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Assessment of the size and function of a functional single ventricle (FSV) is a key element in the management of patients after the Fontan procedure. Measurement variability of ventricular mass, volume, and ejection fraction (EF) among observers by echocardiography and cardiac magnetic resonance imaging (CMR) and their reproducibility among readers in these patients have not been described. From the 546 patients enrolled in the Pediatric Heart Network Fontan Cross-Sectional Study (mean age 11.9 +/- 3.4 years), 100 echocardiograms and 50 CMR studies were assessed for measurement reproducibility; 124 subjects with paired studies were selected for comparison between modalities. Interobserver agreement for qualitative grading of ventricular function by echocardiography was modest for left ventricular (LV) morphology (kappa = 0.42) and weak for right ventricular (RV) morphology (kappa = 0.12). For quantitative assessment, high intraclass correlation coefficients were found for echocardiographic interobserver agreement (LV 0.87 to 0.92, RV 0.82 to 0.85) of systolic and diastolic volumes, respectively. In contrast, intraclass correlation coefficients for LV and RV mass were moderate (LV 0.78, RV 0.72). The corresponding intraclass correlation coefficients by CMR were high (LV 0.96, RV 0.85). Volumes by echocardiography averaged 70% of CMR values. Interobserver reproducibility for the EF was similar for the 2 modalities. Although the absolute mean difference between modalities for the EF was small (<2%), 95% limits of agreement were wide. In conclusion, agreement between observers of qualitative FSV function by echocardiography is modest. Measurements of FSV volume by 2-dimensional echocardiography underestimate CMR measurements, but their reproducibility is high. Echocardiographic and CMR measurements of FSV EF demonstrate similar interobserver reproducibility, whereas measurements of FSV mass and LV diastolic volume are more reproducible by CMR. [ABSTRACT FROM AUTHOR]

Objectives: Posterior fossa brain arteriovenous malformations (PFbAVMs) are rare lesions. Management is complicated by eloquence of adjacent neurological structures, multimodality treatment is often necessary, and obliteration is not always possible. We describe a 15-year experience in the management of posterior fossa brain AVMs with a focus on clinical outcome.Methods: From 1989 to 2004, prospectively collected information on 106 patients with diagnosis of a PFbAVMs was obtained. Clinical and angioarchitectural characteristics, management options and complications are described and reviewed to evaluate their impact on final outcome as measured by the Modified Rankin Score (mRS).Results: Ninety-eight patients were followed for an average of 3.3 years (1-14.6). The male-to-female ratio was 1:1. Ninety-five out of 98 patients (96.9%) were symptomatic at presentation, with 61 (62.2%) intracranial haemorrhages. Sixty-two patients were treated (46 cerebellar, 16 brainstem). Ten haemorrhages occurred in follow-up (4.1%/year). The mRS was obtained in 62 patients and was classified as low (good, mRSor=3). Haemorrhage was the only predictor of poor mRS at presentation (p = 0.0229). A poor clinical outcome was correlated with the presence of AA (p = 0.0276), a poor initial mRS (p<0.0001) and the number of treatments needed (p = 0.0434). Patients were significantly more likely to improve than to deteriorate over time (p = 0.0201).Conclusion: The final clinical outcome in PFbAVMs relates directly with the presence of associated aneurysms, number of treatments needed to obliterate the AVM and mRS at presentation. Despite the fact that patients tend to improve after brain AVM haemorrhage, the relationship of MRS at presentation and final outcome suggests that an expedited, more definitive treatment is probably a better choice, especially in patients with good grades after the initial bleeding. [ABSTRACT FROM AUTHOR]

Purpose.The purpose of this study was to investigate the determinants and correlates of return to productivity (RTP) defined here as return to paid employment and/or school four years following traumatic brain injury (TBI). Method.Participants included 46 people with TBI, part of a prospective, cohort study, and 14 friend/family member controls all employed and/or in school at time of injury or inception into the study. Variables were selected for investigation based on two models of recovery. Demographic and injury severity data including time to recover free recall were collected at time of injury, on admission to a trauma unit. Data on other variables (neuropsychological, psychological, physical, spiritual, environmental) were collected concurrent with productivity status at a mean of 4.3 years post-TBI. Results.Time to recover free recall (measured acutely), neuropsychological status, pain severity, depression, and the use of maladaptive coping behaviours were all related to productivity status (p < 0.05). When these variables were entered into exploratory, planned hierarchical logistic regression models time to free recall, pain, and maladaptive coping remained in the models with depression only dropping out because of the high correlation with pain (r > 0.80). Conclusions.Injury severity (time to free recall), physical status (pain), and psychological status (depression, coping) are important to understanding differences in productivity outcomes. Addressing pain, depression and coping in rehabilitation programs may have a positive impact on outcomes. [ABSTRACT FROM AUTHOR]

