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In this paper, the writers examine different investment mechanisms for transportation infrastructure projects involving the private enterprise in developing countries. Roles identified vary from those of a financier to an operator for successful public-private ventures. A case study involving such a joint venture in India, the Mumbai-Pune Expressway/National Highway 4 is presented, and fiscal implications of the program, both from the perspective of the public and the private enterprise, are examined. The study concludes that if properly planned, joint ventures can be mutually beneficial. A joint public-private program may enable the public agency to use the resources saved for other public projects. It also provides the private agency an opportunity to invest funds in a profitable enterprise that yields social benefits, (e.g., improving mobility, promoting economic development, etc.). Careful analysis must be conducted before the project is undertaken to assess the financial and economic implications of the project from each participant's viewpoint, with due regard to risks and uncertainties associated with such long-term investments. DOI: 10.1061/(ASCE)0733-9488(2010)136:1(94) CE Database subject headings: Investments; Joint ventures; Economic factors; Financial factors; Social factors; Developing countries. Author keywords: Investment mechanism; Public-private ventures; Economic and financial analysis; Social benefits.

The study was conducted to investigate the impact of an Interpreter Service on intensity of Emergency Department (ED) services, utilization, and charges. This study describes the effects of language barriers on health care service delivery for the index ED visit and a subsequent 90-day period. In all 26,573 ED records from July to November, 1999, resulted in a data set of 500 patients with similar demographic characteristics, chief complaint, acuity, and admission rate. Noninterpreted patients (NIPs) who did not speak English had the shortest ED stay (LOS) and the fewest tests, IVs and medications; English-speaking patients had the most ED services, LOS, and charges. Subsequent clinic utilization was lowest for NIPs. Among discharged patients, return ED visit and ED visit charges were lowest for interpreted patients (IPs). Use of trained interpreters was associated with increased intensity of ED services, reduced ED return rate, increased clinic utilization, and lower 30-day charges, without any simultaneous increase in LOS or cost of visit. [ABSTRACT FROM AUTHOR]

C-H activation is a powerful strategy for forming C-C bonds without the need for prefunctionalization. In this paper, we present a general, direct, and regioselective palladium-catalyzed functionalization of a phosphorus heterocycle, 2-phenyl-1 H -isophosphinoline 2-oxide. The mild reaction conditions enabled the introduction of various functionalized alkenes. Moreover, the flame-retardant properties of selected products clearly highlighted the synergy between the phosphine oxide and another heteroatom-based group, even in the condensed phase.

"Intensification of Vaporization by Decompression to the Vacuum" (IVDV) has initially emerged as a technology primarily employed for expanding and enhancing the texture of biological products. However, its recent applications have showcased significant promise in the realm of extracting bioactive molecules from various plant materials. In this context, optimization using response surface methodology was conducted to investigate the impact of IVDV pretreatment on the extractability of phenolic compounds from Eryngium creticum leaves and stems, as well as their biological activities. Using IVDV preceding the extraction led to higher total phenolic content (TPC) and enhanced antiradical activities in treated materials compared to untreated ones. The optimal processing conditions in terms of water content, steam pressure and treatment time were determined in order to maximize TPC (89.07 and 20.06 mg GAE/g DM in leaves and stems, respectively) and antiradical (DPPH) inhibition percentage (93.51% and 27.54% in leaves and stems, respectively). IVDV-treated extracts showed superior antioxidant, antibacterial and antibiofilm capacities compared to raw extracts. Using RP-UHPLC-PDA-MS, caffeic acid and rosmarinic acid were identified in IVDV-treated leaves. IVDV can be implemented as an innovative treatment applied prior to extraction to boost the recovery of biomolecules from plant matrices., Competing Interests: 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., (© 2024 The Authors.)

