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Dextromethorphan (DM) is a popular over-the-counter antitussive medication. Although adverse effects from appropriate use are rare, a specific toxidrome with significant psychomimetic effects occurs with ingestions in excess of those recommended. Both DM and its active metabolite, dextrorphan (DOR), share pharmacologic and neurobehavioral properties similar to opiates and phencyclidine (PCP). As such, cases of recreational DM abuse and, rarely, dependence, have been reported, and some data suggest that such abuse is on the rise. DM may be considered by substance abusers, especially adolescents, to be a dissociative agent devoid of financial concerns, legal limitations, negative stigma, problems with access or adverse health consequences. However, DM's popularity among adolescent substance abusers is generally not matched by adequate health care provider awareness, pharmacological understanding or epidemiological characterization. In this review, we summarize the current understanding of DM's addiction medicine-based neuropharmacology and epidemiology, describe social characteristics more unique to DM as an agent of abuse, review treatment and prevention issues, and identify areas in need of further research. [ABSTRACT FROM AUTHOR]

Background: In 2004 and 2008 two large prospective, multicenter studies were published which resulted in improved understanding of operative indications for the treatment of Legg-Calvé-Perthes disease (LCPD) based on patient age, disease severity, and resultant radiographic outcomes. The primary aim of this study is to evaluate the trends in surgical management of LCPD in the United States prior, and subsequent to, the publication of these landmark studies., Methods: Cross-sectional retrospective analysis of US pediatric hospitalizations for the surgical management of LCPD was conducted using the Kids' Inpatient Database from 2000 to 2016. Patients 12 years of age and younger were included who had a primary admission diagnosis of LCPD and a LCPD-related procedure during the hospitalization. Data was subsequently weighted to produce national-level estimates and variables pertaining to patient age group, procedure, demographics, and hospital characteristics were analyzed. In a post hoc analysis, the results of the Kids' Inpatient Database were also corroborated with the Pediatric Health Information System database., Results: A weighted sample of 2786 LCPD surgical admissions met inclusion and exclusion criteria; 11.2% of surgical admissions were patients below 6 years of age, 35.9% were 6 to 8 years of age, and 52.9% were above 8 years of age. There was a significant decrease in admissions for surgical management of LCPD in all age groups over time, however there was no appreciable change in the proportion of LCPD surgical admissions performed among the above 8 to below 12, above 6 to below 8, or below 6 years age groups. Femoral osteotomy remained the most common surgical procedure, while other osteotomy types, including pelvic and unspecified osteotomies involving the hip, decreased over time ( P <0.001)., Conclusions: There is a decreasing rate of hospital admissions for LCPD surgery since 2000, perhaps indicating a decline in incidence of disease. Furthermore, despite evidence supporting LCPD surgical outcomes related to patient age, there has been no change in the proportion of patients undergoing surgery by age group over time., Level of Evidence: Level III-retrospective study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes., Methods: 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests., Results: Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed., Conclusion: Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH., Methods: Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented., Results: Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant., Conclusions: Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort., Level of Evidence: Level II-prospective cohort., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

During the early stages of the COVID-19 pandemic in 2020, Mayor Bill de Blasio ordered the release of individuals incarcerated in New York City jails who were at high risk of contracting the disease and at low risk of committing criminal reoffense. Using public information, we construct and analyze a database of nearly 350,000 incarceration episodes in the city jail system from 2014-2020, paying special attention to what happened during the week of March 23-29, 2020, immediately following the mayor's order. In concordance with de Blasio's stated policy, we find that being discharged during this focus week is associated with a lower probability of readmission as compared to being discharged during the same calendar week in previous years. Furthermore, comparing the individuals discharged during the focus week of 2020 to those discharged during the same calendar week in previous years, we find that the former group was, on average, slightly older than the latter group, although the difference is not large. Additionally, the individuals in the former group had spent substantially longer in jail than those in the latter group. With the release of long-serving individuals demonstrated to be feasible, we also examine how the jail population would have looked over the past six years had caps in incarceration been in place. With a cap of one year, the system would experience a 15% decrease in incarceration. With a cap of 100 days, the reduction would be over 50%. Because our results are only as accurate as New York City's public-facing jail data, we discuss numerous challenges with this data and suggest improvements related to the incarcerated individual's age, gender, race, and more. Finally, we discuss the policy implications of our work, highlight some opportunities and challenges posed by incarceration caps, and suggest key areas for reform. One such reform might involve identifying and discharging low-risk individuals sooner in general, which might be feasible given the de Blasio administration's actions during the early stages of COVID-19., Competing Interests: The authors have declared that no competing interests exist.

Comparing ecological communities across environmental gradients can be challenging, especially when the number of different taxonomic groups in the communities is large. In this setting, community-level summaries called diversity indices are widely used to detect changes in the community ecology. However, estimation of diversity indices has received relatively little attention from the statistical community. The most common estimates of diversity are the maximum likelihood estimates of the parameters of a multinomial model, even though the multinomial model implies strict assumptions about the sampling mechanism. In particular, the multinomial model prohibits ecological networks, where taxa positively and negatively co-occur. In this article, we leverage models from the compositional data literature that explicitly account for co-occurrence networks and use them to estimate diversity. Instead of proposing new diversity indices, we estimate popular diversity indices under these models. While the methodology is general, we illustrate the approach for the estimation of the Shannon, Simpson, Bray-Curtis, and Euclidean diversity indices. We contrast our method to multinomial, low-rank, and nonparametric methods for estimating diversity indices. Under simulation, we find that the greatest gains of the method are in strongly networked communities with many taxa. Therefore, to illustrate the method, we analyze the microbiome of seafloor basalts based on a 16S amplicon sequencing dataset with 1425 taxa and 12 communities., (© The Author 2020. Published by Oxford University Press.)