This article conveys the history of establishing the health education program, the current delivery model, and the lessons learned from the process including practical applications for the practice setting. The evolution of health education in Kaiser Permanente reflects its history and describes the continued need for and relevance of health education. The era of the patient as the passive recipient of care is being replaced by an emphasis on the patient as a partner in care. Every health education program emphasizes shared responsibility and encourages active participation by the patient, family, and other social supports. Multiple modalities of self-care and/or self-management resources and services increase member access to needed health education, health promotion, and prevention information that facilitate lifestyle behavior changes for better health and simultaneously improve organizational clinical outcome measures. Ongoing efforts align health education with regulatory requirements and the organization's commitment to culturally and linguistically appropriate patient information. [ABSTRACT FROM AUTHOR]

A family is described in which 5 of 9 living children were found to have restrictive cardiomyopathy associated with skeletal muscle and orthopedic abnormalities. In the absence of another identifiable etiology, a genetic cause for restrictive cardiomyopathy in this family is probable. Consistent with the poor prognosis encountered for children with restrictive cardiomyopathy, 2 children in this family died, whereas a third was symptomatic by age 3 years. [ABSTRACT FROM AUTHOR]

Cup choice, a properly selected and prepared patient, and a knowledgeable surgeon all are of great importance in maximizing the likelihood of success and minimizing risks associated with vacuum extraction. [ABSTRACT FROM AUTHOR]

Will this new, less invasive alternative to hysterectomy and myomectomy become an accepted option for treating fibroids? If so, you'll need to know how to counsel patients on its pros and cons--and to meet the challenge of postprocedural complications like postembolization syndrome. [ABSTRACT FROM AUTHOR]

A prospective study was completed on 25 baseball players with medial side elbow pain. They were evaluated preoperatively with both computed tomography arthrogram and magnetic resonance imaging examinations of the elbow to assess the ulnar collateral ligament. At surgery, 16 of 25 patients had an abnormal ulnar collateral ligament and 9 patients had a normal ulnar collateral ligament. The computed tomography arthrogram detected abnormalities in 12 of the 14 patients with ulnar collateral ligament tearing (sensitivity, 86%). The magnetic resonance imaging scan indicated abnormalities in 8 of 14 patients (sensitivity, 57%). The specificity of the computed tomography arthrogram was 91% and the magnetic resonance imaging was 100%. A newly described 'T-sign' was seen on the computed tomography arthrogram in the patients with an undersurface tear of the ulnar collateral ligament. This represented the dye leaking around the detachment of the ulnar collateral ligament from its bony insertion but remaining contained within the intact superficial layer of the ulnar collateral ligament and capsule. Both the computed tomography arthrogram and the magnetic resonance imaging scan were accurate in diagnosing a complete tear of the ulnar collateral ligament preoperatively in all cases. The main advantage of the computed tomography arthrogram was in evaluating the partial undersurface tear. [ABSTRACT FROM AUTHOR]

Magnetic resonance-guided, focused ultrasound thalamotomy is a neurosurgical treatment for refractory essential tremor. This study examined cognitive outcomes following unilateral magnetic resonance-guided, focused ultrasound thalamotomy, targeting the ventral intermediate nucleus of the thalamus for essential tremor. The research was conducted at two sites: Sunnybrook Research Institute in Toronto, Canada, and West Virginia University School of Medicine Rockefeller Neuroscience Institute in West Virginia, USA. The study focused on cognitive changes at both the group and individual levels. Patients with refractory essential tremor completed cognitive testing before and after magnetic resonance-guided, focused ultrasound thalamotomy at both sites. The cognitive testing assessed domains of attention, processing speed, working memory, executive function, language and learning/memory. Postoperative changes in cognition were examined using paired t -tests and Wilcoxon signed-rank tests, as appropriate. Reliable change indices were calculated to assess clinically significant changes at the individual level. A total of 33 patients from Toronto and 22 patients from West Virginia were included. Following magnetic resonance-guided, focused ultrasound thalamotomy, there was a significant reduction in tremor severity in both cohorts. At the group level, there were no significant declines in postoperative cognitive performance in either cohort. The reliable change analyses revealed some variability at the individual level, with most patients maintaining stable performance or showing improvement. Taken together, the results from these two independent cohorts demonstrate that unilateral magnetic resonance-guided, focused ultrasound thalamotomy significantly reduces tremor severity without negatively impacting cognition at both the group and individual levels, highlighting the cognitive safety of magnetic resonance-guided focused ultrasound thalamotomy for essential tremor., Competing Interests: The main authors do not have competing interests., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Background: There remains high variability in clinical outcomes when the same magnetic resonance image-guided focused ultrasound (MRgFUS) thalamotomy target is used for both essential tremor (ET) and tremor-dominant Parkinson's disease (TDPD)., Objective: Our goal is to refine the MRgFUS thalamotomy target for TDPD versus ET., Methods: We retrospectively performed voxel-wise efficacy and structural connectivity mapping using 3-12-month post-procedure hand tremor scores for a multicenter cohort of 32 TDPD patients and a previously published cohort of 79 ET patients, and 24-hour T1-weighted post-MRgFUS brain images. We validated our findings using Unified Parkinson's Disease Rating Scale part III scores for an independent cohort of nine TDPD patients., Results: The post-MRgFUS clinical improvements were 45.9% ± 35.9%, 55.5% ± 36%, and 46.1% ± 18.6% for ET, multicenter TDPD and validation TDPD cohorts, respectively. The TDPD and ET efficacy maps differed significantly (p permute  < 0.05), with peak TDPD improvement (87%) at x = -13.5; y = -15.0; z = 1.5, ~3.5 mm anterior and 3 mm dorsal to the ET target. Discriminative connectivity projections were to the motor and premotor regions in TDPD, and to the motor and somatosensory regions in ET. The disorder-specific voxel-wise efficacy map could be used to estimate outcome in TDPD patients with high accuracy (R = 0.8; R 2  = 0.64; P < 0.0001). The model was validated using the independent cohort of nine TDPD patients (R = 0.73; R 2  = 0.53; P = 0.025-voxel analysis)., Conclusion: We demonstrated that the most effective MRgFUS thalamotomy target in TDPD is in the ventral intermediate nucleus/ventralis oralis posterior border region. This finding offers new insights into the thalamic regions instrumental in tremor control, with pivotal implications for improving treatment outcomes. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society., (© 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.)