Extraction of polyphenols from Centranthus longiflorus stems was conducted using ultrasound and infrared Ired-Irrad ® extract obtained under the optimal conditions: 55 °C, 127 min, 48% ( Ired-Irrad ® extract obtained under the optimal conditions: 55 °C, 127 min, 48% ( v / v ) ethanol. Biological activities (antioxidant, antibacterial and antibiofilm) of the three extracts were assessed. All C . longiflorus stems extracts showed limited antibacterial effects regardless of the extraction method (MIC = 50 mg/mL), whereas Ired-Irrad ® extract exhibited the highest biofilm eradication and prevention capacities (93% against Escherichia coli and 97% against Staphylococcus epidermidis , respectively). This bioactivity is likely related to abundant caffeoylquinic acid and quercetin rutinoside, as identified by RP-UHPLC-PDA-MS analysis. The results obtained further promote the effectiveness of Ired-Irrad ® as a highly flexible and cost-efficient extraction technique.

Focus group discussions (FGDs) and individual interviews (IIs) with community members are common methods used in evaluations of all kinds of projects, including those in international development. As resources are often limited, evaluators must carefully choose methods that yield the best information for their particular program. A concern with FGDs and IIs is how well they elicit information on potentially sensitive topics; very little is known about differences in disclosure by methodology in the domain of justice. Using FGDs (n = 16) and IIs (n = 46) from a USAID project in Haiti, we systematically coded responses based on a shared elicitation guide around access to and engagement with the formal and informal justice systems and performed thematic and statistical comparisons across the two methods. We introduce the continuous thought as the novel standard unit for statistical comparison. Participants in IIs were statistically more likely to provide themes relevant to genderbased violence. Importantly, sensitive themes extracted in IIs (e.g., related to sexual violence, economic dimensions, and restorative justice) did not emerge in FGDs. Given these results and other limitations to the FGD, prioritizing interviews over focus group modalities may be appropriate to guide targeted, effective programming on justice or other socially sensitive topics., Competing Interests: Declaration of interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Grape seeds are the wineries' main by-products, and their disposal causes ecological and environmental problems. In this study seeds from the pomace waste of autochthonous grape varieties from Lebanon, Obeidi (white variety) and Asswad Karech (red variety) were used for a multi-step biomass fractionation. For the first step, a lipid extraction was performed, and the obtained yield was 12.33% ( w / w ) for Obeidi and 13.04% ( w / w ) for Asswad Karech. For the second step, polyphenols' recovery from the defatted seeds was carried out, resulting in 12.0% ( w / w ) for Obeidi and 6.6% ( w / w ) for Asswad Karech, with Obeidi's extract having the highest total phenolic content (333.1 ± 1.6 mg GAE/g dry matter) and antioxidant activity (662.17 ± 0.01 µg/mL of Trolox equivalent). In the third step, the defatted and dephenolized seeds were subsequently extracted under alkaline conditions and the proteins were isoelectric precipitated. The recovered protein extract was 3.90% ( w / w ) for Obeidi and 4.11% ( w / w ) for Asswad Karech seeds, with Asswad Karech's extract having the highest protein content (64 ± 0.2 mg protein/g dry matter). The remaining exhausted residue can be valorized in cosmetic scrubs formulations as a replacement for plastic microbeads. The designed zero-waste approach multi-step biomass fractionation has the potential to improve the valorization of the side products (grape seeds) of these two Lebanese autochthonous grape varieties.

