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IntroductionCurrent common sample types for sows, such as serum and tonsil scraping, require snaring the animals, which can be labor-intensive and raise concerns regarding animal welfare. Obtaining oral fluids (OF) from individual sows in field conditions presents challenges, as not all sows readily respond to the rope method. The Tonsil-Oral-Scrubbing (TOSc) collector allows for the rapid retrieval of fluids from the sow’s oral and tonsillar areas without the need for snaring. Previous studies have reported comparable detection rates of porcine reproductive and respiratory syndrome virus (PRRSV) RNA between TOSc and tonsil scraping, with significantly higher positivity observed in TOSc compared to serum in acutely infected sows.MethodsGiven that PRRSV RNA detection rates can vary among different sample types and fluctuate over time, this field study aimed to compare PRRSV real-time reverse-transcription polymerase chain reaction (RT-rtPCR) positivity and cycle threshold (Ct) values between TOSc, serum, OF, and tonsil scraping at three time points following live-virus inoculation (LVI) in sows. This study was conducted within a breeding herd attempting to eliminate PRRSV following an outbreak. Four sample types were collected from each of the 61 conveniently selected sows at 30, 60, and 90 days post-LVI in the order of OF, TOSc, tonsil scraping, and serum, and subsequently tested for PRRSV RNA.ResultsThe results indicated that TOSc and tonsil scraping exhibited decreased PRRSV RNA detection rates over time, whereas the detection rates for OF and serum remained relatively stable. Moreover, the median Ct values for TOSc and tonsil scraping were numerically lower than those for OF and serum at all sampling points. Specifically, tonsil scraping demonstrated significantly higher PRRSV RNA positivity than the other three sample types. TOSc also exhibited significantly higher PRRSV RNA positivity than OF and serum at both 30 and 60 days post-LVI. By 90 days post-LVI, there was a significant difference in the PRRSV RNA detection rates between TOSc and tonsil scraping. However, no significant difference was observed between TOSc and OF or between TOSc and serum. According to the RT-rtPCR results, most PRRSV RNA-positive sows detected via TOSc and tonsil scraping turned negative by 90 days post-LVI, although a small proportion remained positive. Conversely, a small number of previously negative sows tested positive at 60 and 90 days post-LVI, indicating an intermittent mode of PRRSV RNA detection for both sample types.

The aim was to explore the relation of human milk lutein; choline; and docosahexaenoic acid (DHA) with recognition memory abilities of six-month-olds. Milk samples obtained three to four months postpartum were analyzed for fatty acids, lutein, and choline. At six months, participants were invited to an electrophysiology session. Recognition memory was tested with a 70–30 oddball paradigm in a high-density 128-lead event-related potential (ERP) paradigm. Complete data were available for 55 participants. Data were averaged at six groupings (Frontal Right; Frontal Central; Frontal Left; Central; Midline; and Parietal) for latency to peak, peak amplitude, and mean amplitude. Difference scores were calculated as familiar minus novel. Final regression models revealed the lutein X free choline interaction was significant for the difference in latency scores at frontal and central areas (p < 0.05 and p < 0.001; respectively). Higher choline levels with higher lutein levels were related to better recognition memory. The DHA X free choline interaction was also significant for the difference in latency scores at frontal, central, and midline areas (p < 0.01; p < 0.001; p < 0.05 respectively). Higher choline with higher DHA was related to better recognition memory. Interactions between human milk nutrients appear important in predicting infant cognition, and there may be a benefit to specific nutrient combinations.

Objective: This study investigates cancer risk in idiopathic inflammatory myopathy (IIM) relative to the general population. Methods: We conducted a single‐center, retrospective cohort study of IIM patients and malignancy. Myositis‐specific and ‐associated autoantibodies were determined by Euroimmun line blot, enzyme‐linked immunosorbent assay, and immunoprecipitation. We calculated standardized prevalence ratios (SPRs) and adjusted for calendar year, age, sex, race, and ethnicity by comparing observed cancers in IIM patients versus expected cancers in the general population using the Surveillance, Epidemiology, and End Results registry. Results: Of 1,172 IIM patients, 203 (17%) patients with a cancer history were studied. Over a median follow‐up of 5.2 years, the observed number of IIM patients diagnosed with cancer was increased 1.43‐fold (SPR 1.43 [95% confidence interval (95% CI) 1.15–1.77]; P = 0.002). Within 3 years of IIM symptom onset, an increased SPR was observed for anti–transcription intermediary factor 1γ (anti‐TIF1γ)–positive patients for ovarian and breast cancer (ovarian SPR 18.39 [95% CI 5.01–47.08], P < 0.001; breast SPR 3.84 [95% CI 1.99–6.71], P < 0.001). As expected, anti‐TIF1γ positivity was associated with a significantly elevated SPR; however, only 55% (36 of 66) of all cancers within 3 years of dermatomyositis onset were observed in anti‐TIF1γ–positive patients. Other myositis‐specific autoantibodies, including anti–Mi‐2, anti–small ubiquitin‐like modifier activating enzyme (SAE), and anti‐nuclear matrix protein 2 (NXP‐2), accounted for 26% (17 of 66) of cancers diagnosed within 3 years of dermatomyositis onset. No cancer association, positive or negative, was observed for patients with antisynthetase, anti–melanoma differentiation–associated protein 5 (anti–MDA‐5), or anti–hydroxymethylglutaryl‐coenzyme A reductase (anti‐HMGCR) antibodies. Conclusion: In a tertiary referral center population, anti‐TIF1γ was most strongly associated with breast and ovarian cancer. Patients with antisynthetase, anti–MDA‐5, or anti‐HMGCR antibodies had the same cancer risk as the general population. [ABSTRACT FROM AUTHOR]

