Coral species-specific loss and physiological legacy effects are elicited by an extended marine heatwave.

Marine heatwaves are increasing in frequency and intensity, with potentially catastrophic consequences for marine ecosystems such as coral reefs. An extended heatwave and recovery time-series that incorporates multiple stressors and is environmentally realistic can provide enhanced predictive capacity for performance under climate change conditions. We exposed common reef-building corals in Hawai'i, Montipora capitata and Pocillopora acuta, to a 2-month period of high temperature and high PCO2 conditions or ambient conditions in a factorial design, followed by 2 months of ambient conditions. High temperature, rather than high PCO2, drove multivariate physiology shifts through time in both species, including decreases in respiration rates and endosymbiont densities. Pocillopora acuta exhibited more significantly negatively altered physiology, and substantially higher bleaching and mortality than M. capitata. The sensitivity of P. acuta appears to be driven by higher baseline rates of photosynthesis paired with lower host antioxidant capacity, creating an increased sensitivity to oxidative stress. Thermal tolerance of M. capitata may be partly due to harboring a mixture of Cladocopium and Durusdinium spp., whereas P. acuta was dominated by other distinct Cladocopium spp. Only M. capitata survived the experiment, but physiological state in heatwave-exposed M. capitata remained significantly diverged at the end of recovery relative to individuals that experienced ambient conditions. In future climate scenarios, particularly marine heatwaves, our results indicate a species-specific loss of corals that is driven by baseline host and symbiont physiological differences as well as Symbiodiniaceae community compositions, with the surviving species experiencing physiological legacies that are likely to influence future stress responses.

Long-term outcomes following pediatric endoscopic titanium ossiculoplasty: A single-institution experience.

INTRODUCTION: Endoscopic ossicular chain reconstruction (OCR) in adults has demonstrated equivalent outcomes to the traditional microscopic approach. Less data exist on endoscopic OCR outcomes in children, who have unique considerations including a smaller transcanal corridor and variable pathology. The purpose of this study was to investigate surgical and audiometric outcomes in children undergoing fully endoscopic and endoscopic-assisted OCR in both the short and long-term. METHODS: Retrospective review of all children (<17 years) who underwent endoscopic OCR at one tertiary care center between 2017 and 2021. Children undergoing primary and revision endoscopic OCR with either partial (PORP) and total ossicular reconstruction prostheses (TORP) were included. Children undergoing surgery for juvenile otosclerosis or congenital stapes fixation, or any child receiving a stapes prosthesis were excluded. Primary outcome measures were post-operative change in 4 frequency (500 Hz, 1, 2, 4 KHz) air conduction pure tone average (AC PTA) and change in air-bone gap (ABG). Secondary measures included need for readmission and/or revision surgery, complication rate, and surgery duration. RESULTS: Seventeen patients met inclusion criteria. Average age was 11.3 years (range, 5-17 years); 14 were male. A variety of fixed length, titanium total and partial prostheses were used. The most common prosthesis length was 2 mm (range 2-5 mm), and there were no intra- or perioperative complications. Mean long-term follow-up was 2.6 years. Most common pathology was congenital cholesteatoma (11/17, 64%), followed by chronic otitis media with tympanic membrane perforation (5/17, 29.4%), and extruded prosthesis (1/17, 5.9%). Intraoperatively, the most common finding was incus erosion (10/17, 58.8%), followed by malleus erosion (6/17, 35.3%), stapes erosion (4/17, 23.5%), and stapes absence (4/17, 23.5%). Eight children (47%) were reconstructed with PORPs, and 9 children (52.9%) were reconstructed with TORPs. Average ABG improved from 36.8 dB preoperatively to 19.9 dB postoperatively in the short-term and remained stable at 19.5 dB in the long-term. Average short-term ABG improvement was 4.2 dB for PORPs and 18 dB for TORPs. In the long-term, average ABG improved by 2.3 dB in PORPs and 13.4 dB in TORPs. PORPs had higher rates of ABG closure and lower AC PTAs than TORPs in the long-term. DISCUSSION: Endoscopic ossiculoplasty is a viable option in children presenting with ossicular erosion from various causes. Audiometric improvement following endoscopic partial and total ossicular reconstruction remains stable over time, with a preference towards partial in the long-term, and mirrors published outcomes for microscopic surgery.

