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Erica Ai Li,1 Claire A Wilson,2 Jacob Davidson,2 Aaron Kwong,1 Amrit Kirpalani,3 Peter Zhan Tao Wang2,4 1Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; 2Division of Pediatric Surgery, London Health Sciences Centre, London, Ontario, Canada; 3Division of Pediatric Nephrology, London Health Sciences Centre, London, Ontario, Canada; 4Division of Urology, London Health Sciences Center, London, Ontario, CanadaCorrespondence: Erica Ai Li, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, Ontario, N6A 5C1, Canada, Email ali2024@meds.uwo.caBackground: There is limited work exploring competency-based medical education (CBME) in undergraduate medical education. We aimed to assess medical students’ and faculty’s perception of CBME in the undergraduate medicine setting after its implementation at our institution through a Content, Input, Process, Product (CIPP) program evaluation model.Methods: We explored the rationale for the transition to a CBME curriculum (Content), the changes to the curriculum and the teams involved in the transition (Input), medical students’ and faculty’s perception of the current CBME curriculum (Process), and benefits and challenges of implementing undergraduate CBME (Product). A cross-sectional online survey was delivered over 8-weeks in October 2021 to medical students and faculty as part of the Process and Product evaluation.Results: Medical students displayed greater optimism towards CBME, compared to faculty, in terms of its role in medical education (p< 0.05). Faculty were less certain about how CBME was currently implemented (p< 0.05), as well as how feedback to students should be delivered (p< 0.05). Students and faculty agreed on perceived benefits to CBME implementation. Faculty time commitment to teaching and logistical concerns were reported as perceived challenges.Conclusion: Education leaders must prioritize faculty engagement and continued professional development of faculty to facilitate the transition. This program evaluation identified strategies to aid the transition to CBME in the undergraduate setting.Keywords: competency-based medical education, competency by design, undergraduate, medical student, faculty

Hand telerehabilitation currently has limitations for accurate and remote assessment of range of motion (ROM) in small finger joints. ‘DIGITS’ application utilises the front smartphone camera to measure finger ROM in a reliable and rapid assessment protocol. Our initial beta-phase testing examined the consistency of our software measurements to in-person goniometry. 6 to 9 degrees of difference existed between the smartphone application recorded data versus the in-person measurements. This range is within acceptable 7 to 9 degree tolerance for interrater goniometry measurements. The effect of environmental factors such as hand distance, lightings and hand orientation was evaluated. The intraclass correlation coefficient (ICC) was 0.98–0.98 for finger extension and 0.78–0.81 for finger flexion recorded across different environmental conditions. Overall, ‘DIGITS’ provides an augmented reality tool to generate reliable finger ROM tracking for hand telerehabilitation. ‘DIGITS’ has the potential to transform hand therapy and improve our knowledge of hand pathology recovery.

When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization.We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori.One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications.Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.

Wilms tumor (WT) is the most common renal malignancy in children. Children with favorable histology WT achieve survival rates of over 90%. Twelve percent of patients present with metastatic disease, most commonly to the lungs. The presence of a pleural effusion at the time of diagnosis of WT may be noted on staging imaging; however, minimal data exist regarding the significance and prognostic importance of this finding. The objectives of our study are to identify the incidence of pleural effusions in patients with WT, and to determine the potential impact on oncologic outcomes. A multi-institutional retrospective review was performed from January 2009 to December 2019, including children with WT and a pleural effusion on diagnostic imaging treated at Pediatric Surgical Oncology Research Collaborative (PSORC) participating institutions. Of 1259 children with a new WT diagnosis, 94 (7.5%) had a pleural effusion. Patients with a pleural effusion were older than those without (median 4.3 vs 3.5 years; P = .004), and advanced stages were more common (local stage III 85.9% vs 51.9%; P .0001). Only 14 patients underwent a thoracentesis for fluid evaluation; 3 had cytopathologic evidence of malignant cells. Event-free and overall survival of all children with WT and pleural effusions was 86.2% and 91.5%, respectively. The rate and significance of malignant cells present in pleural fluid is unknown due to low incidence of cytopathologic analysis in our cohort; therefore, the presence of an effusion does not appear to necessitate a change in therapy. Excellent survival can be expected with current stage-specific treatment regimens.