Abstract Objective The objectives of the study were to assess emergency medicine (EM) physician perceptions of the EM job market 2 years after “The Emergency Medicine Physician Workforce: Projections for 2030” was published in Annals of Emergency Medicine and to examine how the workforce report may have influenced perceptions about job prospects. Methods A cross‐sectional survey was conducted in 2022 of EM residents, fellows, and attendings at 21 practice sites. Main outcomes were perceptions of the likelihood of currently finding any job, currently finding a desirable job, and confidence in the future EM job market. Results Note that 831 of 1938 physicians (42.9%) responded. A total of 92.4% reported a high likelihood of finding any job currently, 49.8% reported a high likelihood of finding a desirable job currently, and 44.4% reported future confidence. Workforce report familiarity was associated with greater likelihood of finding a desirable job. Fellows were least confident in the future. Residents with desired Midwest location were twice as confident in the future job market; those with desired West location were less confident. Attendings 20 or more years post‐training were more than twice as likely to report a high likelihood of finding a desirable job and almost twice as likely to report future confidence. Attendings in leadership were nearly three times as likely to report high a likelihood of finding a desirable job and future confidence. Conclusion EM trainees and attendings have favorable perceptions of the current job market but are less confident in future prospects. As the projected surplus of EM physicians appears to have had an impact, updated projections are needed for more accurate assessments of the future of the specialty.

Yellowstone National Park thermal features regularly discharge various heavy metals and metalloids. These metals are taken up by microorganisms that often form mats in thermal springs. These microbial mats also serve as food sources for invertebrate assemblages. To examine how heavy metals move through insect food webs associated with hot springs, two sites were selected for this study. Dragon-Beowulf Hot Springs, acid-sulfate chloride springs, have a pH of 2.9, water temperatures above 70 °C, and populations of thermophilic bacterial, archaeal, and algal mats. Rabbit Creek Hot Springs, alkaline springs, have a pH of up to 9, some water temperatures in excess of 60 °C, and are populated with thermophilic and phototrophic bacterial mats. Mats in both hydrothermal systems form the trophic base and support active metal transfer to terrestrial food chains. In both types of springs, invertebrates bioaccumulated heavy metals including chromium, manganese, cobalt, nickel, copper, cadmium, mercury, tin and lead, and the metalloids arsenic, selenium, and antimony resulting from consuming the algal and bacterial mat biomass. At least two orders of magnitude increase in concentrations were observed in the ephydrid shore fly Paracoenia turbida, as compared to the mats for all metals except antimony, mercury, and lead. The highest bioaccumulation factor (BAF) of 729 was observed for chromium. At the other end of the food web, the invertebrate apex predator, Cicindelidia haemorrhagica, had at least a 10-fold BAF for all metals at some location-year combinations, except with antimony. Of other taxa, high BAFs were observed with zinc for Nebria sp. (2180) and for Salda littoralis (1080). This accumulation, occurring between primary producer and primary consumer trophic levels at both springs, is biomagnified through the trophic web. These observations suggest trace metals enter the geothermal food web through the microbial mat community and are then transferred through the food chain. Also, while bioaccumulation of arsenic is uncommon, we observed five instances of increases near or exceeding 10-fold: Odontomyia sp. larvae (13.6), P. turbida (34.8), C. haemorrhagica (9.7), Rhagovelia distincta (16.3), and Ambrysus mormon (42.8).