Reassessing the Utility of Surgical Intervention for Skull Base Osteomyelitis: A 16-Year Experience.

OBJECTIVE: The role of surgery in lateral skull base osteomyelitis (SBO) is controversial. Surgical intervention is often requested by consulting services in the interest of additional culture data to inform medical management. However, whether surgery alters subsequent antibiotic treatment or modifies disease outcome remains unknown. The aim of this study was to investigate the role of surgical intervention in the treatment of SBO by (1) comparing nonsurgical and surgical culture data and (2) assessing clinical outcomes and treatment course following surgical intervention. STUDY DESIGN: Retrospective. SETTING: Tertiary care center. METHODS: The electronic record was queried for all patients with SBO who presented to a single institution over a 16-year period (2007-2023). Information recorded included history and exam, bedside and intraoperative culture data, antibiotic course, and disease outcomes. Primary outcome measures included change in medical management based on intraoperative cultures, recurrence rates, and mortality rates. RESULTS: Forty patients (41 ears, average age 73 ± 13 years) met inclusion criteria. Out of 13 (32%) patients who underwent surgical intervention, one intraoperative culture changed the antibiotic course due to identification of resistance to the original antibiotic used. Surgery did not demonstrate a benefit in overall mortality (23% vs 18%, P = 0.36) or facial nerve function (33% vs 50%, P = 0.56) compared to medical management, and was associated with increased recurrence rates (54% vs 11%, P = 0.05). CONCLUSION: Surgical cultures rarely changed antibiotic selection. Surgical debridement in treatment-refractory SBO was also not associated with improvement in recurrence or mortality rates, though this may reflect underlying differences in disease severity.

Factors for which radiology residents choose fellowship.

PURPOSE: The objective of this study is to assess factors that influence radiology residents' decision to pursue fellowship. Historically a large majority of Diagnostic Radiology (DR) residents have pursued fellowship, but with changes in the job market and the Covid-19 pandemic, this study analyzes the current trends associated with radiology fellowship choice. MATERIALS AND METHODS: An anonymous 28-question survey was constructed based on literature review and pilot feedback from university radiology residents. The survey was distributed through APDR and to all program coordinators to be distributed to residents. Demographic information and questions related to fellowship choice were assessed. The survey was conducted through RedCap and consisted of multiple choice and sliding scale questions. RESULTS: 214 radiology residents responded, representing 4.6 % of US DR residents across 199 programs. The top fellowship choices included neuroradiology (20.5 %), musculoskeletal imaging (17.3 %), body imaging (16.8 %), and breast imaging (16.4 %). Most influential factors for fellowship selection were strong personal interest, enjoyable rotation, work hours, job security, and compensation. Least influential factors were research opportunities and specific group practice. CONCLUSION: The decision to pursue fellowship remains almost unanimous among US DR residents. Strong personal interest, enjoyable rotations, and favorable work hours were rated as the most important factors in the decision to pursue fellowship. Neuroradiology, musculoskeletal, and body imaging remained the most popular specialties, with a notable increase in interest in breast radiology compared to literature. To attract prospective fellows, residency and fellowship programs should emphasize aforementioned factors and offer more early exposure to subspecialties during residency.

Physical late effects of treatment among survivors of childhood cancer in low- and middle-income countries: a systematic review.

PURPOSE: Physical late effects of treatment are well-documented among childhood cancer survivors in high-income countries, but whether prevalence and risk factors are comparable in low- and middle-income countries (LMICs) is unclear. We conducted a systematic review to assess physical late effect outcomes among childhood cancer survivors in LMICs. METHODS: Five health sciences databases were searched from inception to November 2022 in all languages. We included observational studies conducted in LMICs that evaluated physical late effects of treatment in childhood cancer survivors. Mean or median cohort follow-up must have been ≥ 5 years from original cancer diagnosis. RESULTS: Sixteen full articles and five conference abstracts were included. Studies were conducted in lower-middle (n = 12, 57%) or upper-middle income (n = 9, 43%) countries; nearly half (n = 9, 43%) were conducted in India. Five cohorts (24%) were comprised entirely of 5-year survivors. Subsequent malignant neoplasms were reported in 0-11% of survivors (n = 10 studies). Hypothyroidism and metabolic syndrome prevalence ranged from 2-49% (n = 4 studies) and 4-17% (n = 5 studies), respectively. Gonadal dysfunction ranged from 3-47% (n = 4 studies). Cardiac dysfunction ranged from 1-16% (n = 3 studies). Late effects of the musculoskeletal and urinary systems were least investigated. CONCLUSIONS: Substantial knowledge gaps exist in LMIC childhood cancer survivorship. No low-income country data were found. In middle-income countries, late effects were defined and assessed variably and limited by selection bias and small sample sizes. IMPLICATIONS FOR CANCER SURVIVORS: Survivors in LMICs can experience physical late effects of treatment, though additionally systematically collected data from survivor cohorts are needed to fill knowledge gaps.

