Sequence introgression from exogenous lineages underlies genomic and biological differences among Cryptosporidium parvum IOWA lines

The IOWA strain of Cryptosporidium parvum is widely used in studies of the biology and detection of the waterborne pathogens Cryptosporidium spp. While several lines of the strain have been sequenced, IOWA-II, the only reference of the original subtype (IIaA15G2R1), exhibits significant assembly errors. Here we generated a fully assembled genome of IOWA-CDC of this subtype using PacBio and Illumina technologies. In comparative analyses of seven IOWA lines maintained in different laboratories (including two sequenced in this study) and 56 field isolates, IOWA lines (IIaA17G2R1) with less virulence had mixed genomes closely related to IOWA-CDC but with multiple sequence introgressions from IOWA-II and unknown lineages. In addition, the IOWA-IIaA17G2R1 lines showed unique nucleotide substitutions and loss of a gene associated with host infectivity, which were not observed in other isolates analyzed. These genomic differences among IOWA lines could be the genetic determinants of phenotypic traits in C. parvum. These data provide a new reference for comparative genomic analyses of Cryptosporidium spp. and rich targets for the development of advanced source tracking tools.

Characterizing the microstructures of mammalian enamel by synchrotron phase contrast microCT

The enamel of mammalian teeth is a highly mineralized tissue that must endure a lifetime of cyclic contact and is inspiring the development of next-generation engineering materials. Attempts to implement enamel-inspired structures in synthetic materials have had limited success, largely due to the absence of a detailed understanding of its microstructure. The present work used synchrotron phase-contrast microCT imaging to evaluate the three-dimensional microstructure of enamel from four mammals including Lion, Gray Wolf, Snow Leopard, and Black Bear. Quantitative results of image analysis revealed that the decussation pattern of enamel consists of discrete diazone (D) and parazone (P) bands of rods organized with stacking arrangement of D+/P/D-/P in all mammals evaluated; the D+ and D- refer to distinct diazone bands with juxtaposed rod orientations from the reference plane. Furthermore, the rod orientations in the bands can be described in terms of two principal angles, defined here as the pitch and yaw. While the pitch angle increases from the outer enamel to a maximum (up to ≈ 40°) near the dentin enamel junction, minimal spatial variations are observed in yaw across the enamel thickness. There are clear differences in the decussation parameters of enamel across species that are interpreted here with respect to the structural demands placed on their teeth. The rod pitch and band width of enamel are identified as important design parameters and appear to be correlated with the bite force quotient of the four mammals evaluated. STATEMENT OF SIGNIFICANCE: The multi-functionality of tooth enamel requires both hardness and resistance to fracture, properties that are generally mutually exclusive. Ubiquitous to all mammalian teeth, the enamel is expected to have undergone adaptations in microstructure to accommodate the differences in diet, body size and bite force across animals. For the first time, we compare the complex three-dimensional microstructure of enamel from teeth of multiple mammalian species using synchrotron micro-computed tomography. The findings provide new understanding of the "design" of mammalian enamel microstructures, as well as how specific parameters associated with the decussation of rods appear to be engineered to modulate its fracture resistance.

Factors affecting judgment accuracy when scoring children's responses to non-word repetition stimuli in real time

BACKGROUND

Non-word repetition (NWR) tests are an important way speech and language therapists (SaLTs) assess language development. NWR tests are often scored whilst participants make their responses (i.e., in real time) in clinical and research reports (documented here via a secondary analysis of a published systematic review).

AIMS

The main aim was to determine the extent to which real-time coding of NWR stimuli at the whole-item level (as correct/incorrect) was predicted by models that had varying levels of detail provided from phonemic transcriptions using several linear mixed method (LMM) models.

METHODS & PROCEDURES

Live scores and recordings of responses on the universal non-word repetition (UNWR) test were available for 146 children aged between 3 and 6 years where the sample included all children starting in five UK schools in one year or two consecutive years. Transcriptions were made of responses to two-syllable NWR stimuli for all children and these were checked for reliability within and between transcribers. Signal detection analysis showed that consonants were missed when judgments were made live. Statistical comparisons of the discrepancies between target stimuli and transcriptions of children's responses were then made and these were regressed against live score accuracy. Six LMM models (three normalized: 1a, 2a, 3a; and three non-normalized: 1b, 2b, 3b) were examined to identify which model(s) best captured the data variance. Errors on consonants for live scores were determined by comparison with the transcriptions in the following ways (the dependent variables for each pair of models): (1) consonants alone; (2) substitutions, deletions and insertions of consonants identified after automatic alignment of live and transcribed materials; and (3) as with (2) but where substitutions were coded further as place, manner and voicing errors.

OUTCOMES & RESULTS

The normalized model that coded consonants in non-words as 'incorrect' at the level of substitutions, deletions and insertions (2b) provided the best fit to the real-time coding responses in terms of marginal R2, Akaike's information criterion (AIC) and Bayesian information criterion (BIC) statistics.

CONCLUSIONS & IMPLICATIONS

Errors that occur on consonants when non-word stimuli are scored in real time are characterized solely by the substitution, deletion and insertion measure. It is important to know that such errors arise when real-time judgments are made because NWR tasks are used to assess and diagnose several cognitive-linguistic impairments. One broader implication of the results is that future work could automate the analysis procedures to provide the required information objectively and quickly without having to transcribe data.

WHAT THIS PAPER ADDS

What is already known on this subject Children and patients with a wide range of cognitive and language difficulties are less accurate relative to controls when they attempt to repeat non-words. Responses to non-words are often scored as correct or incorrect at the time the test is conducted. Limited assessments of this scoring procedure have been conducted to date. What this study adds to the existing knowledge Live NWR scores made by 146 children were available and the accuracy of these judgements was assessed here against ones based on phonemic transcriptions. Signal detection analyses showed that live scoring missed consonant errors in children's responses. Further analyses, using linear mixed effect models, showed that live judgments led to consonant substitution, deletion and insertion errors. What are the practical and clinical implications of this work? Improved and practicable NWR scoring procedures are required to provide SaLTs with better indications about children's language development (typical and atypical) and for clinical assessments of older people. The procedures currently used miss substitutions, deletions and insertions. Hence, procedures are required that provide the information currently only available when materials are transcribed manually. The possibility of training automatic speech recognizers to provide this level of detail is raised.

Real-world four-year functional and surgical outcomes of Rezum therapy in younger versus elderly men

BACKGROUND

Management of urinary symptoms in elderly patients with benign prostatic hyperplasia (BPH) is complex given challenges with medications and invasive surgeries. Rezum, a minimally invasive water vapor therapy, is an emerging alternative. We compare real-world Rezum outcomes between young and elderly patients over 4 years.

METHODS

We retrospectively analyzed a multiethnic population treated with Rezum at a single center between 2017-2019. Patients were stratified into young (<65 years) or elderly (≥65 years) cohorts. International Prostate Symptom Score (IPSS), Quality of Life (QoL), maximum urinary flow rate (Qmax), decisional regret scores, and adverse events (AEs) were assessed at baseline, 1-, 3-, 6-, 12-, and/or 48-months. Descriptive statistics were compared using t-tests, Chi-squared, or Mann-Whitney U tests. Changes in outcomes were assessed using Wilcoxon signed-rank tests, stratified by age.

RESULTS

256 patients - 146 (57%) young and 110 (43%) elderly - were included. The majority were Asian (33.2%) or non-Hispanic Black (28.9%). Significant improvements were observed in the combined cohort at 4-years in IPSS, QoL, and Qmax when compared to baseline (all p < 0.05). Between the age cohorts, there were no significant differences in IPSS, QoL, or Qmax at any follow-up. Within both cohorts, significant improvements in IPSS and QoL were found from baseline to all follow-ups. In the young cohort, Qmax was significantly improved from baseline to all follow-ups while in the elderly cohort, this was observed only at the 3-month follow-up. No significant differences in AEs or regret was found between cohorts. There was no significant difference in 4-year surgical retreatment rates between cohorts (elderly 4.0% vs young 4.4%, p = 0.86).