(1) Background: Eryngium creticum is a plant medicinally valued, and used in pharmacopeia to treat various diseases. No previous studies have been reported on E. creticum leaf extracts using an IR-assisted technique; thus, this study aimed to intensify polyphenol extraction using Ired-Irrad ® , comparing it to the conventional water bath (WB) method. (2) Methods: Optimization of polyphenol extraction from E. creticum leaves was conducted using Response Surface Methodology. Ired-Irrad ® was used and compared to the WB method. The biological activities (antiradical, antioxidant, antibacterial, and antibiofilm) of both extracts were assessed. UHPLC analysis was performed to analyze the phytochemical profile of both extracts. (3) Results: Under optimal conditions, IR improved the polyphenol extraction yield by 1.7 times, while lowering ethanol consumption by 1.5 times. Regarding the antibacterial activity, both WB and IR E. creticum leaf extracts exhibited the highest antibacterial activity against Staphylococcus epidermidis . The maximum biofilm prevention capacity was also noticed against S. epidermidis . UHPLC-MS analysis quantified two major phenolic compounds in both extracts: rutin and sinapic acid. (4) Conclusions: Ired-Irrad ® technology proved to be an effective technique in intensifying polyphenol recovery, while preserving their quantity and quality.

Glioblastoma multiforme is a type of brain cancer associated with a very low survival rate since a large number of cancer cells remain infiltrated in the brain despite the treatments currently available. This work presents a macroporous hydrogel trap, destined to be implanted in the surgical cavity following tumor resection and designed to attract and retain cancer cells, in order to eliminate them afterward with a lethal dose of stereotactic radiotherapy. The biocompatible hydrogel formulation comprises sodium alginate (SA) and chitosan (CHI) bearing complementary electrostatic charges and stabilizing the gels in saline and cell culture media, as compared to pristine SA gels. The highly controlled and interconnected porosity, characterized by X-ray microCT, yields mechanical properties comparable to those of brain tissues and allows F98 glioblastoma cells to penetrate the gels within the entire volume, as confirmed by fluorescence microscopy. The addition of a grafted -RGD peptide on SA, combined with CHI, significantly enhances the adhesion and retention of F98 cells within the gels. Overall, the best compromise between low proliferation and a high level of accumulation and retention of F98 cells was obtained with the hydrogel formulated with 1% SA and 0.2% CHI, without the -RGD adhesion peptide.

Objectives: Appropriate management of chronic rhinosinusitis (CRS) among patients with cystic fibrosis (CF) is important in improving quality of life. Otolaryngologists play a critical role in reducing CRS symptom burden. This study seeks to evaluate the role of patient-reported quality-of-life measures in guiding interventions for CF-related sinus disease., Methods: We performed a prospective, cross-sectional study of 105 patients presenting to a CF-accredited clinic between July and September 2018. Demographic data and sinus surgery history were collected, in addition to Sino-Nasal Outcome Test (SNOT-22) and Questionnaire of Olfactory Disorders (QOD-NS) scores. Statistical analysis was conducted using correlation and non-parametric Mann-Whitney U tests., Results: Baseline well-care visits accounted for 71.4% of all clinical evaluations. Prior otolaryngology intervention was noted in 69 (66%) patients, where the majority of these patients (63/69; 91%) underwent endoscopic sinus surgery (ESS). Patients with a history of otolaryngology intervention had an average SNOT-22 score of 33.2 (SD = 20.6) compared to 24.9 (SD = 18.5) for patients without prior intervention ( P  = .048). The average QOD-NS score was 5.5 (SD = 6.4) among patients referred to otolaryngologists and 3.1 (SD = 5.7) for non-referred patients ( P  = .012). SNOT-22 and QOD-NS scores were modestly correlated ( R of .43)., Conclusion: CF patients with symptoms resulting in worse quality-of-life assessments were more likely to have established coordinated care with an otolaryngologist. Further validation of the utility of SNOT-22 and QOD-NS questionnaires as care coordination metrics is necessary in the CF population.