Background: This study aims to determine (a) if home-based anodal transcranial direct current stimulation (a-tDCS) delivered to the left supramarginal gyrus (SMG) coupled with verbal short-term memory/working memory (vSTM/WM) treatment (“RAM”, short for “Repeat After Me”) is more effective than sham-tDCS in improving vSTM/WM in patients with primary progressive aphasia (PPA), and (b) whether tDCS effects generalize to other language and cognitive abilities. Methods: Seven PPA participants received home-based a-tDCS and sham-tDCS coupled with RAM treatment in separate conditions in a double-blind design. The treatment task required participants to repeat word spans comprising semantically and phonologically unrelated words in the same and reverse order. The evaluation of treatment effects was carried out using the same tasks as in the treatment but with different items (near-transfer effects) and tasks that were not directly related to the treatment (far-transfer effects). Results: A-tDCS showed (a) a significant effect in improving vSTM abilities, measured by word span backward, and (b) a generalization of this effect to other language abilities, namely, spelling (both real words and pseudowords) and learning (retention and delayed recall). Conclusions: These preliminary results indicate that vSTM/WM intervention can improve performance in trained vSTM/WM tasks in patients with PPA, especially when augmented with home-based tDCS over the left SMG.

Introduction There are unmet mental health needs of depressed adolescents and young adults (AYAs) across the USA. Behavioural technology adequately integrated into clinical care delivery has potential to improve care access and efficiency. This multisite randomised controlled trial evaluates how a coach-enhanced digital cognitive behavioural intervention (dCBI) enhances usual care for depressed AYAs in paediatric practices with minority enriched samples.Methods and analysis Participants (n=750) ages 16–22 who meet threshold criteria for depressive severity (Patient Health Questionnaire-9; PHQ-9 score 10-24) will be recruited through paediatric practices across three academic institutions (Boston, Pittsburgh and San Diego). Participants will be randomised to 12 weeks of dCBI+treatment as usual (TAU) (n=450) or TAU alone (n=300) in outpatient paediatric practices. Assessments will be completed at baseline, 6 weeks and 12 weeks with the primary outcome being improvement in clinician-rated and self-reported depressive severity (Children’s Depression Rating Scale—Revised and PHQ-9) and secondary outcomes being self-reported suicidal ideation (item 9 on PHQ-9), anxiety severity (Generalised Anxiety Disorder), general quality of life (Satisfaction with Life Scale) and general functioning (Children’s Global Assessment Scale). The study design is an intent-to-treat mixed effects regression with group, and covariates nested within the sites.Ethics and dissemination All participants or their parent/guardian (under 18 years or unemancipated) will give informed consent to a study team member. All data are expected to be collected over 18 months. The Institutional Review Board (IRB) is a board at each institution in the United States that reviews and monitors research involving human subjects. IRB approval from the University of Pittsburgh was obtained on 30 November 2021 (STUDY21080150), from the University of California San Diego’s Human Research Protection Program IRB on 14 July 2022 (802047), and from the Boston Children’s Hospital IRB on 25 October 2022 (P00040987). Full study results are planned to be published within 2 years of initial study recruitment (October 2024). Dissemination of findings will occur in peer-reviewed journals, professional conferences and through reports to participating entities and stakeholders.Trial registration number NCT05159713; ClinicalTrials.gov

Abstract The evolution of evidence and availability of Clinical Pharmacogenetic Implementation Consortium (CPIC) guidelines have enabled assessment of pharmacogenetic (PGx) actionability and clinical implementation. However, population‐level actionability is not well‐characterized. We leveraged the Alabama Genomic Health Initiative (AGHI) to evaluate population‐level PGx actionability. Participants (>18 years), representing all 67 Alabama counties, were genotyped using the Illumina Global Screening array. Using CPIC guidelines, actionability was evaluated using (1) genotype data and genetic ancestry, (2) prescribing data, and (3) combined genotype and medication data. Of 6,331 participants, 4230 had genotype data and 3386 had genotype and prescription data (76% women; 76% White/18% Black [self‐reported]). Genetic ancestry was concordant with self‐reported race. For CPIC level A genes, 98.6% had an actionable genotype (99.4% Blacks/African; 98.5% White/European). With the exception of DPYD and CYP2C19, the prevalence of actionable genotypes by gene differed significantly by race. Based on prescribing, actionability was highest for CYP2D6 (70.9%), G6PD (54.1%), CYP2C19 (53.5%), and CYP2C9 (47.5%). Among participants prescribed atenolol, carvedilol, or metoprolol, ~ 50% had an actionable ADRB1 genotype, associated with decreased therapeutic response, with higher actionability among Blacks compared to Whites (62.5% vs. 47.4%; p