A wheelchair is usually a source of mobility for people with moderate to severe cerebral palsy, who are unable to walk. They spend long periods of time sitting in their wheelchair, which can affect their head and neck alignment. Opening the seat to back support angle of the wheelchair can modify realignment of body segments and improve posture. Aims : To examine the effect of seat to back support angle adjustments on head, neck, and shoulder postural alignment in people with cerebral palsy. Methods : Nine participants with cerebral palsy who use a wheelchair for mobility sat in a research wheelchair. Sagittal head angle (SHA), cervical angle (CVA), and shoulder angle (SA) from photographs were examined using the Coach's Eye device during three different seat to back support angles of the wheelchair (90°, 100°, 110°). Results : There were significant differences in mean SHA and CVA among the different seat to back support angles ( p < .001). However, there was no significant difference in mean SA. Conclusion : Head (SHA) and (CVA) alignment was closest to neutral posture with seat to back support angles set at 110°. Thus, adjusting the wheelchair back support to a 110º would provide the most appropriate sagittal head and cervical angle for this population.

Background: Osgood-Schlatter disease (OSD) and tibial tubercle fractures are pathologies that affect the tibial tubercle apophysis in preadolescents and adolescents. Anatomic alignment of the proximal tibia may explain why some children develop OSD or sustain tibial tubercle fractures and some do not. Recent data has shown an association between posterior tibial slope angle (PTSA) and both OSD and proximal tibia physeal fractures. In this study, we compare radiographic parameters between patients with non-OSD knee pain, knees with OSD, and knees with tibial tubercle fracture to elucidate a difference between these groups., Methods: Patients treated for OSD, tibial tubercle fractures, and knee pain, from 2012 to 2018, were retrospectively reviewed. Radiographic parameters for each study group included PTSA, anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, patellar articular height, and the distance from the inferior aspect of the patellar articular surface. Caton-Deschamps index was then calculated. Demographic data was collected including age, sex, and body mass index. Demographic and radiographic data was compared using analysis of variance tests, χ2 tests, 2-sample t tests, and multiple linear regression., Results: Two hundred fifty-one knees in 229 patients met inclusion criteria for the study. In all, 76% were male and the average age of the overall cohort was 14 years old. In patients with tibial tubercle fractures, the majority of fractures were Ogden type 3b (65%). After controlling for demographic variability, average PTSA in the fracture cohort was significantly greater than that in the control cohort (β=3.49, P<0.001). The OSD cohort had a significantly greater posterior slope (β=3.14) than the control cohort (P<0.001). There was no statistically significant difference between the fracture and OSD cohorts. There was also no difference in Caton-Deschamps index between the 2 study groups when compared with the control group., Conclusion: This study demonstrates that patients with tibial tubercle fractures and patients with OSD have an increased PTSA when compared with the control group. This information adds to the body of evidence that increased tibial slope places the proximal tibial physis under abnormal stress which may contribute to the development of pathologic conditions of proximal tibia such as OSD and tibial tubercle fractures., Level of Evidence: Level III; retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The benefits of deammonification to remove nitrogen from sidestreams, i.e., sludge dewatering liquors, in municipal wastewater treatment plants are well accepted. The ammonia removal from dewatering liquors originated from thermal hydrolysis/anaerobic digestion (THP/AD) are deemed challenging. Many different commercial technologies have been applied to remove ammonia from sidestreams, varying in reactor design, biomass growth form and instrumentation and control strategy. Four technologies were tested (a deammonification suspended sludge sequencing batch reactor (S-SBR), a deammonification moving bed biofilm reactor (MEDIA), a deammonification granular sludge sequencing batch reactor (G-SBR), and a nitrification suspended sludge sequencing batch reactor (N-SBR)). All technologies relied on distinct control strategies that actuated on the feed flow leading to a range of different ammonia loading rates. Periods of poor performance were displayed by all technologies and related to imbalances in the chain of deammonification reactions subsequently effecting both load and removal. The S-SBR was most robust, not presenting these imbalances. The S-SBR and G-SBR presented the highest nitrogen removal rates (NRR) of 0.58 and 0.56 kg N m -3  d -1 , respectively. The MEDIA and the N-SBR presented an NRR of 0.17 and 0.07 kg N m -3  d -1 , respectively. This study demonstrated stable ammonia removal from THP/AD dewatering liquors and did not observe toxicity in the nitrogen removal technologies tested. It was identified that instrumentation and control strategy was the main contributor that enabled higher stability and NRR. Overall, this study provides support in selecting a suitable biological nitrogen removal technology for the treatment of sludge dewatering liquors from THP/AD., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Children with Legg-Calvé-Perthes disease (LCPD) are classically described as small, thin, high-energy children presenting with a painless limp. Epidemiologic studies have historically been retrospective and regional in nature. The purpose of this study was to determine the demographic and clinical features of children presenting in the early stages of LCPD in an international, multicenter cohort., Methods: Children (6 to 10 years) in the early stages of LCPD (modified Waldenström stage I to IIa) were enrolled in a prospective, multicenter study. Demographic and clinical data at presentation were analyzed. Body mass index percentiles were determined using country-specific growth charts for children in the United States and India, two countries with largest enrollment. Statistical analyses included t-tests and chi-square., Results: A total of 209 children (86% males; mean age 7.9 ± 1.2 years) from 25 centers (six countries) were included. Eight-four percent of children presented with pain with or without a limp. Average pain score at presentation was 3 ± 2 (range 0 to 9), and 63% of children (n = 105) used pain medications. Of these children 65% required medication more than once per week. Thirty percent of children missed school due to pain in the past month, and of those, 74% missed at least 1 day per week. Twenty-nine percent of children from the United States and 20% of children from India were overweight or obese. Nineteen percent reported household smoking., Discussion: This prospective study provides a new international multicenter representation of early LCPD. The frequency of pain and missed school highlights the substantial morbidity and potential social cost and burden for children and families. The prevalence of being overweight/obese in our LCPD cohort was comparable to rates within the pediatric cohort as a whole, and fewer children have a history of smoke exposure than in previous reports., Level of Evidence: Level II, prospective comparative study.

