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Background: To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement., Methods: We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated., Results: A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility., Conclusions: The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use., Methods: A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use., Results: Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index., Conclusions: The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2023. Published by Elsevier Inc.)

Maternal protein restriction is often associated with structural and functional sequelae in offspring, particularly affecting growth and renal-cardiovascular function. However, there is little understanding as to whether hypertension and kidney disease occur because of a primary nephron deficit or whether controlling postnatal growth can result in normal renal-cardiovascular phenotypes. To investigate this, female Sprague-Dawley rats were fed either a low-protein (LP, 8.4% protein) or normal-protein (NP, 19.4% protein) diet prior to mating and until offspring were weaned at postnatal day (PN) 21. Offspring were then fed a non 'growth' (4.6% fat) which ensured that catch-up growth did not occur. Offspring growth was determined by weight and dual energy X-ray absorptiometry. Nephron number was determined at PN21 using the disector-fractionator method. Kidney function was measured at PN180 and PN360 using clearance methods. Blood pressure was measured at PN360 using radio-telemetry. Body weight was similar at PN1, but by PN21 LP offspring were 39% smaller than controls (P diet < 0.001). This difference was due to proportional changes in lean muscle, fat, and bone content. LP offspring remained smaller than NP offspring until PN360. In LP offspring, nephron number was 26% less in males and 17% less in females, than NP controls (P diet < 0.0004). Kidney function was similar across dietary groups and sexes at PN180 and PN360. Blood pressure was similar in LP and NP offspring at PN360. These findings suggest that remaining on a slow growth trajectory after exposure to a suboptimal intrauterine environment does not lead to the development of kidney dysfunction and hypertension.

Background: In patients who have had proximal digit amputation, metacarpal distraction osteogenesis is an option to improve digital length and function. One drawback is that traditional external distraction devices are large and cumbersome; the option of a low-profile internal device is therefore appealing. Internal distractors are commonly used in craniofacial reconstruction, but use in the hand has not been reported. We describe a case series of the novel use of an internal distractor in metacarpal lengthening., Methods: In this single-center case series, patients who underwent metacarpal distraction by the senior author using a uniplanar internal distractor were reviewed, and indications, outcomes, and complications were analyzed., Results: There were 5 cases in 4 patients (age range: 7-33 years). Indications were traumatic amputation in 4 cases and congenital hypoplasia in 1. All were successfully distracted, with a mean final length gain of 1.3 cm (range: 1.0-1.7 mm). Mean time from device placement to consolidation was 3.5 months. Complications included activation arm site infection in 2 cases, both occurring after the distraction period, necessitating device removal before full consolidation. In these cases, the device was removed after the distraction period and replaced with a Kirschner wire for stabilization through the consolidation period., Conclusions: Metacarpal distraction was successfully achieved with an internal distraction device. Although infection was common, it occurred after the distraction period and did not preclude length gain. We feel that this low-profile device offers advantages over cumbersome external devices typically used for metacarpal lengthening.

