with an independent T-DNA insertion line in the same gene, encoding the high-affinity amino acid transporter LYSINE HISTIDINE TRANSPORTER 1 (LHT1). Uptake experiments with yeast cells expressing LHT1 and mass spectrometry-based quantification of RBH and BABA in leaves of lht1 mutant and LHT1 overexpression lines revealed that LHT1 acts as the main transporter for cellular uptake and systemic distribution of RBH and BABA. Subsequent characterization of lht1 mutant and LHT1 overexpression lines for IR and growth responses revealed that the levels of LHT1-mediated uptake determine the tradeoff between IR and plant growth by RBH and BABA.

This year, 2021, marks the 40th anniversary of the iconic Slip! Slop! Slap! campaign which launched Australia's status as a global leader in skin cancer prevention. Since the campaign first aired in the summer of 1980-81, notable successes have been achieved, with melanoma rates declining in younger age groups. While skin cancer prevention is rightly considered a triumph of Australian public health, challenges remain. Australia still has one of the highest rates of skin cancer in the world, with about 2000 deaths per year from the disease. Skin cancer also presents the highest cost burden to the health system of any cancer type. Despite this, government investment at the national level is lacking. It is more difficult than ever to collect valuable representative national data on population skin cancer prevention behaviours to underpin and evaluate programs, as the methodology used previously has become unfeasible. There has not been a national skin cancer prevention mass-media campaign for over a decade, indicating complacency from policy makers. State and territory governments could also do more to implement evidence-based policies aimed at protecting children from ultraviolet radiation. This paper sets out Australia's skin cancer prevention landscape in 2021, and makes the case for a renewed focus from government on sun protection to safeguard the significant gains made over four decades and to protect future generations from an almost entirely preventable cancer.

Despite autonomous vehicles (AVs) being safer than human drivers, people are averse to their presence on roads. Across three studies (N = 4,014), we examined peoples’ perceptions of human drivers and AVs acting within a moral dilemma. Scenarios involved an out-of-control vehicle (piloted by a human, or autonomously) that could stay on its present course and hit five pedestrians, or swerve and hit a single stranger. Participants were given a description of the pilot’s final action and then judged them on several dimensions (e.g., blame, acceptability, predictability). We find evidence of AV aversion across all studies, with participants judging AVs more negatively (e.g., more blameworthy) than human drivers despite performing identical actions. Additionally, Studies 1 and 2 presented some participants with a statement outlining the consistency of AV algorithms, which increased perceived predictability and reduced AV aversion in some cases. In Study 3, some participants were given scenarios in which control of the vehicle was transferred prior to a pilot’s actions. Participants’ were averse to this transfer, as both AVs and human drivers were perceived as less predictable and judged more negatively after taking control of the vehicle. Overall, our findings highlight peoples’ aversion to autonomous and semi-autonomous vehicles, while also demonstrating that messages highlighting the consistency of AV algorithms have the potential to improve perceptions and thus reduce barriers for their eventual mass adoption.

Rationale & Objective The KDIGO (Kidney Disease: Improving Global Outcomes) definition of acute kidney injury (AKI) is frequently used in studies to examine the epidemiology of AKI. This definition is variably interpreted and applied to routinely collected health care data. The aim of this study was to examine this variation and to achieve consensus in how AKI should be defined for research using routinely collected health care data. Sources of Evidence and Study Design Scoping review via searching Medline and EMBASE for studies using health care data to examine AKI by using the KDIGO creatinine-based definition. An international panel of experts formed to participate in a modified Delphi process to attempt to generate consensus about how AKI should be defined when using routinely collected laboratory data. Charting Methods and Analytical Approach The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews was followed. For the Delphi process, 2 rounds of questions were distributed via internet-based questionnaires to all participants with a prespecified cutoff of 75% agreement used to define consensus. Results The scoping review found 174 studies that met the inclusion criteria. The KDIGO definition was inconsistently applied, and the methods for application were poorly described. We found 58 (33%) of papers did not provide a definition of how the baseline creatinine value was determined, and only 34 (20%) defined recovery of kidney function. Of 55 invitees to the Delphi process, 35 respondents participated in round 1, and 25 participated in round 2. Some consensus was achieved in areas related to how to define the baseline creatinine value, which patients should be excluded from analysis of routinely collected laboratory data, and how persistent chronic kidney disease or nonrecovery of AKI should be defined. Limitations The Delphi panel members predominantly came from the United Kingdom, the United States, and Canada, and there were low response rates for some questions in round 1. Conclusions The current methods for defining AKI using routinely collected data are inconsistent and poorly described in the available literature. Experts could not achieve consensus for many aspects of defining AKI and describing its sequelae. The KDIGO guidelines should be extended to include a standardized definition for how AKI should be defined when using routinely collected data.

