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Introduction and Objectives: Hepatitis C Virus (HCV) is a blood-borne, hepatotropic RNA virus causing both acute and chronic infection. Chronic HCV infection predisposes individuals to liver fibrosis, cirrhosis and hepatocellular carcinoma. Staging of fibrosis prior to treatment to determine either treatment choice or required follow up, is standard practice. However, this often acts as a barrier to treatment initiation. We sought to validate the hypothesis that those individuals; mono-infected with HCV, ≤35 years of age; with no additional hepatic insult were unlikely to have significant fibrosis. Methods: We performed a retrospective analysis of a Hepatitis C Virus database; with collation of relevant basic demographics including age, sex and baseline Transient Elastography measurements pre-treatment. Additionally, we compared the reliability of biochemical fibrosis scores with corresponding transient elastography scores. Results: Our results support the hypothesis that those individuals with chronic HCV ≤35 years old, with no additional risk for fibrogenesis did not have significant liver fibrosis within our cohort. Conclusion: Patients ≤35 years old likely do not necessitate fibrosis assessment prior to Direct Acting Antiviral (DAA) treatment in the absence of other significant risk factors for fibrosis. Given the emerging evidence that DAA treatment results in a significant decrease in all-cause mortality and hepatocellular carcinoma development, treatment of those with chronic HCV represents a global priority.

Efficient trunk flexion and extension training is paramount to stabilize heavy weights lifted overhead in weightlifting. A strong and balanced trunk, which includes several muscle groups (not just those superficial muscles that can be seen but perhaps even more importantly the deep ones that hold most of the load), is necessary for success. This article will discuss the importance of balance between flexion and extension exercises of the trunk, stabilization movements of the trunk, and specific exercises that can be used in a weightlifting training program to most effectively train for stabilization of the weight overhead. [ABSTRACT FROM AUTHOR]

BACKGROUND: In pregnancies with small for gestational age (SGA) fetuses, elevated amniotic fluid tumor necrosis factor-alpha (TNF-alpha) levels have been reported. TNF-alpha has been shown to induce insulin resistance in rodents and humans. We hypothesized that an adverse fetal or early neonatal environment for SGA, twin, and premature children leads to persistently elevated TNF-alpha levels that induce insulin resistance in each of these groups. METHODS: The study group consisted of 16 SGA, 14 premature, 53 twin subjects, and the control group of 40 normal subjects (10 short-stature and 30 normal-stature). All subjects were prepubertal and non-obese. Insulin sensitivity (S(I)) was measured in all but the normal-statured control subjects. Fasting plasma TNF-alpha and cortisol levels were measured in all subjects. RESULTS: The study group had reduced S(I)[SGA 18.5 +/- 3, premature 17.8 +/- 2, twin 12.7 +/- 0.7 (x10(-4)/min/ microU/mL)] compared to the short normal control subjects (43 +/- 8 x 10(-4)/min/ microU/mL, p < 0.001). Plasma TNF-alpha levels were lower in the insulin-resistant study group when compared to the control group (2.9 +/- 0.1 vs. 5.0 +/- 0.2 pg/mL, p < 0.001). An association was present between reduced S(I) and low plasma TNF-alpha levels in the study group (p = 0.01, r = 0.4). Fasting plasma cortisol was lower in the study compared to the control group (266 +/- 16 vs. 341 +/- 28 nmol/L, p < 0.01) due to the influence of the twin study subgroup. There was no relationship between plasma cortisol and TNF-alpha levels (p = 0.3). CONCLUSION: SGA, premature, and twin children are insulin resistant and have low plasma TNF-alpha and cortisol levels. We speculate that the mechanism leading to insulin resistance in these subjects is also suppressing plasma TNF-alpha and cortisol concentrations. [ABSTRACT FROM AUTHOR]

Spontaneous mouse behavior is composed from repeatedly used modules of movement (e.g., rearing, running or grooming) that are flexibly placed into sequences whose content evolves over time. By identifying behavioral modules and the order in which they are expressed, researchers can gain insight into the effect of drugs, genes, context, sensory stimuli and neural activity on natural behavior. Here we present a protocol for performing Motion Sequencing (MoSeq), an ethologically inspired method that uses three-dimensional machine vision and unsupervised machine learning to decompose spontaneous mouse behavior into a series of elemental modules called 'syllables'. This protocol is based upon a MoSeq pipeline that includes modules for depth video acquisition, data preprocessing and modeling, as well as a standardized set of visualization tools. Users are provided with instructions and code for building a MoSeq imaging rig and acquiring three-dimensional video of spontaneous mouse behavior for submission to the modeling framework; the outputs of this protocol include syllable labels for each frame of the video data as well as summary plots describing how often each syllable was used and how syllables transitioned from one to the other. In addition, we provide instructions for analyzing and visualizing the outputs of keypoint-MoSeq, a recently developed variant of MoSeq that can identify behavioral motifs from keypoints identified from standard (rather than depth) video. This protocol and the accompanying pipeline significantly lower the bar for users without extensive computational ethology experience to adopt this unsupervised, data-driven approach to characterize mouse behavior., (© 2024. Springer Nature Limited.)