Use of Soft Cervical Collar Improves Surgeon Ergonomics During Simulated Otologic Surgery.

OBJECTIVE: To determine whether surgeon use of a soft cervical collar during endoscopic and microscopic otologic surgery is feasible and impacts surgeon ergonomics as measured by inertial sensors. STUDY DESIGN: Prospective crossover trial. SETTING: US-based otolaryngology training program. PATIENTS: Otolaryngology residents and fellows. INTERVENTIONS: Therapeutic-use of a soft cervical collar during simulated otologic surgery. MAIN OUTCOME MEASURES: Time spent in high-risk angles of neck and back flexion and extension; average angle of neck flexion, extension, rotation, and lateral bending; validated assessment of neck pain; average daily phone use. RESULTS: Fifteen subjects met criteria for inclusion. Ten of 15 (67%) were male. Seven of 15 (47%) were postgraduate year 1-2. Seven of 15 (47%) reported a history of neck pain. None reported prior spinal steroid injections or surgery. Across all subjects, use of the soft cervical collar significantly reduced time spent in high-risk angles of neck flexion/extension during both endoscopic (56% vs. 35%, p < 0.05) and microscopic (60% vs. 32%, p < 0.05) otologic surgery. There was no effect on back flexion or extension. There was no difference in time spent in high-risk neck or back angles between endoscopic and microscopic surgery. Average angles of neck or back flexion, extension, lateral bending, and rotation were not significantly different for subgroups with more operative experience, increased phone use, perception of good posture, or history of neck pain. CONCLUSIONS: Use of a soft cervical collar during simulated otologic surgery significantly reduced time spent in high-risk neck positions. These data support feasibility of soft collar use during otologic surgery and hold promise for reduction in the high rates of neck pain reported by neurotologists. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Improving surgeon ergonomics for otologic surgery. LEARNING OBJECTIVE: To identify a therapeutic intervention to mitigate neck pain in surgeons caused by assumption of high-risk cervical neck flexion and extension. DESIRED RESULT: To demonstrate that use of a readily available soft cervical collar reduces risk of neck pain in otologic surgeons. LEVEL OF EVIDENCE: II. INDICATE IRB OR IACUC: Exempt.

Hepatic Arteriovenous Malformation in a Preterm Infant With High-Output Cardiac Failure.

Congenital hepatic arteriovenous malformations (HAVM) are rare and serious with a known high mortality rate. They are mostly described in the term population and, if symptomatic, present with early-onset congestive heart failure. To our knowledge, there have been no published cases of an affected very preterm infant. Prenatal diagnosis and preprocedural planning are paramount in these critically ill infants. Strategies for management of HAVM differ depending on the size of both the infant and HAVM as well as severity of symptoms. Management may include supportive pharmacologic therapy, transcatheter embolization, and surgical resection or ligation. In this report, we present the case of a 28-week gestation infant with high-output cardiac failure secondary to prenatally diagnosed hepatic arteriovenous malformation. On day of life 3, the infant underwent successful transcatheter occlusion. However, despite maximal medical management and partial embolization of his HAVM, he did not survive.

A fusion of VGG-16 and ViT models for improving bone tumor classification in computed tomography.