Purpose A pre-test, post-test, control group design was employed to investigate the impact of a tailored patient activation intervention (PAI) among inflammatory bowel disease (IBD) patients. Methods Patients who met the inclusion criteria were selected from medical records via convenience sampling, were consented, and completed a baseline survey. Based on responses to the baseline 13-item patient activation measure (PAM-13), they were categorized into one of four patient activation stages. During office visits, intervention patients (N=23) were given a tailored PAI based on their baseline stage, which consisted of an information booklet and focused discussion with the gastroenterologist, while the control group (N=27) received usual care. Baseline and 1-month post-intervention scores were compared between the intervention (N=20) and control (N=21) groups for changes in patient activation score, medication adherence, and satisfaction with care. Results Most participants were Caucasian (88%), female (64%), college graduates (56%), and had Crohn's disease (59.2%). Overall, females had a significantly higher (p=0.04) mean activation score (mean=70.9±15.4) than males (mean=60.9±10.7) at baseline. This trend was the same post-intervention (75.6 females vs 64.4 males; p=0.03). The difference in mean activation scores pre- vs post-intervention was not statistically significant between the intervention and control groups (mean=4.9±12.3, p=0.21). However, this difference could be considered to be clinically significant based on results from previous studies. There were no significant differences in medication adherence or satisfaction scores pre- vs post-intervention for either group. Conclusion Tailored PAIs have the potential to increase activation level of patients with inflammatory bowel disease. This customized medical interaction increased patient involvement in disease management and could potentially lead to improved health outcomes.

Study objective It is unknown whether regionalization of postarrest care by interfacility transfer to cardiac arrest receiving centers reduces mortality. We seek to evaluate whether treatment at a cardiac arrest receiving center, whether by direct transport or early interfacility transfer, is independently associated with long-term outcome. Methods We performed a retrospective cohort study including adults resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania and neighboring Ohio, West Virginia, and Maryland, which includes approximately 5.7 million residents in urban, suburban, and rural counties. Patients were treated by 1 of 78 ground emergency medical services agencies or 2 air medical transport agencies between January 1, 2010, and November 30, 2014. Our primary exposures of interest were interfacility transfer to a cardiac arrest receiving center within 24 hours of arrest or any treatment at a cardiac arrest receiving center regardless of transfer status. Our primary outcome was vital status, assessed through December 31, 2014, with National Death Index records. We used unadjusted and adjusted survival analyses to test the independent association of cardiac arrest receiving center care, whether through direct or interfacility transport, on mortality. Results Overall, 5,217 cases were observed for 3,629 person-years, with 3,865 total deaths. Most patients (82%) were treated at 42 non–cardiac arrest receiving centers with median annual volume of 17 cases (interquartile range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac arrest receiving centers receiving at least 1 interfacility transfer per month. In adjusted models, treatment at a cardiac arrest receiving center was independently associated with reduced hazard of death compared with treatment at a non–cardiac arrest receiving center (adjusted hazard ratio 0.84; 95% confidence interval 0.74 to 0.94). These effects were unchanged when analysis was restricted to patients brought from the scene to the treating hospital. No other hospital characteristic, including total out-of-hospital cardiac arrest patient volume and cardiac catheterization capabilities, independently predicted outcome. Conclusion Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality.