Study Design: Narrative review and case series., Introduction: The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis., Methods: We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data., Results: We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients., Discussion: We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use., Conclusions: There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Asthma is associated with increased risk of cardiovascular diseases. Despite many presenting with symptoms of asthma, asthma cannot always be confirmed by physiological assessment. It is thus far unknown if the heightened cardiovascular risk applies to this group. The purpose of this study was to examine markers of cardiovascular risk, including endothelial function, arterial stiffness, and systemic inflammation, in individuals with confirmed asthma, unconfirmed asthma, and healthy controls. As short-acting beta agonist (SABA) use is associated with increased cardiovascular risk, a secondary analysis was conducted to investigate the impact of regular SABA use on vascular outcomes., Methods: Individuals with confirmed asthma (n = 26), unconfirmed asthma (n = 15), and healthy controls (n = 26) were recruited for this cross-sectional study. Asthma was confirmed by FEV 1 reversibility, methacholine challenge, or exercise challenge. Endothelial function was assessed using flow-mediated dilation (FMD), arterial stiffness using pulse wave velocity (PWV), and systemic inflammation by C-reactive protein (CRP) levels., Results: FMD was significantly lower in both asthma groups compared to controls (confirmed: 7.7 ± 3.6%, unconfirmed: 7.3 ± 3.5%, controls: 10.4 ± 3.6%, p = 0.02). No difference was found in PWV nor CRP. Asthma participants who used SABA had increased arterial stiffness compared to those without SABA (9.2 ± 2.7 m/s, 7.7 ± 1.1 m/s respectively, p = 0.03). No difference was seen in FMD or CRP between SABA groups., Conclusion: Individuals with a clinical history of asthma symptoms demonstrate vascular impairments regardless of physiological confirmation of disease. Regular SABA use increases arterial stiffness. Avoiding potentially inappropriate SABA use among people without physiologically confirmed asthma may thus be beneficial in curbing cardiovascular risk., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The consumption of lycopene-rich foods may lower cardiovascular disease (CVD) risk. Lycopene circulates in the blood bound to lipoproteins, including high-density lipoproteins (HDLs). Preliminary data from our group showed that increased consumption of tomato-based food or lycopene supplement in middle-aged subjects led to functional changes to HDL's sub-fractions, HDL 2 and HDL 3 . These changes were also associated with a decrease in serum amyloid A (SAA), potentially enhancing their anti-atherogenic properties., Objective: We carried out a comprehensive randomized controlled intervention trial with healthy middle-aged volunteers to assess whether the consumption of tomato-based foods or lycopene supplements affects HDL functionality and associated inflammatory markers, and lipoprotein subfractions size and distribution., Design: Volunteers (225, aged 40-65 years) were randomly assigned to one of three dietary intervention groups and asked to consume a control diet (low in tomato-based foods, <10 mg lycopene/week), a lycopene-rich diet (224-350 mg lycopene/week), or the control diet with a lycopene supplement (70 mg lycopene/week). HDL 2 and HDL 3 were isolated by ultracentrifugation. Compliance was monitored by assessing lycopene concentration in serum. Systemic and HDL-associated inflammation was assessed by measuring SAA concentrations. HDL functionality was determined by monitoring paraoxonase-1 (PON-1), cholesteryl ester transfer protein (CETP), and lecithin cholesterol acyltransferase (LCAT) activities. The lipoprotein subfractions profile was assessed by NMR., Results: Lycopene in serum and HDL significantly increased following consumption of both the high tomato diet and lycopene supplement ( p ≤ 0.001 for both). Lycopene, either as a tomato-rich food or a supplement, enhanced both serum- and HDL 3 -PON-1 activities ( p ≤ 0.001 and p = 0.036, respectively), while significantly reducing HDL 3 -SAA-related inflammation ( p = 0.001). Lycopene supplement also significantly increased HDL 3 -LCAT activity ( p = 0.05), and reduced the activity of both HDL 2 - and HDL 3 -CETP ( p = 0.005 and p = 0.002, respectively). These changes were not associated with changes in the subclasses distribution for all lipoprotein fractions or the size of lipoprotein subclasses., Conclusion: Our results showed that dietary lycopene can significantly enhance HDL functionality, without associated changes in particle size and distribution, by modulating the activity of HDL-associated enzymes. Concomitantly, dietary lycopene significantly decreased serum- and HDL 3 -associated SAA, confirming that SAA may represent a sensitive inflammatory biomarker to dietary change., Clinical Trial Register: (https://www.isrctn.com), ISRCTN34203810., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 McEneny, Henry, Woodside, Moir, Rudd, Vaughan and Thies.)

Spinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy., Competing Interests: Conflict of Interest None declared., (The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Somatic manifestations of mental illness sometimes occur in patients presenting to hand specialists. These conversion disorders can also occur in groups, a phenomenon known as "mass psychogenic illness." The increasing penetrance of the Internet and social media in modern society has greatly facilitated the interaction of patients with others with similar disorders. One example relevant to hand surgery is "Morgellons disease," a disorder popularized in 2002 and characterized by a firm belief in foreign material extruding from the skin, leading to nonhealing, self-inflicted ulcerations and excoriations. A series of 4 patients collected through an informal survey of hand surgeons regarding experience with Morgellons disease is reviewed and discussed. All patients in the series presented with a chief complaint of foreign material extruding from the hand. In 1 case, the complaint was made by a young patient's mother. In none of the patients were foreign bodies identified, although 2 patients demonstrated significant ulcerations and scars from self-excoriation. Three patients had a somatic condition affecting the hand or upper extremity, 1 directly related to self-excoriation and 2 unrelated. Treatments, workups, and ultimate outcomes varied among patients. Patients presenting with Morgellons disease often undergo multiple unnecessary tests and are at risk of inappropriate procedures. It is therefore important that providers have a compassionate understanding of the involved psychology. Herein, we offer an approach to the recognition of and treatment strategies for these patients.