CONCLUSIONS

There were no significant differences in IPSS, QoL, or AEs between elderly and younger men over 4 years following Rezum, suggesting comparable benefits and risks. Future research is warranted to clarify the impact of Rezum on Qmax in elderly men.

Comparison of performance of automatic recognizers for stutters in speech trained with event or interval markers

Introduction

Automatic recognition of stutters (ARS) from speech recordings can facilitate objective assessment and intervention for people who stutter. However, the performance of ARS systems may depend on how the speech data are segmented and labelled for training and testing. This study compared two segmentation methods: event-based, which delimits speech segments by their fluency status, and interval-based, which uses fixed-length segments regardless of fluency.

Methods

Machine learning models were trained and evaluated on interval-based and event-based stuttered speech corpora. The models used acoustic and linguistic features extracted from the speech signal and the transcriptions generated by a state-of-the-art automatic speech recognition system.

Results

The results showed that event-based segmentation led to better ARS performance than interval-based segmentation, as measured by the area under the curve (AUC) of the receiver operating characteristic. The results suggest differences in the quality and quantity of the data because of segmentation method. The inclusion of linguistic features improved the detection of whole-word repetitions, but not other types of stutters.

Discussion

The findings suggest that event-based segmentation is more suitable for ARS than interval-based segmentation, as it preserves the exact boundaries and types of stutters. The linguistic features provide useful information for separating supra-lexical disfluencies from fluent speech but may not capture the acoustic characteristics of stutters. Future work should explore more robust and diverse features, as well as larger and more representative datasets, for developing effective ARS systems.

SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment

Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.

Electronic Health Record Usage Patterns Across Surgical Subspecialties

OBJECTIVES

This study aimed to utilize metrics from physician action logs to analyze surgeon clinical, volume, electronic health record (EHR) efficiency, EHR proficiency, and workload outside scheduled time as impacted by physician characteristics such as years of experience, gender, subspecialty, academic title, and administrative title.

METHODS

We selected 30 metrics from Epic Signal, an analytic tool in Epic that extracts metrics related to clinician documentation. Metrics measuring appointments, messages, and scheduled hours per day were used as a correlate for volume. EHR efficiency, and proficiency were measured by scores built into Epic Signal. Metrics measuring time spent in the EHR outside working hours were used as a correlate for documentation burden. We analyzed these metrics among surgeons at our institution across 4 months and correlated them with physician characteristics.

RESULTS

Analysis of 133 surgeons showed that, when stratified by gender, female surgeons had significantly higher EHR metrics for time per day, time per appointment, and documentation burden, and significantly lower EHR metrics for efficiency when compared to male surgeons. When stratified by experience, surgeons with 0 to 5 years of experience had significantly lower EHR metrics for volume, time per day, efficiency, and proficiency when compared to surgeons with 6 to 10 and more than 10 years of experience. On multivariate analysis, having over 10 years of experience was an independent predictor of more appointments per day, greater proficiency, and spending less time per completed message. Female gender was an independent predictor of spending more time in notes per appointment and time spent in the EHR outside working hours.

CONCLUSION

The burden associated with volume, proficiency, efficiency, and workload outside scheduled time related to EHR use varies by gender and years of experience in our cohort of surgeons. Evaluation of physician action logs could help identify those at higher risk of burnout due to burdensome medical documentation.

Use of Upadacitinib in 16 Tofacitinib-refractory Ulcerative Colitis Patients: A Single-center Case 2Series

We present a case series of 16 patients with ulcerative colitis who received upadacitinib after failing tofacitinib. Five patients (36%) achieved steroid-free clinical remission. Five (62%) demonstrated endoscopic response, while 2 patients (25%) achieved endoscopic remission. Adverse events were low.

Enhanced Bonding to Caries-Affected Dentin Using an Isocyanate-Based Primer

Dental caries is the most common oral disease and the most common cause of resin restorations. In minimally invasive dentistry, the principle behind cavity preparation is to remove external caries-infected dentin (CID) and preserve internal caries-affected dentin (CAD) and sound dentin (SD). The cavity floor is mainly composed of CAD, but the poor bonding performance of CAD has become a widespread concern. This study evaluated the performance of a new collagen-reactive monomer (ITCM) used as a primer to improve the bonding performance of CAD. The experimental specimens were grouped as follows: SD, CAD, and ITCM-pretreated CAD (CAD-ITCM). Dentin slices were obtained for attenuated total reflectance-Fourier transform infrared (ATR-FTIR) analysis. The bonded samples were subjected to microtensile bond strength analysis after 24 h of water storage or aging by thermocycling, and the bonding interface quality was evaluated by nanoleakage assessment, interfacial nanoindentation testing, and in situ zymography. Cytotoxicity experiments with ITCM were performed. ATR-FTIR showed that the isocyanate groups in ITCM can covalently bind and form hydrogen bonds with the collagen in CAD to mediate chemical bonding. ITCM pretreatment significantly improved the bond strength of CAD (P < 0.05), reduced interfacial nanoleakage, improved the sealing of the bonding interface, enhanced the homogeneity of the hybrid layer, and inhibited matrix metalloproteinase activity. In addition, ITCM presented acceptable biocompatibility for dental restorative application. Taken together, this study reported the application of ITCM to induce collagen-based chemical bonding in the CAD bonding system, which fills the gap in strategies to improve the bonding performance of CAD immediately and after aging and has important clinical application prospects.

Lung Cancer in Never Smokers: Delving into Epidemiology, Genomic and Immune Landscape, Prognosis, Treatment, and Screening

Lung cancer in never smokers (LCINS) represents a growing and distinct entity within the broader landscape of lung malignancies. This review provides a comprehensive overview of LCINS, encompassing its epidemiologic trends, risk factors, distinct genomic alterations, clinical outcomes and the ongoing initiative aimed at formulating screening guidelines tailored to this unique population. As LCINS continues to gain prominence, understanding its intricate genomic landscape has become pivotal for tailoring effective therapeutic strategies. Moreover, LCINS does not meet the criteria for lung cancer screening as per the current guidelines. Hence, there is an urgent need to explore its heterogeneity in order to devise optimal screening guidelines conducive to early-stage detection. This review underscores the vital importance of detailed research to elucidate the multifaceted nature of LCINS, with the potential to shape future clinical management and screening recommendations for this unique and growing patient cohort.

A search-based geographic metadata curation pipeline to refine sequencing institution information and support public health

Background

The National Center for Biotechnology Information (NCBI) Sequence Read Archive (SRA) has amassed a vast reservoir of genetic data since its inception in 2007. These public data hold immense potential for supporting pathogen surveillance and control. However, the lack of standardized metadata and inconsistent submission practices in SRA may impede the data's utility in public health.

Methods

To address this issue, we introduce the Search-based Geographic Metadata Curation (SGMC) pipeline. SGMC utilized Python and web scraping to extract geographic data of sequencing institutions from NCBI SRA in the Cloud and its website. It then harnessed ChatGPT to refine the sequencing institution and location assignments. To illustrate the pipeline's utility, we examined the geographic distribution of the sequencing institutions and their countries relevant to polio eradication and categorized them.

Results

SGMC successfully identified 7,649 sequencing institutions and their global locations from a random selection of 2,321,044 SRA accessions. These institutions were distributed across 97 countries, with strong representation in the United States, the United Kingdom and China. However, there was a lack of data from African, Central Asian, and Central American countries, indicating potential disparities in sequencing capabilities. Comparison with manually curated data for U.S. institutions reveals SGMC's accuracy rates of 94.8% for institutions, 93.1% for countries, and 74.5% for geographic coordinates.