Background and Objective: Bone tumors present significant challenges in orthopedic medicine due to variations in clinical treatment approaches for different tumor types, which includes benign, malignant, and intermediate cases. Convolutional Neural Networks (CNNs) have emerged as prominent models for tumor classification. However, their limited perception ability hinders the acquisition of global structural information, potentially affecting classification accuracy. To address this limitation, we propose an optimized deep learning algorithm for precise classification of diverse bone tumors. Materials and Methods: Our dataset comprises 786 computed tomography (CT) images of bone tumors, featuring sections from two distinct bone species, namely the tibia and femur. Sourced from The Second Affiliated Hospital of Fujian Medical University, the dataset was meticulously preprocessed with noise reduction techniques. We introduce a novel fusion model, VGG16-ViT, leveraging the advantages of the VGG-16 network and the Vision Transformer (ViT) model. Specifically, we select 27 features from the third layer of VGG-16 and input them into the Vision Transformer encoder for comprehensive training. Furthermore, we evaluate the impact of secondary migration using CT images from Xiangya Hospital for validation. Results: The proposed fusion model demonstrates notable improvements in classification performance. It effectively reduces the training time while achieving an impressive classification accuracy rate of 97.6%, marking a significant enhancement of 8% in sensitivity and specificity optimization. Furthermore, the investigation into secondary migration's effects on experimental outcomes across the three models reveals its potential to enhance system performance. Conclusion: Our novel VGG-16 and Vision Transformer joint network exhibits robust classification performance on bone tumor datasets. The integration of these models enables precise and efficient classification, accommodating the diverse characteristics of different bone tumor types. This advancement holds great significance for the early detection and prognosis of bone tumor patients in the future.

Morphological and genetic mechanisms underlying the plasticity of the coral Porites astreoides across depths in Bermuda.

The widespread decline of shallow-water coral reefs has fueled interest in assessing whether mesophotic reefs can act as refugia replenishing deteriorated shallower reefs through larval exchange. Here we explore the morphological and molecular basis facilitating survival of planulae and adults of the coral Porites astreoides (Lamarck, 1816; Hexacorallia: Poritidae) along the vertical depth gradient in Bermuda. We found differences in micro-skeletal features such as bigger calyxes and coarser surface of the skeletal spines in shallow corals. Yet, tomographic reconstructions reveal an analogous mineral distribution between shallow and mesophotic adults, pointing to similar skeleton growth dynamics. Our study reveals patterns of host genetic connectivity and minimal symbiont depth-zonation across a broader depth range than previously known for this species in Bermuda. Transcriptional variations across life stages showed different regulation of metabolism and stress response functions, unraveling molecular responses to environmental conditions at different depths. Overall, these findings increase our understanding of coral acclimatory capability across broad vertical gradients, ultimately allowing better evaluation of the refugia potential of mesophotic reefs.

Establishing a pediatric interventional radiology inpatient consult service.

OBJECTIVE: To delineate pediatric interventional radiology (IR) inpatient consult growth and resulting collections after implementation of a pediatric IR consult service. METHODS: An inpatient IR consult process was created at a single academic children's hospital in October 2019. IR consult note templates were created in Epic (Epic Systems Corporation, Verona, Wisconsin) and utilized by 4 IR physicians. Automatic charge generation was linked to differing levels of evaluation and management (E&M) service relating to current procedural terminology (CPT) inpatient consult codes 99251-99255. The children's hospital informatics division identified IR consult notes entered from the implementation of the consult service: October 2019 to January 2022. The university radiology department billing office provided IR service E&M charge, payment, and relative value units (RVU) information during this study period. A chart review was performed to determine the IR procedure conversion rate. Mann-Whitney and a two-sample t-test statistical analyses compared use of the 25-modifier, monthly consult growth and monthly payment growth. P-value < 0.05 was considered statistically significant.  RESULTS: Within this 27-month period, a total of 2153 inpatient IR consults were performed during 1757 Epic hospital encounters; monthly consult peak was reached 5 months into the study period. Consult level breakdown by CPT codes: 99251-8.7%, 99252-81.7%, and 99253-8.8%. 69.7% of IR consults had consult-specific billing with payments in 96.4% resulting in $143,976 new revenue. From 2020 to 2021, IR consult volume trended upward by 13.4% (P =0.069), and consult-specific payments increased by 84.1% (P<0.001). IR consult procedure conversion rate was 96.5%. CONCLUSION: An inpatient pediatric IR consult service was quickly established and maintained by four physicians over a 27-month study period. Annual IR consult volume trended upward and consult-specific payments increased, resulting in previously uncaptured IR service revenue.