Summary: Craniofacial free tissue transfer is sometimes complicated by insufficient pedicle length and/or paucity of recipient vessels. A saphenous vein graft can be used to reach the high-flow, large-caliber vessels of the neck, but because of the vein's taper and thick wall, there is often a mismatch. Following the principle of like-for-like, the authors prefer the descending branch of the lateral circumflex femoral vessels to achieve a more anatomical pedicle extension for free tissue transfer in complex craniofacial reconstruction. The authors' experience using the descending branch of the lateral circumflex femoral pedicle extender from 2010 to 2019 was reviewed. Indications, patient characteristics, reconstruction site, flap type, pedicle length, recipient vessels, and vascular complications were noted. The authors reviewed two strategies for implementation of the pedicle extender: in some cases, the flap was first transferred and allowed to perfuse on the descending branch of the lateral circumflex femoral vessels in the thigh, and then transferred to the recipient vessels (double-ischemia transfer); and in other cases, the flap and pedicle extender were transferred such that the flap underwent a single period of ischemia (single-ischemia transfer). The descending branch of the lateral circumflex femoral pedicle extender was used in 17 craniofacial cases. Indications included tumor, trauma, osteoradionecrosis, and congenital. Double-ischemia transfer was used in eight cases and single-ischemia transfer in nine. The longest pedicle extender in the series was 15 cm. Arterial thrombosis occurred in one case. This case series demonstrates that the descending branch of the lateral circumflex femoral pedicle extender is a viable option for complex craniofacial free tissue transfer cases. It provides ample length and excellent vessel match, following the like-for-like principle., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

A maternal low protein (LP) diet in rodents often results in low nephron endowment and renal pathophysiology in adult life, with outcomes often differing between male and female offspring. Precisely how a maternal LP diet results in low nephron endowment is unknown. We conducted morphological and molecular studies of branching morphogenesis and nephrogenesis to identify mechanisms and timepoints that might give rise to low nephron endowment. Sprague-Dawley rats were fed a normal protein (19.4% protein, NP) or LP (9% protein) diet for 3 weeks prior to mating and throughout gestation. Embryonic day 14.25 (E14.25) kidneys from males and females were either cultured for 2 days after which branching morphogenesis was quantified, or frozen for gene expression analysis. Real-time PCR was used to quantify expression of key nephrogenesis and branching morphogenesis genes at E14.25 and 17.25. At E17.25, nephron number was determined in fixed tissue. There was no effect of either maternal diet or sex on branching morphogenesis. Nephron number at E17.25 was 14% lower in male and female LP offspring than in NP controls. At E14.25 expression levels of genes involved in branching morphogenesis (Gfrα1, Bmp4, Gdnf) and nephrogenesis (Hnf4a, Pax2, Wnt4) were similar in the dietary groups, but significant differences between sexes were identified. At E17.25, expression of Gfrα1, Gdnf, Bmp4, Pax2 and Six2 was lower in LP offspring than NP offspring, in both male and female offspring. These findings provide new insights into how a LP diet leads to low nephron endowment and renal sexual dimorphism., (© 2020 American Association for Anatomy.)

Study Design: A retrospective, single-center, consecutive case series., Introduction: In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs., Purpose of the Study: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs., Methods: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks., Results: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures., Conclusion: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary., (Copyright © 2019 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.)