Background and Aims Pain is one of the commonest symptoms in patients with chronic kidney disease (CKD), with a large proportion undertreated. Managing chronic pain in CKD patients is problematic due to the altered pharmacokinetic and pharmacodynamic related to the reduced renal clearance making it challenging for physicians to find appropriate pain management strategies. The aim of this systematic review was to estimate the overall prevalence of different types of analgesia in patients with CKD and investigate their safety. Method The population comprised of all adult patients with CKD defined as an estimated glomerular filtration rate (eGFR) less than 60mL/min/1.73m2 which included CKD-non dialysis (CKD-ND), kidney transplant recipients (KTR), patients undergoing dialysis and those receiving palliative care. Analgesics investigated included opioids, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), gabapentinoids and acetaminophen. All studies reporting a prevalence of analgesic use and/or exploring the association between analgesic consumption and adverse outcomes were included. Medline, Embase, CENTRAL, CINAHL and the grey literature were searched up to December 2020. Random-effect meta-analyses were conducted using a Generalised Linear Mixed Model approach to estimate the overall prevalence of analgesics use in the CKD population, displayed in forest-plots. Evidence gathered from studies investigating the adverse outcomes related to analgesics consumption was synthesised in ‘harvest plots’. Results Sixty-three studies reporting a prevalence of analgesic use in patients with CKD were included. The overall prevalence of analgesic consumption was 42% (95% CI, 35-50%) in the general CKD population and 70% (95% CI, 62-68%) among those experiencing chronic pain. Seventeen studies reported a prevalence of opioid use with 36% (95% CI, 23-51%) of patients with CKD receiving at least one opioid prescription while 16% (95% CI, 11-22%) were on chronic opioid therapy. The chronic use of oxycodone, tramadol, propoxyphene, fentanyl and hydromorphone were 3.6%, 2.0%, 1.3%, 1.1% and 0.05% respectively. NSAIDs usage was estimated to 20% (95% CI, 15-25%) among patients with CKD (ibuprofen 4.6%, diclofenac 1.7%) and 8% (95% CI, 5-12%) took NSAIDs chronically, with a higher prevalence among dialysis patients (17%) compared with CKD-ND (7%) and KTR (5%) (p Twenty studies assessing the association between analgesic use and adverse outcomes were included (Figure 1). Five of them demonstrated an association between opioid use and increased mortality, in all CKD subgroups; and three out of four studies reported more hospitalizations in opioid-users.Four studies highlighted an increased risk of gastro-intestinal bleeding associated with NSAIDs consumption and three studies found a significant association between gabapentin use and neurologic adverse events. Conclusion Only 70% of CKD patients experiencing chronic pain received an analgesic, suggesting that pain remains a significant public health burden. Despite limited evidence, opioids, NSAIDs and gabapentinoids seem to be associated with major adverse events. Their use requires cautious prescription, consideration of optimal dosage, and the development of therapeutic patient education to promote risk awareness. More evidence is warranted to better understand the adverse outcomes associated with long-term analgesic consumption and provide safe pain management strategies for patient with CKD.

Attention on P-20 science, technology, engineering, and mathematics (STEM) education has increased tremendously in recent years. Many efforts are underway to promote STEM major and career selection...

Summary: Postoperative acute kidney injury (AKI) is a common complication of surgery that is associated with significant adverse outcomes, including increased morbidity and mortality. The perioperative burden of AKI risk factors is complex and potentially large, including high-risk nephrotoxic medications, hypotension, hypovolemia, radiologic contrast, anemia, and surgery-specific factors. Understanding the pathogenesis, risk factors, and potential cumulative impact of perioperative nephrotoxic exposures is particularly important in the prevention and reduction of perioperative AKI. This review outlines the possible strategies to reduce perioperative nephrotoxicity and the development of postoperative AKI.