Background: Historically sinonasal malignancies were always addressed via open craniofacial surgery for an oncologic resection. Increasingly esthesioneuroblastomas are excised using an exclusively endoscopic approach, however, the rarity of this disease limits the availability of long-term and large scale outcomes data., Objective: The primary objective is to evaluate the treatment modalities used and the overall survival of patients with esthesioneuroblastoma managed with exclusively endoscopic surgery., Methods: In accordance with PRISMA guidelines, PubMed was queried to identify studies describing outcomes associated with endoscopic management of esthesioneuroblastomas., Results: Forty-four out of 2462 articles met inclusion criteria, totaling 399 patients with esthesioneuroblastoma treated with an exclusively endoscopic approach. Seventy-two patients (18.0%) received adjuvant chemotherapy and 331 patients (83.0%) received postoperative radiation therapy. The average age was 50.6 years old (range 6-83). Of the 399 patients, 57 (16.6%) were Kadish stage A, 121 (35.2%) were Kadish stage B, 145 (42.2%) were Kadish stage C, and 21 (6.1%) were Kadish stage D. Pooled analysis demonstrated that 66.0% of patients had Hyams histologic Grade Ⅰ or Ⅱ, while 34.0% of patients had Grade Ⅲ or Ⅳ disease. Negative surgical margins were achieved in 86.9% of patients, and recurrence was identified in 10.3% of patients. Of those with 5-year follow-up, reported overall survival was 91.1%., Conclusion: Exclusively endoscopic surgery for esthesioneuroblastoma is performed for a wide range of disease stages and grades, and the majority of these patients are also treated with adjuvant chemotherapy or radiation therapy. Reported overall recurrence rate is 10.3% and 5-year survival is 91.1%., Competing Interests: The authors declare no conflicts of interest., (© 2022 The Authors. World Journal of Otorhinolaryngology ‐ Head and Neck Surgery published by John Wiley & Sons, Ltd on behalf of Chinese Medical Association.)

Objective/hypothesis: The aim of this study is to assess the ethnic and racial demographics of patients enrolled in prospective chronic rhinosinusitis (CRS) studies relative to the corresponding geographic demographics of the United States (U.S.) census data., Study Design: Systematic Review and Population analysis., Methods: A systematic review was performed to identify CRS clinical trials, conducted in the U.S. and published between 2010 and 2020 in which patients were prospectively enrolled. Pooled racial and ethnicity data were compared to national and corresponding regional census data., Results: Eighty-three studies were included, comprising 12,027 patients. 50.4% were male and the average age was 49.2 years. 8,810 patients underwent a surgical procedure. Of the 12,027 patients, 81.67% were identified as White, 5.35% as Black, 1.27% as Asian, 0.02% as Pacific Islander, 0.12% as American Indian, and 11.57% were classified as Other. The racial and ethnic composition of the pooled study population differs significantly from the national U.S. census data with the underrepresentation of each minority population (P ≤ .0002). Regional sub-analyses yield variable results. In the Northeast and West, there was an underrepresentation of all minority populations. In the South and Midwest, Black enrollment was similar to the U.S. census data, while all other minorities were underrepresented., Conclusions: The racial and ethnic composition of patients enrolled in prospective CRS clinical trials differs significantly from the demographics of the U.S., Population: The generalizability and external validity of findings derived from studies comprised of demographically mismatched populations has not been established. Future efforts to enroll more representative populations should be emphasized by the research community, funding bodies, and editorial boards., Level of Evidence: NA Laryngoscope, 131:1722-1728, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Craniopharyngiomas (CP) are suprasellar tumors that can grow into vital nearby structures and thus cause significant visual, endocrine, and hypothalamic dysfunction. Debate persists as to the optimal treatment strategy for these benign lesions, particularly with regards to the extent of surgical resection. The goals of tumor resection are to eliminate the compressive effect of the tumor on surrounding structures and minimize recurrence. It remains unclear whether a gross total resection (GTR) or subtotal resection (STR) with adjuvant therapy confers a better prognosis. Chemotherapy and radiation therapy (RT) have been explored as both neoadjuvant and adjuvant treatments to decrease tumor burden and prevent recurrence. The objective of this paper is to review the risks and benefits of GTR versus STR, specifically with regard to risk of recurrence and postoperative morbidity. Aggregated data suggest that STR monotherapy is associated with higher rates of recurrence relative to GTR (50.6% ± 22.1% vs 20.2% ± 13.5%), while STR combined with RT leads to recurrence rates similar to GTR. However, both GTR and RT are independently associated with higher rates of comorbidities including panhypopituitarism, diabetes insipidus, and visual deficits. The treatment strategy for CPs should ultimately be tailored to each patient's individual tumor characteristics, risk, symptoms, and therapeutic goals., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Rosmarinus officinalis is an evergreen aromatic plant with important commercial interest as it contains numerous essential oils (composed of terpenoid compounds) and phenolic constituents (natural antioxidant compounds). This work aims at evaluating the concomitant effects of different inorganic and organic fertilization treatments and the subsequent increases in soil nutrient availability on terpenoids and other carbon-based secondary metabolites, e.g., flavonoids and phenolic compounds, in Rosmarinus officinalis leaves. The results showed that, as expected, the structural carbohydrate content (lignocellulosic compounds) in stems was higher in fertilized plants than in controls. Additionally, positive correlations were observed of the absolute amounts of total terpenoids and some single terpenoid compounds with N or P contents in leaves. On the contrary, the phenolic and flavonoid concentrations in all the rosemary plant parts were lower with the fertilization treatments. Indeed, negative correlations between the phenolic compounds (and flavonoids) and N in rosemary leaves were also found. Overall, the results suggest that the terpenoid production's response to fertilization was due to N, which is essential for protein synthesis and terpene synthase activity, and to P, which is necessary for the synthesis of both terpenoid precursors and ATP and NADPH, also needed for terpenoid synthesis. On the other hand, the basis for the fertilization's effects on the production of phenolic compounds is the direct nitrogen trade-off between growth and the shikimic acid pathway by which phenolics compounds are synthesized.