Context: Early tailored transplant education could help patients make informed transplant choices., Objective: We interviewed 40 patients with chronic kidney disease (CKD) stages 3 to 5, 13 support persons, and 10 providers at Kaiser Permanente Southern California to understand: (1) barriers to transplant education and (2) transplant educational preferences and recommendations based on CKD stage and primary language spoken., Design: A grounded theory analysis identified central themes related to transplant education barriers, preferences, and recommendations., Results: Barriers included confusion about diagnosis and when transplant may be necessary, concerns about transplant risks, families' lack of transplant knowledge, financial burdens, transportation and scheduling, and the emotional overload of chronic illness. Hispanic and Spanish-speaking participants reported difficulty in understanding transplant education and medical mistrust. Recommendations included providing general education, earlier introduction to transplant, wait-listing information, transplant education for support persons, living donation education for patients and potential donors, opportunities to meet living donors and kidney recipients, information on the benefits of transplant, recovery, and available financial resources, flexible class scheduling, online and print resources, and more provider follow-up. Spanish-speaking and Hispanic participants recommended using bilingual educators, print, video, and online resources in Spanish, and culturally responsive education. Patients with CKD stages 3 to 4 wanted information on slowing disease progression and avoiding transplant., Conclusion: Increasing access to culturally responsive transplant education in multiple languages, pairing appropriate content to the disease stage, and increasing system-wide follow-up as the disease progresses might help patients make more informed choices about transplant.

Background: More than 50,000 randomized controlled trials and 8000 systematic reviews are anticipated to be published annually in the coming years. This huge volume of published findings makes it challenging for health care delivery systems to review new evidence, prioritize health care practices that warrant implementation, and implement best practices., Objective: The objective of this study was to describe the Kaiser Permanente Southern California E-SCOPE (Evidence Scanning for Clinical, Operational, and Practice Efficiencies) program, a systematic method to accelerate the implementation of evidence-based practices in clinical care settings., Methods: E-SCOPE uses a strategic evidence search algorithm to conduct proactive literature searches to identify high-quality studies of interventions that yield improved health outcomes, quality and/or efficiency of care delivery, or cost savings. Each quarterly search yields 500-1000 abstracts; about 5%-10% of studies are selected each quarter for consideration for implementation. These studies are presented to clinical and operational leaders and other stakeholders to make the final determination regarding the implementation of the practice; E-SCOPE staff work closely with stakeholders to develop an implementation plan, identify practice owners, and ensure sustainability., Results: The time from study publication to implementation using the E-SCOPE process ranges from 4 to 36 months, with an average of ∼16 months. Four examples of E-SCOPE implementation efforts, including new deployment, scale-up/spread, deimplementation, and operational efforts, are described., Conclusion: A single, centralized program for the proactive identification of the most up-to-date, evidence-based best practices and facilitated implementation can efficiently and effectively promote continuous learning and implementation in a learning health care system.

