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In adult women, most malignant ovarian tumors are epithelial in origin. The use of intra-operative frozen section to distinguish between benign and malignant histology is reliable in guiding operative decision-making to determine the extent of surgical staging required. Pediatric and adolescent patients with ovarian masses have a much different spectrum of pathology with most tumors arising from germ cell precursors. This review was undertaken to assess the concordance between the intra-operative frozen section and the final diagnosis as an aid to guide extent of surgical staging in a group of pediatric and adolescent patients with malignant ovarian germ cell tumors.Records of patients aged 0 to 20 years with malignant ovarian germ cell tumors enrolled on Children's Oncology Group study AGCT0132 were reviewed. Pathology reports from patients who had both intra-operative frozen section diagnosis and final paraffin section diagnosis were compared using descriptive statistics. By inclusion criteria for the study, all patients had a final diagnosis of malignancy with required yolk sac tumor, choriocarcinoma or embryonal carcinoma histology. Available central review of pathology final paraffin section slides were compared with final institution pathology reports.Of 131 eligible patients with ovarian germ cell tumors, 60 (45.8%) had both intra-operative frozen section and final paraffin section diagnoses available. Intra-operative frozen section diagnoses were classified as: incorrect diagnosis of benign tumor (13.3%), confirmation of malignancy (61.7%), immature teratoma (16.7%), germ cell tumor not otherwise specified (5%) and no diagnosis provided (3.3%). Intra-operative frozen section was incorrect in 23 of 60 (38.3%) patients evaluated. Central pathology review was concordant with the final institution pathology diagnosis in 76.3% of patients. Central pathology review identified additional germ cell tumor components in 23.7% of patients.In pediatric and adolescent patients with a confirmed final diagnosis of ovarian germ cell malignancy, intra-operative frozen section diagnosis is not reliable to inform the extent of surgical staging required. Central review by an expert germ cell tumor pathologist provides important additional information to guide therapy.

ObjectiveTo compare food and drink in the UK National Diet and Nutrition Survey (NDNS) database based on their front of package label multiple traffic light (FOPL MTL) score, nutrient content and NOVA classification.DesignNational cross-sectional nutrient profiling analysis.SettingThe UK food and drink supply. Food and drink items were obtained from Intake24, the electronic dietary assessment method used in NDNS Year 12 (2019–20).Main outcome measuresNutrient content, FOPL MTL and the NOVA classification of each item. Items were coded into minimally processed food (MPF), processed culinary ingredients (PCI), processed food (PF) and ultra-processed food (UPF) according to the NOVA classification, and coded into green, amber and red FOPL traffic lights according to Food Standards Agency guidance on fat, saturated fat, total sugar and salt content per 100g.ResultsOut of 2,980 items, 55.4% were UPF, 33.1% were MPF, 9.5% were PF, and 2.0% were PCI. UPFs contained greater fat, saturated fat, total sugar, and salt per 100g than MPFs, and had a higher energy density and greater proportion of hyper-palatable items (pConclusionsMost items in the UK are UPF. UPFs have an unhealthier nutritional profile than MPFs, are more likely to have an unhealthier FOPL MTL score and be more energy-dense and hyper-palatable. When considering items without any red FOPL, UPFs still have a poorer nutritional profile than MPFs, with a higher energy density and hyper-palatability. But, not all UPFs were unhealthy according to FOPL. The results have important implications for understanding how consumers may interpret the healthiness of UPFs or FOPL MTLs, and updating UK food and drink labelling.What is known:Nutrient content is an important determinant of diet-related health. Nutrient content is reflected in UK national dietary guidelines, and at point of purchase through front of package label multiple traffic light (FOPL MTL) scores for nutrients of concern.Higher intakes of ultra-processed food (UPF), as defined by the NOVA classification, are associated with higher risks of adverse health outcomes including obesity and cardiometabolic disease.The overlap between the nutrient content and FOPL MTLs of the UK food and drink supply with food processing is unknown. How FOPL MTLs might be used to guide consumer purchasing behaviour of UPFs is unclear.What this study adds:This is the first study to compare the nutritional characteristics of food and drink items representative of the UK supply with the NOVA classification.There is partial overlap between FOPL MTL and NOVA; UPFs tend to have an unhealthier nutrient profile, but a considerable number of UPFs are considered healthy, based on their FOPL MTL score.UPFs also tend to be more energy dense and hyper-palatable than MPFs, even when considering only ‘healthy’ items (without any red FOPL traffic lights).