Background: In cystic fibrosis (CF), the relationship between chronic rhinosinusitis (CRS) and pulmonary disease is poorly understood. The purpose of this study was to evaluate the relationship between scores on the 22-item Sino-Nasal Outcome Test (SNOT-22) and CF Questionnaire-revised for adolescents and adults over 14 (CFQ-R 14+), and pulmonary function tests in 2 cohorts of CF patients: those at their baseline health and those with a pulmonary exacerbation., Methods: Patients >18 years old seen in a Cystic Fibrosis Foundation-accredited clinic completed the SNOT-22 and CFQ-R 14+ instruments. Patients presenting for routine care represented the baseline cohort. Patients diagnosed with a pulmonary exacerbation represented the exacerbation cohort. Average SNOT-22 and CFQ-R 14+ scores for both groups were compared using a 2-sample t test, and correlation coefficient was calculated., Results: One hundred three patients were enrolled over 3 months (30 exacerbations and 73 baseline). Patients' mean age was 32 years (56% female and 44% male). Average SNOT-22 and CFQ-R 14+ scores were significantly worse for exacerbation patients (p = 0.001 and p = 0.0003, respectively). Percent predicted forced expiratory volume in 1 second and forced vital capacity were both higher for baseline patients (p = 0.002 and p = 0.001, respectively). Average SNOT-22 score for all patients was worse than the average score for non-CF, non-CRS patients., Conclusion: CF patients with pulmonary exacerbations have worse SNOT-22 and CFQ-R 14+ scores than CF patients at their baseline health. This finding suggests a temporal relationship between sinonasal and pulmonary quality of life, and that worsening of both is associated with reduced pulmonary function., (© 2019 ARS-AAOA, LLC.)