Conclusion

SGMC may represent a novel approach using a generative AI model to enhance geographic data (country and institution assignments) for large numbers of samples within SRA datasets. This information can be utilized to bolster public health endeavors.

[Clinical outcomes of endovascular therapy in acute stroke patients with anterior circulation tandem occlusions due to atherosclerosis and dissection]

Objective: To compare the clinical outcomes of endovascular therapy in acute stroke patients with anterior circulation tandem occlusions caused by atherosclerosis or dissection. Methods: A retrospective cohort study. A total of 98 patients with anterior circulation tandem lesions undergoing endovascular therapy in the Wuhan NO.1 Hospital (March 2016 to March 2022) were analyzed. Median age was 64(55,71) years old, and 82.7% (81/98 cases) were males. According to the lesion etiology, the patients were divided into atherosclerosis and dissection groups. The differences in clinical outcomes between the two groups were investigated, including favorable 90-day functional outcome (modified Rankin Scale score of 0-2), successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction score of 2b-3), symptomatic intracranial hemorrhage, stroke-associated pneumonia, 90-day all-cause mortality, and average hospitalization days. Logistic regression analysis was used to adjust for potential confounders affecting functional outcomes in both groups, and to determine odds ratios and 95% confidence intervals. Results: Seventy-one patients were grouped into the atherosclerotic cause and 27 into the dissection cause cohorts. The rate of favorable 90-day functional outcome was 43.7% (31/71 cases) in the atherosclerosis group versus 55.6% (15/27 cases) in the dissection group (adjusted odds ratio=1.339; 95% confidence interval, 0.374-4.798; P=0.654). No significant differences were found in other clinical outcomes between the two groups (all P>0.05). Conclusion: The clinical prognosis of patients with tandem lesions caused by atherosclerotic stenosis or artery dissection was similar after endovascular therapy. Future studies are still needed to verify our results.

Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery

BACKGROUND

Travel time can be used to assess health services accessibility by reflecting the proximity of services to the people they serve. We aimed to demonstrate an indicator of physical access to cataract surgery and identify subnational locations where people were more at risk of not accessing cataract surgery.

METHODS

We used an open-access inventory of public health facilities plus key informants in Kenya, Malawi and Rwanda to compile a geocoded inventory of cataract facilities. For each country, gridded estimates of the population aged ≥ 50 years and a travel-time friction surface were combined and a least-cost-path algorithm applied to estimate the shortest travel time between each grid and the nearest cataract facility. We categorised continuous travel time by 1-, 2- and 3 h thresholds and calculated the proportion of the population in each category.

RESULTS

At the national level, the proportion of the population aged ≥ 50 years within 2 h travel time to permanent cataract surgical services was 97.2% in Rwanda (n = 10 facilities), 93.5% in Kenya (n = 74 facilities) and 92.0% in Malawi (n = 6 facilities); this reduced to 77.5%, 84.1% and 52.4% within 1 h, respectively. The least densely populated subnational regions had the poorest access to cataract facilities in Malawi (0.0%) and Kenya (1.9%).

CONCLUSION

We demonstrated an indicator of access that reflects the distribution of the population at risk of age-related cataract and identifies regions that could benefit from more accessible services. This indicator provides additional demand-side context for eye health planning and supports WHO's goal of advancing integrated people-centred eye care.

Global database of cement production assets and upstream suppliers

Cement producers and their investors are navigating evolving risks and opportunities as the sector's climate and sustainability implications become more prominent. While many companies now disclose greenhouse gas emissions, the majority from carbon-intensive industries appear to delegate emissions to less efficient suppliers. Recognizing this, we underscore the necessity for a globally consolidated asset-level dataset, which acknowledges production inputs provenance. Our approach not only consolidates data from established sources like development banks and governments but innovatively integrates the age of plants and the sourcing patterns of raw materials as two foundational variables of the asset-level data. These variables are instrumental in modeling cement production utilization rates, which in turn, critically influence a company's greenhouse emissions. Our method successfully combines geospatial computer vision and Large Language Modelling techniques to ensure a comprehensive and holistic understanding of global cement production dynamics.

[The progress of clinical research and treatment of monocular elevation deficiency]

Monocular elevation deficiency (MED) is a functional defect in upward eye movement caused by paralysis, restriction, or a combination of factors. The affected eye experiences limited movement in the upward, nasal, and temporal directions, often accompanied by downward deviation and ptosis. Previously known as double elevator palsy (DEP), MED can result from muscle paralysis responsible for upward movement, restriction of the inferior rectus muscle, or lesions in the supranuclear pathway. The Knapp procedure was once the most commonly used surgical approach for MED. However, in cases involving restriction of the inferior rectus muscle, a staged approach combining inferior rectus muscle weakening and subsequent Knapp procedure is necessary to avoid anterior segment ischemia. This has led to the development of alternative surgical techniques, such as single-rectus muscle transposition, partial tendon transposition, and muscle belly transposition. Differentiating MED subtypes based on the underlying paralysis or restriction etiology is crucial for determining the appropriate surgical plan. This review article summarizes the clinical features, classification, and available surgical options for MED, aiming to provide valuable insights for clinical research and treatment.

Efficacy and safety of the Rezum system for the treatment of catheter-dependent urinary retention: Three-year real-world outcomes in a multimorbid, multiethnic population

OBJECTIVES

To evaluate the long-term real-world efficacy and safety of Rezum for the treatment of catheter-dependent urinary retention in a multimorbid, multiethnic population.

METHODS

A single-office, retrospective study was conducted on patients treated with Rezum between 2017 and 2019. Patients were included if they had catheter-dependent urinary retention prior to treatment and at least one follow-up within 36 months postoperatively. Patient demographics, procedural characteristics, adverse events (AEs), and outcome measures, including benign prostate hyperplasia (BPH) medication usage and postvoid residual (PVR), were collected at 3, 6, 12, and/or 36 months postoperatively. Regret was assessed at 36 months using the 5-item Decisional Regret Scale (DRS).

RESULTS

A total of 27 patients met the inclusion criteria, with the majority being Asian (29.6%), followed by non-Hispanic Black (26.0%) and Hispanic (22.2%). Most patients (77.8%) had at least one comorbidity. Trial of void (TOV) was attempted at a median of 8 days (7, 13). Fourteen patients (51.9%) failed their initial TOV. Median time until catheter independence was 13.5 days (8.5, 28.8). Common AEs included urinary retention (51.9%), urinary tract infections (UTIs) (25.9%), and dysuria (25.9%). All cases of UTIs (7/7) and most cases of dysuria (6/7) occurred in patients who failed their initial TOV. At 36 months, there was a significant median percentage change in PVR (-100.0% [-100.0, -36.7], p = .049), and 40.4% of patients discontinued their BPH medications (p = .001). Of the 11 patients who filled out the DRS, 10 (90.9%) agreed/strongly agreed that they made the right decision. By 36 months, 4 patients (14.8%) underwent reoperation and 24 (88.9%) remained catheter-independent.

CONCLUSIONS

At long-term follow-up, Rezum effectively treated catheter-dependent urinary retention with minimal decisional regret. In patients with urinary retention, urologists should consider delaying TOV until 2 weeks postoperatively to maximize the likelihood of a successful TOV and minimize the risk of AEs.

Rezum water vapor therapy for patients with mild, moderate, or severe lower urinary tract symptoms: A retrospective study in a multiethnic population

BACKGROUND

The Rezum System (Rezum) represents a novel, minimally invasive surgical therapy used to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). We evaluated the safety and efficacy of Rezum in patients with mild, moderate, or severe LUTS.