Background The Ultraviolet (UV) Index provides a reliable means of monitoring the strength of UV radiation at the Earth’s surface, which can be used to indicate the potential for skin damage. This qualitative study aims to examine public understanding of the UV Index among Australians who routinely use UV forecast information as well as those who do not. Methods Recent use of the SunSmart app (a popular mobile and tablet app that provides UV forecast information) served as a proxy for use of UV forecast information. Six focus groups were conducted with ‘new users’, who trialled the SunSmart app for the first time in the two weeks preceding the group discussion. In addition, 15 in-depth interviews were conducted with ‘existing users’, who routinely used the SunSmart app. Thematic discourse analysis was undertaken to compare views and experiences. Results Misperceptions about UV radiation were common. Participants learnt new information about UV radiation, the UV Index, and the times of the day that sun protection is recommended. Among adults who were using UV forecast information for the first time, this learning rarely translated to new behaviours; for these participants, the UV Index forecast information and recommendations were inconsistent with their own observation of the weather and subsequent judgement about their propensity to burn. Thus new users considered the UV forecast information to be overly cautious. In contrast, existing users recognised their inability to judge the UV Index level; for these participants, UV forecast information provided by the SunSmart app was incorporated into their daily routines and used to inform their sun protection behaviours. Conclusions/implications No matter how broadly UV forecast information is promoted, it is unlikely to improve sun protection behaviours across the Victorian population due to the low level of basic understanding of UV radiation. Public education strategies that correct the commonly held misperception that temperature and/or sunshine can reliably predict the potential for UV damage are required. Improved public awareness about UV radiation and how the UV Index can be used to prevent skin cancer may help Australians to develop more effective sun protection habits.

Objectives Evidence has shown that a prophylactic antibiotic regimen of flucloxacillin and gentamicin for orthopaedic surgery was associated with increased rates of post-operative acute kidney injury (AKI). This resulted in changes in the national antibiotic policy recommendation for orthopaedic surgical prophylaxis. This study aimed to assess whether this change from flucloxacillin and gentamicin to co-amoxiclav was associated with changes in the rates of AKI and Clostridium difficile infection (CDI). Methods An observational study and interrupted time series analyses were used to assess rates of post-operative AKI separately in patients undergoing neck of femur (NOF) repair and other orthopaedic operations that required antibiotic prophylaxis. Incidence rate ratios were used to evaluate changes in CDI rates. Results Following the change in policy, from flucloxacillin and gentamicin to co-amoxiclav, there was a relative change in rates of post-operative AKI of -63% (95% CI -77% to -49%) at 18 months in the other orthopaedic operations group. In the NOF repair group, there was no change in the rate of post-operative AKI [-10% (95% CI -35%-15%)] at 18 months. The incident rate ratio for CDI in the other orthopaedic operations group was 0.29 (95% CI 0.09-0.96) and in the NOF repair group was 0.76 (95% CI 0.28-2.08). Conclusions The use of co-amoxiclav for antibiotic prophylaxis in orthopaedic surgery was associated with a decreased rate of post-operative AKI compared with flucloxacillin and gentamicin and was not associated with increased rates of CDI.

Introduction Obtaining high quality informed consent for endoscopic procedures is frequently devolved to Junior Doctors, within NHS Tayside there was previously no standardised induction or education for Junior Doctors regarding consent for endoscopic procedures. We wished to assess Junior Doctors’ confidence with regard to the consent process for endoscopy and then develop an educational tool to improve this process as part of a quality improvement project. Methods An online questionnaire was distributed to Junior Doctors (FY1-CMT2) working within Medical Specialities in Ninewells Hospital, Dundee in August 2017. Information was gathered both regarding frequency and the nature of procedures consented for. Alongside this self-assessment of confidence and competency in gaining consent for individual procedures as well as any barriers to gaining patient consent and ideas to improve the process was sought. This data was analysed and a simulated consent video (focussing on ERCP) was produced and delivered as a short educational intervention to Junior Doctors. Further questionnaires were used pre and post educational intervention to assess Junior Doctors confidence and competency. Results 24 Junior Doctors completed the initial questionnaire; 8 CT1s/GPSTs, 7 FY2s, 6 FY1s, 2 CT2s and 1 PA (physician associate). 54.17% of respondents were asked to gain patient consent for procedures at least weekly and 8.33% daily. The most common procedures Junior Doctors were asked to consent for were OGD (95.83%), colonoscopy (70.83%) and ERCP (50%). 75% felt comfortable and competent to gain consent for OGD, 79.17% for colonoscopy, but only 54.17% for ERCP. 10 Junior Doctors received a short educational session focused around the simulated ERCP consent recording. Prior to the education 70% did not feel confident and competent to gain consent for ERCP. Following the intervention 100% feel confident and competent to gain consent for ERCP. Conclusions A short educational intervention has been shown to be successful in improving Junior Doctors confidence and competence consenting patients for ERCP, with self-rated confidence and competence improving from 30% to 100% following the intervention. A wider number of junior doctors will be shown the video in the future and there are plans to expand this to all endoscopic procedures and embed this process as part of the Junior Doctor induction in the Gastroenterology Department.