Purpose: Physician burnout is an issue that has come to the forefront in the past decade. While many factors contribute to burnout the impact of impostorism and self-doubt has largely been ignored. We investigated the relationship of anxiety and impostorism to burnout in postgraduate medical learners. Materials and methods: Postgraduate learners in four diverse training programs: Family Medicine (FM), Paediatric Medicine (PM), Anesthesiology (AN), and General Surgery (GS) were surveyed to identify the incidence of impostorism (IP), anxiety, and burnout. IP, anxiety, and burnout were evaluated using the Clance Impostor Phenomenon Scale (CIPS), Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and the General Anxiety Disorder-7 (GAD-7) questionnaires, respectively. Burnout was defined as meeting burnout criteria on all three domains. Relationships between IP, anxiety, and burnout were explored. Results: Two hundred and sixty-nine residents responded to the survey (response rate 18.8%). Respondents were distributed evenly between specialties (FM = 24.9%, PM = 33.1%, AN = 20.4%, GS = 21.6%). IP was identified in 62.7% of all participants. The average score on the CIPS was 66.4 (SD = 14.4), corresponding to ‘frequent feelings of impostorism.’ Female learners were at higher risk for IP (RR = 1.27, 95% CI: 1.03–1.57). Burnout, as defined by meeting burnout criteria on all three subscales, was detected in 23.3% of respondents. Significant differences were seen in burnout between specialties (p = 0.02). GS residents were more likely to experience burnout (31.7%) than PM and AN residents (26.7 and 10.0%, respectively, p = 0.02). IP was an independent risk factor for both anxiety (RR = 3.64, 95% CI:1.96–6.76) and burnout (RR = 1.82, 95% CI: 1.07–3.08). Conclusions: Impostorism is commonly experienced by resident learners independent of specialty and contributes to learner anxiety and burnout. Supervisors and Program Directors must be aware of the prevalence of IP and the impact on burnout. Initiatives to mitigate IP may improve resident learner wellness and decrease burnout in postgraduate learners.

Studies indicate that learning surgical skills on low-fidelity models is equally beneficial to learning on high-fidelity models in terms of skills retention and transfer. However, it is unclear how low-fidelity simulation training impacts retention and transfer in novice learners, particularly on complex surgical tasks that incorporate multiple challenging skills. This study explores the capacity of complete novices to learn and transfer complex surgical skills from a low-fidelity model to a high-fidelity simulation after a delay.Task-naïve medical and nonmedical undergraduate students (n = 62) participated in a three-phase prospective double-arm randomized (2:1) experimental study. Participants completed two skills training sessions (end-to-side anastomosis) on a low-fidelity bench model. After a 4-week delay, participants completed the task again either using the low-fidelity model or a high-fidelity model (cadaver) and were assessed using a validated checklist.There was a significant time × fidelity group interaction (P = 0.004). Simple effects analysis indicated the high-fidelity group (MThese findings suggest that for novice populations, relying on low-fidelity simulation training as a source of teaching complex skills may not provide a reliable transfer to high-fidelity models and in turn clinical settings.

Summary Background Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure. Objective To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period. Study design Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal–Wallis tests, Chi-square tests, and logistic regression. Results A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5–48.0) and 7.5 h (IQR 4.0–28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04). Discussion We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group. Conclusions In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

Reports of septic hip arthritis in children with cerebral palsy are exceedingly rare. This case report describes a 10-year-old boy with spastic triplegic cerebral palsy (Gross Motor Functional Classification System), who presented with fever and irritability. This case highlights the difficulties in diagnosing septic joint arthritis in patients with cerebral palsy who are nonverbal and have limited mobility. A high index of suspicion is necessary in this population when presented with fever and new limitations in mobility.

The objective of this study was to examine the association between learner personality and capacity to be trained (i.e., performance improvement) on a surgical task, and how instructor perceptions of the learners' capacity to be trained interact with learner personality and performance during training and feedback. There is meaningful heterogeneity in the degree of learner surgical skills acquisition despite receiving the same amount of training. While learner personality may independently contribute to skill acquisition, the instructor-learner feedback process is also important to consider. To better understand this interpersonal relationship, it is necessary to also consider instructor factors (i.e., perceptions), and how this may contribute to learner variability in skills training.This exploratory study employed a prospective two-phase design. Medical and non-medical undergraduate students (N = 62) completed measures of personality and participated in two 20-minute training sessions with expert feedback 2 weeks apart, performing an end-to-side anastomosis on a low-fidelity model. Learner performance and instructors' perceptions of a learner's capacity to be trained were assessed.Sixty-two medical and non-medical undergraduate students.There was a significant interaction between learner Extraversion and instructor's perceptions of learner capacity to be trained. Higher learner Extraversion was only associated with an increase in performance improvement for those who were considered trainable (OR = 4.83, p = 0.017). Post hoc analysis revealed a significant difference in the amount of feedback provided to participants who were considered trainable (M = 9.45) versus not trainable (M = 16.48).This study highlights the importance of both individual learner factors and instructor perceptions on surgical skill acquisition.