A 72-year-old gentleman with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the healthcare agent, and the team, the patient requested to be do-not-attempt-resuscitation and do-not-intubate (DNR/DNI) before losing decision-making capacity. When the patient's brother and another son heard of the code status change, they insisted on a return to Full Code. Although the youngest son (the healthcare agent) was present for the patient's request to be DNR/DNI, he declined to represent the patient's wishes and agreed with a return to Full Code. Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life, and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities., (Copyright © 2024. Published by Elsevier Inc.)

To navigate through the environment, humans must be able to measure both the distance traveled in space, and the interval elapsed in time. Yet, how the brain holds both of these metrics simultaneously is less well known. One possibility is that participants measure how far and how long they have traveled relative to a known reference point. To measure this, we had human participants (n = 24) perform a distance estimation task in a virtual environment in which they were cued to attend to either the spatial or temporal interval traveled while responses were measured with multiband fMRI. We observed that both dimensions evoked similar frontoparietal networks, yet with a striking rostrocaudal dissociation between temporal and spatial estimation. Multivariate classifiers trained on each dimension were further able to predict the temporal or spatial interval traveled, with centers of activation within the SMA and retrosplenial cortex for time and space, respectively. Furthermore, a cross-classification approach revealed the right supramarginal gyrus and occipital place area as regions capable of decoding the general magnitude of the traveled distance. Altogether, our findings suggest the brain uses separate systems for tracking spatial and temporal distances, which are combined together along with dimension-nonspecific estimates., (© 2023 Massachusetts Institute of Technology.)

While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness., (© 2023. Journal of Bioethical Inquiry Pty Ltd.)

Applying construal level theory, this study examined how social distance (thinking of self/children), front-of-package (FOP) claim type (nutrient/health/control), and perceived importance of eating healthily (low/high) impact consumer responses (attitudes/purchase intent) to healthier food products through an online experiment with 171 U.S. parents from low-to-mid socio-economic households. Participants were randomly assigned to view controlled images of healthier foods with packaging that bore different claim types for real and fictitious brands. Results revealed that when choosing for themselves, consumer attitudes were more positive when the healthier food package carried a nutrient (vs. health) claim, however, control claims received the most positive evaluations. When choosing for children, attitudes were more positive when the package carried a health (vs. nutrient/control) claim. Attitudes toward healthier foods were higher for consumers with high (vs. low) perceived importance of eating healthily when the package bore a nutrient claim, however, their attitudes did not significantly differ when the package bore a health/control claim. Purchase intent for healthier foods was higher for consumers with high (vs. low) perceived importance of healthy eating when shopping for self; whereas, when shopping for children, purchase intent did not significantly differ between consumers who varied in perceived importance of eating healthily.

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, nursing practice has much to contribute to the ethical practice of healthcare, and with the strong grounding in ethics and aspiration for social justice considerations in nursing, there is no wonder that the specific role of the nurse ethicist has emerged. Nurse ethicists, expert in nursing practice and the application of ethical theories and concepts, are well positioned to guide nurses through complex ethical challenges. However, there is limited discussion within the field regarding the specific job responsibilities that the nurse ethicist ought to have. The recent appearance of job postings with the title "nurse ethicist" suggest that some healthcare institutions have identified the value of a nurse in the practice of ethics and are actively recruiting. Discomfort about the possibility of others defining the role of the nurse ethicist inspired this paper (and special issue). If the nurse ethicist is to be seen as an integral part of addressing ethical dilemmas and ethical conflicts that arise in healthcare, then nurse ethicists ought to be at the forefront of defining this role. In this paper, we draw upon our own experiences as nurse ethicists in large academic healthcare systems to describe the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a clinical setting linked to academic programs. Drawing upon our experience and the literature, we describe how we perceive the nurse ethicist adds value to healthcare organizations and teams of professional ethicists., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GM serves on the editorial board for the journal Nursing Ethics.