Introduction: The purpose of this randomized clinical trial was to evaluate healing after endodontic microsurgery (EMS) using mineral trioxide aggregate (MTA) versus EndoSequence root repair material (RRM; Brasseler, Savannah, GA) as root-end filling materials., Methods: Two hundred forty-three teeth with persistent or recurrent apical periodontitis were randomly assigned to either the MTA or RRM group. EMS was performed, and follow-up visits with clinical and radiographic investigation were scheduled at 6, 12, and 24 months with follow-up cone-beam computed tomographic (CBCT) imaging after 12 months., Results: One hundred twenty teeth with an average follow-up of 15 months were evaluated. The overall success rate was 93.3% for periapical (PA) evaluation and 85% for CBCT evaluation. The RRM group exhibited 92% and 84% success rates as assessed on PA and CBCT imaging, respectively. The MTA group exhibited 94.7% and 86% success rates as assessed on PA and CBCT imaging, respectively. No significant difference was observed between the 2 groups. Microsurgical classification, root canal filling quality, root-end filling material depth, and root fracture were found to be significant outcome predictors., Conclusions: EMS is a predictable procedure with successful outcome both 2-dimensional and 3-dimensional radiographic evaluation when RRM or MTA was used as the root-end filling material., (Copyright © 2019. Published by Elsevier Inc.)

Background: Respiratory epithelial adenomatoid hamartoma (REAH) is a recently classified histopathologic diagnosis often identified incidentally following endoscopic sinus surgery (ESS) for presumed chronic rhinosinusitis. Limited data exist defining preoperative imaging features and surgical outcomes. The purpose of this study is to examine characteristic imaging findings of REAH and postoperative olfactory and recurrence outcomes., Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines on articles published from 1995 to present. PubMed, EMBASE, and Ovid MEDLINE databases were queried for studies pertinent to imaging findings of REAH and surgical outcomes. Quality of articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS)., Results: A total of 294 articles were identified, with 15 meeting inclusion criteria. Seven articles assessed both imaging findings and surgical outcomes. Three articles focused exclusively on imaging, whereas 5 examined surgical outcomes. Olfactory cleft (OC) widening greater than 10 mm on computed tomography (CT) was characteristic of REAH. A total of 441 patients with REAH were included; 221 patients (50.1%) had concurrent nasal polyposis, whereas 154 patients (34.9%) had isolated REAH. Surgical intervention ranged from simple excision to complete ESS. Sixty-five percent (65%) of patients reported improved olfaction; 4.1% of patients recurred with follow-up ranging from 4 months to 5 years., Conclusion: A widened OC may suggest the presence of REAH. This disease process has been identified in patients with nasal polyposis or encountered as an isolated lesion. Targeted surgery may result in improved olfaction and a low likelihood of recurrence, though long-term prospective studies are necessary., (© 2019 ARS-AAOA, LLC.)

Cystic fibrosis patients frequently develop chronic rhinosinusitis as a result of their propensity to form inspissated mucus and impairment of mucociliary clearance. They exhibit variable symptom burden even in the setting of positive radiographic and endoscopic findings. Current evidence suggests a positive effect of managing sinonasal disease on pulmonary health. Topical antimicrobial and mucolytic therapies are frequently required to manage the disease with surgery reserved for refractory cases. Endoscopic sinus surgery has been demonstrated to be safe and efficacious in controlling symptoms of chronic rhinosinusitis in patients with comorbid cystic fibrosis. However, the impact of surgery on pulmonary health remains an active area of investigation. In addition, a growing body of research has suggested a more extended surgical approach creating large sinonasal cavities with gravity-dependent drainage pathways, followed by adjuvant medical therapies, as an ideal strategy to optimally control disease and prevent pulmonary exacerbations. In this manuscript, we provide an up-to-date review of current evidence in the surgical management of chronic rhinosinusitis in cystic fibrosis patients.