The emergence of SARS-CoV-2 variants has exacerbated the COVID-19 global health crisis. Thus far, all variants carry mutations in the spike glycoprotein, which is a critical determinant of viral transmission being responsible for attachment, receptor engagement and membrane fusion, and an important target of immunity. Variants frequently bear truncations of flexible loops in the N-terminal domain (NTD) of spike; the functional importance of these modifications has remained poorly characterised. We demonstrate that NTD deletions are important for efficient entry by the Alpha and Omicron variants and that this correlates with spike stability. Phylogenetic analysis reveals extensive NTD loop length polymorphisms across the sarbecoviruses, setting an evolutionary precedent for loop remodelling. Guided by these analyses, we demonstrate that variations in NTD loop length, alone, are sufficient to modulate virus entry. We propose that variations in NTD loop length act to fine-tune spike; this may provide a mechanism for SARS-CoV-2 to navigate a complex selection landscape encompassing optimisation of essential functionality, immune driven antigenic variation and ongoing adaptation to a new host.

The COVID-19 pandemic has negatively impacted people living with obesity. The aim was to examine the continued impact of the COVID-19 pandemic on the mental health of people living with obesity and associations with food insecurity, loneliness and health-related behaviours.The study recruited 1187 UK adults living with obesity who completed an online survey, which examined mental health and associations with food insecurity, loneliness and health-related behaviours from July 2020 (end of the first lockdown in the United Kingdom) to the point they completed the survey in 2021. Regression analyses were used to examine relationships between outcome variables and demographic factors, and hierarchical linear regression models were used to assess levels of loneliness, depression and well-being.Participants reported worse loneliness, depression, well-being and food insecurity compared to pre-COVID. However, participants reported attempting to lose weight, healthier food shopping, diet and increased physical activity. Quality and quantity of sleep deteriorated compared to prior to COVID-19.Adults living with obesity in the United Kingdom report a continued negative impact of the COVID-19 pandemic upon their mental health together with increased loneliness and food insecurity. However, our findings suggest that UK adults living with obesity have increased their engagement in positive health behaviours and were attempting to lose weight.

Background Physical inactivity is a leading risk factor for many health conditions, including cardiovascular disease, diabetes, and cancer; therefore, increasing physical activity (PA) is a public health priority. Health care professionals (HCPs) in primary care are pivotal in addressing physical inactivity; however, few HCPs provide PA advice to patients. There can be obstacles to delivering PA advice, including lack of time, confidence, or knowledge. Digital technology has the potential to overcome obstacles and facilitate delivering PA advice. However, it is unknown if and how digital tools are used to deliver PA advice in primary care consultations and what factors influence their use. Objective We aimed to understand the use of digital tools to support primary care consultations and to identify the barriers to and facilitators of using these systems. Methods Overall, 25 semistructured interviews were conducted with primary care HCPs. Professionals were sampled based on profession (general practitioners, practice nurses, and health care assistants), prevalence of long-term conditions within their practice area, and rural-urban classification. The data were analyzed thematically to identify the influences on the use of digital tools. Themes were categorized using the COM-B (capability, opportunity, and motivation—behavior) model and the Theoretical Domains Framework to identify the barriers to and facilitators of using digital tools to support the delivery of PA advice in primary care consultations. Results The identified themes fell within 8 domains of the Theoretical Domains Framework. The most prominent influence (barrier or facilitator) within psychological capability was having the skills to use digital tools. Training in the use of digital tools was also mentioned several times. The most notable influences within physical opportunity were limited digital tools to prompt/support the provision of PA advice, time constraints, efficiency of digital tools, simplicity and ease of use of digital tools, and integration with existing systems. Other physical opportunity influences included lack of access to digital tools and technical support in the use of digital tools. Within social opportunity, a notable barrier was that digital tools reduce interpersonal communication with patients. Patient preference was also identified. Several important influences were within reflective motivation, including confidence to use digital tools, beliefs about the usefulness of digital tools, the belief that digital tools “are the way forward,” beliefs related to data privacy and security concerns, and perceptions about patient capabilities. About automatic motivation, influences included familiarity and availability regarding digital tools and the fact that digital tools prompt behavior. Conclusions A variety of influences were identified on the use of digital tools to support primary care consultations. These findings provide a foundation for designing a digital tool addressing barriers and leverages the facilitators to support PA advice provision within primary care to elicit patient behavior change and increase PA.