CCTV footage is commonly used in the court room to help visualise the crime in question and to help identify the offender. Unfortunately the majority of surveillance cameras produce such poor quality images that the task of identifying individuals can be extremely difficult. This study aimed at determining whether the task of identifying the offender in CCTV footage was one which a jury should be competent to do, or whether expert evidence would be beneficial in such cases. The ability of potential jury members, the general public, was tested by asking participants to play the role of a jury member by means of an online survey. Potential jury members viewed CCTV in which a simulated offence took place, and were subsequently asked to compare still images of a defendant to the offender to try to determine if they were competent and confident about making a judgement as to whether the defendant committed the crime. Factors such as age, gender and profession of the potential jury members were considered, as well as the type of crime committed, in order to establish if these play any role in the decision made by potential jury members. These factors did not appear to play a significant role; however confidence was also investigated and it became very evident that this was a factor that must be taken into consideration when determining the requirement for expert contribution in facial comparisons. Jury members may well be willing and competent to a basic level in carrying out a facial comparison but if they lack a certain level of confidence in their ability and decision making then this task is more suitable for an expert with experience and skills in this field.

Background: The purpose was to determine if an 8-week nutrition education and exercise program for families could influence health and fitness parameters, and retention of nutrition knowledge. Methods: Eighteen children (mean age: 10.52 ± 1.26 year; 50% boys, 50% girls; 56% white, 25% black, 19% multiracial) participated in the Families in Transformation (FIT) program. Preand post-study anthropocentric, blood pressure, fitness, and nutrition knowledge data was collected. Results: Diastolic blood pressure decreased for the total group (66.63 ± 8.81 to 63.75 ± 11.81mm Hg). Significant (P < 0.05) increases were seen for the group for push-ups (14.31 ± 7.62 to 19.63 ± 6.62) and chair squats (30.50 ± 10.21 to 34.44 ± 7.39). The reinforcing physical activity group performed significantly better on nutrition knowledge quizzes. Conclusion: Although, body mass index (BMI) z-scores did not change, there was a decrease in diastolic blood pressure, increase in fitness parameters, and increased retention of nutrition knowledge.

Aim The aim of the present study was to describe the health and dietary treatment of people with coeliac disease in New Zealand. Methods The New Zealand Coeliac Health Survey was a self-administered cross-sectional survey adapted, with permission, from the Canadian Celiac Health Survey. All members of Coeliac New Zealand Incorporated (n = 2720) were surveyed, primarily online (n = 2383). Surveys were posted to those without an email address (n = 337). Results The overall response rate was 46.5% (n = 1264). This analysis included biopsy-positive respondents aged 16 years and over (n = 936). Mean age at diagnosis was 43.5 (SD: 15.5) years. The median time between reported onset of symptoms and diagnosis of coeliac disease was 5 years (IQR 1–16). Most (88.4%) described their diet as being strictly gluten free, yet many had incomplete recovery from symptoms. Of 81.6% reported being referred to a dietitian, 19.9% considered the information they received to be fair or poor. Following a gluten-free diet was very difficult for 6.2%, and moderately difficult for 29.8%. Common problems included finding good quality gluten-free foods and identifying whether foods were gluten free or not from the label. More than one-third (36.3%) avoided travelling because of coeliac disease at least some of the time, and one-quarter (25.6%) never or rarely ate at restaurants. Conclusions Although coeliac disease is a common condition in New Zealand, ongoing symptoms among patients suggest that dietary management is inadequate. Knowledge of a gluten-free diet and its implementation among dietitians, and the preparation of commercial and restaurant gluten-free foods could be improved.

Nurses need the tools to reenvision processes and alleviate pressures on nursing staff.