Microalgae are increasingly considered as sources of renewable feedstocks for industrial production, and microalgae production now focuses on the multiproduct microalgal biorefinery. However, such a biorefinery presents several bottlenecks that are mainly associated with downstream processes. This reduced downstream efficiency results from unsolved problems related to the culture strategy for the accumulation of different products - the protein versus lipid dilemma - and the dilute nature of the microalgal culture. We identify new trends and propose promising solutions for realizing microalgal biorefineries at industrial scale. New perspectives and challenges are identified in protein properties and in the integration and cooptimization of culture and downstream processes., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Chronic rhinosinusitis (CRS) is nearly ubiquitous in patients with cystic fibrosis (CF). CF CRS is a challenging entity to define, diagnose, and treat, as patients often have severe refractory sinus disease in addition to complex medical comorbidities. The purpose of this article is to review the literature on the medical management of CF CRS and determine how to best identify, diagnose, and manage CF CRS. Ultimately, the treatment of these patients requires a multi-disciplinary approach involving the pulmonologist and otolaryngologist.

Purpose: NSAIDs and analgesic drugs are used intra-articularly after knee arthroscopy for pain relief. However, synovial effusion is still a common cause of delayed physical therapy. The aim of this study was to demonstrate the beneficial effect of intra-articular injection of Tenoxicam on knee effusion after arthroscopy., Method: This was a prospective non-randomized study on 134 patients with a mean age of 36.7 years. Knee arthroscopy on a day-case basis was performed; normal saline was used for irrigation. At the end of the procedure, fluid was aspirated from the knee joint and 20 ml of Tenoxicam diluted with 20 ml of 0.9% normal saline was injected into the knee five minutes before deflation of limb tourniquet. The same surgeon performed clinical examination for knee effusion 14 days postoperatively., Results: Encountered pathologies included meniscal injury, degenerative arthropathy, synovial plica and ACL rupture. Knee effusion developed in 15.7% of the patients, particularly in those with degenerative arthropathy (p = 0.006) and meniscal lesions (p = 0.06)., Conclusion: Intra-articular Tenoxicam is a simple method for the prevention of postoperative knee effusion. Degenerative arthropathy and meniscal lesions are major risk factors for post arthroscopy knee effusion.

Pathogen transmission cycles require many steps: initial colonization, growth and persistence, shedding, and transmission to new hosts. Alterations in the membrane components of the bacteria, including lipid A, the membrane anchor of lipopolysaccharide, could affect any of these steps via its structural role protecting bacteria from host innate immune defenses, including antimicrobial peptides and signaling through Toll-like receptor 4 (TLR4). To date, lipid A has been shown to affect only the within-host dynamics of infection, not the between-host dynamics of transmission. Here, we investigate the effects of lipid A modification in a mouse infection and transmission model. Disruption of the Bordetella bronchiseptica locus (BB4268) revealed that ArnT is required for addition of glucosamine (GlcN) to B. bronchiseptica lipid A. ArnT modification of lipid A did not change its TLR4 agonist activity in J774 cells, but deleting arnT decreased resistance to killing by cationic antimicrobial peptides, such as polymyxin B and β-defensins. In the standard infection model, mutation of arnT did not affect B. bronchiseptica colonization, growth, persistence throughout the respiratory tract, recruitment of neutrophils to the nasal cavity, or shedding of the pathogen. However, the number of bacteria necessary to colonize a host (50% infective dose [ID50]) was 5-fold higher for the arnT mutant. Furthermore, the arnT mutant was defective in transmission between hosts. These results reveal novel functions of the ArnT lipid A modification and highlight the sensitivity of low-dose infections and transmission experiments for illuminating aspects of infectious diseases between hosts. Factors such as ArnT can have important effects on the burden of disease and are potential targets for interventions that can interrupt transmission.

Objective: Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices., Methods: ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program (www.ed.bmc.org/sbirt). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure., Results: Among 402 ED providers, 74% reported < 10 hours of prior professional alcohol-related education and 78% had < 2 hours exposure in the previous year. At 3-month follow-up, scores for self-reported confidence in ability, responsibility to intervene, and actual utilization of SBIRT skills all improved significantly over baseline. Gains decreased somewhat at 12 months, but remained above baseline. Length of time in practice was positively associated with SBIRT utilization, controlling for gender, race and type of profession. Persistent barriers included time limitations and lack of referral resources., Conclusions: ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.