Background: Given high rates of early complications and non-reversibility, refined targeting is necessitated for magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for essential tremor (ET). Selection of lesion location can be informed by considering optimal stimulation area from deep brain stimulation (DBS)., Methods: 118 patients with ET who received DBS (39) or MRgFUS (79) of the ventral intermediate nucleus (VIM) underwent stimulation/lesion mapping, probabilistic mapping of clinical efficacy and normative structural connectivity analysis. The efficacy maps were compared, which depict the relationship between stimulation/lesion location and clinical outcome., Results: Efficacy maps overlap around the VIM ventral border and encompass the dentato-rubro-thalamic tract. While the MRgFUS map extends inferiorly into the posterior subthalamic area, the DBS map spreads inside the VIM antero-superiorly., Conclusion: Comparing the efficacy maps of DBS and MRgFUS suggests a potential alternative location for lesioning, more antero-superiorly. This may reduce complications, without sacrificing efficacy, and individualise targeting., Trial Registration Number: NCT02252380., Competing Interests: Competing interests: AML is a consultant to Abbott, Boston Scientific, Insightec and Medtronic and Scientific Director at Functional Neuromodulation. SKK holds honoraria, speakers fees and/or indirect support Abbott/Boston/Medtronic. AF holds honoraria, speakers fees and/or indirect support Abbott/Boston/Medtronic., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Much is known about the biomechanical performance of various types of suture anchors commonly used for labral fixation in the shoulder; however, similar studies in the hip are less common. We sought to compare all-suture and polyether ether ketone small-diameter anchors in the setting of labral repair during hip arthroscopy, with and without acetabuloplasty. We hypothesized that the biomechanical properties of the all-suture group when compared to polyether ether ketone anchors would be similar amongst native acetabula and significantly less following acetabuloplasty and that pullout forces would be reduced in the anterior and inferior regions of the acetabulum compared to the superior region. Bone density was measured in nine matched pairs of fresh-frozen cadaveric acetabula in the superior, anterosuperior, and anterior regions. Acetabuloplasty was performed in all three regions, while the contralateral acetabulum was left in situ as a control. Suture anchors were placed such that one each of two different types was placed within each region. Specimens were tested in cyclic fatigue and loaded to failure. The all-suture group had significantly higher cyclic displacement compared to the polyether ether ketone, but there was no significant difference in ultimate load, regardless of acetabuloplasty. Amongst all non-resected specimens, the lowest bone density was observed consistently in the inferior region. Our results indicate that, with or without acetabuloplasty, a small-diameter polyether ether ketone anchor appears to be more stable than an all-suture anchor, which needs to be set first., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: All authors declare study sponsorship from Smith & Nephew in the form of direct funding as well as in-kind donation of cadaveric specimens. Dr. Emblom declares payments unrelated to the study from Arthrex for royalties, consulting, and other services. Dr. Walters declares payments unrelated to the study from Arthrex for non-consulting services. Dr. Ryan declares payments unrelated to the study from Arthrex for non-consulting services. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Emblom et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The marine ribbon worm genus Tetranemertes Chernyshev, 1992 currently includes three species: the type species T.antonina (Quatrefages, 1846) from the Mediterranean Sea, T.rubrolineata (Kirsteuer, 1965) from Madagascar, and T.hermaphroditica (Gibson, 1982) from Australia. Seven new species are described: T.bifrost sp. nov. , T.ocelata sp. nov. , T.majinbuui sp. nov. , and T.pastafariensis sp. nov. from the Caribbean Sea (Panamá), and three species, T.unistriata sp. nov. , T.paulayi sp. nov. , and T.arabica sp. nov. , from the Indo-West Pacific (Japan and Oman). As a result, an amended morphological diagnosis of the genus is offered. To improve nomenclatural stability, a neotype of Tetranemertesantonina is designated from the Mediterranean. The newly described species, each characterized by features of external appearance and stylet apparatus, as well as by DNA-barcodes, form a well-supported clade with T.antonina on a molecular phylogeny of monostiliferan hoplonemerteans based on partial sequences of COI, 16S rRNA, 18S rRNA, and 28S rRNA. Six of the seven newly described species, as well as T.rubrolineata , possess the unusual character of having a central stylet basis slightly bilobed to deeply forked posteriorly in fully grown individuals, a possible morphological synapomorphy of the genus. In addition, an undescribed species of Tetranemertes is reported from the Eastern Tropical Pacific (Panamá), increasing the total number of known species in the genus to eleven., Competing Interests: The authors have declared that no competing interests exist., (Irina Cherneva, Christina I. Ellison, Eduardo E. Zattara, Jon L. Norenburg, Megan L. Schwartz, Juan Junoy, Svetlana A. Maslakova.)