COVID-19 pandemic restrictions impacted dietary habits during the initial months of the pandemic, but long-term effects are unclear. In this longitudinal study, self-selected UK adults (n = 1,733, 71.1% female, 95.7% white ethnicity) completed three online surveys (May–June, August–September, and November–December 2020, with a retrospective pre-pandemic component in the baseline survey), self-reporting sociodemographics, lifestyle, and behaviours, including high fat, salt, and sugar (HFSS) snacks, HFSS meals, and fruit and vegetable (FV) intake. Data were analysed using generalised estimating equations. Monthly HFSS snacks portion intake increased from pre-pandemic levels (48.3) in May–June (57.6, p < 0.001), decreased in August–September (43.7, p < 0.001), before increasing back to pre-pandemic levels in November–December (49.2, p < 0.001). A total of 48.5% self-reported increased [25.9 (95% confidence interval: 24.1, 27.8)] and 47.7% self-reported decreased [24.1 (22.4, 26.0)] monthly HFSS snacks portion intakes in November–December compared with pre-pandemic levels. Monthly HFSS meals portion intake decreased from pre-pandemic levels (7.1) in May–June (5.9, p < 0.001), was maintained in August–September (5.9, p = 0.897), and then increased again in November–December (6.6, p < 0.001) to intakes that remained lower than pre-pandemic levels (p = 0.007). A total of 35.2% self-reported increased [4.8 (4.3, 5.3)] and 44.5% self-reported decreased [5.1 (4.6, 5.6)] monthly HFSS meals portion intakes in November–December compared with pre-pandemic levels. The proportion meeting FV intake recommendations was stable from pre-pandemic through to August–September (70%), but decreased in November–December 2020 (67%, p = 0.034). Increased monthly HFSS snacks intake was associated with female gender, lower quality of life, and – in a time - varying manner – older age and higher HFSS meals intake. Increased monthly HFSS meals intake was associated with female gender, living with adults only, and higher HFSS snacks intake. Reduced FV intake was associated with higher body mass index (BMI) and lower physical activity. These results suggest large interindividual variability in dietary change during the first year of the pandemic, with important public health implications in individuals experiencing persistent increases in unhealthy diet choices, associated with BMI, gender, quality of life, living conditions, physical activity, and other dietary behaviours.

Objectives The objective was to determine the effect of apneic oxygenation (AP OX) on first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods Continuous quality improvement data were prospectively collected on all patients intubated in an academic ED from July 1, 2013, to June 30, 2015. During this period the use of AP OX was introduced and encouraged for all patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data form that included information on patient, operator, and intubation characteristics. Adult patients 18 years of age or greater who underwent RSI in the ED by emergency medicine residents were included in the analysis. The primary outcome was FPS-H, which was defined as successful tracheal intubation on a single laryngoscope insertion without oxygen saturation falling below 90%. A multivariate logistic regression analysis was performed to determine the effect of AP OX on FPS-H. Results During the 2-year study period, 635 patients met inclusion criteria. Of these, 380 (59.8%) had AP OX utilized and 255 (40.2%) had no AP OX utilized. In the AP OX cohort the FPS-H was 312/380 (82.1%) and in the no AP OX cohort the FPS-H was 176/255 (69.0%) (difference = 13.1%, 95% confidence interval [CI] = 6.2% to 19.9%). In the multivariate logistic regression analysis, the use of AP OX was associated with an increased odds of FPS-H (adjusted odds ratio = 2.2, 95% CI = 1.5 to 3.3). Conclusions The use of AP OX during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of AP OX has the potential to increase the safety of RSI in the ED by reducing the number of intubation attempts and the incidence of hypoxemia.

418 Background: Patients with clinical stage I (CS I: cN0M0) germ cell tumors (GCT) exhibit favorable oncologic outcomes. While prognostic features can help inform treatment in adults with CS I GCT, we lack reliable means to predict relapse among pediatric patients. We sought to identify predictors of relapse in children with CS I GCT. Methods: We performed a pooled post hoc analysis on pediatric CS I GCT patients enrolled in 3 prospective trials: INT-0097 (phase II), INT-0106 (phase III), and AGCT0132 (phase III). Pathology was centrally reviewed. Patient demographics, pT stage, serum tumor markers, margin status, histology, relapse, and survival were compiled. Cox regression analyses were used to identify predictors of outcomes. Results: 88 patients were identified with histologic data available. Most patients were pT1-2 stage. Yolk sac tumor was present in 75%, while 16% had embryonal carcinoma, and 9% had choriocarcinoma. When evaluable, lymphovascular invasion (LVI) was present in 36/66 (55%) of patients. Over a median follow-up of 5.0 years, no patients died and 24 patients (27%) relapsed (median relapse-free survival not reached). Predictors of relapse included presence of choriocarcinoma (HR 4.3, p=0.004), embryonal carcinoma (HR 3.8, p=0.002), pT3 stage (HR 6.9, p=0.027), and age >12 years (HR 3.1, p=0.011). LVI (HR 2.4, p=0.072), serum tumor markers, and dominant tumor size did not reach significance. Pediatric CS I GCT patients exhibit remarkable 5-year survival. Conclusions: Using combined data from multiple prospective trials, our study identifies clinicopathologic features that predict relapse and potentially inform personalized treatment for these patients.