METHODS

A single office, retrospective study was conducted on patients from a multiethnic population treated with Rezum between 2017 and 2019. Patients were categorized into three cohorts based on baseline International Prostate Symptom Score (IPSS) LUTS severity: mild LUTS (IPSS ≤ 7), moderate LUTS (IPSS 8-19), or severe LUTS (IPSS ≥ 20) cohorts. Outcome measures, including IPSS, quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), BPH medication usage, and adverse events (AEs) were collected and analyzed at baseline, 1-, 3-, 6-, and/or 12-months postoperatively.

RESULTS

A total of 238 patients were included: 33 with mild LUTS, 109 with moderate LUTS, and 96 with severe LUTS. At 1-month follow-up, the moderate and severe LUTS cohorts saw significant improvements in IPSS (moderate LUTS: -3.0 [-6.0, 1.5], p < 0.001; severe LUTS: -10.0 [-16.0, -5.0], p < 0.001) and QoL (moderate LUTS: -1.0 [-3.0, 0.0], p < 0.001; severe LUTS: -1.0 [-3.0, 0.0], p < 0.001) and improvements remained durable up to 12-months (p < 0.001). The mild LUTS cohort saw significant worsening in IPSS by 2.0 (0.0, 12.0) at 1-month (p = 0.002) but returned to baseline at 3-months (p = 0.114). However, the mild LUTS cohort experienced significant improvements in QoL by -0.5 (-3.0, 0.0) at 3-months (p = 0.035) and nocturia by 0.0 (-1.0, 0.0) at 6-months (p = 0.002), both of which remained durable to 12-months (p < 0.05). Most AEs were transient and nonserious, with gross hematuria (66.5%) being most common. There were no significant differences in QoL point reduction, Qmax improvement, PVR reduction, and AE occurrence between the cohorts at 12-months (p > 0.05). At 12-months, 80.0%, 87.5%, and 66.0% of the patients in the mild, moderate, and severe LUTS cohorts discontinued their BPH medications, respectively.

CONCLUSIONS

Rezum provides rapid and durable relief in LUTS in patients with moderate or severe LUTS and can be offered to patients with mild LUTS who have bothersome nocturia and wish to discontinue their BPH medications.

Background, techniques, applications, current trends, and future directions of minimally invasive endoscopic spine surgery: A review of literature

Across many of the surgical specialties, the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization. Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades, allowing surgeons to achieve similar or better outcomes, while reducing cost and recovery time. However, to date, the axial skeleton, with its close proximity to critical neural and vascular structures, has not adopted endoscopic techniques at as rapid of a rate. Over the past decade, increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery. In addition, there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques. There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders, many of which are evolving rapidly. Here we present a review of the field of endoscopic spine surgery, including the background, techniques, applications, current trends, and future directions, to help providers gain a better understanding of this growing modality in spine surgery.

Opioid Prescription Patterns 90 Days After Arthroscopic Rotator Cuff Repair: A 10-Year National Database Analysis

Background

Arthroscopic rotator cuff repair (ARCR) is a common procedure that typically requires opioid prescription for postoperative pain management.

Purpose

To investigate the current prescription patterns and factors influencing 90-day postoperative opioid prescription trends for opioid-naïve patients who underwent ARCR.

Study Design

Case series; Level of evidence, 4.

Methods

Opioid-naïve adult patients who underwent ARCR between January 2010 and September 2020 and had a record of opioid prescriptions during the 90-day postoperative period were identified in the PearlDiver Mariner91 national administrative database. Exclusions included patients with prior shoulder procedures, a history of chronic pain, and opioid prescription records dated earlier than 4 weeks before surgery. Covariates included age group, sex, Elixhauser Comorbidity Index, and prescriber specialty (orthopaedic or nonorthopaedic). The primary outcome-90-day postoperative morphine milligram equivalents (MMEs) prescribed per patient-was compared using univariate and multivariate regression analyses, and 90-day postoperative opioid prescription trends over the 10-year study period were analyzed with linear regression.

Results

In total, 55,345 ARCR cases were identified. The mean ± SD amount prescribed within the first 90 days was 742.4 ± 256.5 MMEs, and the median was 487.5 MMEs. Multivariate linear regression analysis predicted higher 90-day postoperative MMEs for female patients and younger patients (P < .01 for both). From 2010 to 2020, there was a 66% decrease in mean MME prescribed per patient (▵ = 660.4 MME; P < .01), with a mean reduction of 55.1 MME per patient per year. In 2020, the mean 90-day postoperative amount prescribed was 341.1 MME, which is equivalent to 51 tablets of 5-mg oxycodone (Percocet).

Conclusion

Female sex and younger age were predictors of more MME being prescribed after ARCR. While opioid prescriptions following ARCR have substantially decreased over the past decade, the amount prescribed warrants further attention.

Anterior Cervical Discectomy and Fusion Outcomes in Patients With and Without Bariatric Surgery-Weight Loss Does Make a Difference

STUDY DESIGN

A retrospective comparative cohort study.

OBJECTIVE

To compare outcomes of elective non-obese anterior cervical discectomy and fusion (ACDF) patients with those that underwent bariatric surgery (BS).

SUMMARY OF BACKGROUND DATA

Morbid obesity (MO) has been associated with an increased risk of complications following procedures such as elective ACDF. While pre-emptive BS has been considered for those with MO (body mass index [BMI] ≥35 kg/m 2 ), the impact of this intervention on BMI and its resultant correlation with surgical outcomes remains limited.

METHODS

The PearlDiver 2010-Q1 2020 MSpine database was used to identify patients undergoing elective isolated ACDF. Three sub-cohorts were defined as follows: (1) Non-obese controls without a history of BS, (2) patients with BS procedure within two years with a BMI <35 kg/m 2 (BS+MO-), and (3) patients with BS procedure within the two years with a BMI ≥35 kg/m 2 (BS+MO+). Univariate and multivariate regression analyses were performed to compare 90-day adverse event rates adjusting for age, sex, Elixhauser Comorbidity Index, and length of stay. Kaplan-Meier analysis was performed to assess five-year cervical reoperation rates.

RESULTS

Of 160,166 elective ACDF patients, prior BS was identified for 479. Of these, 136 patients were BS+MO- and 343 were BS+MO+. On multivariate analysis, BS+MO- were not at increased odds of adverse events, but BS+MO+ were at greater odds of 90-day pulmonary embolism (odds ratio 3.28, P =0.043), wound dehiscence (5.02, P <0.001), hematomas (2.52, P =0.042), and overall minor adverse events (1.61, P =0.011) compared with controls. Five-year reoperation rates were not significantly different between the groups.

CONCLUSION

Twenty-eight percent of those with BS before ACDF fell out of the categorization of MO. Among this group, the odds of adverse events were similar to non-obese patients. These findings suggest that the psychological preparation and BS alone are insufficient to reduce the risk of adverse events after ACDF. Weight reduction must be achieved as well, ideally moving patients out of the BMI range for morbid obesity.

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries

OBJECTIVES

Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage.

METHODS

We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment.

RESULTS

Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries.

CONCLUSION

VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

From sonority hierarchy to posterior probability as a measure of lenition: The case of Spanish stops

A deep learning Phonet model was evaluated as a method to measure lenition. Unlike quantitative acoustic methods, recurrent networks were trained to recognize the posterior probabilities of sonorant and continuant phonological features in a corpus of Argentinian Spanish. When applied to intervocalic and post-nasal voiced and voiceless stops, the approach yielded lenition patterns similar to those previously reported. Further, additional patterns also emerged. The results suggest the validity of the approach as an alternative or addition to quantitative acoustic measures of lenition.

Rezum Outcomes in Relationship to Number of Injections: Is Less More?