Aim: The genetic etiologies of cardiomyopathies and arrhythmias have not been fully elucidated. Materials & methods: Research findings from genome analyses in a cardiomyopathy and arrhythmia cohort were gathered. Gene-disease relationships from two databases were compared with patient phenotypes. A literature review was conducted for genes with limited evidence. Results: Of 43 genes with candidate findings from 18 cases, 23.3% of genes had never been curated, 15.0% were curated for cardiomyopathies, 16.7% for arrhythmias and 31.3% for other conditions. 25.5% of candidate findings were curated for the patient's specific phenotype with 11.8% having definitive evidence. MYH6 and TPCN1 were flagged for recuration. Conclusion: Findings from genome sequencing in disease cohorts may be useful to guide gene-curation efforts.

Tremor is a debilitating symptom that can lead to functional impairment. Pharmacotherapy is often successful, but up to 50% of patients are resistant to medications or cannot tolerate side effects. Thalamotomy to the ventral intermediate nucleus of the thalamus is a surgical intervention for refractory tremor. Thalamotomy surgeries include radiofrequency and incisionless procedures, such as Gamma Knife radiosurgery and magnetic resonance-guided focused ultrasound. Cognitive changes following thalamotomy have been inconsistently reported across studies. We performed a meta-analysis to summarize the impact of unilateral thalamotomy to the ventral intermediate nucleus of the thalamus across multiple cognitive domains. We searched MEDLINE, Embase Classic, Embase and EBM Reviews for relevant studies. Neuropsychological tests were categorized into seven cognitive domains: global cognition, verbal memory, non-verbal memory, executive function, phonemic fluency, semantic fluency and visuospatial processing. We calculated standardized mean differences as Hedges' g and 95% confidence intervals of the change between pre- and postoperative cognitive scores. Pooling of standardized mean differences across studies was performed using random-effects models. Risk of bias across studies and quality of evidence for each cognitive domain were assessed with the National Institute of Health quality assessment tool and the GRADEpro Guideline Development Tool, respectively. Of the 1251 records reviewed, eight studies met inclusion criteria. We included 193 patients with essential tremor, Parkinson's disease, or multiple sclerosis in the meta-analysis. There was a small significant decline in phonemic fluency [standardized mean difference = -0.29, 95% confidence interval: (-0.52, -0.05), P = 0.017] and a trend towards a decline in semantic fluency [standardized mean difference = -0.19, 95% confidence interval: (-0.40, 0.01), P = 0.056]. No postoperative changes were observed in the other cognitive domains ( P values >0.14). In secondary analyses, we restricted the analyses to studies using magnetic resonance-guided focused ultrasound given its growing popularity and more precise targeting. In those analyses, there was no evidence of cognitive decline across any domain ( P values >0.37). In terms of risk of bias, five studies were rated as 'good' and three studies were rated as 'fair'. According to GRADEpro guidelines, the certainty of the effect for all cognitive domains was low. This study provides evidence that unilateral thalamotomy to the ventral intermediate nucleus of the thalamus is relatively safe from a cognitive standpoint, however, there may be a small decline in verbal fluency. Magnetic resonance-guided focused ultrasound might have a more favourable postoperative cognitive profile compared with other thalamotomy techniques., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Background: MR-guided focused ultrasound (MRgFUS) thalamotomy has been shown to be a safe and effective treatment for essential tremor (ET)., Objective: To investigate the effects of MRgFUS in patients with ET with an emphasis on ipsilateral-hand and axial tremor subscores., Methods: Tremor scores and adverse effects of 100 patients treated between 2012 and 2018 were assessed at 1 week, 3, 12, and 24 months. A subgroup analysis of ipsilateral-hand tremor responders (defined as patients with ≥30% improvement at any time point) and non-responders was performed. Correlations and predictive factors for improvement were analysed. Weighted probabilistic maps of improvement were generated., Results: Significant improvement in axial, contralateral-hand and total tremor scores was observed at all study visits from baseline (p<0.0001). There was no significant improvement in ipsilateral subscores. A subset of patients (n=20) exhibited group-level ipsilateral-hand improvement that remained significant through all follow-ups (p<0.001). Multivariate regression analysis revealed that higher baseline scores predict better improvement in ipsilateral-hand and axial tremor. Probabilistic maps demonstrated that the lesion hotspot for axial improvement was situated more medially than that for contralateral improvement., Conclusion: MRgFUS significantly improved axial, contralateral-hand and total tremor scores. In a subset of patients, a consistent group-level treatment effect was observed for ipsilateral-hand tremor. While ipsilateral improvement seemed to be less directly related to lesion location, a spatial relationship between lesion location and axial and contralateral improvement was observed that proved consistent with the somatotopic organisation of the ventral intermediate nucleus., Trial Registration Numbers: NCT01932463, NCT01827904, and NCT02252380., Competing Interests: Competing interests: KY, GJBE, AB, JG, AML, LB, DG, RG, SXL, AZ, AV, MA, GD, MC, KH, NS and MLS report no disclosures relevant to the manuscript. CS has been receiving fellowship grants from Michael and AD Foundation and Turkish Neurosurgical Society. SEJ receives salary from General Electric. AML is scientific director for Functional Neuromodulation and a consultant to Medtronic, Abbott, Boston Scientific, Insightec and Focused Ultrasound Foundation. AF reports the following: consultancies from Abbvie, Medtronic, Boston Scientific, Sunovion, Chiesi Farmaceutici, UCB and Ipsen; membership in advisory boards of Abbvie, Boston Scientific and Ipsen; receiving honoraria from Abbvie, Medtronic, Boston Scientific, Sunovion, Chiesi farmaceutici, UCB and Ipsen; receiving grants from University of Toronto, Weston foundation, Abbvie, Medtronic and Boston Scientific., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of this study was to evaluate, at 4 and 5 years posttreatment, the long-term safety and efficacy of unilateral MRI-guided focused ultrasound (MRgFUS) thalamotomy for medication-refractory essential tremor in a cohort of patients from a prospective, controlled, multicenter clinical trial., Methods: Outcomes per the Clinical Rating Scale for Tremor (CRST), including postural tremor scores (CRST Part A), combined hand tremor/motor scores (CRST Parts A and B), and functional disability scores (CRST Part C), were measured by a qualified neurologist. The Quality of Life in Essential Tremor Questionnaire (QUEST) was used to assess quality of life. CRST and QUEST scores at 48 and 60 months post-MRgFUS were compared to those at baseline to assess treatment efficacy and durability. All adverse events (AEs) were reported., Results: Forty-five and 40 patients completed the 4- and 5-year follow-ups, respectively. CRST scores for postural tremor (Part A) for the treated hand remained significantly improved by 73.3% and 73.1% from baseline at both 48 and 60 months posttreatment, respectively (both p < 0.0001). Combined hand tremor/motor scores (Parts A and B) also improved by 49.5% and 40.4% (p < 0.0001) at each respective time point. Functional disability scores (Part C) increased slightly over time but remained significantly improved through the 5 years (p < 0.0001). Similarly, QUEST scores remained significantly improved from baseline at year 4 (p < 0.0001) and year 5 (p < 0.0003). All previously reported AEs remained mild or moderate, and no new AEs were reported., Conclusions: Unilateral MRgFUS thalamotomy demonstrates sustained and significant tremor improvement at 5 years with an overall improvement in quality-of-life measures and without any progressive or delayed complications. Clinical trial registration no.: NCT01827904 (ClinicalTrials.gov).