Background: Asthmatics are at increased cardiovascular disease risk, which has been linked to beta2(β 2 )-agonist use. Inhalation of β 2 -agonists increases sympathetic nerve activity (SNA) in healthy individuals, however the systemic impact of salbutamol in asthmatics using β 2 -agonists regularly is unknown., Objectives: This study compared the systemic vascular responses to a clinical dose of salbutamol (Phase I) and following an acute increase in SNA (Phase II) in asthmatics and controls., Methods: Fourteen controls and 14 asthmatics were recruited for Phase I. On separate days, flow-mediated dilation (FMD) and peripheral arterial stiffness (pPWV) were evaluated at baseline and following either 400 μg inhaled salbutamol or a placebo inhaler. For Phase II, heart rate, blood pressure, vascular conductance, pPWV, and central (c)PWV were evaluated in response to a large increase in SNA brought on by cold-water hand immersion (i.e. cold-pressor test) or body-temperature water hand immersion (i.e. control) in 10 controls and 10 asthmatics., Results: Following salbutamol, asthmatics demonstrated reduced FMD (-3.0%, p < 0.05) and increased pPWV (+0.7 m/s, p < 0.05); however, salbutamol had no effect in controls. The cold-pressor test resulted in similar increases in blood pressure, vascular flow rates and conductance, pPWV, and cPWV in both asthmatics and controls, suggesting similar neurovascular transduction in asthmatics and controls., Conclusion: Inhaled Salbutamol leads to increased arterial stiffness and reduced FMD in asthmatics. As asthmatics and controls had similar vascular responses to an increase in SNA, these findings suggest asthmatics have heightened sympathetic responses to β 2 -agonists which may contribute to the increased cardiovascular risk in asthma., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Five-year survival on dialysis is only 40%, compared to 74% with a deceased donor kidney transplant (DDKT) and 87% with a living donor kidney transplant (LDKT). An American Society of Transplantation (AST) Consensus Conference recommended that patients with chronic kidney disease (CKD) Stages 3-5 have the opportunity to learn about and decide which treatment option is right for them, particularly about LDKT. However, early education about LDKT and DDKT outside of transplant centers is inconsistent and often poor, with patients in CKD 3 and 4 and ethnic/racial minorities even less likely to receive it. A new randomized control trial (RCT), in partnership with Kaiser Permanente Southern California (KPSC), will assess knowledge gaps and the effectiveness of a supplementary video-guided, print and technology-based education intervention for English- and Spanish-speaking patients in CKD Stages 3, 4, and 5 to increase LDKT knowledge and decision-making. To date, no published LDKT educational interventions have studied such a large and diverse CKD population., Methods: In this RCT, 1200 English and Spanish-speaking CKD Stage 3-5 patients will be randomly assigned to one of two education conditions: ET@Home or KPSC standard of care education. Randomization will be stratified by CKD stage and primary language spoken. Those in the ET@Home condition will receive brochures, postcards, DVDs, and text messages delivering educational content in modules over a six-month period. Baseline data collection will measure demographics, transplant derailers, and the amount of previous CKD and transplant education they have received. Changes in CKD and transplant knowledge, ability to make an informed decision about transplant, and self-efficacy to pursue LDKT will be captured with surveys administered at baseline and at six months., Discussion: At the conclusion of the study, investigators will understand key knowledge gaps for patients along the CKD continuum and between patients who speak different languages and have assessed the effectiveness of both English- and Spanish-language supplementary education in increasing KPSC patients' knowledge about the opportunities for and risks and benefits of LDKT. We hope this program will reduce disparities in access to transplant., Trial Registration: ClinicalTrials.gov Identifier: NCT03389932; date registered: 12/26/2017.

In the original publication, age stratified mortality rates were incorrectly added in Fig. 2. The correct Fig. 2 is given below.

Purpose: The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD., Methods: A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics., Results: Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk., Conclusion: Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.

Background: Cognitive deficits are common among individuals on haemodialysis (HD). The degree of dysfunction may shift over the course of the interdialytic interval., Objectives: To use ecological momentary assessment (EMA) to examine the relationship between the length of the interdialytic interval and reports of cognitive dysfunction., Design: A quantitative study whereby each patient's cognitive functioning was measured during both short and long interdialytic intervals., Participants: Adults maintained on HD (Female n = 15, Male n = 11; M Age  = 42.7 ± 15.8 years) were drawn from a standalone HD unit within a large university medical centre., Measurements: Tests of baseline neurocognitive functioning were undertaken (Mini-Mental Status Examination, Digit Span, California Verbal Learning Test, Benton Visual Retention Test, Trail-Making Test) and smartphone-based electronic diary reports of cognitive impairment were made around six times each day for one week., Results: Cognitive function and aptitude in this sample, although low, did not reflect clinically-significant impairment, with a mean Mini-Mental Status Exam score of 25.7 ± 3.0. Diary reports of cognitive impairment were also minimal, with an overall mean rating of .22 out of 5. Contrary to expectations, cognitive impairment was significantly greater on the one-day interdialytic days than on Day 2 of the two-day interdialytic interval (β = .094, p = .017)., Conclusions: Although cognitive impairment appears to be mild in stable, young patients with end stage renal disease, volumetric disruptions caused by HD may exacerbate such dysfunction., (© 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Rhodopseudomonas palustris is a species of purple photosynthetic bacteria that has a multigene family of puc genes that encode the alpha and beta apoproteins, which form the LH2 complexes. A genetic dissection strategy has been adopted in order to try and understand which spectroscopic form of LH2 these different genes produce. This paper presents a characterisation of one of the deletion mutants generated in this program, the pucBA d only mutant. This mutant produces an unusual spectroscopic form of LH2 that only has a single large NIR absorption band at 800 nm. Spectroscopic and pigment analyses on this complex suggest that it has basically a similar overall structure as that of the wild-type HL LH2 complex. The mutant has the unique phenotype where the mutant LH2 complex is only produced when cells are grown at LL. At HL the mutant only produces the LH1-RC core complex.