Objectives: To assess efficacy and safety outcomes in relationship to the number of injections given during Rezum treatment. Methods: A retrospective study was conducted on patients with moderate to severe lower urinary tract symptoms (LUTS) treated with Rezum. Patients were stratified into cohorts based on the number of injections received per lateral prostatic lobe: 1, 2, 3, or 4 injections. International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), International Index of Erectile Function (IIEF)-Erectile Function, IIEF-Orgasmic Function, and adverse events were collected at baseline, 1, 3, 6, and/or 12 months postoperatively. Results: A total of 179 patients were included: 58, 91, 22, and 8 patients in the 1, 2, 3, and 4 injections cohorts, respectively. Baseline demographics significantly different across cohorts were age, history of urinary retention, prostate-specific antigen, prostate volume, prostatic urethral length, and presence of median lobe. At 3 months, all cohorts reported significant improvements in IPSS and QoL, which remained durable to 12 months. There were no significant differences in changes in IPSS, QoL, PVR, and IIEF-Erectile and Orgasmic Function between the cohorts at any follow-up. Multiple linear regression showed that the number of injections did not predict changes in IPSS, QoL, PVR, and IIEF-Erectile and Orgasmic Function at any follow-up (p > 0.05) but predicted change in Qmax at 3 months (β = 5.7, p = 0.019). Multiple logistic regression showed that for each additional injection, the odds of gross hematuria, penile burning, penile pain, and dysuria increased by 3.8, 2.6, 2.2, and 3.0, respectively. Conclusions: Utilizing less injections represents a safe treatment strategy without compromising Rezum's efficacy in providing durable relief in LUTS.

Multiple introductions and recombination events underlie the emergence of a hyper-transmissible Cryptosporidium hominis subtype in the USA

The parasite Cryptosporidium hominis is a leading cause of the diarrheal disease cryptosporidiosis, whose incidence in the United States has increased since 2005. Here, we show that the newly emerged and hyper-transmissible subtype IfA12G1R5 is now dominant in the United States. In a comparative analysis of 127 newly sequenced and 95 published C. hominis genomes, IfA12G1R5 isolates from the United States place into three of the 14 clusters (Pop6, Pop13, and Pop14), indicating that this subtype has multiple ancestral origins. Pop6 (IfA12G1R5a) has an East Africa origin and has recombined with autochthonous subtypes after its arrival. Pop13 (IfA12G1R5b) is imported from Europe, where it has recombined with the prevalent local subtype, whereas Pop14 (IfA12G1R5c) is a progeny of secondary recombination between Pop6 and Pop13. Selective sweeps in invasion-associated genes have accompanied the emergence of the dominant Pop14. These observations offer insights into the emergence and evolution of hyper-transmissible pathogens.

Risk Factors and Real-World Short-Term Outcomes of a Failed Trial of Void After Rezum Therapy in a Multiethnic Population

Background: Postoperative urinary retention is a common complication following surgery for benign prostatic hyperplasia. We aimed to identify risk factors for a failed trial of void (TOV) following treatment with the Rezum system and assess the impact of a failed TOV on short-term outcomes. Methods: A single-office retrospective study was conducted on patients treated with Rezum therapy between 2017 and 2019. A urinary catheter was placed in all patients following Rezum therapy. Demographic data and outcome measures, including the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), and adverse events, were analyzed at baseline and 1, 3, and/or 6 months postoperatively. Risk factors were identified through multivariate logistic regression analysis. Results: A total of 289 patients were included. Thirty-five patients (12.1%) failed a TOV, while 254 (87.9%) had an effective TOV. All patients were given a TOV after a median of 5 days (4-5). Those who failed the TOV spent an additional mean of 13.7 ± 13.3 days with a catheter. Patients who failed the TOV were more likely to get a urinary tract infection compared with those who had an effective TOV (20.0% vs 4.7%, p < 0.001). All patients experienced significant improvements in IPSS, QoL, and Qmax at 1, 3, and/or 6 months. On multivariate analysis, a high baseline PVR was the only independent predictor of a failed TOV (odds ratio: 1.01, 95% confidence interval 1.00-1.01). A greater proportion of patients with a baseline PVR >200 mL failed the TOV (40.0%) compared with patients with a baseline PVR <200 mL (10.9%, p = 0.008). Conclusions: Approximately one in eight patients failed the TOV following Rezum therapy. Baseline PVR was the only independent risk factor for a failed TOV. Nevertheless, all patients experienced significant relief of urinary symptoms. Patients with high baseline PVR, particularly >200 mL, may require a catheter for an extended duration.

Detection of carbapenem-resistant hypervirulent Klebsiella pneumoniae ST11-K64 co-producing NDM-1 and KPC-2 in a tertiary hospital in Wuhan

BACKGROUND

Carbapenem-resistant hypervirulent Klebsiella pneumoniae (CR-hvKP) poses serious challenges to public health. Only a few sporadic reports of strains co-producing NDM-1 and KPC-2 (NDM-1-KPC-2-CR-hvKP strains) are available to date.

OBJECTIVES

This retrospective study investigated the clinical features, prevalence and antibiotic resistance of hvKP in a tertiary hospital in central China, and characterized an NDM-1-KPC-2-CR-hvKP strain (KP169).

METHODS

Clinical data were collected. Antimicrobial and virulence-associated phenotyping and genotyping, capsular serotype gene analysis and multi-locus sequence typing of hvKP isolates were performed. Whole-genome sequencing (WGS) was performed on strain KP169.

RESULTS

Forty-five of 109 K. pneumoniae clinical isolates were hvKP. Of these, 37 originated from nosocomial infections and 24 expressed carbapenemases. Eight NDM-1-KPC-2-CR-hvKP strains were identified, and enterobacterial repetitive intergenic consensus polymerase chain reaction showed that they were clonally related. WGS revealed that strain KP169, which belongs to ST11-K64, had a single 5.5-Mb chromosome and six plasmids of 5.5-221.6 kb. The bla_NDM-1 gene was located on plasmid pKP169-P3, and bla_KPC-2, bla_SHV-12 and bla_TEM-1 were located on IncFII/IncR pKP169-P2. IncHI 1/IncFIB virulence plasmid pKP169-P1 was similar to pKPC-CR-hvKP-C789 plasmid reported previously. Plasmid stability testing showed that bla_KPC-2- and bla_NDM-1-harbouring plasmids were maintained stably in the host.

CONCLUSION

To the best of the authors' knowledge, this study identified the largest cohort, to date, of eight NDM-1-KPC-2-CR-hvKP strains, and suggests that antimicrobial stewardship and protocols to prevent transmission are needed urgently.

[The regularity of sensory recovery after wound repair on the wrist and back of hand with anterolateral femoral flap without nerve anastomosis]