Objective: To describe a case of functional tremor occurring after a successful MR-guided focused ultrasound thalamotomy (MRgFUS) for essential tremor., Methods: A 71-year-old right-handed man with essential tremor was referred to us for consideration of deep brain stimulation surgery for worsening bilateral upper limb tremor after a successful left MRgFUS for essential tremor., Results: On clinical exam, signs compatible with a functional tremor were noted, including entertainability and suppressibility. Electrophysiological studies were consistent with essential tremor and superimposed tremor fulfilling the laboratory-supported criteria for functional tremor., Discussion: We describe the first reported case of a functional movement disorder occurring after successful MRgFUS procedure for essential tremor. Recognising this entity and its development after such therapeutic interventions is essential to avoid further unnecessary invasive therapies., Competing Interests: Competing interests: AML is consultant to Medtronic, Abbott, Boston Scientific and Insightec, and a Scientific Director at Functional Neuromodualtion. Other authors report no conflicts., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Biodiversity assessments are critical for setting conservation priorities, understanding ecosystem function and establishing a baseline to monitor change. Surveys of marine biodiversity that rely almost entirely on sampling adult organisms underestimate diversity because they tend to be limited to habitat types and individuals that can be easily surveyed. Many marine animals have planktonic larvae that can be sampled from the water column at shallow depths. This life stage often is overlooked in surveys but can be used to relatively rapidly document diversity, especially for the many species that are rare or live cryptically as adults. Using DNA barcode data from samples of nemertean worms collected in three biogeographical regions-Northeastern Pacific, the Caribbean Sea and Eastern Tropical Pacific-we found that most species were collected as either benthic adults or planktonic larvae but seldom in both stages. Randomization tests show that this deficit of operational taxonomic units collected as both adults and larvae is extremely unlikely if larvae and adults were drawn from the same pool of species. This effect persists even in well-studied faunas. These results suggest that sampling planktonic larvae offers access to a different subset of species and thus significantly increases estimates of biodiversity compared to sampling adults alone. Spanish abstract is available in the electronic supplementary material.