SummaryBackground The transition from senior medical student to working safely and effectively as a new junior doctor is one of the biggest challenges that a new graduate will face. In 2014 the General Medical Council published The state of medical education and practice in the UK, reporting that some new doctors continue to struggle with increased responsibilities. We classify these instances as a ‘performance gap’, describing occasions in clinical practice where an individual exceeds their performance capacity. The Medical Mentorship Programme addressed identified performance gaps through a structured curriculum of simulation-based education and facilitated clinical practice. Methods Programme content was based on the experiences of the authors and their peers in graduating from their undergraduate training programme and becoming junior doctors. A questionnaire was disseminated to junior doctors in their first clinical rotation. The questionnaire asked doctors to describe instances where they experienced a performance gap. These data informed the development of the Medical Mentorship Programme. The effect of this programme was then evaluated via focus group discussion. Results The Medical Mentorship Programme has been shown to be an effective conduit for supporting the transfer of learning needed to address performance gaps in students. The programme increased the confidence of students in preparation for clinical practice and allowed junior doctors to reflect on their professional development. The programme combined complementary teaching techniques – mentorship, simulation and direct clinical experience – to aid the professional development of both students and mentors. Some new doctors continue to struggle with increased responsibilities

Based on an interdisciplinary linguistic ethnography, I apply the term ‘non-place’ to the collective identity of a Slavic migrant congregation in the United States. Those members socialised into their faith before migration had already been marginalised in their resistance to the former national Soviet identity. The New Literacy Studies in particular help to describe their historic Protestant literacy practices regarding a sacred, and thus fixed, text. A fixed sacred text provided the freedom to interpret the group's context, a perceived narrative to join, and authority for leadership to dictate a way of life. Events around text were warm and welcoming, utilising Western texts for legitimatised scripture interpretation, and accessible to both Russian speakers and second-generation English speakers. With the assumed permanence of a sacred text, new believers retold their own narratives as part of the scriptural one, and had a ‘home land’ they had never stepped foot in.

There is a vital need to understand details of the methylisocyanate (MIC) release that occurred at the 1984 Union Carbide Ltd. pesticide plant in Bhopal, India in order to avoid or respond to such releases in the future. However, we believe there are serious deficiencies in currently available dispersion predictions of the impact of toxic materials on humans and animals downwind of the plant. Specifically, cloud densities have been underestimated due to failure to account for the presence of a liquid/solid aerosol that would have been produced by the chemical reactions that caused the problem. Using data reported in Union Carbide's own investigation of the accident, which included chemical reaction data, we estimated aerosol compositions and cloud densities, then modeled the Bhopal release, simulating potential exposure levels at various locations under a number of wind-condition scenarios. For the worst-case (low wind speed and high aerosol densities), our predicted MIC concentrations at ground level are at least one order of magnitude greater than any previously published estimates. The centerline elevation of the jetting plume released at 33 m elevation is predicted to rise to about 41 m before falling, resulting in a 40 ppm (Immediately Dangerous to Life or Health, IDLH) concentration contour that reaches the ground at about 410 m downwind of the release location. This is consistent with observations that the plant environs were not hard-hit while the public immediately downwind of the plant perimeter was severely exposed. Concentrations on the order of 1000 ppm are predicted at some ground-level locations, which are more consistent than previous estimates with the reported large numbers of deaths and injuries of humans and animals.

This article is an amendment to Drengson (2011) that offers examples from fieldwork and reporting of practices influenced by the technocratic paradigm. Specifically (1) Krippner's work with Brazilian shamans and the theft of their tribal knowledge by the biotechnology industry that Krippner refers to as ecopiratism. (2) Hitchcock's field research with indigenous populations in the northwestern Kalahari Desert region of southern Africa and his documented assault of these indigenous peoples by private companies that Hitchcock refers to as developmental genocide. And (3) Walker's summary of Monsanto's patenting of seeds, and her warning of the health and environmental problems associated with genetically modified organisms. These examples offer support for the hypothesis that the eco-crisis is born of conscious agency. Beyond documenting and diagnosing these symptoms of the eco-crisis, this article puts forth the thesis that a transformation of consciousness would change the conditions of our present situation by providing the opportunity for different solutions to be found through the creation of a new mind set to make the necessary decisions for change. Many refer to the emerging field concerned with developing approaches to this transformation of consciousness as ecopsychology that Schroll prefers to call transpersonal ecosophy.