X-linked spinal and bulbar muscular atrophy (SBMA; Kennedy's disease) is a rare neuromuscular disorder characterized by adult-onset proximal muscle weakness and lower motor neuron degeneration. SBMA was the first human disease found to be caused by a repeat expansion mutation, as affected patients possess an expanded tract of CAG repeats, encoding polyglutamine, in the androgen receptor (AR) gene. We previously developed a conditional BAC fxAR121 transgenic mouse model of SBMA and used it to define a primary role for skeletal muscle expression of polyglutamine-expanded AR in causing the motor neuron degeneration. Here we sought to extend our understanding of SBMA disease pathophysiology and cellular basis by detailed examination and directed experimentation with the BAC fxAR121 mice. First, we evaluated BAC fxAR121 mice for non-neurological disease phenotypes recently described in human SBMA patients, and documented prominent non-alcoholic fatty liver disease, cardiomegaly, and ventricular heart wall thinning in aged male BAC fxAR121 mice. Our discovery of significant hepatic and cardiac abnormalities in SBMA mice underscores the need to evaluate human SBMA patients for signs of liver and heart disease. To directly examine the contribution of motor neuron-expressed polyQ-AR protein to SBMA neurodegeneration, we crossed BAC fxAR121 mice with two different lines of transgenic mice expressing Cre recombinase in motor neurons, and after updating characterization of SBMA phenotypes in our current BAC fxAR121 colony, we found that excision of mutant AR from motor neurons did not rescue neuromuscular or systemic disease. These findings further validate a primary role for skeletal muscle as the driver of SBMA motor neuronopathy and indicate that therapies being developed to treat patients should be delivered peripherally., (© 2023. The Author(s).)

Behavior is shaped by both the internal state of an animal and its individual behavioral biases. Rhythmic variation in gonadal hormones during the estrous cycle is a defining feature of the female internal state, one that regulates many aspects of sociosexual behavior. However, it remains unclear whether estrous state influences spontaneous behavior and, if so, how these effects might relate to individual behavioral variation. Here, we address this question by longitudinally characterizing the open-field behavior of female mice across different phases of the estrous cycle, using unsupervised machine learning to decompose spontaneous behavior into its constituent elements. 1 , 2 , 3 , 4 We find that each female mouse exhibits a characteristic pattern of exploration that uniquely identifies it as an individual across many experimental sessions; by contrast, estrous state only negligibly impacts behavior, despite its known effects on neural circuits that regulate action selection and movement. Like female mice, male mice exhibit individual-specific patterns of behavior in the open field; however, the exploratory behavior of males is significantly more variable than that expressed by females both within and across individuals. These findings suggest underlying functional stability to the circuits that support exploration in female mice, reveal a surprising degree of specificity in individual behavior, and provide empirical support for the inclusion of both sexes in experiments querying spontaneous behaviors., Competing Interests: Declaration of interests S.R.D. sits on the scientific advisory boards of Neumora, Inc. and Gilgamesh Therapeutics., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Resilience refers to an individual's ability to maintain effective functioning, by resisting, withstanding or recovering from stressors or adversity, including pain associated with physical injury (J Clin Psychol Med Settings 28:518-28, 2021). The aim of this scoping review is to determine the role of resilience in the experience of movement-evoked pain (MEP) and return to functional activity following a musculoskeletal injury., Methods: This review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and the scoping review protocol of the Joanna Briggs Institute (JBI). Five databases and one grey literature database were searched using predetermined key words and index terms to capture published and unpublished records on the topic. Two authors independently screened the title and abstract of each record, with the full-text of eligible records being reviewed. Papers were eligible for inclusion if they examined the population, concept and context of interest, were written in English and the full text was available. Data were extracted from each eligible record to guide discussion of the available literature on this topic., Results: Of 4771 records, 2695 articles underwent screening based on their title and abstract. After title and abstract screening 132 articles were eligible for full text review, with 24 articles included in the final analysis. This review identified that psychological resilience has primarily been investigated in the context of a range of age-related pathologies. The choice of functional and movement-evoked pain assessments in the included studies were often guided by the pathology of interest, with some being general or injury specific., Conclusion: This scoping review identified inconsistent conclusions regarding the role of resilience in the experience of MEP and the ability to return to function for older adults with a musculoskeletal injury. This scoping review highlights the need for longitudinal research to be conducted that allows a broader age range, including younger adults, to determine if multidimensional resilience may promote recovery form musculoskeletal injury., (© 2022. The Author(s).)