Objective: To investigate the regularity of sensory recovery after repairing the wounds on the wrist and back of hand with anterolateral femoral flap without nerve anastomosis. Methods: A cross-sectional study was conducted. From January 2018 to December 2020, patients who underwent free anterolateral femoral flaps without nerve anastomosis to repair wounds on the wrist and back of hand and met the inclusion criteria in Changshu Hai Yu Health Centre and Suzhou Ruihua Orthopedic Hospital were included in this study. Depending on the time interval between the day of the patient's surgery and the day of the cross-sectional survey, 80 patients were divided into 6-month group (15 males and 5 females, aged 22-63 years), 12-month group (16 males and 4 females, aged 21-65 years), 18-month group (15 males and 5 females, aged 25-61 years), and 24-month group (14 males and 6 females, aged 20-65 years), with 20 patients in each group. The area of skin and soft tissue defects after debridement ranged from 6.0 cm×4.5 cm to 18.0 cm×9.0 cm. Anterolateral femoral flaps were cut with areas of 7 cm×5 cm to 20 cm×10 cm and a thickness of 1.0 to 2.5 cm. Each transplanted flap was divided into A (proximal), B/D (bilateral), C (distal), and E (central) regions. The pain sensation, touch sensation, cold sensation, warmth sensation, and two-point discrimination (2-PD) in the aforementioned five regions and the differences in the five senses of the whole flap were tested and compared. Data were statistically analyzed with one-way analysis of variance, Fisher's exact probability test, chi-square test, or McNemar test. Results: In A region of anterolateral femoral flap without nerve anastomosis, compared with those in 6-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 12-month group were significantly recovered (with χ2 values of 10.10, 14.55, 12.13, and 4.29, respectively, P<0.05 or P<0.01); compared with that in 12-month group, the warmth sensation of flap of patients in 18-month group recovered significantly (χ2=5.23, P<0.05). In B region, compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of flap of patients in 12-month group recovered significantly (with χ2 values of 5.58, 3.96, and 4.29, respectively, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ2 values of 5.58, 3.96, 7.03, and 12.38, respectively, P<0.05 or P<0.01). In C region, compared with that in 6-month group, the pain sensation of flap of patients in 12-month group recovered significantly (χ2=4.80, P<0.05); Compared with that in 12-month group, the warmth sensation of flap of patients in 18-month group recovered significantly (χ2=10.16, P<0.01). In D region, compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of flap of patients in 12-month group recovered significantly (with χ2 values of 5.58, 4.29, and 3.96, respectively, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ2 values of 5.58, 4.29, 3.96, and 10.10, respectively, P<0.05 or P<0.01). In E region, compared with that in 6-month group, the cold sensation of flap of patients in 12-month group recovered significantly (χ2=4.80, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ2 values of 6.47, 4.91, and 9.23, respectively, P<0.05 or P<0.01). The five senses in the 5 regions of flap of patients in 24-month group were similar to those in 18-month group (P>0.05). The recovery of 2-PD in the 5 regions of flap of patients was similar between the two adjacent groups (P>0.05). In 12-month group, the recoveries of pain sensation, touch sensation, and cold sensation of flap of patients in A region were better than those in the other 4 regions (P<0.05 or P<0.01), the recovery of warmth sensation was better than that of B region, C region, and E region (P<0.05 or P<0.01); in 18-month group, the recovery of pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in A region of was better than those in area C region (P<0.05). Compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of the whole flap of patients in 12-month group recovered significantly (with χ2 values of 7.62, 7.03, and 5.58, respectively, P<0.05 or P<0.01). Compared with the 12-month group in which 10, 11, 10, and 4 patients had a recovery of pain, touch sensation, cold sensation, and warmth sensation in the whole flap, the 18-month group had significantly more patients with sensations recovered, which were 17, 17, 16, and 14, respectively (with χ2 values of 5.58, 4.29, 3.96, and 10.10, respectively, P<0.05 or P<0.01). The five senses of the whole flap of patients in 24-month group were similar to those in 18-month group (P>0.05). Conclusions: In the anterolateral femoral flap without nerve anastomosis for repairing wounds on the wrist and back of hand, the sensation gradually recovered from the proximal end to the distal end. The sensation of touch, pain, and cold began to recover from 6 months after operation, and entered the stable recover period at 18 months after operation. Warmth sensation began to recover from 12 months after operation, and entered the stable recovery period at 18 months after operation. The 2-PD of most flaps was still not recovered 2-year after operation.

Impact and cost-effectiveness of rotavirus vaccination in Niger: a modelling study evaluating alternative rotavirus vaccines

OBJECTIVES

To evaluate the cost-effectiveness of alternative rotavirus vaccines in Niger, using UNIVAC, a proportionate outcomes model.

SETTING

The study leverages global, regional and local data to inform cost-effectiveness modelling. Local data were collected as part of a clinical trial taking place in the Madarounfa district, Maradi region, Niger.

PARTICIPANTS

The study models impact of infants vaccination on rotavirus gastroenteritis in children under 5 years of age.

INTERVENTIONS

We compared the use of ROTARIX (GlaxoSmithKline, Belgium), ROTAVAC (Bharat Biotech, India) and ROTASIIL (Serum Institute, India) to no vaccination and to each other over a 10-year period starting in 2021.

RESULTS

We estimated that ROTARIX, ROTAVAC and ROTASIIL would each prevent 13 million cases and 20 000 deaths of children under 5 years over a 10-year period in Niger. Compared with no vaccination, the cost to avert a disability-adjusted life-year was US$146 with ROTARIX, US$107 with ROTASIIL and US$76 with ROTAVAC from the government perspective. ROTAVAC dominated ROTARIX and ROTASIIL (eg, provided similar or higher benefits at a lower cost) and had 90% chance to be cost-effective at a US$100 willingness-to-pay threshold.

CONCLUSIONS

This study can inform decision-making around rotavirus vaccination policy in Niger, demonstrating that ROTAVAC is likely the most cost-effective option. Alternative products (ROTASIIL and ROTARIX) may also be considered by decision-makers if they are priced more competitively, or if their cold chain requirements could bring additional economic benefits.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

Professional Burnout of Advanced Practice Providers Based on 2019 American Urological Association Census Data

INTRODUCTION

Burnout has been recognized as an occupational hazard among health care professionals. The objective of this study was to assess the extent and pattern of burnout in advanced practice providers (APPs) in urology by analyzing American Urological Association Census data.

METHODS

The American Urological Association conducts an annual census survey to all providers in the urological care community, including APPs. In the 2019 Census, the Maslach Burnout Inventory questionnaire was included to measure burnout among APPs. Demographic and practice variables were assessed to establish correlating factors to burnout.

RESULTS

A total of 199 APPs (83 physician assistants and 116 nurse practitioners) completed the 2019 Census. Slightly more than 1 in 4 APPs experienced professional burnout (25.3% in physician assistants and 26.7% in nurse practitioners). Observed higher burnout rates were seen in APPs who were aged 45 to 54 (34.3%), women (29.6% vs 10.8% in men, p value <0.05), non-White (33.3% vs 24.9% in White), those who had 4-9 years of practice (32.4%) and those who practiced in academic medical centers (31.7%). Except for gender, none of the above observed differences were statistically significant. Using a multivariate logistic regression model, gender remained the only significant factor associated with burnout (women vs men with an odds ratio of 3.2 [95% confidence interval: 1.1-9.6]).

CONCLUSIONS

Overall, APPs in urological care reported lower levels of burnout than urologists; however, there was a higher chance of female APPs experiencing higher professional burnout in comparison to their male counterparts. Future studies are needed to investigate possible reasons for this finding.

Cost-effectiveness of routine versus indicated antibiotic therapy in the management of severe wasting in children

Background

In the outpatient management of severe wasting, routine antibiotic therapy is recommended for all children upon admission regardless of whether clinical signs of infection are present. Indicated antibiotic therapy, where antibiotics are provided only upon presentation of clinical signs of infection, may be considered for its potential to allow for more prudent antibiotic use and greater program coverage, reducing the risk of antibiotic resistance as well as costs and logistical burdens associated with treatment. We therefore conducted a cost-effectiveness analysis to measure the effects of indicated antibiotic therapy compared to routine antibiotic therapy in terms of incremental cost-per-life-year saved in Niger.

Methods

We used a cohort model to conduct a cost-effectiveness analysis from a healthcare system perspective to project and weigh the lifetime discounted costs and effects of indicated antibiotic therapy compared to routine antibiotic therapy in the treatment of uncomplicated severe wasting in children in Niger. We calculated incremental cost-effectiveness ratios (ICERs) in terms of treatment-related healthcare costs per discounted life-years saved (LYS), and conducted program coverage scenario and sensitivity analyses to assess model uncertainty.

Results

The ICER for indicated antibiotic therapy compared to routine antibiotic therapy was $8.5/LYS, which is under the cost-effectiveness threshold for Niger. The probability of the indicated strategy being optimal was 76.1% when program coverage was equal to coverage associated with routine therapy but was 100% likely to be optimal in probabilistic sensitivity analysis scenarios where indicated program coverage improved 5 percentage points.