Background Verification of surgical staging has received little attention in clinical oncology trials. Central surgical review was undertaken during a study of malignant pediatric germ cell tumors. Methods Children's Oncology Group study AGCT0132 included central surgical review during the study. Completeness of submitted data and confirmation of assigned stage were assessed. Review responses were: assigned status confirmed, assignment withheld pending review of additional information requested, or institutional assignment of stage disputed with explanation given. Changes in stage assignment were at the discretion of the enrolling institution. Results A total of 206 patients underwent central review. Failure to submit required data elements or need for clarification was noted in 40%. Disagreement with stage assignment occurred in 10% with 17/21 discordant patients reassigned to stage recommended by central review. Four ovarian tumor patients not meeting review criteria for Stage I remained in that stratum by institutional decision. Two-year event free survival in Stage I ovarian patients was 25% for discordant patients compared to 57% for those meeting Stage I criteria by central review. Conclusions Central review of stage assignment improved complete data collection and assignment of correct tumor stage at study entry, and allowed for prompt initiation of chemotherapy in patients determined not to have Stage I disease.

Introduction: Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program. Methods: This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders. Results: Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%-75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%-76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%-77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%-82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%-87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%-93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9-1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0-2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1-3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1-8.0, p

Objectives The objective was to compare the first-pass success and clinical performance characteristics of the reusable standard GlideScope® video laryngoscope (sGVL) and the disposable Cobalt GlideScope® video laryngoscope (cGVL). Methods This was a retrospective analysis of prospectively collected data recorded into a continuous quality improvement database at an urban academic emergency department (ED). The intent of the database is to evaluate operator performance and to track practice patterns used for intubation in the ED. Between July 1, 2007, and June 30, 2013, operators recorded all consecutive intubations performed in the ED. The database included patient demographics and detailed information about each intubation, such as device(s) used, reason for device selection, method of intubation, difficult airway characteristics, number of intubation attempts, and outcome of each attempt. The operator also evaluated the presence of lens fogging and extent of lens contamination. The primary outcome measure was first-pass success. Secondary outcome measures were ultimate success, Cormack-Lehane (CL) view of the airway, presence of lens fogging, and extent of lens contamination. Only adult patients age 18 years or older intubated with the sGVL or cGVL using a stylet, and who had data forms completed at the time of intubation, were included in this study. Results A total of 583 intubations were included in the study, 504 with the sGVL and 79 with cGVL. First pass success was achieved in 81.0% (95% confidence interval [CI] = 77.3% to 84.3%) of patients in the sGVL group and in 58.2% (95% CI = 46.6% to 69.2%) of patients in the cGVL group. In a multivariate logistic regression analysis, the sGVL was associated with a higher first pass success than the cGVL (odds ratio [OR] = 3.3, 95% CI = 1.9 to 5.8). The ultimate success of the sGVL was 92.1% (95% CI = 89.4% to 94.3%) and the cGVL was 72.2% (95% CI = 60.9% to 81.7%). A CL grade I or II view was obtained in 93.2% (95% CI = 90.7% to 95.3%) in the sGVL group and 86.1% (95% CI = 76.5% to 92.8%) in the cGVL group. Lens fogging occurred in 33.3% (95% CI = 29.2% to 37.6%) of the cases in the sGVL group and 