Objectives/hypothesis: To evaluate trends in contemporary positive surgical margin incidence in cT1-T2 oral cavity squamous cell carcinoma and to evaluate factors associated with surgical margin status., Study Design: Retrospective analysis of large dataset., Methods: Retrospective analysis of the National Cancer Database., Results: Between 2004 and 2016, 39,818 patients with cT1 or cT2 oral cavity squamous cell carcinoma received primary curative-intent surgery. Positive surgical margins were present in 7.95% of patients, and univariable adjusted probability of positive surgical margins over the study period declined by 1% per year (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-1.0; P = .049). Multivariable regression revealed the annual rate of positive surgical margins declined significantly (OR, 0.95 per year; 95% CI, 0.92-0.97; P < .001). Factors associated with increased odds of positive surgical margins included cT2 disease, subsite, understaged disease, lymphovascular invasion, tumor grade, and positive lymph nodes. Race and socioeconomic status were not associated with surgical margin status. Treatment at an academic center was associated with increased time to definitive surgery (median 35 days IQR 22-50 vs. median 27 days IQR 14-42; P < .001) and a 20% reduction in positive surgical margin rate (OR, 0.80; 95% CI, 0.71-0.90; P < .001). Treatment at high-volume centers was less likely to be associated with positive surgical margins (OR, 0.85; 95% CI, 0.74-0.98; P = .02)., Conclusion: Surgical subsite, clinical T and N category, presence of lymphovascular invasion, and histologic grade were independent predictors of positive surgical margins. Patients are increasingly being treated at high-volume and academic centers. Overall, the rate of positive surgical margins in cT1-T2 oral cavity squamous cell carcinoma is decreasing., Level of Evidence: 4 Laryngoscope, 132:1962-1970, 2022., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Background and objective Athletics is the leading cause of pediatric concussion, and depression is a major comorbidity associated with concussion in the pediatric population. Prior studies have described the risk of depression after concussion in high school-, collegiate-, and elite-level athletes, but there is scarce data on younger athletes. Interpretation of existing research on the association of depression with concussions in youth athletes is complicated by diverse study designs, varying measures of depression, differing timelines for symptom development, and a lack of control groups. Furthermore, limited research exists on sex-related differences in the development of depressive symptoms following sports-related concussions (SRC) in younger athletes. This study used the Seattle Pediatric Concussion Research Collaborative (SPCRC) Data Repository to compare depressive symptoms between youth athletes at one month post-SRC and non-concussed age-matched controls by using a standardized measure of depressive symptoms: the Patient Health Questionnaire-9 (PHQ-9). The secondary goal was to compare PHQ-9 scores between males and females for both concussed and non-concussed groups. Methods This study entailed a secondary analysis of data collected as part of the SPCRC Data Repository. We conducted a retrospective subgroup analysis of PHQ-9 scores at one month post-concussion for concussed youth athletes. We compared the PHQ9 scores of concussed youth athletes with PHQ-9 scores collected at the time of enrollment for non-concussed youth athletes. Results After random age-matching, a cohort of 266 patients (133 in the concussed group and 133 in the non-concussed control group) was included in the final analysis. The mean age was 13.8 years (range: 5-18 years). For the concussed group, a history of SRC was associated with a higher mean total PHQ-9 score at one month post-concussion compared with the control group at the time of enrollment (6.14 ±5.46 versus 1.53 ±1.81, respectively, p<0.0001). All nine subdomains of the PHQ-9 showed significantly higher scores in the concussion group compared with the control group (p<0.0001). Significantly higher scores were observed when comparing mean total PHQ-9 scores for male athletes in the concussion group with male athletes in the control group (7.03 ±5.72 versus 1.59 ±1.66, p<0.0001) and for female athletes in the concussion group compared with female controls (5.28 ±5.10 versus 1.49 ±1.92, p<0.0001). No significant differences were observed between sexes for total PHQ-9 scores or PHQ-9 subscores. Conclusion At one month post concussion, youth with SRC demonstrated higher levels of depressive symptoms as measured by PHQ-9 compared with age-matched typically developing controls. No significant differences were identified in total PHQ-9 scores and subscores between male and female participants for either the concussion or control group. This study suggests that clinicians need to be vigilant and monitor for symptoms of depression in young athletes for at least one month post-concussion., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Robinson et al.)

Objectives: We used data from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial to examine the impact of self-reported chronic obstructive pulmonary disease, coronary artery disease, stroke, and diabetes mellitus on diagnostic complications in lung cancer screening evaluation., Methods: In our analysis, we included individuals from the usual care and intervention (annual chest x-ray) of the lung cancer screening trial with equal or greater than 55 years of age with a 20 pack-year smoking history who had undergone an invasive procedure. We performed multivariate logistic regression analysis to estimate the association of comorbidity on procedure complication. Our primary outcome was the incidence of major or moderate complications., Results: Features associated with high-risk complication included older age (OR = 1.03 per year, P = .001), history of coronary artery disease (OR = 1.40, P = .03), history of diabetes mellitus (OR = 0.41, P < .001, current smoking status (OR = 1.46, P ≤ .001), surgical biopsy (OR = 7.39, P < .001), needle biopsy (OR = 1.94, P < .001), and other invasive procedure (OR = 1.58, P < .001). We did not find an associated with complication and history of stroke (OR = 0.84, P = .53) or chronic obstructive pulmonary disease (OR = 1.27, P = .06)., Conclusion: Patient and procedure-level factors may alter the benefits of lung cancer screening. Data concerning individual risk factors and high-risk complications should therefore be incorporated into diagnostic algorithms to optimize clinical benefit and minimize harm. Further study and validation of the risk factors identified herein are warranted., (Copyright © 2022. Published by Elsevier Inc.)

Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients., (© 2020. Springer Nature B.V.)

The efficacy of direct-acting antivirals (DAA) provides an excellent opportunity to scale up HCV diagnosis and treatment, achieving the WHO target of HCV elimination by 2030. However, HCV reinfection among people who inject drugs (PWID) remains a concern and may impede elimination efforts. We assessed reinfection rates among PWID across six specialized treatment pathways, following DAA-based and interferon-based therapies in Tayside, Scotland. Data were collected retrospectively for every treatment episode that resulted in a sustained viral response (SVR) after undergoing treatment. Reinfection rates were calculated for each treatment pathway: hospital outpatient clinic; community pharmacy; drug treatment outreach; prison clinic; nurse-led outreach clinic; and injection equipment provision site. Reinfection is defined as a positive RNA test result after SVR. Incidences of reinfection are expressed in 100 person-years (PYs). In total, 916 treatment episodes met selection criteria. Of these, 100 reinfections were identified, generating an overall reinfection rate of 5.27 per 100 PYs (95%CI: 4.36-6.38). The hospital outpatient clinic had the lowest reinfection incidence (1.81 per 100 PYs, 95%CI: 1.11-2.93), with the injection equipment provision site treatment pathway having the highest reinfection incidence (19.89 per 100 PYs, 95%CI: 14.91-26.54). The incidence of reinfection among those treated with interferon-based therapies and those treated with DAA-based therapies was 4.93 per 100 PYs (95%CI: 3.97-6.11) and 7.17 per 100 PYs (95%CI: 4.75-10.82), respectively. Specialized treatment pathways in Tayside yield varying reinfection incidence rates, with different subpopulations of patients at varying risk of reinfection post-SVR. Results suggest that resources should be targeted at the injection equipment provision site pathway in order to reduce the incidence of reinfection and achieve elimination targets. The study found comparable rates of reinfection following interferon-based and DAA-based therapies, providing support for widening access to treatment services., (© 2021 John Wiley & Sons Ltd.)

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, thirty-nine (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent , p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families., (© 2021. Journal of Bioethical Inquiry Pty Ltd.)

Background: Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress., Objectives: The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points., Methods: Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used., Results: At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly., Discussion: This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Chronic hepatitis C virus (HCV) is one of the leading causes of liver cirrhosis and hepatocellular carcinoma. The WHO 2030 Elimination Goals require each country to evaluate their response to their epidemics. This can be achieved by visualization of cascades of care, depicting how infected cases move through disease control stages. However, methods of displaying data are debated and lack practical application. This project proposes a new way of codifying and displaying HCV data using Tayside as a case study. 1464 cases of active HCV infections in Tayside from 2015 to 2019 were analysed from NHS Tayside's HCV Database. Variables were evaluated to create a systematic coding framework that was then used to code each patient's diagnosis, treatment and cure status each year from 2015 to 2019. Graphical representation of the data in the form of a stacked clustered bar chart demonstrates general trends and conversion rates. For example, Tayside has seen an increase in diagnosis-to-cure rates from 18% to 49% (2015-2019). This method also demonstrates the portion of newly and previously diagnosed people accessing treatment, those with unsuccessful or incomplete treatments, completed treatments with unconfirmed cure, and the number of deaths and relocations. In conclusion, this project proposes a novel way of displaying cascades of care data that relays yearly snapshots of an epidemic, cumulative progression over time, nuanced information of each stage and progression towards elimination targets. This method can be meaningfully used to improve local service planning, knowledge exchange across health systems and reporting to bodies like the WHO., (© 2021 The Authors. Journal of Viral Hepatitis published by John Wiley & Sons Ltd.)

Abstract: Craniofacial surgery continues to be a rapidly evolving field, due in part to interdisciplinary collaboration that has allowed for sharing of knowledge and methodologies, which has expanded greatly due to online journals and publications. The Journal of Craniofacial Surgery (JCS) is a highly regarded journal that has attracted attention for its mission to increase diversity and global representation in manuscript submissions and research publications. The purpose of this study is to provide an objective measurement of global participation in craniofacial research specifically as it pertains to the JCS. Through a bibliometric analysis, the country of origin of all articles published in the JCS from 2010 to 2019 was analyzed. In line with its mission, the JCS increased its overall production 1.9 times during the past decade and increased its global representation 1.6 times, as represented by the number of countries contributing (78). The journal produced 8147 articles with Turkey (1424), USA (1397), China (1178), South Korea (1023), and Italy (644) being the top producers. The highest represented states were Florida (156), New York (130), California (117), Massachusetts (112), and Pennsylvania (106). The Journal of Craniofacial Surgery has the greatest diversity of country representation of the major plastic and reconstructive journals compared. Overall the JCS has stayed true to its mission to foster craniofacial research and is a valuable resource for craniofacial surgeons across the world. This study provides an analysis of trends in global contributions to craniofacial research and highlights areas for further increasing global contributors to the field of craniofacial surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