Conclusions

Indicated antibiotic therapy likely represents a cost-effective strategy, particularly if indicated treatment can result in expanded coverage. With the risk of increasing antibiotic resistance worldwide, antibiotic stewardship and simplified treatment protocols for severe wasting using indicated antibiotic therapy may represent good value for money in some low risk populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00374-z.

Assessing the Quality of YouTube Videos on Adhesive Capsulitis

Introduction 

YouTube is the most popular video-based source of information on the Internet. It is accessed by over 1 billion users, which approximates to almost one-third of all Internet users. Orthopaedic video content published on YouTube is not screened and does not go through an editorial process, and most videos do not have information about authorship or appropriate references. Users who do not have the knowledge to assess the accuracy and reliability of the source may be misinformed about their medical condition. Previous studies have evaluated the quality of YouTube content for information in orthopaedics such as meniscus,kyphosis, and anterior cruciate ligament (ACL), but the quality of frozen shoulder videos on YouTube has not been investigated. The purpose of this study is to evaluate the quality and educational value of YouTube videos concerning adhesive capsulitis.

Methods

A YouTube search was performed using the term "frozen shoulder." Videos were excluded if they had no audio, were in a language other than English, or were longer than 10 minutes. A total of 70 videos were screened, and the first 50 videos that met the inclusion criteria were evaluated by three observers. Six video characteristics were extracted, and videos were categorized by source and content. Quality and educational value were assessed using the DISCERN (score range, 0-5), Global Quality score (GQS; score range, 0-4), and a Frozen Shoulder-Specific Score (FSSS; score range, 0-16).

Results 

The mean video duration was 242.46 ± 164.32 seconds. The mean number of views was 137,494 ± 262,756 and the total view count across 50 videos was 6,874,706. The mean DISCERN, GQS, and FSSS scores were 2.72 ± 0.85, 2.37 ± 0.895, and 4.42 ± 3.15, respectively. The video sources were primarily from non-physician healthcare professionals (32%), and most of the video content was focused on disease-specific information (50%). Significant between-group effects were observed for the DISCERN score and video source (P = .005), with videos from academic sources having the highest mean DISCERN score. DISCERN scores also differed significantly based on video content (P = .007), with disease content having the highest DISCERN score. Both GQS and FSSS scores differed significantly based on video content (both P < .001) but did not differ significantly based on the video source.

Conclusions

Information about frozen shoulder on YouTube is low quality and has limited educational value. Thus, providers for orthopaedic conditions should warn their patients and provide better alternatives for education.

The contribution of object identity and configuration to scene representation in convolutional neural networks

Scene perception involves extracting the identities of the objects comprising a scene in conjunction with their configuration (the spatial layout of the objects in the scene). How object identity and configuration information is weighted during scene processing and how this weighting evolves over the course of scene processing however, is not fully understood. Recent developments in convolutional neural networks (CNNs) have demonstrated their aptitude at scene processing tasks and identified correlations between processing in CNNs and in the human brain. Here we examined four CNN architectures (Alexnet, Resnet18, Resnet50, Densenet161) and their sensitivity to changes in object and configuration information over the course of scene processing. Despite differences among the four CNN architectures, across all CNNs, we observed a common pattern in the CNN's response to object identity and configuration changes. Each CNN demonstrated greater sensitivity to configuration changes in early stages of processing and stronger sensitivity to object identity changes in later stages. This pattern persists regardless of the spatial structure present in the image background, the accuracy of the CNN in classifying the scene, and even the task used to train the CNN. Importantly, CNNs' sensitivity to a configuration change is not the same as their sensitivity to any type of position change, such as that induced by a uniform translation of the objects without a configuration change. These results provide one of the first documentations of how object identity and configuration information are weighted in CNNs during scene processing.

Limited Supply of Protein and Lysine Is Prevalent among the Poorest Households in Malawi and Exacerbated by Low Protein Quality

We estimated dietary supplies of total and available protein and indispensable amino acids (IAAs) and predicted the risk of deficiency in Malawi using Household Consumption and Expenditure Survey data. More than half of dietary protein was derived from cereal crops, while animal products provided only 11%. The supply of IAAs followed similar patterns to that of total proteins. In general, median protein and IAA supplies were reduced by approximately 17% after accounting for digestibility, with higher losses evident among the poorest households. At population level, 20% of households were at risk of protein deficiency due to inadequate available protein supplies. Of concern was lysine supply, which was inadequate for 33% of households at the population level and for the majority of the poorest households. The adoption of quality protein maize (QPM) has the potential to reduce the risk of protein and lysine deficiency in the most vulnerable households by up to 12% and 21%, respectively.

Intoxication and pitch control in tonal and non-tonal language speakers

Alcohol intoxication is known to affect pitch variability in non-tonal languages. In this study, intoxication's effects on pitch were examined in tonal and non-tonal language speakers, in both their native language (L1; German, Korean, Mandarin) and nonnative language (L2; English). Intoxication significantly increased pitch variability in the German group (in L1 and L2), but not in the Korean or Mandarin groups (in L1 or L2), although there were individual differences. These results support the view that pitch control is related to the functional load of pitch and is an aspect of speech production that can be advantageously transferred across languages, overriding the expected effects of alcohol.

AB0339 EFFICACY, PHARMACOKINETICS AND SAFETY BETWEEN CT-P13 AND CHINA-APPROVED INFLIXIMAB: 54 WEEK RESULT FROM A PHASE III RANDOMIZED CONTROLLED TRIAL IN CHINESE PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS

Background

CT-P13 is an approved biosimilar to EU-approved and US-licensed Infliximab (INX) for the indications of rheumatoid arthritis (RA), adult and paediatric Crohn’s disease, adult and paediatric ulcerative colitis, ankylosing spondylitis, psoriatic arthritis and psoriasis.

Objectives

The purpose of this study was to demonstrate equivalence of efficacy and compare PK and safety profiles of CT-P13 and China-approved INX.

Methods

In this randomized, double blinded, multicenter, parallel-group, phase III study, patients with active RA who had been responding inadequately to methotrexate for at least 3 months, were randomized to receive either CT-P13 or China-approved INX. Patients were treated with doses of 3 mg/kg at Weeks 0, 2, 6, then every 8 weeks up to Week 54. Prior to dosing at Week 30, patients randomized to China-approved INX underwent a second randomization either to continue China-approved INX or to switch to CT-P13 at Week 30. Results of patients who underwent transition to CT-P13 were included in the China-approved INX group. The primary efficacy endpoint was change in DAS28 (CRP) from baseline to Week 14, which was analyzed using an analysis of covariance. Equivalence was determined if the 90% CI for the estimate of treatment difference was entirely contained within the predefined equivalence margin of -0.6 to 0.6.

Results

270 patients were randomly assigned to 2 treatment groups in a 1:1 ratio (136 and 134 patients in the CT-P13 and China-approved INX groups, respectively) and 184 patients completed the study. The least square mean change (standard error) of DAS28 (CRP) from baseline to Week 14, -1.566 [0.1419] and -1.547 [0.1491], was similar between the CT-P13 and China-approved INX groups, respectively. The 90% CI for the estimate of treatment difference (-0.29, 0.25) was contained within the predefined equivalence margin, which demonstrated therapeutic equivalence between the groups. The mean actual values for DAS28 (CRP) decreased from baseline to Week 54 and were similar between the groups (Figure 1). Additional efficacy endpoints, including ACR responses (ACR20 at Week 14; 60.6%, 54.8% and at Week 54; 65.1%, 60.6% in the CT-P13 and China-approved INX groups, respectively), EULAR responses, CDAI, and SDAI, were similar between the groups, even after switching at Week 30. During the study, mean serum INX concentrations were similar between the groups. Between Weeks 14 and 22, mean (percent coefficient of variation) AUCτ were 11156333.615 (44.796) ng·h/mL and 11462884.280 (51.057) ng·h/mL, and Cmax,ss were 66577.2 (31.4) ng/mL and 66356.1 (21.0) ng/mL in the CT-P13 and China-approved INX groups, respectively, which were similar between the groups. Most treatment-emergent AEs were grade 1 or 2 in intensity. One malignancy was reported in the CT-P13 group and no deaths were reported. The proportions of patients with anti-drug antibodies were similar between the groups, even after switching at Week 30. The overall safety profile of CT-P13 was comparable to that of China-approved INX and no new safety issues were observed (Table 1).