59.5% (95% CI = 47.9% to 70.4%) of the cases in the cGVL group. Significant lens contamination occurred in 5.0% (95% CI = 3.2% to 7.2%) of the sGVL group and 21.5% (95% CI = 13.1% to 32.2%) of the cGVL group. Conclusions In this observational study, the sGVL had higher first pass and overall success than the disposable cGVL. The cGVL had significantly higher incidence of lens fogging and contamination, which may partially account for its lower success. A prospective randomized trial is needed to confirm these findings. Resumen Objetivos Comparar el exito del primer paso y las caracteristicas de rendimiento clinico del laringoscopio GlideScope® Estandar Reutilizable (VLGE) con los del laringoscopio Cobalt GlideScope® Desechable (VLCG). Metodologia Analisis retrospectivo de los datos recogidos de forma prospectiva en una base de datos de mejora continua de la calidad en un servicio de urgencias (SU) universitario. La intencion de la base de datos es evaluar el rendimiento del operador y monitorizar los patrones de practica utilizados para la intubacion en el SU. Entre el 1 de julio de 2007 y el 30 de junio de 2013, los operadores grabaron todas las intubaciones consecutivas realizadas en el SU. La base de datos incluyo datos demograficos del paciente e informacion detallada de cada intubacion, como el dispositivo usado, la razon de eleccion del dispositivo, el metodo de intubacion, las caracteristicas de la via area dificil, el numero de intentos de intubacion y el resultado de cada intento. El operador tambien evaluo la presencia de empanamiento de las lentes y la extension de la contaminacion de las lentes. La medida de resultado principal fue el exito de primer paso. Las medidas de resultado secundarias fueron el exito final, la vision de la via aerea de Cormack-Lehane, la presencia de empanamiento de las lentes y la extension de la contaminacion de las lentes. Se incluyeron en este estudio los pacientes adultos de 18 anos o mas intubados con VLGE o con VLCG usando un estilete y que tenian los formularios de los datos completados en el momento de la intubacion. Resultados Se incluyeron 583 intubaciones, 504 con VLGE y 79 con VLCG. El exito del primer paso se alcanzo en un 81,0% (IC 95% = 77,3% a 84,3%) de los pacientes en el grupo de VLGE y en un 58,2% (IC 95% = 46,6% a 69,2%) de los pacientes en el grupo de VLCG. En un analisis de regresion logistica multivariable, el VLGE se asocio con un mayor exito en el primer paso que VLCG (OR 3,3, IC 95% = 1,9 a 5,8). El exito final de la VLGE fue de un 92,1% (IC 95% = 89,4% a 94,3%) yd el VLCG fue de un 72,2% (IC 95% = 60,9% a 81,7%). Se obtuvo una vision grado I o II de Cormack-Lehane en un 93,2% (IC 95% = 90,7% a 95,3%) en el grupo VLGE y en un 86,1% (IC 95% = 76,5% a 92,8%) en el grupo VLCG. El empanamiento de la lentes ocurrio en un 33,3% (IC 95% = 29,2% a 37,6%) de los casos en el grupo VLGE y en un 59,5% (IC 95% = 47,9% a 70,4%) de los casos en el grupo VLCG. Una contaminacion significativa de la lentes ocurrio en un 5,0% (IC 95% = 3,2% a 7,2%) del grupo VLGE y en un 21,5% (IC 95% = 13,1% a 32,2%) del grupo VLCG. Conclusiones En este estudio observacional, la VLG estandar tuvo mayor exito de primer paso y global que el VLCG desechable. El VLCG tuvo una incidencia significativamente mayor de empanamiento y contaminacion de las lentes, que puede parcialmente contribuir a sus menores exitos. Se necesita un ensayo clinico prospectivo aleatorizado para confirmar estos hallazgos.

The objective of the study is to compare the efficacy of video laryngoscopy (VL) to direct laryngoscopy (DL) on the first pass intubation success of patients with difficult airway characteristics (DACs) in the emergency department (ED). Over a 6-year period, between July 1 2007 and June 30 2013, all intubations performed in an academic ED were recorded in a continuous quality improvement (CQI) database by the operators. The CQI form included information such as patient demographics, operator level of training, device(s) used, number of attempts and outcome of each attempt. In addition, operators performed a difficult airway assessment and noted the presence or absence of the following difficult airway characteristics (DACs): airway edema, cervical immobility, facial/neck trauma, large tongue, obesity, short neck, small mandible, and blood or vomit in the airway. Patients