The perception and measurement of spatial and temporal dimensions have been widely studied. Yet, whether these two dimensions are processed independently is still being debated. Additionally, whether EEG components are uniquely associated with time or space, or whether they reflect a more general measure of magnitude quantity remains unknown. While undergoing EEG, subjects performed a virtual distance reproduction task, in which they were required to first walk forward for an unknown distance or time, and then reproduce that distance or time. Walking speed was varied between estimation and reproduction phases, to prevent interference between distance or time in each estimate. Behaviorally, subject performance was more variable when reproducing time than when reproducing distance, but with similar patterns of accuracy. During estimation, EEG data revealed the contingent negative variation (CNV), a measure previously associated with timing and expectation, tracked the probability of the upcoming interval, for both time and distance. However, during reproduction, the CNV exclusively oriented to the upcoming temporal interval at the start of reproduction, with no change across spatial distances. Our findings indicate that time and space are neurally separable dimensions, with the CNV both serving a supramodal role in temporal and spatial expectation, yet an exclusive role in preparing duration reproduction., Competing Interests: Declaration of Competing Interest The authors declare no competing financial interests., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC)., Study Design: Retrospective cohort study., Methods: In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach., Results: Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival., Conclusion: For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone., Level of Evidence: 4., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Chronic liver disease (CLD) is a significant health problem affecting millions of people worldwide. In Scotland, CLD is a major cause of premature mortality. Liver function tests (LFTs) are a panel of frequently requested blood tests which may indicate liver disease. However, LFTs commonly contain at least one abnormal result, and abnormalities are rarely investigated to the extent recommended by national guidelines. The intelligent Liver Function Testing (iLFT) pathway is a novel, automated system designed to improve early diagnosis of liver disease. Initial abnormal LFT results trigger a cascade of reflexive testing to help identify the cause of any liver dysfunction. Algorithms combine these results with demographic and clinical data (such as patient age, body mass index, and alcohol intake) and fibrosis estimates to produce an electronic diagnosis and management plan. The pilot trial demonstrated that iLFT increased diagnosis of liver disease whilst remaining cost-effective. As such, iLFT has been fully operational across our region (NHS Tayside, Scotland) since August 2018. In the first year, iLFT generated over 2000 diagnoses from 1824 patient samples with an abnormality in the initial LFTs. The majority of these patients could be safely managed in primary care. iLFT allows maximal value to be obtained from liver blood tests across biochemistry, virology, immunology, and hematology with only minor changes to working practices. 'Intelligent', algorithm-led testing pathways break down the barrier between clinical and laboratory medicine and offer solutions to many of the challenges experienced in modern healthcare systems., (© American Association for Clinical Chemistry 2020.)

There is emerging evidence that Hepatitis C (HCV) treatment engagement is associated with change in drug behaviours and reduced drug-related death rates among people who inject drugs (PWID). The project aims to investigate whether HCV diagnosis and treatment engagement reduces all-cause mortality and drug-related death, and whether any effect is dependent on treatment regimen and intensity of engagement with staff. Case-control studies comparing: PWID with active HCV infection (PCR positive) to PWID HCV infected but spontaneously resolved (PCR negative); PCR-positive patients who engaged with treatment services to nonengagers; and patients who received interferon vs direct-acting antiviral (DAA) based treatment. No differences in risk of all-cause mortality or drug-related death between PCR-negative controls and PCR-positive cases were detected. The odds of all-cause mortality was 12.2 times higher in nonengaging persons compared to treatment engaging cases (aOR 12.15, 95% CI 7.03-20.99, P < .001). The odds of a drug-related death were 5.5 times higher in nonengaging persons compared with treatment engaging cases (aOR 5.52, 95% CI 2.67- 11.44, P < .001). No differences in risk of all-cause mortality or drug-related death between interferon-treated cases and DAA-treated controls were detected. HCV treatment engagement is significantly protective against all-cause mortality and drug-related death. This engagement effect is independent of treatment regimen, with the introduction of DAA therapies not increasing risk of drug-related death, suggesting intensity of HCV therapy provider interaction is not an important factor., (© 2020 The Authors. Journal of Viral Hepatitis published by John Wiley & Sons Ltd.)