Using a sample from a population to estimate the proportion of the population with a certain category label is a broadly important problem. In the context of microbiome studies, this problem arises when researchers wish to use a sample from a population of microbes to estimate the population proportion of a particular taxon, known as the taxon's relative abundance. In this paper, we propose a beta-binomial model for this task. Like existing models, our model allows for a taxon's relative abundance to be associated with covariates of interest. However, unlike existing models, our proposal also allows for the overdispersion in the taxon's counts to be associated with covariates of interest. We exploit this model in order to propose tests not only for differential relative abundance, but also for differential variability. The latter is particularly valuable in light of speculation that dysbiosis, the perturbation from a normal microbiome that can occur in certain disease conditions, may manifest as a loss of stability, or increase in variability, of the counts associated with each taxon. We demonstrate the performance of our proposed model using a simulation study and an application to soil microbial data.

Most infants with cystic fibrosis (CF) have pancreatic exocrine insufficiency that results in nutrient malabsorption and requires oral pancreatic enzyme replacement. Newborn screening for CF has enabled earlier diagnosis, nutritional intervention and enzyme replacement for these infants, allowing most infants with CF to achieve their weight goals by 12 months of age 1 . Nevertheless, most infants with CF continue to have poor linear growth during their first year of life 1 . Although this early linear growth failure is associated with worse long-term respiratory function and survival 2,3 , the determinants of body length in infants with CF have not been defined. Several characteristics of the CF gastrointestinal (GI) tract, including inflammation, maldigestion and malabsorption, may promote intestinal dysbiosis 4,5 . As GI microbiome activities are known to affect endocrine functions 6,7 , the intestinal microbiome of infants with CF may also impact growth. We identified an early, progressive fecal dysbiosis that distinguished infants with CF and low length from infants with CF and normal length. This dysbiosis included altered abundances of taxa that perform functions that are important for GI health, nutrient harvest and growth hormone signaling, including decreased abundance of Bacteroidetes and increased abundance of Proteobacteria. Thus, the GI microbiota represent a potential therapeutic target for the correction of low linear growth in infants with CF.

Study Design: Retrospective review of prospectively collected data., Objective: Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency., Methods: A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay., Results: Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001)., Conclusions: Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS., Level of Evidence: Level III.

Background: Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost., Objective: The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion., Methods: Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression., Results: For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P < 0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference = -0.47 [95% CI -0.70 to -0.23]; P < 0.001), received a significantly higher total anti-fibrinolytic dose (mean difference = -3939 [95% CI -5364 to -2495]; P < 0.001), and were exposed to shorter surgical times (mean difference = 0.72 [95% CI 0.36-1.09]; P < 0.001)., Conclusions: Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions., (© 2019 John Wiley & Sons Ltd.)

The under-five mortality rate (U5MR) is a critical and widely available population health indicator. Both the MDGs and SDGs define targets for improvement in the U5MR, and the SDGs require spatial disaggregation of indicators. We estimate trends in the U5MR for Admin-1 subnational areas using 122 DHS surveys in 35 countries in Africa and assess progress toward the MDG target reductions for each subnational region and each country as a whole. In each country, direct weighted estimates of the U5MR from each survey are calculated and combined into a single estimate for each Admin-1 region across five-year periods. Our method fully accounts for the sample design of each survey. The region-time-specific estimates are smoothed using a Bayesian, space-time model that produces more precise estimates (when compared to the direct estimates) at a one-year scale that are consistent with each other in both space and time. The resulting estimated distributions of the U5MR are summarized and used to assess subnational progress toward the MDG 4 target of two-thirds reduction in the U5MR during 1990-2015. Our space-time modeling approach is tractable and can be readily applied to a large collection of sample survey data. Subnational, regional spatial heterogeneity in the levels and trends in the U5MR vary considerably across Africa. There is no generalizable pattern between spatial heterogeneity and levels or trends in the U5MR. Subnational, small-area estimates of the U5MR: (i) identify subnational regions where interventions are still necessary and those where improvement is well under way; and (ii) countries where there is very little spatial variation and others where there are important differences between subregions in both levels and trends. More work is necessary to improve both the data sources and methods necessary to adequately measure subnational progress toward the SDG child survival targets., Competing Interests: The authors have declared that no competing interests exist.

Background: Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS., Methods: A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability., Results: The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts., Conclusions: Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increasingly stricter phosphorus discharge limits represent a significant challenge for the wastewater industry. Hybrid media comprising anionic exchange resins with dispersions of hydrated ferric oxide nanoparticles have been shown to selectively remove phosphorus from wastewaters, and display greater capacity and operational capability than both conventional treatment techniques and other ferric-based adsorbent materials. Spectrographic analyses of the internal surfaces of a hybrid media during kinetic experiments show that the adsorption of phosphorus is very rapid, utilising 54% of the total capacity of the media within the first 15 min and 95% within the first 60 min. These analyses demonstrate the importance of intraparticle diffusion on the overall rate in relation to the penetration of phosphorus. Operational capacity is a function of the target effluent phosphorus concentration and for 0.1 mg P L -1 , this is [Formula: see text], which is 8-13% of the exhaustive capacity. The adsorbed phosphorus can be selectively recovered, offering a potential route to recycle this important nutrient. The main implication of the work is that the ferric nanoparticle adsorbent can provide a highly effective means of achieving a final effluent phosphorus concentration of 0.1 mg P L -1 , even when treating sewage effluent at 5 mg P L -1 .