Background: Healthcare systems and providers are encouraged to prepare their patients with advanced chronic kidney disease (CKD) for a planned start to renal replacement therapies (RRT). Less well understood are the socioemotional experiences surrounding the optimal start of RRT versus suboptimal haemodialysis (HD) starts with a central catheter., Objectives: To characterise the experiences of patients beginning RRT., Design: Qualitative, semi-structured phone interviews., Participants: A total of 168 patients with stage 5 CKD initiating RRT in an integrated, capitated learning healthcare system., Approach: Qualitative data from patients were collected as part of a quality improvement initiative to better understand patient-reported themes concerning preparation for RRT, patients' perceptions of their transition to dialysis and why sub-optimal starts for RRT occur within our healthcare system. Dual review and verification was used to identify key phrases and themes within and across each domain, using both deductive a priori codes generated by the interview guide and grounded discovery of emergent themes., Results: From the patient perspective, preparing for RRT is an experience rooted in deep feelings of fear. In addition, a number of key factors contributed to patients' preparation (or failure to prepare) for RRT. While the education provided by our system was viewed as adequate overall, patients often felt that their emotional and psychosocial needs went unmet, regardless of whether or not, they experienced an optimal dialysis start., Conclusions: Future efforts should incorporate additional strategies for helping patients with advanced CKD achieve emotional and psychological safety while preparing for RRT., (© 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Recognized for nearly four decades, most juvenile suspects waive their Miranda rights and almost immediately provide self-incriminating evidence. Miranda-specific measures were eventually developed to understand their capacities and limitations. With extensive revisions, the Miranda Rights Comprehension Instruments (MRCI) were normed and validated. Beyond reliability, the current study addresses the convergent and discriminant validity of the MRCI. In response to Frumkin and Sellbom's criticism of the MRCI's norms, the current research provides representative data on 245 legally involved juveniles with percentiles to facilitate the interpretation of MRCI data. The current investigation is also the first MRCI study to link directly Miranda comprehension (i.e., the knowing prong) to Miranda reasoning (i.e., the intelligent prong) of waiver decisions.

We describe a new method for the immobilisation of DNA into defined patterns with sub-micron resolution, using the fluorous effect. The method is fully reversible via a simple solvent wash, allowing the patterning, regeneration and re-patterning of surfaces with no degradation in binding efficiency following multiple removal/attachment cycles of different DNA sequences.

Background: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy., Methods: A retrospective analysis of one surgeon's consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups., Results: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28)., Conclusions: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon's practice., Clinical Question/level of Evidence: Therapeutic, III.