Background: The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention., Objective: The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital., Methods: We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital., Results: Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital., Conclusion: The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults., (Copyright © 2019 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making., Research Question/aim: To discover how effective the participants perceived the program and if their goals of participation had been met., Research Design: A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to graduates., Ethical Considerations: Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted., Findings: An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a "moral compass to navigate the many gray areas of decision-making that confront them in daily practice." Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process., Discussion: Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency., Conclusion: Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making.

Background: Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety., Objective: To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families., Methods: In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables., Results: The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change., Conclusions: When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced., (©2020 American Association of Critical-Care Nurses.)

Background: There has been growing interest in limited resection and nonsurgical treatment for small lung cancers. We examined the pattern and rate of occult N1 nodal metastasis in patients with peripheral, small (≤2 cm), clinically node-negative non-small cell lung cancer (NSCLC)., Methods: Patients with peripheral small (≤2 cm) NSCLC with no evidence of locally advanced or metastatic disease (clinical T1a-b N0 M0, American Joint Committee on Cancer 8th Edition Cancer Staging Manual), who were deemed eligible for lobectomy or sublobar resection, were identified from preregistration eligibility screening logs for the Alliance/Cancer and Leukemia Group B 140503 trial at our institution. Pathologic outcomes were examined in all patients undergoing anatomic resection with mediastinal and hilar lymphadenectomy., Results: Included were 58 patients treated between November 2014 and January 2017 who met the inclusion criteria: 51 underwent lobectomy, and 7 underwent segmentectomy. Mean tumor diameter on computed tomography was 1.5 cm, and mean positron emission tomography maximal standardized uptake value was 3.9. The mean consolidation-to-tumor ratio was 0.77. Occult nodal metastases in N1 stations were found in 8 of 58 patients (14%), and most of these nodes were found in interlobar or peribronchial stations (11 or 12). An additional 2 patients (3%) had occult positive N2 nodes. Overall, the false-negative rate for clinical staging was 16%., Conclusions: Occult nodal disease was frequently identified in peripheral N1 stations (11-13) in patients with small (≤2 cm) clinical N0 NSCLC. Hilar lymphadenectomy is essential for accurate staging in the management of patients with small clinical N0 NSCLC., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring., (© 2019 The Association for the Publication of the Journal of Internal Medicine.)

Background & Aims: Liver function tests (LFTs) are frequently requested blood tests which may indicate liver disease. LFTs are commonly abnormal, the causes of which can be complex and are frequently under investigated. This can lead to missed opportunities to diagnose and treat liver disease at an early stage. We developed an automated investigation algorithm, intelligent liver function testing (iLFT), with the aim of increasing the early diagnosis of liver disease in a cost-effective manner., Methods: We developed an automated system that further investigated abnormal LFTs on initial testing samples to generate a probable diagnosis and management plan. We integrated this automated investigation algorithm into the laboratory management system, based on minimal diagnostic criteria, liver fibrosis estimation, and reflex testing for causes of liver disease. This algorithm then generated a diagnosis and/or management plan. A stepped-wedged trial design was utilised to compare LFT outcomes in general practices in the 6 months before and after introduction of the iLFT system. Diagnostic outcomes were collated and compared., Results: Of eligible patients with abnormal LFTs, 490 were recruited to the control group and 64 were recruited to the intervention group. The primary diagnostic outcome was based on the general practitioner diagnosis, which agreed with the iLFT diagnosis in 67% of cases. In the iLFT group, the diagnosis of liver disease was increased by 43%. Additionally, there were significant increases in the rates of GP visits after diagnosis and the number of referrals to secondary care in the iLFT group. iLFT was cost-effective with a low initial incremental cost-effectiveness ratio of £284 per correct diagnosis, and a saving to the NHS of £3,216 per patient lifetime., Conclusions: iLFT increases liver disease diagnoses, improves quality of care, and is highly cost-effective. This can be achieved with minor changes to working practices and exploitation of functionality existing within modern laboratory diagnostics systems., Lay Summary: There is a growing epidemic of advanced liver disease, this could be offset by early detection and management. Checking liver blood tests (LFTs) should be an opportunity to diagnose liver problems, but abnormal results are often incompletely investigated. In this study we were able to substantially increase the diagnostic yield of the abnormal LFTs using the automated intelligent LFT system. With the addition of referral recommendations and management plans, this strategy provides optimum investigation and management of LFTs and is cost saving to the NHS., (Copyright © 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: As a result of routine low-dose computed tomographic screening, lung cancer is more frequently diagnosed at earlier, operable stages of disease. In treating local non-small-cell lung cancer, video-assisted thoracoscopic surgery (VATS), a minimally invasive surgical approach, has replaced thoracotomy as the standard of care. While short-term quality-of-life outcomes favor the use of VATS, the impact of VATS on long-term health-related quality of life (HRQoL) is unknown., Patients and Methods: We studied patients who underwent lobectomy for the treatment of non-small-cell lung cancer from January 2006 to January 2013 at a single institution (n = 456). Patients who underwent segmentectomy (n = 27), who received neoadjuvant therapy (n = 13), or who were found to have clinical stage > T2 or > N0 disease (n = 45) were excluded from analysis. At time of HRQoL assessment, 199 patients were eligible for study and were mailed the generic HRQoL instrument 15D., Results: A total of 180 patients (90.5%) replied; 92 respondents underwent VATS while 88 underwent open thoracotomy. The VATS group more often had adenocarcinoma (P = .006), and lymph node stations were sampled to a lesser extent (P = .004); additionally, hospital length of stay was shorter among patients undergoing VATS (P = .001). No other clinical or pathologic differences were observed between the 2 groups. Surprisingly, patients who underwent VATS scored significantly lower on HRQoL on the dimensions of breathing, speaking, usual activities, mental function, and vitality, and they reported a lower total 15D score, which reflects overall quality of life (P < .05)., Conclusion: In contrast to earlier short-term reports, long-term quality-of-life measures are worse among patients who underwent VATS compared to thoracotomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases.