Since the first description of Legg-Calvé-Perthes disease a century ago, the diagnosis, staging, prognosis, and treatment decisions have been based on plain radiographs. The goal of treatment is prevention of femoral head deformity, yet radiographic prognostic classifications are applied in the fragmentation stage, often after deformity occurs. These classifications are assigned too late in the progression of the disease to maximize the effects of intervention. Thus, alternative mechanisms to determine femoral head involvement earlier in the disease course are warranted. Increasingly, MRI has been used in the study of the disease. Gadolinium-enhanced and diffusion-weighted MRI has shown promising results that correlate with radiographic classifications and the early radiographic outcome. Advanced imaging has improved the assessment of hinge abduction, yet the exact definition remains controversial. The role of imaging in the management of Legg-Calvé-Perthes disease is rapidly evolving. New or refined imaging techniques may eventually allow earlier prognosis and treatment.

Introduction: The dangers of radiation exposure in children have been well studied, with assessment of adolescent idiopathic scoliosis (AIS) documented as having the potential for notable patient exposure. The purposes of this study were to evaluate a consecutive series of patients referred to a tertiary care pediatric hospital for AIS and to assess the type and quality of imaging obtained before referral for specialist evaluation., Methods: We performed a prospective study of consecutive patients referred over a 6-month period to a pediatric orthopaedic practice at a large, free-standing, urban children's hospital for evaluation of AIS. We assessed prereferral radiographic exposure, evaluating the utilization and adequacy of these radiographs., Results: Of a total of 131 patients enrolled in the study, 79 had received radiographs before the visit; of these, only 59 patients (75%) brought the previously obtained radiographs to the specialist consultation, and 45 patients (76%) of this subset were found to be adequate for evaluation of AIS. Of the total cohort, 56 patients (43%) required repeat radiographs because of missing or inadequate radiographs., Discussion: We found a large number of missing or inadequate radiographs, leading to repeat radiation exposure in this cohort. Improvements in the utilization of radiographs before orthopaedic referral could decrease unnecessary patient radiation exposure.

Background: On May 14, 2013, the National Transportation Safety Board (NTSB) proposed that states lower the blood alcohol concentration (BAC) illegal limit from 0.08 to 0.05 g/dL (also referred to as the 0.08 law and the 0.05 limit, respectively). In March 2017, this recommendation was signed into law in the State of Utah., Objective: The objective of this survey is to investigate perceptions regarding enforcement of the 0.05 g/dL BAC limit., Method: Opinions of law enforcement officers, prosecutors, and defense attorneys were obtained through a series of questionnaires and focus groups., Results: Survey data were collected from 32 law enforcement officers, 20 prosecutors, and 4 defense attorneys. The participants rated the usefulness of the NHTSA's driving while intoxicated (DWI) driving cues lower for the 0.05 limit than for the 0.08 law. Some of the participants believed that training would be needed in regard to sobriety testing under the 0.05 limit. Participants also stated that adequately preparing for prosecution of drunk drivers would be more difficult under the 0.05 limit. In addition, it was believed that drunk driving cases are more likely to be withdrawn and fewer plea agreements and guilty pleas are likely under the 0.05 limit. Prosecutors were concerned that the 0.05 limit would result in poorly investigated cases and overburden the court system. Defense attorneys were concerned about the social and economic costs of a 0.05 limit., Discussion: Overall, it appears that the 0.05 limit is viewed as enforceable and it will save lives; however, the usefulness of the NHTSA DWI Detection Guide and of the standardized field sobriety tests need to be established for lower BACs, and efforts must be made to educate people regarding the relationship between BAC and impairment and impairment and driving with the risk of injury and death., Conclusion: Though the 0.05 limit offers promise in saving lives, the following issues associated with changing the limit to 0.05 need to be resolved prior to implementation: Validating the sobriety tests for the 0.05 limit; if needed, modifying the sobriety tests to make them effective and valid at the 0.05 limit; and training law enforcement personnel and educating the public regarding the 0.05 limit.

Bacterial communities are composed of distinct groups of potentially interacting lineages, each thought to occupy a distinct ecological niche. It remains unclear, however, how quickly niche preference evolves and whether more closely related lineages are more likely to share ecological niches. We addressed these questions by following the dynamics of two bloom-forming cyanobacterial genera over an 8-year time-course in Lake Champlain, Canada, using 16S amplicon sequencing and measurements of several environmental parameters. The two genera, Microcystis ( M ) and Dolichospermum ( D ), are frequently observed simultaneously during bloom events and thus have partially overlapping niches. However, the extent of their niche overlap is debated, and it is also unclear to what extent niche partitioning occurs among strains within each genus. To identify strains within each genus, we applied minimum entropy decomposition (MED) to 16S rRNA gene sequences. We confirmed that at a genus level, M and D have different preferences for nitrogen and phosphorus concentrations. Within each genus, we also identified strains differentially associated with temperature, precipitation, and concentrations of nutrients and toxins. In general, niche similarity between strains (as measured by co-occurrence over time) declined with genetic distance. This pattern is consistent with habitat filtering - in which closely related taxa are ecologically similar, and therefore tend to co-occur under similar environmental conditions. In contrast with this general pattern, similarity in certain niche dimensions (notably particulate nitrogen and phosphorus) did not decline linearly with genetic distance, and instead showed a complex polynomial relationship. This observation suggests the importance of processes other than habitat filtering - such as competition between closely related taxa, or convergent trait evolution in distantly related taxa - in shaping particular traits in microbial communities.