Introduction: Patient-facing online tools for managing preventive and chronic care can be a resource-effective way to increase patient agency in health promotion. Recently, Kaiser Permanente Southern California added the Online Personal Action Plan (oPAP) to the member web portal to better enable members to access information about prevention, health promotion, and care gaps. This study described Kaiser Permanente Southern California members who use oPAP, as well as how members use oPAP to close five different care gaps: hemoglobin A1c testing, pneumonia vaccination, and three cancer screenings., Methods: Care gap closure rates between oPAP users and members not registered on the online patient portal between December 2014 and March 2015 were compared. Data were analyzed in 2015. A total of 838,638 cases (48.9% women; mean age, 49.5 years; 40.4% oPAP users) were examined., Results: Adjusting for demographics, BMI, smoking status, health and insurance status, and number of open care gaps, oPAP access was associated with a somewhat greater likelihood of care gap closure within 90 days for select care gap types, particularly hemoglobin A1c testing and breast, cervical, and colorectal cancer screening among eligible members. The effect of oPAP access on care gap closure differed by certain ethnic minority groups., Conclusions: Although healthcare organizations have developed approaches to managing and closing preventive care gaps, these efforts are resource intensive. Users of oPAP are more likely than non-registered members to close gaps, especially cancer screening tests. The oPAP appears to be an effective tool at improving patient engagement in preventive health care., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine the influence of patient-reported medication adherence and phosphorus-related knowledge on phosphorus control and pharmacy-reported adherence to phosphorus binding medication among patients on maintenance hemodialysis., Design: Retrospective, cross-sectional cohort study., Subjects: Seventy-nine hemodialysis patients (mean age 64.2 years, SD = 14 years; 46.8% female) in a stand-alone hemodialysis unit within an integrated learning healthcare system. Ten percent (10%) of subjects were Caucasian, 42% Latino, 19% African American, and 29% Asian. Forty-eight percent had diabetes; 72% had BMI ≥ 30. Inclusion criteria included the provision of survey data and having medication refill data available in the pharmacy system. 77.2% had mean phosphorus levels ≤ 5.5 mg/dL; 22.8% had mean phosphorus levels > 5.5 mg/dL., Intervention: Subjects were administered the 8-item Morisky Medication Adherence Scale (MMAS-8) and also reported on their phosphorus-related knowledge., Main Outcome Measure: Phosphorus levels within an adequate range., Results: The mean serum phosphorus level was 4.96 mg/dL (SD = 1.21). In the well-controlled group, mean phosphorus was 4.44 mg/dL (SD = 0.76). In the poorly controlled group, mean phosphorus was 6.69 mg/dL (SD = 0.74). A total of 61% of patients reported at least some unintentional medication nonadherence, and 48% reported intentional medication nonadherence. Phosphorus-specific knowledge was low, with just under half of patients reporting that they could not name two high-phosphorus foods or identify a phosphorus-related health risk. Phosphorus binder-related nonadherence was substantially higher in the uncontrolled than the controlled group. Adjusting for age, individuals with poorer self-reported binder adherence were less likely to have controlled phosphorus levels (odds ratio = 0.71, P = .06)., Conclusion: Phosphorus-related non-adherence, but not low phosphorus-specific knowledge, was associated with poorer phosphorus control. Such findings provide important information for the development of evidence-based strategies for improving phosphorus control among patients on dialysis., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

This manuscript describes the surface immobilization of a light-harvesting complex to prescribed locations directed by the sequence-selective recognition of duplex DNA. An engineered light-harvesting complex (RC-LH1) derived from Rhodopseudomonas (Rps.) palustris containing the zinc finger (ZF) domain zif268 was prepared. The zif268 domain directed the binding of zfRC-LH1 to target double-stranded DNA sequences both in solution and when immobilized on lithographically defined micro-patterns. Excitation energy transfer from the carotenoids to the bacteriochlorophyll pigments within zfRC-LH1 confirmed that the functional and structural integrity of the complex is retained after surface immobilization.

Background: Extracranial-to-intracranial (EC-IC) arterial bypass is a technically demanding procedure used to treat complex cerebral artery diseases. The indications, proper surgical techniques, and outcomes of this procedure have been under debate over the recent decades., Methods: Between January 2004 and December 2012, 28 patients, including patients with cerebral artery occlusion, intracranial aneurysm, cranial base tumor, and Moyamoya disease, underwent EC-IC bypass. Patients' records were retrospectively reviewed for demography, indications, complications, high-flow versus low-flow bypass, patency rate of bypass, and neurological outcome. The patients were sorted into prophylactic (n = 16) and therapeutic (n = 12) groups based on the preoperative presentation of their neurological symptoms. Follow-up evaluation was performed at a mean of 32.7 ± 24.3 months., Results: The overall patency rate of bypass was 100%, the postoperative stroke rate was zero, and the surgical complication rate was 14.3%. There was no significant difference in the bypass patency rate between the 2 groups or between the high-flow and low-flow bypass patients. Patients who underwent prophylactic bypass had minimal surgical and total complications (P = 0.03 and P < 0.01, respectively) and a better neurological outcome. Surgical complications were more common in patients who underwent therapeutic bypass (25%)., Conclusions: The collaboration of neurosurgeons and plastic surgeons in performing EC-IC bypass can result in excellent outcomes with a high bypass patency rate and few complications, particularly for prophylactic EC-IC bypass.