The care of lung transplant recipients with prolonged index hospitalizations can be ethically complex, with conflicts arising over whether the expected outcomes justify ongoing intensive interventions. There are limited data to guide these conversations. The objective of this study was to evaluate survival to discharge for lung transplant recipients based on length of stay (LOS). This was a retrospective cohort study of adult lung transplant recipients in the Scientific Registry of Transplant Recipients. For each day of the index hospitalization the mortality rate among patients who survived to that length of stay or longer was calculated. Post-discharge survival was compared in those with and without a prolonged hospitalization (defined as the 97th percentile [>90 days]). Among the 19 250 included recipients, the index hospitalization mortality was 5.4%. Posttransplant stroke and need for dialysis were the strongest predictors of index hospitalization mortality. No individual or combination of available risk factors, however, was associated with inpatient mortality consistently above 50%. Recipients with >90 day index hospitalization had a 28.8% subsequent inpatient mortality. Their 1, 3 and 5 year survival following discharge was 53%, 26%, and 16%. These data provide additional context to goals of care conversations for transplant recipients with prolonged index hospitalizations., (© 2018 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Anxiety is common among pediatric surgical patients and their parents. Numerous studies have examined interventions to reduce pediatric patients' anxiety; however, less is known about reducing parental anxiety. In other populations, producing art has been shown to significantly reduce anxiety., Purpose: This study aimed to determine whether parents' anxiety decreased after coloring while their child is in surgery., Design and Methods: A block randomized controlled trial was conducted with a convenience sample of 106 parents of children who were having a scheduled surgery. Each day of data collection was randomized where all parents enrolled that day would either color a pre-drawn art template for 30min or would simply wait in the waiting room for 30min. The primary outcome measure was anxiety, measured by the 6-item short form of the Spielberger State Trait Anxiety Inventory (STAI)., Results: Parents' average anxiety score decreased from the initial measurement to the measurement 30min later in both the control group and the intervention group. The reduction in anxiety was significantly greater for those parents who participated in coloring during their wait (p<0.0001)., Conclusions: Coloring is a creative, simple, low cost, and effective activity to reduce anxiety among parents in a pediatric surgical waiting area., Practice Implications: Providing coloring materials and information about the benefits of coloring in pediatric surgery waiting areas is an easy to implement intervention to reduce parental anxiety., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Patients with thick primary melanomas (≥4 mm) have highly variable survival outcomes. Cell proliferation marker Ki-67 has been identified as promising biomarker in thick melanoma but has not been evaluated since the wide spread adoption of sentinel lymph node biopsy. We revisit its prognostic relevance in the sentinel node era., Methods: We studied patients with thick (≥4 mm) primary melanoma prospectively enrolled in a clinicopathological biospecimen database from 2002 to 2015, and evaluated the prognostic value of Ki-67 expression while controlling for features included in the existing staging criteria., Results: We analyzed 68 patients who underwent lymph node sampling and who had an available tumor for Ki-67 immunohistochemical (IHC) staining. The median tumor thickness was 6.0 mm; the median follow-up was 2.6 years. In multivariable analysis including nodal status and primary tumor ulceration, Ki-67 expression was an independent predictor of worse recurrence-free survival (HR 2.19, P = 0.024) and overall survival (HR 2.49, P = 0.028). Natural log-transformed tumor thickness (ln [thickness]) was also significantly associated with worse OS (HR 2.39, P = 0.010)., Conclusion: We identify Ki-67 and ln (thickness) as potential biomarkers for patients with thick melanoma who have undergone nodal staging. If validated in additional studies, these biomarkers could be integrated into the staging criteria to improve risk-stratification., (© 2018 Wiley Periodicals, Inc.)

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work.