Background Although the C-MAC (Karl Storz, Tuttlingen, Germany) is a video laryngoscope (VL), it can also be used as a direct laryngoscope (DL). Objective The goal of this study was to evaluate the utility of the C-MAC as a DL for intubations in the emergency department (ED). Methods This was an analysis of prospectively collected continuous quality-improvement data during the 6-year period from February 1, 2009 to January 31, 2015, when both the C-MAC and Macintosh DL (Mac DL) were clinically available in our ED. This analysis included adult patients who underwent rapid sequence intubation by an emergency medicine resident in the ED with a C-MAC initially used as a DL or a Mac DL. The primary outcome measure was the first pass success (FPS). Results When the C-MAC was used as a DL, the initial DL attempt was successful in 199 of 346 (57.6%) cases. When the attempt could not be completed using the C-MAC as a DL, the operator utilized the video monitor and successfully completed the intubation using VL in 104 of 134 (77.6%) cases, thus achieving an overall FPS of 303 of 346 (87.6%). When the Mac DL was used, the FPS was 505 of 671 (75.3%). Conclusions The C-MAC is a useful device for DL because in the event of a failed DL attempt, operators have the option of switching to the video monitor to successfully complete the intubation using VL without having to make a second attempt.

In the pediatric population, caudal epidural anesthesia has been the mainstay of providing pain control for gastrointestinal and abdominal surgeries. However, the increased prevalence of ultrasound has allowed more practitioners to administer targeted nerve blocks for these surgeries. Pain following abdominal surgery is largely derived from the abdominal wall incision; ultrasound-guided rectus sheath and transversus abdominis plane (TAP) blocks have proven beneficial for controlling this pain while reducing the risks, side effects, and effort that associated with epidural blockade. The rectus sheath block is generally used for any midline abdominal incisions (i.e., umbilical and epigastric hernia repairs) and is valuable in the outpatient setting. The aim during the block is to deposit local anesthetic between the rectus abdominis muscle and the posterior wall of the rectus sheath. If longer-duration analgesia is desired, a rectus sheath catheter can be inserted. Similarly, TAP blocks are used for anesthesia of nerves supplying the anterior abdominal wall and are commonly used in procedures such as bowel resection, appendectomy, and renal transplant. As with rectus sheath blocks, a TAP catheter(s) can be placed either by ultrasound guidance or direct vision by the surgeon to achieve longer-lasting analgesia. Landmark- and ultrasound-guided approaches to rectus sheath and TAP blocks are described in this chapter.

Background Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel. Methods We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence. Conclusion Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.

We have investigated the growth of barium titanate thin films on bulk crystalline and amorphous substrates utilizing biaxially oriented template layers. Ion beam-assisted deposition was used to grow thin, biaxially textured, magnesium oxide template layers on amorphous and silicon substrates. Growth of highly oriented barium titanate films on these template layers was achieved by molecular beam epitaxy using a layer-by-layer growth process. Barium titanate thin films were grown in molecular oxygen and in the presence of oxygen radicals produced by a 300 W radio frequency plasma. We used X-ray and in situ reflection high-energy electron diffraction (RHEED) to analyze the structural properties and show the predominantly c-oriented grains in the films. Variable angle spectroscopic ellipsometry was used to analyze and compare the optical properties of the thin films grown with and without oxygen plasma. We have shown that optical quality barium titanate thin films, which show bulk crystal-like properties, can be grown on any substrate through the use of biaxially oriented magnesium oxide template layers.

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation

Objectives: To examine a population-based cohort for the association between clinicopathologic predictors of survival and immunohistochemical markers (IHC), and to assess changes in gene expression that are associated with lymphovascular invasion (LVI). Summary Background Data: LVI has been associated with poor survival and aggressive tumor behavior. The molecular changes responsible for the behavior of gastric cancer have yet to be determined. Characterization of IHC markers and gene expression profiles may identify molecular alterations governing tumor behavior. Methods: Clinicopathologic and survival data of 114 patients were reviewed. Archival specimens were used to construct a multitumor tissue array that was subjected to IHC of selected protein targets. Correlation of IHC with tumor thickness (T status), LVI and prognosis was studied. Microarray analysis of fresh gastric cancer tissue was conducted to examine the gene expression profile with respect to LVI. Results: In a multivariate analysis, nodal status (N), metastasis (M), and LVI were independent predictors of survival. LVI was associated with a 5-year survival of 13.9% versus 55.9% in patients in whom it was absent. LVI correlated with advancing T status (P 0.001) and N status (P 0.001). IHC staining of cyclooxygenase-2 (COX-2) correlated with T status, tumor grade, lymph node positivity, and IHC staining of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9). Microarray analyses suggested differential expression of oligophrenin-1 (OPHN1) and ribophorin-II (RPNII) with respect to LVI. Conclusion: LVI was an independent predictor of survival in gastric cancer. Expression of COX-2 may facilitate tumor invasion through MMP-2 and MMP-9 activation. OPHN1 and RPN II appeared to be differentially expressed in gastric cancers exhibiting LVI. The reported function of OPHN1 and RPN II makes these gene products promising candidates for future studies involving LVI in gastric cancer. (Ann Surg 2006;243: 64‐73)