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection., Data Sources: We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website., Data Collection/extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users., Study Design: This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs., Principal Findings: The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries., Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection., (© 2021 Health Research and Educational Trust.)

Objective: Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes., Design: We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes., Setting and Participants: The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods., Methods: We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases., Results: NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices., Conclusions and Implications: This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

The Home Health Value-Based Purchasing Model (HHVBP) is a new Medicare model wherein home health agencies compete to achieve higher reimbursements by demonstrating improved value according to clinical and patient experience-related quality measures. Many measures used in HHVBP overlap with measures used in quality star ratings for home health agencies. Thus, improvements in quality measures used in HHVBP may also be reflected in changes in star ratings. However, it is unclear whether agencies competing in HHVBP improve their Centers for Medicare & Medicaid Services star ratings compared with those not competing. Using publicly available data from Centers for Medicare & Medicaid Services, we evaluated the effect of HHVBP on quality of patient care and patient experience composite star ratings over a 2-year period using a difference-in-differences analysis. We found evidence for a small, statistically significant increase in quality of patient care star ratings for agencies participating in HHVBP, and no effect on patient experience ratings.

To facilitate home health agency (HHA) selection, CMS released patient experience star ratings on the Home Health Compare website in January 2016. Our objective was to understand the relationship between patient experience and outcomes in HHAs. We utilized publicly reported data to evaluate the relationships among patient experience star ratings, summary quality of care star ratings (comprised primarily of outcome measures), and individual outcome measures for 4,249 HHAs. Results indicate a weak correlation between patient experience and quality stars ( r = .13, p < .001). The difference between the lowest and highest rated HHAs for patient experience is associated with only a half-star improvement in quality stars. The associations between patient experience and individual outcome measures varied, with functional outcomes most strongly associated with patient experience. Findings highlight the importance of reporting separate quality domains; however, conflicting ratings may complicate the HHA selection process and introduce misaligned incentives for HHAs.

Gene editing in C. elegans using plasmid-based CRISPR reagents requires microinjection of many animals to produce a single edit. Germline silencing of plasmid-borne Cas9 is a major cause of inefficient editing. Here, we present a set of C. elegans strains that constitutively express Cas9 in the germline from an integrated transgene. These strains markedly improve the success rate for plasmid-based CRISPR edits. For simple, short homology arm GFP insertions, 50-100% of injected animals typically produce edited progeny, depending on the target locus. Template-guided editing from an extrachromosomal array is maintained over multiple generations. We have built strains with the Cas9 transgene on multiple chromosomes. Additionally, each Cas9 locus also contains a heatshock-driven Cre recombinase for selectable marker removal and a bright fluorescence marker for easy outcrossing. These integrated Cas9 strains greatly reduce the workload for producing individual genome edits., Competing Interests: The authors have declared that no competing interests exist.

Problem: In March 2020, the novel coronavirus 2019 (COVID-19) became a global pandemic. Medical schools around the United States faced difficult decisions, temporarily suspending hospital-based clerkship rotations for medical students due to potential shortages of personal protective equipment and a need to social distance. This decision created a need for innovative, virtual learning opportunities to support undergraduate medical education., Approach: Educators at Yale School of Medicine developed a novel medical student curriculum converting high-fidelity, mannequin-based simulation into a fully online virtual telesimulation format. By using a virtual videoconferencing platform to deliver remote telesimulation as an immersive educational experience for widely dispersed students, this novel technology retains the experiential strengths of simulation-based learning while complying with needs for social distancing during the pandemic. The curriculum comprises simulated clinical scenarios that include live patient actors; facilitator interactions; and real-time assessment of vital signs, labs, and imaging. Each 90-minute session includes 2 sets of simulation scenarios and faculty-led teledebriefs. A team of 3 students performs the first scenario, while an additional team of 3 students observes. Teams reverse roles for the second scenario., Outcomes: The 6-week virtual telesimulation elective enrolled the maximum 48 medical students and covered core clinical clerkship content areas. Communication patterns within the virtual telesimulation format required more deliberate turn-taking than normal conversation. Using the chat function within the videoconferencing platform allowed teams to complete simultaneous tasks. A nurse confederate provided cues not available in the virtual telesimulation format., Next Steps: Rapid dissemination of this program, including online webinars and live demonstration sessions with student volunteers, supports the development of similar programs at other universities. Evaluation and process improvement efforts include planned qualitative evaluation of this new format to further understand and refine the learning experience. Future work is needed to evaluate clinical skill development in this educational modality., (Copyright © 2021 by the Association of American Medical Colleges.)