People in wheelchairs spend a long time in the sitting position and often incur alignment problems resulting in neck and back pain. This study: (1) assessed the validity/reliability of Coach's Eye (CE) smart device application, (2) examined the effect of seat to back support angle adjustments on head, neck, and shoulder posture in the sitting position, and (3) compared changes in cervical rotation at each back support angle. Abled subjects sat in a wheelchair with back support angles positioned at 90°, 100°, and 110°. CE, as well as ImageJ software, was used to analyze three angles: sagittal head angle (SHA), cervical angle (CVA), and shoulder angle (SA). There were highly significant differences for CVA and SA (p < 0.001) among the three seat to back support angles. Validity of CE was examined by correlating CE with ImageJ scores. CE had high validity for all angles (r = 0.99, 0.98, 0.99 respectively, p < 0.001). Inter-rater reliability for SHA, CVA, and SA was high (intraclass correlation coefficient [ICC] ranged from 0.95 to 0.99). Head (CVA) and shoulder (SA) alignment was closest to neutral posture with back support angles set at 110° and 90°, respectively.

We propose and compare combinations of several methods for classifying transportation activity data from smartphone GPS and accelerometer sensors. We have two main objectives. First, we aim to classify our data as accurately as possible. Second, we aim to reduce the dimensionality of the data as much as possible in order to reduce the computational burden of the classification. We combine dimension reduction and classification algorithms and compare them with a metric that balances accuracy and dimensionality. In doing so, we develop a classification algorithm that accurately classifies five different modes of transportation (i.e., walking, biking, car, bus and rail) while being computationally simple enough to run on a typical smartphone. Further, we use data that required no behavioral changes from the smartphone users to collect. Our best classification model uses the random forest algorithm to achieve 96.8% accuracy., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; nor in the decision to publish the results.

Objectives: Pediatric pelvic trauma is associated with high rates of morbidity and mortality. Current classifications do not take into account age-dependent quantitative differences of the pediatric pelvis making accurate diagnosis of pathologic diastasis of the pubic symphysis, sacroiliac (SI) joints, and triradiate cartilage difficult. The purpose of this study was to establish age-based normative values for the width of the pubic symphysis, SI joints, and the triradiate cartilage of the pediatric pelvis., Methods: All computed tomographic (CT) scans of the abdomen and pelvis from patients between the ages 2 and 16 years over a 3-year period at a single institution were evaluated. Patients were excluded if the CT was performed as part of a trauma evaluation or for a history of neuromuscular disease or spinopelvic instrumentation. A total of 821 CT were included. The width of pubic symphysis, right and left SI joints, and each limb of the triradiate cartilages was measured using the PACS digital measurement tool. Left and right measurements of the SI joints and triradiate cartilage were combined and reported together., Results: From age 2 to 16 years, the average widths of the SI joint and pubic symphysis decreased from 3.11 to 1.80 mm and 5.55 to 3.69 mm, respectively. The average widths of the 3 limbs of the triradiate cartilage also slightly decreased from age 2 until closure: ilioischial, iliopubic, and ischiopubic cartilages decreasing from 3.72 to 2.74 mm, 4.42 to 3.52 mm, and 3.08 to 2.97 mm, respectively., Conclusions: This study demonstrates an age-dependent decrease in width of the pubic symphysis and left and right SI joints. By contrast, the widths of the triradiate cartilage remain relatively stable until closure. We believe that these age-based normative values will aid in future diagnosis of pathologic diastasis of these areas of the pediatric pelvis.

Most fungal pathogens of humans display robust protective oxidative stress responses that contribute to their pathogenicity. The induction of enzymes that detoxify reactive oxygen species (ROS) is an essential component of these responses. We showed previously that ectopic expression of the heme-containing catalase enzyme in Candida albicans enhances resistance to oxidative stress, combinatorial oxidative plus cationic stress, and phagocytic killing. Clearly ectopic catalase expression confers fitness advantages in the presence of stress, and therefore in this study we tested whether it enhances fitness in the absence of stress. We addressed this using a set of congenic barcoded C. albicans strains that include doxycycline-conditional tetON-CAT1 expressors. We show that high basal catalase levels, rather than CAT1 induction following stress imposition, reduce ROS accumulation and cell death, thereby promoting resistance to acute peroxide or combinatorial stress. This conclusion is reinforced by our analyses of phenotypically diverse clinical isolates and the impact of stochastic variation in catalase expression upon stress resistance in genetically homogeneous C. albicans populations. Accordingly, cat1Δ cells are more sensitive to neutrophil killing. However, we find that catalase inactivation does not attenuate C. albicans virulence in mouse or invertebrate models of systemic candidiasis. Furthermore, our direct comparisons of fitness in vitro using isogenic barcoded CAT1, cat1Δ and tetON-CAT1 strains show that, while ectopic catalase expression confers a fitness advantage during peroxide stress, it confers a fitness defect in the absence of stress. This fitness defect is suppressed by iron supplementation. Also high basal catalase levels induce key iron assimilatory functions (CFL5, FET3, FRP1, FTR1). We conclude that while high basal catalase levels enhance peroxide stress resistance, they place pressure on iron homeostasis through an elevated cellular demand for iron, thereby reducing the fitness of C. albicans in iron-limiting tissues within the host.