Background: Synthetic lethality (SL) is characterized by the chemical inhibition of multiple aberrant genes to differentially kill malignant cells. We investigated small-molecule combinations for SL through in vitro and in vivo screening and optimization studies (as in the granted patents in USA and China) and demonstrated the synergistic potential of best-in-class combinations of targeted agents, drug repositioning, immune modulation and low-dose combinations. We hypothesize that BTK and mTOR inhibition coupled with an IMID will target multiple key signaling pathways, improve differential apoptosis and target acquired drug resistance. DTRM-555, an optimized mechanism-based combination, consists of the clinically differentiated BTK inhibitor DTRMWXHS-12 (or DTRM-12), everolimus (EV) and pomalidomide (POM). In xenograft tumor models, DTRM-555 administered orally has demonstrated superior efficacy over monotherapy at very low dose combinations of the three agents (1/18 of DTRM-12, 1/6 of EV, and 1/6 of POM). DTRM-12 monotherapy has been safe and well tolerated in simultaneous phase Ia trials (US and China) with preliminary efficacy across 50 mg through 400 mg once daily (QD). Here we report the US clinical results of the oral combination therapies DTRM-505 (DTRM-12 plus EV) and DTRM-555 (DTRM-12 plus EV plus POM) for the first time (NCT02900716). Methods: The safety and anti-tumor activity of the oral doublet therapy DTRM-505 and the oral triplet therapy DTRM-555 are evaluated using a "3+3" study design. Enrollment was conducted concurrently with a phase Ia study of DTRM-12 monotherapy; with DTRM-505 opened for accrual when monotherapy DTRM-12 cleared the 200-mg dose level. Eligible patients are at least 18 years old, having ECOG performance status less than 2 with relapsed/refractory chronic lymphocytic leukemia (CLL), diffuse large B cell lymphoma (DLBCL), mantle cell lymphoma (MCL), follicular lymphoma (FL) or classical Hodgkin lymphoma (cHL). Study treatment is administered daily for 21 consecutive days over a 28-day cycle. The dose-limiting toxicity (DLT) period was defined during the first cycle of therapy, and treatment was continued until disease progression or unacceptable toxicity. Patients underwent tumor evaluations every 2 months and response was recorded using revised response criteria (IWCLL and Cheson 2014). Results: Between 9/2016 and 7/2018, 19 patients have been treated with DTRM-12 monotherapy in the USA (6 pts, 50-300 mg) and China (13 pts, 50-400 mg). Patients have tolerated up to 23+ cycles of DTRM-12 monotherapy. Seven patients, including DLBCL, CLL, MCL, FL and cHL, have been treated with oral doublet therapy DTRM-505 for 2 to 12 cycles. Three patients (2 DLBCL, 1 FL) have been treated with oral triplet therapy DTRM-555, including one patient transitioned from the doublet DTRM-505 under an exploratory arm. No patient has discontinued due to an adverse event (AE) and no DLT has occurred. Recurring AEs are mostly grade 1 or 2 and responses have been seen with DTRM-505 and DTRM-555 across diverse lymphoma histologies (See Tables). All patients evaluable for response demonstrated partial response to DTRM-505 and DTRM-555, with 2/7 (doublet) and 3/3 (triplet) patients remaining on therapy. Conclusion: The maximum tolerated dose has not been reached for DTRM-12 monotherapy and for the current fixed dose doublet and triplet combinations. Toxicities have been mild and repeated cycles of study treatment have been well tolerated without delays of subsequent treatment cycles. Enrollment continues for refractory lymphoma patients to demonstrate the safety and efficacy for the first-in-class oral triplet therapy DTRM-555. Disclosures Huntington: Janssen: Consultancy; Bayer: Consultancy; Celgene: Consultancy. Schuster:Merck: Consultancy, Honoraria, Research Funding; Genentech: Honoraria, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; OncLive: Honoraria; Dava Oncology: Consultancy, Honoraria; Physician's Education Source, LLC: Honoraria; Nordic Nanovector: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis Pharmaceuticals Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees. He:Zhejiang DTRM Biopharma Co. Ltd.: Other: Founder and CEO; Zhejiang DTRM Biopharma LLC: Other: Founder and CEO. Shen:Zhejiang DTRM Biopharma LLC: Other: Clinical Operations Director. Kennard:AbbVie, Gilead, Verastem: Consultancy. Dwivedy Nasta:Incyte: Research Funding; Takeda/Millenium: Research Funding; Debiopharm: Research Funding; Pharmacyclics: Research Funding; Rafael/WF: Research Funding; Aileron: Research Funding; Roche: Research Funding; Merck: Other: DSMC; Celgene: Membership on an entity's Board of Directors or advisory committees. Landsburg:Takeda: Consultancy; Curis: Consultancy, Research Funding. Porter:Novartis: Other: Advisory board, Patents & Royalties, Research Funding; Genentech: Other: Spouse employment; Kite Pharma: Other: Advisory board. Svoboda:Bristol-Myers Squibb: Consultancy, Research Funding; TG Therapeutics: Research Funding; Kyowa: Consultancy; Regeneron: Research Funding; Merck: Research Funding; Seattle Genetics: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; KITE: Consultancy. Song:Peking University Cancer Hospital (Beijing Cancer Hospital): Employment. Zhu:Beijing Cancer Hospital: Employment. Brander:Pharmacyclics, an AbbVie Company: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Other: Institutional research funding for non investigator initiated clinical trial, Research Funding; TG Therapeutics: Consultancy, Honoraria, Other: Institutional research funding for non investigator initiated clinical trial, Research Funding; Novartis: Consultancy, Other: DSMB; Genentech: Consultancy, Honoraria, Other: Institutional research funding for non investigator initiated clinical trial, Research Funding; Teva: Consultancy, Honoraria; Acerta: Other: Institutional research funding for non investigator initiated clinical trial, Research Funding; DTRM: Other: Institutional research funding for non investigator initiated clinical trial, Research Funding; BeiGene: Other: Institutional research funding for non investigator initiated clinical trial, Research Funding. Ding:Merck: Research Funding. Mato:Pharmacyclics, an AbbVie Company: Consultancy, Research Funding; AstraZeneca: Consultancy; Regeneron: Research Funding; Celgene: Consultancy; Acerta: Research Funding; TG Therapeutics: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Portola: Research Funding; Johnson & Johnson: Consultancy; Prime Oncology: Honoraria; Medscape: Honoraria.