Tumor thickness and nodal status are important predictors of survival following curative resection for gastric cancer. Lymphovascular invasion (LVI) is a potential predictor of biological behavior. The relationship between LVI and tumor thickness (T status) has not been established in population-based studies.Clinicopathological and survival data of 577 patients at nine centers, from between 1991 and 1997, was collected from patient records and a Provincial Cancer Registry. The primary endpoint of the study was death. A secondary analysis of a node-negative subgroup examined the significance of LVI with respect to T status.The population disease-specific survival was 28%. In a multivariate analysis, T, N, M, esophageal margin, tumor morphology, and residual tumor category were independent predictors of survival. LVI was documented in 58% of resected tumors. LVI correlated with advancing T and N status but was not significant in a multivariate population model. Subgroup analysis of node-negative gastric cancer found T status and LVI to be independent predictors of survival. LVI was associated with a 5-year survival of 8%, versus 43% among patients in whom it was absent (P.001).T status and N status were the most important independent predictors of survival in a population-based study of gastric cancer. LVI correlated with advancing N and T status. Multivariate analysis of node-negative patients showed LVI and T status are independent predictors of survival.

Objective To compare the effectiveness of the C-MAC® video laryngoscope (CMAC) to the direct laryngoscope (DL) when used to rescue a failed first attempt intubation in the emergency department (ED). Methods Data were prospectively collected on all patients intubated in an academic ED center over a five-year period from February 1, 2009 to January 31, 2014 when both the CMAC and the DL were available. Following each intubation the operator completed a continuous quality improvement (CQI) form documenting patient, operator and intubation characteristics. All orotracheal intubations attempted by emergency physicians (EPs) on adult patients with a failed first intubation attempt, and in which the CMAC or the DL was used for the second attempt, were included. The primary outcome was successful intubation on the second attempt using either the CMAC or the DL. A multivariate logistic regression analysis was performed to adjust for potential confounders. Results During the five-year study period, there were 460 adult orotracheal intubation attempts by EPs which were not successful on the first attempt. In 398 (86.5%) of these cases the same operator performed the second attempt. The CMAC was utilized for the second attempt in 141 cases and was successful in 116 (82.3%; 95% CI 75.0%-88.2%) and the DL was utilized in 94 cases and was successful in 58 (61.7%; 95% CI 51.1%-71.5%). In a multivariate logistic regression analysis the CMAC was associated with an increased odds (adjusted OR 3.5; 95% CI 1.9-6.7) of a second attempt success compared to the DL. Conclusions After a failed first intubation attempt in the ED, regardless of the initial device used, the CMAC was more successful than the DL when used for the second attempt. This suggests that the CMAC is the preferred rescue device after an initial intubation attempt in the ED fails.

To evaluate the outcomes in first pass success (FPS) of GlideScope (GVL) intubations over a seven-year period in an academic ED. Data were prospectively collected on all patients intubated in an academic ED with a level 1 trauma center over the seven-year period from July 1, 2007 to June 30, 2014. Following each intubation, the operator completed a standardized data collection form that included information on patient, operator and procedure characteristics. The primary outcome was first pass success, defined as successful intubation with a single laryngoscope blade insertion. The secondary outcome was the Cormack–Lehane (CL) view of the airway. To adjust for important confounders, a logistic regression model was used to determine the association between academic year and first pass success. In the first year of the study, the first pass success with the GVL was 75.6 % (68/90; 95 % CI 65.4–84.0 %) and the percentage of patients with CL I/II views was 95.6 % (86/90; 95 % CI 89.0–98.8 %). By the seventh year of the study, the first pass success with the GVL increased to 92.1 % (128/139; 95 % CI 86.3–96.0 %) and the percentage of patients with CL I/II views was 94.2 % (131/139; 95 % CI 89.0–97.5 %). In the logistic regression model, first pass success improved during the seven-year period (aOR 3.1; 95 % CI 1.3–7.1; p = 0.008). Over the seven-year period, there was significant improvement in the first pass success of the GVL, without any change in the Cormack–Lehane view, suggesting that there was improvement in the skill of tube delivery with use of the GVL over time.