Graphical abstract, The surgical model of congenital diaphragmatic hernia (CDH) has been utilized in exploring treatments and innovative therapies, such as tracheal occlusion (TO). The rabbit is an excellent surgical model compared to others due to lower cost, ease of care, short gestational period, and large litter size. This model is also ideal in studying lung hypoplasia of CDH because rabbit lung development is most similar to humans as alveolarization begins prior to birth and continues post-natally. However, the surgical technique in creating a rabbit model of CDH is quite difficult and information is lacking on how to establish this model. Therefore, the aim of this paper is to describe: • Surgical technique in establishing a rabbit model of CDH and TO • Perioperative care for pregnant rabbit does

OBJECTIVES Minor pediatric surgeries performed in the minor procedure room (MPR) may be more time efficient and less costly compared to those performed in the operating room (OR). STUDY DESIGN Retrospective review. METHODS This was a retrospective study on cost and efficiency differences of bilateral myringotomy with tube insertions performed in the MPR versus the OR. Charts were reviewed from June 2015 to May 2017. Cost data was based on supply cost and case costing of medical personnel including nurses, aides, and anesthesia assistants. RESULTS Two hundred eighteen patients were included in the study. The median age was 2.7 years (range: 0.8-16.7), and there were no differences in gender between locations. One hundred twenty-three patients had surgery in the MPR (56.4%), and 95 had surgery in the OR (43.6%). The median length of time in the procedure room was 11 minutes shorter for patients who underwent surgery in the MPR (12.0 minutes, range: 3.0-33.0) compared to patients in the OR (23.0 minutes, range: 11.0-52.0; P

OBJECTIVE Demonstrated competence through frequent assessment is an expected goal for progressive development in competency-based medical education curricula. The Objective Structured Assessment of Technical Skill (OSATS) is considered a valid method of formative assessment, but in few instances have standards been set for determining competence. The present study used borderline regression methods to examine standard setting of performance on a complex technical task with novices assessed using an OSATS checklist. METHODS This was a single institution prospective single arm experimental design study. Participants were 58 non-medical undergraduate students with no previous surgical experience, who observed a computer-based training module on end-to-side vascular anastomosis. Subsequently, participants were provided two 20-minute training sessions, two weeks apart where they received expert feedback whilst performing the task on a low-fidelity model. After each training session, participants completed the task unaided. Sessions were recorded and assessed using an OSATS checklist retrospectively by experts. RESULTS Paired t-test analyses indicate that for both the checklist total score (t(52) = 8.05, p < 0.001) and the global rating score (t(53) = 8.15, p < 0.001), individuals performed significantly better in Phase 2. Borderline regression analyses indicated that in Phase 1 (R2 = .60) and Phase 2 (R2 = .75), the OSATS checklist could adequately capture variation in performance in novices. Further, the checklist could reliably classify novices at three of the five global rating performance levels. Pass rates determined by regression equations improved from Phase 1 to Phase 2 on all global rating levels. CONCLUSIONS With the increasing focus on competency-based medical education, it is imperative that training programs have the capacity to accurately assess outcomes and set minimum performance standards. Borderline regression methods can accurately differentiate novice learners of varying performance levels before and after training on a complex technical skill task using an OSATS checklist.

Trampolines are widely used by children, but trampoline injuries can be severe and may require hospital care or even surgery. This pilot study examined the effectiveness of an educational intervention on caregivers' perceptions of trampoline use and safety for their children. Primary caregivers were recruited from the orthopedic clinic at the Children's Hospital at our institution in 2015. Caregivers were asked to complete a survey at two time points, initially in clinic and one week post educational intervention. The educational intervention was a pamphlet outlining trampoline safety data. Data analysis occurred in 2016. From the 100 primary caregivers recruited, 39 caregivers owned a trampoline, and 10 had presented to the emergency department with their child for an injury related to trampoline use. After educational intervention, caregivers had higher rating of perceived danger associated with trampolines (6/10 vs. 8/10, p, Highlights • Rating of perceived danger of trampolines increased after educational intervention. • Educational intervention improved knowledge of safe trampoline practices. • Caregivers are receptive to recommendations against trampoline use from physicians. • Two-thirds agreed that trampolines are dangerous after educational intervention. • After education half of caregivers would still allow their child to use trampolines.