Impink BG, Boninger ML, Walker H, Collinger JL, Niyonkuru C. Ultrasonographic median nerve changes after a wheelchair sporting event. Objectives To investigate the acute median nerve response to intense wheelchair propulsion by using ultrasonography and to examine the relationship between carpal tunnel syndrome (CTS) signs and symptoms and the acute median nerve response. Design Case series. Setting Research room at the National Veterans Wheelchair Games. Participants Manual wheelchair users (N=28) competing in wheelchair basketball. Intervention Ultrasound images collected before and after a wheelchair basketball game. Main Outcome Measures Median nerve cross-sectional area, flattening ratio, and swelling ratio and changes in these after activity. Comparison of median nerve characteristics and patient characteristics between participants with and without positive physical examination findings and with and without symptoms of CTS. Results Significant changes in median nerve ultrasound characteristics were noted after activity. The group as a whole showed a significant decrease in cross-sectional area at the radius of 4.05% ( P =.023). Participants with positive physical examinations showed significantly different ( P =.029) and opposite changes in swelling ratio compared with the normal group. Subjects with CTS symptoms had a significantly ( P =.022) greater duration of wheelchair use (17.1y) compared with the asymptomatic participants (9y). Conclusions Manual wheelchair propulsion induces acute changes in median nerve characteristics that can be visualized by using ultrasound. Studying the acute median nerve response may be useful for optimizing various interventions, such as wheelchair set up or propulsion training, to decrease both acute and chronic median nerve damage and the likelihood of developing CTS.