Ergonomic Analysis of Otologic Surgery: Comparison of Endoscope and Microscope.

OBJECTIVE: The comparative postural health of surgeons performing endoscopic and microscopic otologic surgeries has been a topic of active debate, with many nascent or anecdotal reports suggesting the latter encourages suboptimal ergonomics. Using inertial body sensors to measure joint angles, this study sought to objectively evaluate and compare the ergonomics of surgeons during endoscopic and microscopic otologic surgeries. STUDY DESIGN: Prospective pilot trial. SETTING: Large, multicenter, academic hospital system. Performed 21 otologic operations (10 endoscopic and 11 microscopic) in November 2020 and January 2021. All attendings were fellowship trained in otology/neurotology. SUBJECTS: Eight otolaryngologists (four attendings and four residents) performing 21 otologic surgeries (11 microscopic and 10 endoscopic). INTERVENTION: Approach to otologic surgery: endoscope or microscope. MAIN OUTCOME MEASURES: Surgeons' neck and back angles while wearing ergonomic sensors affixed to either side of each major joint, mental and physical burdens and pain after each surgery (via modified NASA Task Load Index). RESULTS: Residents' necks (9.54° microscopic vs. -4.79° endoscopic, p = 0.04) and backs (16.48° microscopic vs. 3.66° endoscopic, p = 0.01) were significantly more flexed when performing microscopic surgery than when performing endoscopic surgery, although attending neck and back flexion were comparable during microscopic and endoscopic surgeries. Attendings reported significantly higher pain levels after operating microscopically than after operating endoscopically (0.13 vs. 2.76, p = 0.01). CONCLUSIONS: Residents were found to operate with significantly higher risk back and neck postures (as defined by the validated ergonomic tool, Rapid Entire Body Assessment) when operating microscopically. Attendings reported significantly higher levels of pain after operating microscopically versus endoscopically, suggesting that the suboptimal microscopic postures adopted earlier in training may pose an indelible risk later in a surgeon's career.

Intraosseous resection of mandibular arteriovenous malformations: A mandible sparing multi-disciplinary case series.

Mandibular arteriovenous malformations (AVMs) are high flow vascular malformations that can cause pain, hypertrophy, deformity, malocclusion, jaw asymmetry, bone destruction, tooth loss, and severe bleeding [1]. Although general principles apply, the rarity of mandibular AVMs limits definitive agreement on the best course of treatment. Current treatment options include embolization, sclerotherapy, surgical resection, or some combination of techniques [2]. [3]. An alternative multidisciplinary technique of embolization with mandibular-sparing resection is presented. This technique aims to mitigate bleeding with effective removal of the AVM, while preserving mandibular form, function, dentition, and occlusion.

Defining the Learning Curve for Endoscopic Ear Skills Using a Modular Trainer: A Multi-Institutional Study.

OBJECTIVE: Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development. STUDY DESIGN: Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer. SETTING: Two academic teaching hospitals. SUBJECTS: Otolaryngology residents. MAIN OUTCOME MEASURES: Trial completion times; rate of improvement over time. RESULTS: Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001). CONCLUSIONS: Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.

Surgeon-designed patient-specific instrumentation improves glenoid component screw placement for reverse total shoulder arthroplasty in a population with small glenoid dimensions.

PURPOSE: Glenoid component loosening is a potential complication of reverse total shoulder arthroplasty (rTSA), occurring in part due to lack of adequate screw purchase in quality scapular bone stock. This study was to determine the efficacy of a surgeon-designed, 3D-printed patient-specific instrumentation (PSI) compared to conventional instrumentation (CI) in achieving longer superior and inferior screw lengths for glenoid component fixation. METHODS: A multi-centre retrospective analysis of patients who underwent rTSA between 2015 and 2020. Lengths of the superior and inferior locking screws inserted for fixation of the glenoid baseplate component were recorded and compared according to whether patients received PSI or CI. Secondary outcomes included operative duration and incidence of complications requiring revision surgery. RESULTS: Seventy-three patients (31 PSI vs. 42 CI) were analysed. Average glenoid diameter was 24.5 mm (SD: 3.1) and 81% of patients had smaller glenoid dimensions compared to the baseplate itself. PSI produced significantly longer superior (44.7 vs. 30.7 mm; P < 0.001) and inferior (43.0 vs. 31 mm; P < 0.001) mean screw lengths, as compared to CI. A greater proportion of maximal screw lengths for the given rTSA construct (48 mm) were observed in the PSI group (71.9% vs. 11.9% superior, 59.4% vs. 11.9% inferior). Operative duration was not statistically significantly different between the PSI and CI groups (150 min vs. 169 min, respectively; P = 0.229). No patients had radiographic loosening of the glenoid component with an average of 2-year follow-up. CONCLUSION: PSI facilitates longer superior and inferior screw placement in the fixation of the glenoid component for rTSA. With sufficient training, PSI can be designed and implemented by surgeons themselves.