The well known biomarker of oxidative stress, 8-oxo-7,8-dihydroguanine, is more susceptible to further oxidation than the parent guanine base and can be oxidatively transformed to the genotoxic spiroiminodihydantoin (Sp) and 5-guanidinohydantoin (Gh) lesions. Incubation of 135-mer duplexes with single Sp or Gh lesions in human cell extracts yields a characteristic nucleotide excision repair (NER)-induced ladder of short dual incision oligonucleotide fragments in addition to base excision repair (BER) incision products. The ladders were not observed when NER was inhibited either by mouse monoclonal antibody (5F12) to human XPA or in XPC(-/-) fibroblast cell extracts. However, normal NER activity appeared when the XPC(-/-) cell extracts were complemented with XPC-RAD23B proteins. The Sp and Gh lesions are excellent substrates of both BER and NER. In contrast, 5-guanidino-4-nitroimidazole, a product of the oxidation of guanine in DNA by peroxynitrite, is an excellent substrate of BER only. In the case of mouse embryonic fibroblasts, BER of the Sp lesion is strongly reduced in NEIL1(-/-) relative to NEIL1(+/+) extracts. In summary, in human cell extracts, BER and NER activities co-exist and excise Gh and Sp DNA lesions, suggesting that the relative NER/BER product ratios may depend on competitive BER and NER protein binding to these lesions., (© 2016 by The American Society for Biochemistry and Molecular Biology, Inc.)

Background: The Veterans Health Administration (VA) Women's Health Practice-Based Research Network (WH-PBRN) was created to foster innovations for the health care of women veterans. The inaugural study by the WH-PBRN was designed to identify women veterans' own priorities and preferences for mental health services and to inform refinements to WH-PBRN operational procedures. Addressing the latter, this article reports lessons learned from the inaugural study., Methods: WH-PBRN site coordinators at the 4 participating sites convened weekly with the study coordinator and the WH-PBRN program manager to address logistical issues and identify lessons learned. Findings were categorized into a matrix of challenges and facilitators related to key study elements., Results: Challenges to the conduct of PBRN-based research included tracking of regulatory documents; cross-site variability in some regulatory processes; and troubleshooting logistics of clinic-based recruitment. Facilitators included a central institutional review board, strong relationships between WH-PBRN research teams and women's health clinic teams, and the perception that women want to help other women veterans., Conclusion: Our experience with the inaugural WH-PBRN study demonstrated the feasibility of establishing productive relationships between local clinicians and researchers, and of recruiting a special population (women veterans) in diverse sites within an integrated health care system. This identified strengths of a PBRN approach., (© Copyright 2015 by the American Board of Family Medicine.)

Hip subluxation is common in children with spastic cerebral palsy. Most physicians favor intervention to treat hip subluxation in skeletally immature patients with cerebral palsy. However, treatment in skeletally mature patients with cerebral palsy is controversial. The goal of this study was to evaluate radiographic and clinical outcomes after hip reconstruction in skeletally mature patients with cerebral palsy. The authors performed a retrospective review of all skeletally mature patients (n=20) with cerebral palsy who underwent hip surgery for subluxation at the authors' institution between 2005 and 2011. Charts were reviewed for demographic characteristics, procedure, follow-up, and complications. Acetabular index, migration index, and neck-shaft angle were measured on preoperative and most recent radiographs. Average follow-up was 2.2 years. Average migration index for the entire group improved from 57% to 20% (P<.0001). Of patients who had all radiographic abnormalities addressed at surgery (varus derotational femoral osteotomy for neck-shaft angle >135°, open reduction for migration index >50%, and acetabular osteotomy for acetabular index >25°), 91% had a final migration index of less than 25%. In patients who did not have all radiographic abnormalities addressed, 33% had a migration index of less than 25% at final follow-up. No intraoperative complications occurred; however, 13 patients had at least 1 postoperative complication. Hip subluxation in skeletally mature patients with cerebral palsy is difficult to treat and is associated with a high incidence of complications. The likelihood of a successful outcome appears to be related to the appropriateness of the surgical procedure. When all radiographic abnormalities were addressed during surgery, a successful radiographic outcome at final follow-up was much more likely than when intervention was less comprehensive., (Copyright 2015, SLACK Incorporated.)

Hydrated ferric oxide (HFeO), hydrated zirconium oxide (HZrO) and hydrated copper oxide (HCuO) were immobilized within a microporous anion exchange resin (IRA-400), forming hybrid media for enhanced phosphate removal from aqueous systems. Empirical data from batch kinetic trials fitted the pseudo second order mechanism for chemical adsorption and each media was rate limited by intraparticle diffusion overall. These models were also used to predict the adsorption rate constants and the equilibrium adsorption capacities, which ranged from 26.51 to 30.44 mgP g(-1), and from 24.15 to 27.90 mgP g(-1) of media for the calculated and experimental capacities, respectively. The phosphate adsorption behavior by the hybrid materials fit both the Langmuir and Freundlich adsorption isotherms (R(2)>0.94), and the maximum adsorption capacities were 111.1 mgP g(-1) for HFeO, 91.74 mgP g(-1) for HZrO and 74.07 mgP g(-1) for HCuO. The effect of competing ions such as sulfate reduced these capacities to 18.52 mgP g(-1) for HFeO and 18.97 mgP g(-1) for HZrO. Despite this decrease, HFeO was capable of reducing the phosphate in a real wastewater matrix by 83%, and the HZrO media was able to reduce it by 86%, suggesting that such hybrid media have the potential for application at full scale., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

In this study, online Fourier transform infrared (FTIR) spectroscopy has been used to generate the first comprehensive characterization of full-scale carbon contactors for siloxane removal from biogas. Using FTIR, two clear operational regions within the exhaustion cycle were evidenced: an initial period of pseudo-steady state where the outlet siloxane concentration was consistently below the proposed siloxane limits; and a second period characterized by a progressive rise in outlet siloxane concentration during and after breakthrough. Due to the sharp breakthrough front identified, existing detection methods (which comprise field sampling coupled with laboratory-based chromatographic determination) are insufficiently responsive to define breakthrough, thus carbon contactors currently remain in service while providing limited protection to the combined heat and power engine. Integration of the exhaustion cycle to breakthrough identified average specific media capacities of 8.5-21.5 gsiloxane kg(-1)GAC, which are lower than that has been reported for vapour phase granular activated carbon (GAC). Further speciation of the biogas phase identified co-separation of organic compounds (alkanes and aromatics), which will inevitably reduce siloxane capacity. However, comparison of the five full-scale contactors identified that greater media capacity was accessible through operating contactors at velocities sufficient to diminish axial dispersion effects. In addition to enabling significant insight into gas phase GAC contactors, the use of FTIR for online control of GAC for siloxane removal is also presented.