Table 1.

Summary of Safety Results

Number of patients (%)CT-P13 (N=136)China-approved Infliximab (N=133)Treatment-emergent AEsTotal115 (84.6%)107 (80.5%)Related97 (71.3%)86 (64.7%)Treatment-emergent serious AEsTotal17 (12.5%)12 (9.0%)Related10 (7.4%)6 (4.5%)Infusion related reaction/ hypersensitivity/anaphylactic reactionsTotal(=Related)20 (14.7%)19 (14.3%)InfectionsTotal45 (33.1%)43 (32.3%)Related36 (26.5%)40 (30.1%)

Note: Summary is presented for the safety population who received at least 1 dose (full or partial) of study drug.

Conclusion

The study demonstrated that efficacy of CT-P13 is equivalent to that of China-approved INX. Also, the PK and safety profiles of CT-P13 were comparable to those of China-approved INX. No loss of efficacy or difference in safety or immunogenicity was observed after switching from China-approved INX to CT-P13 at Week 30.

Disclosure of Interests

Jonathan Kay Consultant of: Boehringer Ingelheim GmbH; Pfizer Inc.; Samsung Bioepis; Sandoz Inc., Grant/research support from: Pfizer Inc. (paid to UMass Chan Medical School), Xiaofeng Zeng Grant/research support from: Celltrion, Inc, Lin Chen Grant/research support from: Celltrion, Inc, Kaijiang Tang Grant/research support from: Celltrion, Inc, guixiu shi Grant/research support from: Celltrion, Inc, Lin Liu Grant/research support from: Celltrion, Inc, Lijun Wu Grant/research support from: Celltrion, Inc, Yi Liu Grant/research support from: Celltrion, Inc, Jiankang Hu Grant/research support from: Celltrion, Inc, Shengyun Liu Grant/research support from: Celltrion, Inc, Zheng Yi Grant/research support from: Celltrion, Inc, Sung Hyun Kim Employee of: Celltrion, Inc, YunJu Bae Employee of: Celltrion, Inc, JeeHye Suh Employee of: Celltrion, Inc, Seungjin Rhee Employee of: Celltrion, Inc, SeulGi Lee Employee of: Celltrion, Inc, Chankyoung Hwang Employee of: Celltrion, Inc

Rates of Post-Partum Psychosis in women with risk factors cared for by a specialist community perinatal mental health service in London

Introduction

Community Perinatal Mental Health Services (CPMHS) have been established in the UK, however, there is limited research around their real-world effectiveness. Post-Partum Psychosis (PPP), a severe episode of affective psychosis usually occurring soon after birth, has known risk factors. CPMHS offer assessment and interventions for women with risk factors for PPP, with a view to reducing the risk of its occurrence, as well as, where necessary, to proactively manage the illness to minimise the impact on the mother-infant dyad, as well as associated risks to self and/or others.

Objectives

To review the rate of PPP in women with established risk factors, who were referred and managed by our CPMHS between September 2019-September 2021. This rate will be compared with the known rates of PPP reported in the literature. Rates of non-psychotic relapse, acute hospitalisation, children social care supervision and mother-infant separation as a result of postnatal relapse will be (amongst others) secondary outcomes. Perinatal interventions offered to reduce the risk of PPP and contingency planning will also be reviewed.

Methods

This will be a retrospective case review study involving women referred and cared for by our CPMHS from October 2019 to October 2021, with known risk factors for PPP. Women identified as high risk for PPP receive consultant led-care in our service, therefore cases will be identified via the individual caseloads. Subsequently, electronic case notes will be reviewed to determine the primary and secondary outcomes, as well as the perinatal interventions that were offered.

Results

To be reported.

Conclusions

To be reported.

Disclosure

No significant relationships.

Emerging outcomes of water vapor thermal therapy (Rezum) in a broad range of patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia: A systematic review

Water vapor thermal therapy (Rezum) is a novel, minimally invasive surgical technology used to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The objective of this systematic review is to evaluate the latest efficacy and safety profile of Rezum in patients with LUTS secondary to BPH. PubMed/MEDLINE and the Cochrane Library databases were systematically searched, in accordance with the PRISMA statement, for relevant articles in the English language till 1 August 2021. Randomized and nonrandomized studies that evaluated urinary outcomes and/or adverse events were deemed eligible. Nineteen studies (N = 1942), published in 25 articles, were included. International Prostate Symptom Score (IPSS), quality of life (QoL), and maximum urinary flow rate (Qmax) significantly improved as early as 1 month postoperatively and remained durable for up to 5 years. Significant median percent improvements in IPSS, QoL, and Qmax at 3 months were 51%, 51%, and 66%, respectively. Patients with obstructive median lobes, large prostates (>80 g), small prostates (<30 g), and urinary retention also experienced significant relief in LUTS, with 83% of urinary retention patients becoming catheter independent at a median of 14 days. Most adverse events were transient and nonserious and occurred in 0% to 76% of patients (median 29%), with de novo erectile dysfunction rates ranging between 0% and 3.1%. Surgical retreatment rate ranged between 4.4% and 7.5% at 5 years postoperatively. Rezum provides durable improvements in symptoms, irrespective of prostate volume and urinary retention status, and has low rates of sexual dysfunction.

Characterization of a Neisseria gonorrhoeae Ciprofloxacin panel for an antimicrobial resistant Isolate Bank

Objectives

Neisseria gonorrhoeae (gonococcus) infection is one of the most commonly reported nationally notifiable conditions in the United States. Gonococcus has developed antimicrobial resistance to each previously used antibiotic for gonorrhea therapy. However, some isolates may be still susceptible to no longer recommended, yet still effective antibiotics. This in turn suggests that targeted therapy could slow resistance development to currently recommended empirical treatments. We curated a gonococcal Ciprofloxacin Antibiotic Resistance Isolate Bank panel (Cipro-panel) as a tool for validating or developing new tests to determine ciprofloxacin susceptibility.

Method

The Cipro-panel was selected using whole genome sequencing, bioinformatic tools, and antimicrobial susceptibility testing (AST) data. Isolates were further selected based on nucleotide variations in gyrA and parC genes.

Results

We selected 14 unique N. gonorrhoeae isolates from the 2006–2012 Gonococcal Isolate Surveillance Project (GISP) collection. They represented a wide range of antimicrobial susceptibility to ciprofloxacin and commonly observed nucleotide variations of gyrA and parC genes. This Cipro-panel consists of 5 isolates with resistant phenotypes (MIC > = 1 μg/mL), 8 isolates with susceptible phenotypes (MIC < = 0.06 μg/mL), and 1 isolate falling in the Clinical and Laboratory Standards Institute defined intermediate range. Among the gyrA variations we observed a total of 18 SNPs. Four positions had nonsynonymous changes (nucleotide positions 272, 284, 1093, and 1783). The first two positions (272 and 284) have been linked previously with resistance to ciprofloxacin (i.e. amino acid positions 91 and 95). For the parC gene, we observed a total of 21 possible SNPs. Eight of those SNPs resulted in non-synonymous amino acid changes. One location (amino acid 87) has been previously reported to be associated with ciprofloxacin resistance.

Conclusions

This Cipro-Panel is useful for researchers interested in developing clinical tests related to ciprofloxacin. It could also provide additional choices for validation, quality assurance purposes and improve antibiotic usage.