IntroductionJapanese encephalitis virus (JEV) is a mosquito-borne viral pathogen, which is becoming a growing public health concern throughout the Indo-Pacific. Five genotypes of JEV have been identified. Current vaccines are based on genotype III and provide a high degree of protection for four of the five known genotypes.MethodsRT-PCR, Magpix, Twist Biosciences Comprehensive Viral Research Panel (CVRP), and SISPA methods were used to detect JEV from mosquito samples collected in South Korea during 2021. These methods were compared to determine which method would be most effective for biosurveillance in the Indo-Pacific region.ResultsOur data showed that RT-PCR, Twist CVRP, and SISPA methods were all able to detect JEV genotype I, however, the proprietary Magpix panel was only able to detect JEV genotype III. Use of minION sequencing for pathogen detection in arthropod samples will require further method development.ConclusionBiosurveillance of vectorborne pathogens remains an area of concern throughout the Indo-Pacific. RT-PCR was the most cost effective method used in the study, but TWIST CVRP allows for the identification of over 3,100 viral genomes. Further research and comparisons will be conducted to ensure optimal methods are used for large scale biosurveillance.

Introduction: Acute presentation of multiple myeloma in the emergency department (ED) is an uncommon yet life-threatening clinical entity. Case Report: A 42-year-old male presented to the ED with severe generalized fatigue and vision changes most notable in his left eye. Bilateral central retinal vein occlusion (CRVO) was diagnosed on dilated fundus exam in the ED. Conclusion: The most common cause of CRVO in adults over age 50 is vascular disease, but in younger adults, conditions of systemic inflammation or hyperviscosity must be considered. Diagnosis of CRVO requires emergent ophthalmology consultation and further treatment with phototherapy, steroids, and potentially anti-vascular endothelial growth factor. Ultimately, patients require hematology/oncology and ongoing management of acute hyperviscosity syndrome. We present this case to increase awareness surrounding this diagnosis among emergency physicians. Multiple myeloma should be considered in young patients who present to the ED with bilateral CRVO, acute renal failure, and symptomatic anemia.

Background: The effectiveness of PPE in preventing self-contamination of healthcare workers (HCWs) and transmission of pathogens (airborne and contact) in the emergency department (ED) is highly dependent on consistent, appropriate use of and other interactions (eg, storing, cleaning, etc) with the PPE. Pre–COVID-19 studies focused primarily on individual HCW contributions to incorrect or suboptimal PPE use. We conducted an analysis of ED video recordings using a human-factors engineering framework (ie, The Systems Engineering Initiative for Patient Safety, SEIPS), to identify work-system–level contributions to inappropriate PPE usage by HCWs while they provide care in their actual clinical care environment. Methods: In total, 47 video sessions (each ~15 minute) were recorded between June 2020 and May 2021 using a GoPro camera in an 8-bed pod area, designated for persons under investigation (PUI) and confirmed COVID-19–positive patients, in an ED of a large, tertiary-care, academic medical center. These recordings captured a ‘landscape view’: 2 video cameras were set up to capture the entire ED pod area and HCWs as they provided care. A team with hemorrhagic fever expertise, infection prevention and control expertise, and ED expertise reviewed each video together and extracted data using a semistructured form. Results: Guided by the 5 components of the SEIPS work system model, (ie, task, physical environment, person, organization, tools and technology), multiple work system failure points influencing HCWs appropriate use of PPE were identified. For example, under the task component, HCWs were observed not doffing and donning in recommended sequence. Also, inconsistencies with COVID-19 status signage on a patient’s door and ambiguous labelling of work areas designated as clean (donning) and dirty (doffing) sites acted as a barrier to appropriate PPE use under the physical environment section. Conclusions: Human factors–based analysis of video recordings of actual ED work identified a variety of work system factors that impede appropriate or correct use of PPE by HCWs. Future efforts to improve appropriate PPE use should focus on eliminating or mitigating the effects of these work system factors.

Background: Acute stress impairs physician decision-making and clinical performance in resuscitations. Mental skills training, a component of the multistep, cognitive-behavioral technique of stress inoculation, modulates stress response in high-performance fields. Objective: We assessed the effects of mental skills training on emergency medicine (EM) residents’ stress response in simulated resuscitations as well as residents’ perceptions of this intervention. Methods: In this prospective, educational intervention trial, postgraduate year-2 EM residents in seven Chicago-area programs were randomly assigned to receive either stress inoculation training or not. One month prior to assessment, the intervention group received didactic training on the “Breathe, Talk, See, Focus” mental performance tool. A standardized, case-based simulation was used for assessment. We measured subjective stress response using the six-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6). Objective stress response was measured through heart rate (HR) and heart rate variability (HRV) monitoring. We measured subjects’ perceptions of the training via survey. Results: Of 92 eligible residents, 61 participated (25 intervention; 36 control). There were no significant differences in mean pre-/post-case STAI-6 scores (−1.7 intervention, 0.4 control; p = 0.38) or mean HRV (−3.8 milliseconds [ms] intervention, −3.8 ms control; p = 0.58). Post-assessment surveys indicated that residents found this training relevant and important. Conclusion: There was no difference in subjective or objective stress measures of EM resident stress response after a didactic, mental performance training session, although residents did value the training. More extensive or longitudinal stress inoculation curricula may provide benefit.