Institutional Experience With Cochlear Implants Falling Under the 2020 FDA Corrective Action.

OBJECTIVE: To determine the rate of device failure for those cochlear implants falling under the 2020 Food and Drug Administration (FDA) voluntary corrective action. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary otology-neurotology practice. PATIENTS: Those with cochlear implant failure falling under the FDA corrective action. INTERVENTIONS: Cochlear implant explant and reimplantation. OUTCOME MEASURES: Reason for cochlear implant failure, time to failure, symptoms of failure, and benefit from reimplantation. RESULTS: The overall failure rate was 20.0% (18 of 90 ears); of the failures, 15 of 18 (83.3%) were hard device failures, and 3 of 18 (16.7%) were medical or surgical failures. All hard device failures were confirmed with integrity testing as performed by the company. The average time to integrity testing was 38.0 months. Of the hard failures, 14 of 15 had successful initial activation and benefit. Lack of expected progress was seen in 7 of 15 and a sudden decline in function in 8 of 15. Electrodes 9 to 16 were most often defunct. Significant drops in speech perception were often seen in device failure cases. Three medical/surgical failures were explanted; one had migration of the receiver/stimulator causing discomfort, and the other two had electrode migration after partial insertion. Of the reimplanted patients, 11 of 12 are deriving benefit from their new devices. CONCLUSIONS: The rate of device failure for the cochlear implants of interest is significantly higher in our series than reported in the initial FDA voluntary field corrective action publication.

Designing the physical environment for inpatient palliative care: a narrative review.

BACKGROUND: It is essential that the physical environments in which inpatient palliative care is provided support the needs of patients and the facilitate the multidimensional delivery of palliative care. This review aims to identify the features and characteristics of inpatient palliative care environments that enhance or detract from the patient experience; and identify opportunities for progress within this field. METHOD: Three databases were searched: MEDLINE (1946-2020), PsycINFO (1806-2020) and CINAHL (1937-2020). Articles were screened by title and abstract with included studies read in full for data extraction. Data synthesis involved thematic analysis informed by the findings of the included literature. Inclusion criteria were studies with empirical methodology examining adult palliative care in the hospital, hospice or nursing home environment. Studies that examined palliative care delivered within the emergency department, ICU or within the home were excluded, as were those related to paediatric palliative care. RESULTS: Four main themes were identified: the provision of privacy, facilitating interactions with family, facilitating comfort through homeliness and connections to nature. CONCLUSIONS: The board acceptance of single rooms as the preeminent design solution for supporting privacy, dignity and family interaction, alongside current conceptions of homeliness that typically focus on matters of interior design, are limiting possibilities for further design innovation within palliative care settings. Research that investigates a broader set of design strategies through which the built environment can support care, alongside enhanced interdisciplinary collaboration, could positively contribute to patient and family experiences of inpatient palliative care.

The Use of Five-Strand Hamstring Autograft to Increase the Graft Size in Anterior Cruciate Ligament Reconstruction-A Prospective Cohort Study With Satisfactory Early Clinical Results.