Objective: Focused ultrasound thalamotomy is an effective treatment for tremor; however, side effects may occur. The purpose of the present study was to investigate the spatial relationship between thalamotomies and specific sensory side effects and their functional connectivity with somatosensory cortex and relationship to the medial lemniscus (ML)., Methods: Sensory adverse effects were categorized into 4 groups based on the location of the disturbance: face/mouth/tongue numbness/paresthesia, hand-only paresthesia, hemibody/limb paresthesia, and dysgeusia. Then, areas of significant risk (ASRs) for each category were defined using voxel-wise mass univariate analysis and overlaid on corresponding odds ratio maps. The ASR associated with the maximum risk was used as a region of interest in a normative functional connectome to determine side effect-specific functional connectivity. Finally, each ASR was overlaid on the ML derived from normative template., Results: Of 103 patients, 17 developed sensory side effects after thalamotomy persisting 3 months after the procedures. Lesions producing sensory side effects extended posteriorly into the principle sensory nucleus of the thalamus or below the thalamus in the ML. The topography of sensory adverse effects followed the known somatotopy of the ML and the sensory nucleus. Functional connectivity patterns between each sensory-specific thalamic seed and the primary somatosensory areas supported the role of the middle insula in processing of gustatory information and in multisensory integration., Conclusions: Distinct regions in the sensory thalamus and its afferent connections rise to specific sensory disturbances. These findings demonstrate the relationship between the sensory thalamus, ML, and bilateral sensory cortical areas., (© 2021 American Academy of Neurology.)

Background: Transcranial magnetic resonance-guided focused ultrasound (TcMRgFUS) systems currently employ computed tomography (CT)-based aberration corrections, which may provide suboptimal trans-skull focusing., Objectives: The objective of this study was to evaluate a contrast agent microbubble imaging-based transcranial focusing method, echo-focusing (EF), during TcMRgFUS for essential tremor., Methods: A clinical trial of TcMRgFUS thalamotomy using EF for the treatment of essential tremor was conducted (NCT03935581; funded by InSightec [Tirat Carmel, Israel]). Patients (n = 12) were injected with Definity (Lantheus Medical Imaging, North Billerica, MA) microbubbles, and EF was performed using a research feature add-on to a commercial TcMRgFUS system (ExAblate Neuro, InSightec). Subablative thermal sonications carried out using (1) EF and (2) CT-based aberration corrections were compared via magnetic resonance thermometry, and the optimal focusing method for each patient was employed for TcMRgFUS thalamotomy., Results: EF aberration corrections provided increased sonication efficiency, decreased focal size, and equivalent targeting accuracy relative to CT-based focusing. EF aberration corrections were employed successfully for lesion formation in all 12 patients, 3 of whom had previously undergone unsuccessful TcMRgFUS thalamotomy via CT-based focusing. There were no adverse events related directly to the EF procedure., Conclusions: EF is feasible and appears safe during TcMRgFUS thalamotomy for essential tremor and improves on the trans-skull focal quality provided by existing CT-based focusing methods. © 2020 International Parkinson and Movement Disorder Society., (© 2020 International Parkinson and Movement Disorder Society.)

Background: MRI-guided focused ultrasound (MRgFUS) thalamotomy is a promising non-invasive treatment option for medication-resistant essential tremor. However, it has been associated with variable efficacy and a relatively high incidence of adverse effects., Objectives: To assess the evolution of radiological findings after MRgFUS thalamotomy and to evaluate their significance for clinical outcomes., Methods: Ninety-four patients who underwent MRgFUS between 2012 and 2017 were retrospectively evaluated. Lesion characteristics were assessed on routine MRI sequences, as well as with tractography. Relationships between imaging appearance, extent of white matter tract lesioning (59/94, on a 4-point scale) and clinical outcome were investigated. Recurrence was defined as >33% loss of tremor suppression at 3 months relative to day 7., Results: Acute lesions demonstrated blood products, surrounding oedema and peripheral diffusion restriction. The extent of dentatorubrothalamic tract (DRTT) lesioning was significantly associated with clinical improvement at 1 year (t=4.32, p=0.001). Lesion size decreased over time (180.8±91.5 mm 3 at day 1 vs 19.5±19.3 mm 3 at 1-year post-treatment). Higher post-treatment oedema (t=3.59, p<0.001) was associated with larger lesions at 3 months. Patients with larger lesions at day 1 demonstrated reduced rates of tremor recurrence (t=2.67, p=0.019); however, lesions over 170 mm 3 trended towards greater incidence of adverse effects (sensitivity=0.60, specificity=0.63). Lesion encroachment on the medial lemniscus (Sn=1.00, Sp=0.32) and pyramidal tract (Sn=1.00, Sp=0.12) were also associated with increased adverse effects incidence., Conclusion: Lesion size at day 1 predicts symptom recurrence, with fewer recurrences seen with larger lesions. Greater DRTT lesioning is associated with treatment efficacy. These findings may have implications for lesion targeting and extent., Trial Registration Number: NCT02252380., Competing Interests: Competing interests: AML is a consultant for Insightec and reports personal fees from Medtronic, St Jude, Boston Scientific and Functional Neuromodulation during the conduct of the study; grants from GJBE Healthcare, outside the submitted work. AF reports grants, personal fees and non-financial support from Abbvie; grants, personal fees and non-financial support from Medtronic; grants and personal fees from Boston Scientific; personal fees from Sunovion; personal fees from Chiesi Farmaceutici; personal fees from UCB; and grants and personal fees from Ipsen, outside the submitted work., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

This perspective describes the processes, pilot designs, and deployment strategies that the Yale School of Medicine (YSM) employed when integrating iPads into the undergraduate pre-clinical medical curriculum. We also explore the multiplier effect this technology inspired in expanding the program into our clerkship curriculum with the iPad Mini and how integrating mobile technology into our existing E-systems afforded us opportunities to enter the e-book and augmented reality technology spaces. Our hope is that this perspective provides a framework that may guide other institutions researching their own technological innovations., (Copyright ©2020, Yale Journal of Biology and Medicine.)