Background: Combat-related extremity injuries frequently require vascular repair within the combat theater before undergoing definitive reconstruction. This study examines the outcomes of early vascular repair with secondary soft-tissue extremity reconstruction over the past decade of war trauma., Methods: War-related extremity injuries necessitating a downrange vascular procedure followed by a definitive limb reconstruction were reviewed. Patient demographics, type and location of vascular injuries, vascular intervention, and soft-tissue reconstruction procedures were examined. Outcomes of vascular repair, tissue transfer, and limb salvage were analyzed., Results: From 2003 to 2012, 79 extremities in 78 patients had a vascular injury requiring in-theater intervention followed by 87 staged flap reconstructions performed distal to the vascular repair. Of the 74 arterial injuries requiring intervention, 27 were proximally located, with 73 percent requiring bypass. The early primary patency rate was 66 percent and the early primary-assisted patency rate was 93 percent for proximal artery repair procedures. The flap complication rate was 31 percent. Overall complications were examined by subtype and were not significantly different compared with flaps performed without a proximal vascular injury in the same limb. The flap success rate (93 percent) and the limb salvage rate (81 percent) were similar to the comparison cohort., Conclusions: This represents one of the largest series of traumatic extremity injuries requiring secondary limb reconstruction with tissue transfer following a vascular intervention. The authors identified no significant difference in outcomes related to flap coverage or limb salvage for patients with or without vascular injuries. Reconstructive options in combat extremity trauma are not limited by proximal vascular injury., Clinical Question/level of Evidence: Therapeutic, III.

Study Design: Retrospective review., Objective: To determine the rate of abnormal magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS) and the rate of neurosurgical intervention in those patients, and to develop a guideline concerning when to obtain an MRI., Summary of Background Data: The reported rate of intrathecal anomalies associated with presumed IIS varies in the literature (12% to 50%). Conclusions have led to conflicting recommendations concerning when an MRI is indicated., Methods: After appropriate internal review board approval, the authors retrospectively reviewed the medical records of patients from a single institution meeting the inclusion criteria: presumed idiopathic curve with a magnitude of ≥20°, age <36 months at diagnosis, normal neurologic examination, and presentation between 2002 and 2010. The authors reviewed the MRI findings, whether neurosurgical intervention took place, and the orthopedic treatment course (observation, brace, cast, or surgery)., Results: A total of 56 patients were identified and reviewed; 43 had had an MRI. Seven of 43 patients were found to have an anomaly (16.2%). A fatty filum was identified in 2 patients, a syrinx in 3, Chiari I malformation in 2, and a tethered cord in 1 (this patient also had a syrinx). Two of the 7 patients required neurosurgical intervention (28%). Patients who did not have an MRI were statistically younger, had smaller Cobb angles, and required less orthopedic treatment., Conclusions: The incidence of intrathecal anomalies (16.2%) at the authors' institution was similar to previously published reports; however, the need for neurosurgical intervention was significantly lower in this study (28%). For younger patients with small curves (<30°) who do not require orthopedic treatment, MRI under sedation can be delayed or avoided. Clinical judgment should be the determinant for whether to use MRI when evaluating patients with presumed IIS., (Copyright © 2014 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: The management of posttraumatic bone loss is complicated and often requires complex reconstructive procedures. No options exist that are specific to the treatment of the growing skeleton that has intercalary bone loss. We have observed reconstitution of the humerus in 2 cases that have precluded extensive management., Methods: Two pediatric patients sustained traumatic injuries to the upper extremities, including humeral bone loss, and are presented after spontaneous reconstitution of the segmental bone loss., Results: With treatment restricted to soft-tissue injury and bone stabilization with external fixation, both patients demonstrated radiographic healing of humeral segmental bone loss. Both patients were thought to have a partially intact periosteal sleeve. They have returned to sporting activities with mild loss of function., Conclusions: In certain pediatric injuries, spontaneous healing of segmental bone defects can occur. This response may obviate the need for complex, interventional procedures., Levels of Evidence: Level IV-case series.

The multiple mini-interview (MMI) is a reliable and valid method of selecting applicants for admission to health professional schools on the basis of non-cognitive traits. Because the MMI is a series of short interview stations that applicants rotate through in coordinated sequence, it can potentially be resource intensive. However, the MMI design has room for innovation and efficiency. At the University of Manitoba Faculty of Medicine, a 10-minute unsupervised writing station (WS) was incorporated into the MMI to obtain a writing sample from each applicant, to increase the number of independent scores per applicant, and to increase the number of applicants interviewed per circuit without increasing interviewer numbers. One assessor evaluated all the writing samples and assigned a score ranging from 1 to 7. With the inclusion of a WS into an 11-station MMI, the faculty's capacity to interview applicants increased by 9% (from 297 to 324) without substantially increasing interviewer hours needed per day. For 1,257 applicants interviewed in 2008-2011, the mean WS score was 4.03 (SD=1.36), whereas applicants' mean of 10 oral station (OS) scores was 4.62 (SD=0.69). Correlations between WS score and mean OS score ranged from .16 to .27 (p<.01) over the four years. Because inter-station correlations for OS ranged from .01 to .37, the correlation of .21 between WS and mean OS scores for all four years combined appears reasonable. Institutions that want to effectively increase the capacity of their MMI process might consider adding a WS.