When a piezoelectric energy harvester is connected to a simple load circuit, the damping force which the piezoelectric element is able to generate is often below the optimal value to maximize electrical power generation. Circuits that aim to increase the power output of a piezoelectric energy harvester do so by modifying the voltage onto which the piezoelectric current source drives its charge. This paper presents a systematic analysis and comparison of all the principal types of power extraction circuit that allow this damping force to be increased, under both ideal and realistic constraints. Particular emphasis is placed on low-amplitude operation. A circuit called single-supply prebiasing is shown to harvest more power than previous approaches. Most of the analyzed circuits able to increase the power output do so by synchronously inverting or charging the piezoelectric capacitance through an inductor. For inductor Q factors greater than around only 2, the single-supply prebiasing circuit has the highest power density of the analyzed circuits. The absence of diodes in conduction paths, achievable with a minimum number of synchronous rectifiers, means that the input excitation amplitude is not required to overcome a minimum value before power can be extracted, making it particularly suitable for microscale applications or those with a wide variation in amplitude.

Congenital microgastria is an uncommon condition and often associated with other abnormalities. We present 2 patients with congenital microgastria who underwent repair with a Hunt-Lawrence pouch.

We studied active near-infrared metamaterials based on phase transition of vanadium oxide thin films, asymmetrically coupled split-ring resonators for narrowing resonance line-widths , field effect modulation of plasmon propagation and 3D single layer, plasmonic negative-index metamaterials.

We demonstrate control of the surface plasmon polariton wavevector in an active metal-dielectric plasmonic interferometer by utilizing electrooptic barium titanate as the dielectric layer. Arrays of subwavelength interferometers were fabricated from pairs of parallel slits milled in silver on barium titanate thin films. Plasmon-mediated transmission of incident light through the subwavelength slits is modulated by an external voltage applied across the barium titanate thin film. Transmitted light modulation is ascribed to two effects, electrically induced domain switching and electrooptic modulation of the barium titanate index.

Nanoindentation in conjunction with piezoresponse force microscopy was used to study domain switching and to measure the mechanical properties of individual ferroelectric domains in a tetragonal BaTiO3 single crystal. It was found that nanoindentation has induced local domain switching; the a and c domains of BaTiO3 have different elastic moduli but similar hardness. Nanoindentation modulus mapping on the a and c domains further confirmed such difference in elasticity. Finite element modeling was used to simulate the von Mises stress and plastic strain profiles of the indentations on both a and c domains, which introduces a much higher stress level than the critical value for domain nucleation.

Plasmonics has provided nanoscience researchers new control of optical dispersion and light localization at nanoscale dimensions. I will discuss plasmonic concepts that are yielding metamaterials designs and building blocks for chip-based optical device technology.

This update reviews the epidemiology and surgical management, and the controversies of gastric adenocarcinoma. We provide the relevance of outcome data to surgical decision-making and discuss the application of gene-expression analysis to clinical practice.Gastric cancer mortality rates have remained relatively unchanged over the past 30 years, and gastric cancer continues to be one of the leading causes of cancer-related death. Well-conducted studies have stimulated changes to surgical decision-making and technique. Microarray studies linked to predictive outcome models are poised to advance our understanding of the biologic behavior of gastric cancer and improve surgical management and outcome.We performed a review of the English gastric adenocarcinoma medical literature (1980-2003). This review included epidemiology, pathology and staging, surgical management, issues and controversies in management, prognostic variables, and the application of outcome models to gastric cancer. The results of DNA microarray analysis in various cancers and its predictive abilities in gastric cancer are considered.Prognostic studies have provided valuable data to better the understanding of gastric cancer. These studies have contributed to improved surgical technique, more accurate pathologic characterization, and the identification of clinically useful prognostic markers. The application of microarray analysis linked to predictive models will provide a molecular understanding of the biology driving gastric cancer.Predictive models generate important information allowing a logical evolution in the surgical and pathologic understanding and therapy for gastric cancer. However, a greater understanding of the molecular changes associated with gastric cancer is needed to guide surgical and medical therapy.

Layer transfer of thin BaTiO3 films onto silicon-based substrates has been investigated. H+ and He+ ion implantation created a buried sacrificial layer in the BaTiO3 single crystals. Thermodynamics and kinetics of cavity nucleation and growth at the bonding interface have been investigated and single crystal thin film layers were transferred onto amorphous Si3N4 and Pt substrates. We have found that defects generated by ion implantation in ferroelectric materials can be significantly recovered with the subsequent annealing for layer splitting. Also, after high dose ion implantation, the films remain single crystal and stoichiometry. Finally, characterization proves the layer-transferred thin films are ferroelectrically active, with domains and piezoresponse similar to bulk crystals.