BACKGROUND Enteral nutrition (EN) is a safe and cost-effective intervention with significant morbidity and mortality benefit that can also be associated with complications. Peristomal infections can occur in 5%-30% of cases after percutaneous endoscopic gastrostomy placement. Despite this common occurrence, widespread use of objective diagnostic criteria is not prevalent, possibly leading to overuse of antibiotics. METHODS All patients who were reporting symptoms consistent with peristomal infection were evaluated. Criteria based on erythema, induration, and exudates were applied with cumulative score ≥8 indicating peristomal infection. All patients were followed, with additional factors being collected if available. RESULTS Forty-three patients noted complaints consistent with peristomal infection. In patients with a score

Despite an ongoing need for pediatric research, low study enrollment may impede study completion, particularly in critical care. We conducted a prospective cross-sectional survey and chart review study to assess parent experiences with research in a pediatric intensive care unit (PICU). Of the 80 parents who completed the study survey, 54% were approached to participate in a research study in the PICU, and 93% agreed to participate. Motivators included altruism, low burden, low risk, and research that would benefit the child. Barriers included risks to the child, the child's being too sick to participate, feeling overwhelmed, not having enough time to participate, the research's being burdensome, and the research's not being explained well. PICU parents had mostly favorable attitudes toward research participation. Compared with non-Hispanic survey respondents, respondents of Hispanic ethnicity less often reported having been approached for research, which further evidences the need to track research recruitment processes to help avoid underinclusion of members of minority populations.

Purpose: Tracheal occlusion (TO)reverses pulmonary hypoplasia (PH)in congenital diaphragmatic hernia (CDH), but its mechanism of action remains poorly understood. Wnt signaling plays a critical role in lung development, but few studies exist. The purpose of our study was to a)confirm that our CDH rabbit model produced PH which was reversed by TO and b)determine the effects of CDH +/− TO on Wnt signaling. Methods: CDH was created in fetal rabbits at 23 days, TO at 28 days, and lung collection at 31 days. Lung body weight ratio (LBWR)and mean terminal bronchiole density (MTBD)were determined. mRNA and miRNA expression was determined in the left lower lobe using RT-qPCR. Results: Fifteen CDH, 15 CDH + TO, 6 sham CDH, and 15 controls survived and were included in the study. LBWR was low in CDH, while CDH + TO was similar to controls (p = 0.003). MTBD was higher in CDH fetuses and restored to control levels in CDH + TO (p < 0.001). Reference genes TOP1, SDHA, and ACTB were consistently expressed within and between treatment groups. miR-33 and MKI67 were increased, and Lgl1 was decreased in CDH + TO. Conclusion: TO reversed pulmonary hypoplasia and stimulated early Wnt signaling in CDH fetal rabbits. Type of study: Basic science, prospective. Level of evidence: II.

Background Catheter-related bloodstream infection (CRBSI) is a common complication in patients receiving home parenteral nutrition (HPN). Data regarding catheter salvage after a CRBSI episode are limited. We aimed to determine the incidence of CRBSI and rates of catheter salvage in adult patients receiving HPN. Materials and methods We retrospectively searched our prospectively maintained HPN database for the records of all adult patients receiving HPN from January 1, 1990, to December 31, 2013, at our tertiary referral center. Data abstracted from the medical records included demographics, diseases, treatments, and outcomes. The incidence of CRBSI and rates of catheter salvage were determined. Results Of 1040 patients identified, 620 (59.6%) were men. The median total duration on HPN was 124.5 days (interquartile range, 49.0-345.5 days). Mean (SD) age at HPN initiation was 53.3 (15.3) years. During the study period, 465 CRBSIs developed in 187 patients (18%). The rate of CRBSI was 0.64/1000 catheter days. Overall, 70% of catheters were salvaged (retained despite CRBSI) during the study period: 78% of infections with coagulase-negative staphylococci, 87% with methicillin-sensitive Staphylococcus aureus, and 27% with methicillin-resistant S aureus. The percentage of catheters salvaged was 63% from 1990 to 1994, 63% from 1995 to 1999, 61% from 2000 to 2004, 72% from 2005 to 2009, and 76% from 2010 to 2013. Conclusion Catheter salvage is possible after a CRBSI episode. Since most episodes of CRBSI are caused by skin commensals, effective treatment without removal of the central venous catheter is possible in most cases.