BackgroundDespite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. ObjectiveThis study assessed providers’ views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. MethodsParticipating providers included BH and physical health (PH) providers from a women’s health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. ResultsA total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. ConclusionsDigital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow.

Introduction: While burnout is occupation-specific, depression affects individuals comprehensively. Research on interventions for depression in emergency medicine (EM) residents is limited. Objectives: We sought to obtain longitudinal data on positive depression screens in EM residents, assess their association with burnout, and determine whether implementation of a wellness curriculum affected the rate of positive screens. Methods: In February 2017, we administered the Maslach Burnout Inventory and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire two-question depression screen at 10 EM residencies. At five intervention sites, a year-long wellness curriculum was then introduced while five control sites agreed not to introduce new wellness initiatives during the study period. Study instruments were re-administered in August 2017 and February 2018. Results: Of 382 residents, 285 participated in February 2017; 40% screened positive for depression. In August 2017, 247/386 residents participated; 27.9% screened positive for depression. In February 2018, 228/386 residents participated; 36.2% screened positive. A positive depression screen was associated with higher burnout. There were similar rates of positive screens at the intervention and control sites. Conclusion: Rates of positive depression screens in EM residents ranged between 27.9% and 40%. Residents with a positive screen reported higher levels of burnout. Rates of a positive screen were unaffected by introduction of a wellness curriculum.

The aim was to explore the relation of human milk lutein; choline; and docosahexaenoic acid (DHA) with recognition memory abilities of six-month-olds. Milk samples obtained three to four months postpartum were analyzed for fatty acids, lutein, and choline. At six months, participants were invited to an electrophysiology session. Recognition memory was tested with a 70-30 oddball paradigm in a high-density 128-lead event-related potential (ERP) paradigm. Complete data were available for 55 participants. Data were averaged at six groupings (Frontal Right; Frontal Central; Frontal Left; Central; Midline; and Parietal) for latency to peak, peak amplitude, and mean amplitude. Difference scores were calculated as familiar minus novel. Final regression models revealed the lutein X free choline interaction was significant for the difference in latency scores at frontal and central areas (p < 0.05 and p < 0.001; respectively). Higher choline levels with higher lutein levels were related to better recognition memory. The DHA X free choline interaction was also significant for the difference in latency scores at frontal, central, and midline areas (p < 0.01; p < 0.001; p < 0.05 respectively). Higher choline with higher DHA was related to better recognition memory. Interactions between human milk nutrients appear important in predicting infant cognition, and there may be a benefit to specific nutrient combinations. [ABSTRACT FROM AUTHOR]

To examine the differential mechanobiological responses of specific resident tendon cells, we developed an in vivo model of whole-body irradiation followed by injection of either tendon stem/progenitor cells (TSCs) expressing green fluorescent protein (GFP-TSCs) or mature tenocytes expressing GFP (GFP-TNCs) into the patellar tendons of wild type C57 mice. Injected mice were subjected to short term (3 weeks) treadmill running, specifically moderate treadmill running (MTR) and intensive treadmill running (ITR). In MTR mice, both GFP-TSC and GFP-TNC injected tendons maintained normal cell morphology with elevated expression of tendon related markers collagen I and tenomodulin. In ITR mice injected with GFP-TNCs, cells also maintained an elongated shape similar to the shape found in normal/untreated control mice, as well as elevated expression of tendon related markers. However, ITR mice injected with GFP-TSCs showed abnormal changes, such as cell morphology transitioning to a round shape, elevated chondrogenic differentiation, and increased gene expression of non-tenocyte related genes LPL, Runx-2, and SOX-9. Increased gene expression data was supported by immunostaining showing elevated expression of SOX-9, Runx-2, and PPARγ. This study provides evidence that while MTR maintains tendon homeostasis by promoting the differentiation of TSCs into TNCs, ITR causes the onset of tendinopathy development by inducing non-tenocyte differentiation of TSCs, which may eventually lead to the formation of non-tendinous tissues in tendon tissue after long term mechanical overloading conditions on the tendon.