Objectives: To report on the outcomes of using 5-strand hamstring autograft to increase the graft size for anterior cruciate ligament (ACL) reconstruction and to determine whether the clinical results are comparable to using conventional 4-strand graft. Methods: A prospective cohort study of patients with arthroscopic-assisted single-bundle ACL reconstruction using hamstring autograft from January 2019 to June 2021.The patients were prospectively recruited to undergo ACL reconstruction with either 5-strand hamstring graft (group A) or 4-strand hamstring graft (group B). Results: In total, 45 patients were included into the study. The mean diameter of the final graft was 8.9 ± 0.6 cm in the 5-strand group and 7.5 ± 0.8 cm in the 4-strand group (P < .001). Four-strand graft diameter measurements were taken intraoperatively in the 5-strand group before preparation of the 5-strand graft. The mean graft diameter of the 4-strand grafts was similar in both groups: 7.3 ± 0.3 mm in group A and 7.5 ± 0.8 mm in group B (P = .72). There was no statistically significant difference between the 2 groups of patients in terms of the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) Symptoms, KOOS Pain, KOOS Activities of Daily Living, KOOS Sports and KOOS Quality of Life scores. There were no postoperative complications of wound infection in both groups of patients. There was one case of graft rupture (4.8%) in the 4-strand group, which required revision reconstruction with patellar tendon graft 9 months postoperatively. There was no case of graft rupture in the 5-strand group (P = .29). Conclusions: The 5-strand hamstring graft technique provides a graft with significantly larger graft diameter than the quadrupled graft technique, with satisfactory short- to medium-term outcomes. The 5-strand graft is therefore a useful technique to increase the graft size when faced with the problem of small hamstring graft. Level of Evidence: Level II, prospective cohort study.

Honoring Long-Lived Cultural Beliefs for End-of-Life Care: Are We Prepared in the Modern Western Society?

The Hippocratic Oath establishes the principle of primum non nocere or "first do no harm" in Western medicine. This not only includes physical health but also encompasses emotional and spiritual health. Various end-of-life care (EOLC) practices exist in different societies, and it is hard but vital for the healthcare community to be aware of these practices to allow wholesome care for their patients, which is emotionally and spiritually fulfilling.  A 57-year-old male with a history of metastatic squamous cell carcinoma of the head and neck region presented to the emergency department after an out-of-hospital cardiac arrest. After appropriate post-cardiac arrest care, the patient remained unresponsive, and the family decided to transition to comfort-focused care. Based on their religious and cultural preferences, they preferred palliative extubation at a place where the patient would not have a roof over his head at the time of death, as well as sought help to facilitate a same-day funeral. After coordinating with various departments in the hospital, the patient was taken to the hospital helipad and extubated there in the family's presence. The patient's remains were released to the family within an hour of death for a timely funeral.  This case is an example of cultural and religious diversity that exists within our community. Healthcare is a complex field and EOLC is a crucial part of patient care. With a multi-disciplinary approach towards EOLC, the distress related to death can be reduced among families as well as healthcare teams.

Initial Experience With Two Active Transcutaneous Bone-Anchored Hearing Implants.

OBJECTIVE: To analyze our institutional experience with two active transcutaneous bone-anchored hearing aids. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic otology-neurotology practice. PATIENTS: Patients with conductive or mixed hearing losses meeting criteria to receive active transcutaneous bone-anchored hearing aids. INTERVENTIONS: Implantation with one of two active transcutaneous bone-anchored hearing aids. OUTCOME MEASURES: Operative time, dural exposure and decompression, use of lifts, implant position, ease of use, qualitative patient satisfaction, complication rates. RESULTS: Ten patients received Implant 1 and 11 patients received Implant 2. The most common underlying etiologies of hearing loss were chronic suppurative otitis media in 33.3%, atresia/microtia in 23.8%, and cholesteatoma in 23.8%. Average operative times were 99.3 minutes for Implant 1 and 80.9 minutes for Implant 2 ( p = 0.263). Implant 1 required lifts in 60%, dural exposure in 50%, and dural compression in 30%. Overall, placement was difficult in 47.6% of cases. There were no intraoperative complications. There were higher rates of issues with sound quality (27.3% versus 0.0%, p = 0.123) and poor cosmesis (36.4% versus 10.0%, p = 0.360) with Implant 2. Functional gain was not recorded, but all patients derived qualitative benefit from their implant. Three patients had local wound complications that self-resolved or were treated with antibiotics. One patient implanted at an outside institution required explant because of multiple infections. CONCLUSIONS: There were no statistically significant differences in outcomes comparing Implants 1 and 2; however, Implant 2 had much higher rates of issues with audio quality and poor cosmesis. Placing Implant 1 often required special techniques.