Bariatric surgery is one of the most effective techniques for achieving sustained weight loss but can be associated with surgical complications or malabsorption so significant that it leads to malnutrition. Parenteral nutrition (PN) may be necessary to help treat surgical complications or malnutrition from these procedures. There are limited data describing this patient population and role for home PN (HPN).A retrospective review of our HPN database was conducted to identify patients who were initiated on HPN between January 1, 2003, and August 31, 2015, and had a history of bariatric surgery.A total of 54 HPN patients (6.3%) had a history of bariatric surgery. Average age was 52.1 ± 12.8 years, and 80% were female. The most common surgical procedure was Roux-en-Y gastric bypass (72%), with malnutrition or failure to thrive being the most common HPN indication (57%). Weight at the time of HPN initiation was 71.9 ± 20.4 kg and significantly increased to 78.9 ± 24.4 kg by the end of treatment ( P = .0001). Serum albumin levels rose from 2.8 ± 0.77 g/dL to 3.7 ± 0.58 g/dL by the end of HPN ( P.0001). Forty-five of 54 patients (83.3%) went on to revision surgery.The results of this retrospective review support initiation of HPN in the malnourished post-bariatric surgery patient both nutritionally and as a bridge to revision surgery.

Background Since initial report in 1972, misconnections continue to be an issue, especially in hospitalized patients with multiple access devices. A new small-bore connector standard (ENFit) has been proposed in order to minimize misconnections. Methods Commercially available finalized ENFit tubes of a variety of sizes (14 French [Fr] size, 18Fr, 20Fr, 24Fr, and low-profile) were obtained for current testing. Variety of commercially available formulas including blenderized tube feeding (BTF) products (Jevity 1 Cal, Abbott Nutrition, Abbott Park, IL; Nourish, Functional Formularies, Centerville, OH; Real Food Blends, Chesterton, IN) were tested. Results Data from individual measurements were aggregated for ENFit and legacy tubes and revealed higher syringe compression force in legacy tubes compared with ENFit tubes for 20Fr size with Jevity formula. Our institution's BTF formula revealed that legacy tubes had lower syringe compression force than ENFit tubes for 14Fr tube size. Remaining measurements revealed no significant difference. Model 1 of regression analysis revealed that only formula and tube size were significant with R2 of 0.63. Model 2 evaluating the impact of tube size, blender, time of blending, and legacy vs ENFit revealed that tube size, blender used, and blending time were significant with legacy vs ENFit being nonsignificant (R2 of 0.72). Conclusions Overall, only a small number of tube sizes (14Fr and 20Fr) with selected formulas revealed a significant difference between ENFit and Legacy tubes, with remaining studies finding no significant difference. Regression analysis revealed that variables such as formula, size of tube, blender used, and time of blending may have more impact on compression force.

Catheter-related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high-risk patients.Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and18 years old at the initiation of HPN were excluded. Total number of infections before and after ALT or ELT were estimated in all patients.A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75-8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking ( P.001). Rate of infection per 1000 catheter days was 10.97 ± 25.92 before locking and 1.09 ± 2.53 after locking ( P.001).The major findings of the present study reveal that ALT or ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.

Misconnections between enteral supplies and other access devices have led to significant morbidity and mortality. To reduce misconnections, a standard small-bore connector has been developed (International Organization for Standards 80369-8; ENFit). The full impact of transition to this connector is not known, however.Working with major manufacturers and Food and Drug Administration, we obtained ENFit and comparative legacy tubes of variable sizes (low-profile, 14F, 18F, 20F, and 24F balloon gastrostomies). Gravity enteral feeding was simulated with an empty bolus syringe attached to the feeding tube to be tested. The tube was clamped and filled to the 60-mL mark with liquid (water, Jevity 1 Cal, Isosource HN, Isosource 1.5 Cal, Two Cal HN, and Nourish). The clamp was released, and time for formula to leave the syringe was recorded.There was no difference in flow rate between the aggregate legacy and ENFit tubes for the low-profile, 18F, and 20F sizes. The ENFit 14F tubes had a lower flow rate vs the legacy tubes, largely due to the low flow rates seen with the 1 ENFit tube. Similarly, 24F ENFit tubes with some formulas yielded lower flow rates as opposed to legacy.Overall, for the low-profile, 18F, and 20F sizes, the ENFit tubes had similar flow rates when compared with the legacy tubes. For the 14F and 24F sizes, the flow rate of ENFit tubes was significantly lower, which could result in longer EN delivery for patients who are using these tubes to provide gravity feeding.

A priority interrupt controller and synchronizer for a MC68008 microprocessor have been designed with the help of the VHDL language, a silicon compiler and a standard cell library. IEEE Standard 1076 VHSIC Hardware Description Language defines this language as a tool for structural and behavioural specification for very high speed integrated circuits. VHDL supports a wide range of design abstractions. The paper examines the procedures and the use of hardware and software tools in the design and simulation of the circuit.

A single-board microcomputer was built based on the NS32008 microprocessor. It was designed for evaluation of the processor's performance and ease of use, and illustrates some design ideas relevant to those evaluating 16/32-bit microprocessors in the 32000 series.