Background: Knee stiffness is common after femoral lengthening. Certain patients require a quadricepsplasty when therapy does not improve flexion. A small subset of such patients may also have obligate patellar dislocation with knee flexion due to contracture of the extensor mechanism. We describe our surgical approach for both clinical situations and our outcomes in a pediatric population., Methods: Six patients, 2 with obligate patellar dislocation, were reviewed (9% of our femoral lengthening population). Indications for surgery included persistent symptomatic restriction of flexion after at least 3 months of therapy or obligate lateral patellar dislocation with knee flexion. Knee range of motion and clinical strength were assessed. Four patients were available for gait analysis and concentric quadriceps strength testing by isokinetic dynamometer. Patient satisfaction was surveyed by questionnaire., Results: All patients had full flexion before lengthening. The mean length gained (by circular external fixation and/or intramedullary motorized nail) was 10.7 cm. The mean age at the time of quadricepsplasty was 16 years. The average active flexion preoperatively was only 48 degrees. Two patients with obligate patellar dislocation and relatively good knee flexion inflated the average preoperative knee flexion. Although both had knee flexion to 100 degrees, the patella dislocated with flexion beyond 30 degrees. At follow-up (mean, 6.2 y) active flexion averaged 120 degrees (P<0.004). All patients had 5/5 clinical strength and no significant quadriceps lag. No patients had patellar instability postoperatively. Isokinetic dynamometer revealed an average weakness of 63% compared with the nonoperative quadriceps. Gait analysis indicated patients had near-normal gait patterns. All patients were satisfied and would pursue the same treatment., Conclusions: Our quadricepsplasty can significantly increase knee flexion and treat obligate patellar dislocation in the setting of extension contracture after femoral lengthening when nonoperative measures fail., Level of Evidence: Level IV.

Introduction: Students from rural areas are under-represented in medical schools. Concerns have been raised about rural applicants' qualifications relative to those of their urban counterparts, and the impact such potential differences in competitiveness may have on their under-representation. Although studies have reported no differences in Grade Point Average (GPA) and Medical College Admission Test (MCAT) scores between applicants with and without rural attributes, to date no study has assessed if performance on the multiple mini-interview (MMI) varies between the two groups., Methods: The MMI scores of 1257 interviewees for admission to the MD program at the Faculty of Medicine, University of Manitoba, in years 2008 to 2011, were studied for an association with graduation from a rural high school and attributes in the following three domains: rural connections, employment in rural areas, and rural community service., Results: There were 205 (16.3%) rural high school graduates among interviewed applicants. Rural high school graduates scored significantly lower (mean of 4.4 on a scale of 1 to 7; p < 0.05) than urban high school graduates (4.6). Among rural-attribute domains, those with rural community service alone had the highest MMI scores (4.9) while those with rural connections alone had the lowest scores (4.3; p = 0.016). After adjusting for demographics, GPA, and MCAT scores in a multiple linear regression model, rural-attribute domains were not significant predictors of an applicant's MMI score. However, graduation from a rural high school was significantly associated with decreased MMI scores (a 0.122 decrease in predicted MMI scores on a scale of 1 to 7)., Conclusion: Despite graduates from rural and urban high schools having comparable GPA, there exists a rural-urban divide in MMI scores that could exacerbate the under-representation of rural students in medical schools. Aboriginal applicants can also potentially be disproportionately affected, as they were more often from rural high schools than from urban high schools. Future studies need to determine systematic and institutional reasons, if any, for the differential in MMI scoring that can affect admission decisions for some rural applicants. It is also to be noted that the magnitude of difference is small enough that it may ultimately be irrelevant for future physician performance and practitioner outcomes.

Criteria for assessing suitability of applicants for professional degree programs such as veterinary medicine are usually treated as distinct components of a composite scoring procedure that determines applicant ranking. Some components are valued more than others, which is reflected in the relative weights assigned to each component. However, the patterns of dispersal of individual components have the potential to alter the assigned relative weights. Components with larger variances can have greater influences on composite scores than intended. Such unintended altered weighting can be avoided through standardization. Yet non-standardized approaches continue to be used for admissions ranking in several programs. In this study, we documented the potential for differential selection of applicants when non-standardized scoring approaches are applied to admissions assessment components. At our medical school, applicants' component scores with differing variances are standardized by determining Z-scores with a mean of 0 and standard deviation of 1 before mathematically combining to calculate composite scores and admissions ranking. We retrospectively and hypothetically ranked one applicant cohort using non-standardized methods and identified differences in ranking between the standardized and non-standardized approaches. Most differences were observed for applicants in the second, third, and fourth quintiles of the admissions rank list, that is, those for whom admissions cut-off decisions make a marked difference. Observations were supported by lower Spearman's rank correlation coefficients in these quintiles. Although standardization of component scores is not a novel topic, we document the implications of using non-standardized scoring approaches for applicant ranking and underscore the importance of standardization of component scores.

Biologically and chemically mediated adsorption and precipitation processes offer a range of approaches for removing phosphorus (P) from agricultural, domestic and industrial effluents. Technologies implemented at full-scale include filtration by adsorbent media, such as steel slag, and recovery of phosphorus as struvite, which has been successfully commercialised as a fertiliser. Other promising technologies under investigation include P removal by polymers and nanomaterials as well as struvite formation by bacteria. There is a need to focus future research on improving the efficiency of P removal by adsorption and precipitation. This can be achieved by techniques such as regenerating filters, polymers and nanomaterials for renewed P removal. Research is also needed to optimise the fertiliser potential of struvite precipitates., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Reverse micelles (RMs) containing aqueous solutions of Ag(+) ions in their core produce fluorescent Ag species, upon exposure to gamma irradiation. A two-phase liquid system is used for RM formation. The RMs can be employed in novel gamma radiation detectors with appearance of fluorescence indicating that radiation was once present.