Objective: The development of transcranial MR-guided focused ultrasound (MRgFUS) has revitalized the practice of lesioning procedures in functional neurosurgery. Previous health economic analysis found MRgFUS thalamotomy to be a cost-effective treatment for patients with essential tremor, supporting its reimbursement. With the publication of level I evidence in support of MRgFUS thalamotomy for patients with tremor-dominant Parkinson's disease (TDPD), the authors performed a health economic comparison between MRgFUS, deep brain stimulation (DBS), and medical therapy., Methods: The authors used a decision tree model with rollback analysis and one-factor sensitivity analysis. Literature searches of MRgFUS thalamotomy and unilateral DBS of the ventrointermediate nucleus of the thalamus for TDPD were performed to determine the utility and probabilities for the model. Costs in Canadian dollars (CAD) were derived from the Schedule of Benefits and Fees in Ontario, Canada, and expert opinion on usage., Results: MRgFUS was associated with an expected cost of $14,831 CAD. Adding MRgFUS to continued medical therapy resulted in an incremental cost-effectiveness ratio of $30,078 per quality-adjusted life year (QALY), which remained cost-effective under various scenarios in the sensitivity analysis. Comparing DBS to MRgFUS, while DBS did not achieve the willingness-to-pay threshold ($56,503 per QALY) in the base case scenario, it did so under several scenarios in the sensitivity analysis., Conclusions: MRgFUS thalamotomy is a cost-effective treatment for patients with TDPD, particularly over continued medical therapy. While MRgFUS remains competitive with DBS, the cost-effectiveness advantage is less substantial. These results will help inform the integration of this technology in the healthcare system.

Background and Objectives: The study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases., Research Design and Methods: This was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases., Results: Overall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores., Discussion and Implications: This is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Medical schools around the world have been grappling with how to adapt undergraduate medical curricula in the face of the COVID-19 pandemic. Our institution made the decision to suspend all clinical clerkships the day before the Association of American Medical Colleges (AAMC) recommended to US medical schools a similar suspension of "medical student participation in any activities that involved patient contact." This manuscript describes the rapid evolution in our decision-making as we weighed various information, values, and priorities in the face of the emerging public health crisis. We discuss how a compromised learning environment and concerns about student, patient, and the public health led to the suspension. We also consider next steps as we move forward in this uncertain time., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2020.)

Background: This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data., Methods: We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests., Resutls: We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42)., Conclusion: This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Gain-of-function mutations in KCNT1, the gene encoding Slack (K Na 1.1) channels, result in epilepsy of infancy with migrating focal seizures (EIMFS) and several other forms of epilepsy associated with severe intellectual disability. We have generated a mouse model of this condition by replacing the wild type gene with one encoding Kcnt1 R455H , a cytoplasmic C-terminal mutation homologous to a human R474H variant that results in EIMFS. We compared behavior patterns and seizure activity in these mice with those of wild type mice and Kcnt1 -/- mice. Complete loss of Kcnt1 produced deficits in open field behavior and motor skill learning. Although their thresholds for electrically and chemically induced seizures were similar to those of wild type animals, Kcnt1 -/- mice were significantly protected from death after maximum electroshock-induced seizures. In contrast, homozygous Kcnt1 R455H/R455H mice were embryonic lethal. Video-EEG monitoring of heterozygous Kcnt1 +/R455H animals revealed persistent interictal spikes, spontaneous seizures and a substantially decreased threshold for pentylenetetrazole-induced seizures. Surprisingly, Kcnt1 +/R455H mice were not impaired in tasks of exploratory behavior or procedural motor learning. These findings provide an animal model for EIMFS and suggest that Slack channels are required for the development of procedural learning and of pathways that link cortical seizures to other regions required for animal survival.

Many industries, such as manufacturing, aviation, and power generation, employ sensitive measurement devices to be calibrated by certified experts. The diversity and sophistication of measurement devices and their calibration needs require networked and automated solutions. Internet of Measurement Things (IoMT) is an architectural framework that is based on the Industrial Internet of Things for the calibration industry. This architecture involves a layered model with a cloud-centric middle layer. In this article, the realization of this conceptual architecture is described. The applicability of the IoMT architecture in the calibration industry is shown through an editor application for Scope of Accreditation. The cloud side of the implementation is deployed to Microsoft Azure. The editor itself is created as a cloud service, and IoT Hub is used to collect data from calibration laboratories. By adapting the IoMT architecture to a commonly used cloud platform, considerable progress is achieved to encompass Metrology data and serve the majority of the stakeholders.