Asthma management in the digital age.

Asthma affects 25 million people in the United States, and its prevalence is increasing. Access to care and adherence to prescribed asthma-treatment programs remain the principal formidable challenges for asthma management. Telemedicine offers substantial opportunities for improved asthma care of patients across the full range of socioeconomic strata. Ever-improving digital tools for asthma assessment and treatment are key components of telemedicine platforms for asthma management. These include a variety of remote patient-monitoring devices, digital inhaler systems, and mobile-health applications that facilitate ongoing assessment and adherence to treatment protocols. Digital tools for monitoring treatment focus on tracking medication use, inhalation technique, and physiological markers such as peak-flow rate and pulse-oximetry. Telemedicine visits allow for elements of assessment via video, approximating or duplicating many aspects of in-person visits, such as evaluating a patient's general appearance, breathing effort, and cough. Challenges remain in ensuring equitable access to these technologies, especially in rural and low-income areas, and in maintaining patient privacy and data security in digital platforms.

Navigating the spectrum of pediatric sialorrhea management: A narrative review.

OBJECTIVE: This review summarizes the approaches to pediatric sialorrhea management from least-to-most invasive: non-pharmacological management, anticholinergic medications, botulinum neurotoxin, non-invasive surgery, and invasive surgical intervention. REVIEW METHODS: An electronic literature review identified English-language articles on sialorrhea management in pediatric patients. Publications between 1982 and 2022 were used, with a focus on articles published from 2012 to 2022. Additional augmentation of pharmacologic information was obtained from the latest editions of medical textbooks supplemented with official package inserts of investigated medications. CONCLUSIONS: Sialorrhea is abnormal in patients greater than four years of age. Severe cases warrant intervention to improve patient quality of life and reduce caregiver burden. Management starts with conservative approaches. Viable candidates begin with non-pharmacological management options. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus multiple treatments are required. Non-invasive sclerotherapy is an emerging treatment option showing promising results for sialorrhea. In contrast, surgical intervention is reserved as a last-resort treatment for patients with severe symptoms, due to its higher risk for adverse consequences. IMPLICATIONS FOR PRACTICE: Physicians should be familiar with the different pediatric sialorrhea management options, including advantages and disadvantages, to adequately facilitate shared decision making with caretakers of pediatric patients who require treatment.

Association between emergency department disposition and mortality in patients with COVID-19 acute respiratory distress syndrome.

Objectives: Patients hospitalized for COVID-19 frequently develop hypoxemia and acute respiratory distress syndrome (ARDS) after admission. In non-COVID-19 ARDS studies, admission to hospital wards with subsequent transfer to intensive care unit (ICU) is associated with worse outcomes. We hypothesized that initial admission to the ward may affect outcomes in patient with COVID-19 ARDS. Methods: This was a retrospective study of consecutive adults admitted for COVID-19 ARDS between March 2020 and March 2021 at Stanford Health Care. Mortality scores at hospital admission (Coronavirus Clinical Characterization Consortium Mortality Score [4C score]) and ICU admission (Simplified Acute Physiology Score III [SAPS-III]) were calculated, as well as ROX index for patients on high flow nasal oxygen. Patients were classified by emergency department (ED) disposition (ward-first vs. ICU-direct), and 28- and 60-day mortality and highest level of respiratory support within 1 day of ICU admission were compared. A second cohort (April 2021‒July 2022, n = 129) was phenotyped to validate mortality outcome. Results: A total of 157 patients were included, 48% of whom were first admitted to the ward (n = 75). Ward-first patients had more comorbidities, including lung disease. Ward-first patients had lower 4C and similar SAPS-III score, yet increased mortality at 28 days (32% vs. 17%, hazard ratio [HR] 2.0, 95% confidence interval [95% CI] 1.0‒3.7, p = 0.039) and 60 days (39% vs. 23%, HR 1.83, 95% CI 1.04‒3.22, p = 0.037) compared to ICU-direct patients. More ward-first patients escalated to mechanical ventilation on day 1 of ICU admission (36% vs. 14%, p = 0.002) despite similar ROX index. Ward-first patients who upgraded to ICU within 48 h of ED presentation had the highest mortality. Mortality findings were replicated in a sensitivity analysis. Conclusion: Despite similar baseline risk scores, ward-first patients with COVID-19 ARDS had increased mortality and escalation to mechanical ventilation compared to ICU-direct patients. Ward-first patients requiring ICU upgrade within 48 h were at highest risk, highlighting a need for improved identification of this group at ED admission.

Computer Vision and Augmented Reality for Human-Centered Fatigue Crack Inspection.

A significant percentage of bridges in the United States are serving beyond their 50-year design life, and many of them are in poor condition, making them vulnerable to fatigue cracks that can result in catastrophic failure. However, current fatigue crack inspection practice based on human vision is time-consuming, labor intensive, and prone to error. We present a novel human-centered bridge inspection methodology to enhance the efficiency and accuracy of fatigue crack detection by employing advanced technologies including computer vision and augmented reality (AR). In particular, a computer vision-based algorithm is developed to enable near-real-time fatigue crack detection by analyzing structural surface motion in a short video recorded by a moving camera of the AR headset. The approach monitors structural surfaces by tracking feature points and measuring variations in distances between feature point pairs to recognize the motion pattern associated with the crack opening and closing. Measuring distance changes between feature points, as opposed to their displacement changes before this improvement, eliminates the need of camera motion compensation and enables reliable and computationally efficient fatigue crack detection using the nonstationary AR headset. In addition, an AR environment is created and integrated with the computer vision algorithm. The crack detection results are transmitted to the AR headset worn by the bridge inspector, where they are converted into holograms and anchored on the bridge surface in the 3D real-world environment. The AR environment also provides virtual menus to support human-in-the-loop decision-making to determine optimal crack detection parameters. This human-centered approach with improved visualization and human-machine collaboration aids the inspector in making well-informed decisions in the field in a near-real-time fashion. The proposed crack detection method is comprehensively assessed using two laboratory test setups for both in-plane and out-of-plane fatigue cracks. Finally, using the integrated AR environment, a human-centered bridge inspection is conducted to demonstrate the efficacy and potential of the proposed methodology.

The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay.

OBJECTIVE: To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay. SUMMARY BACKGROUND DATA: ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain under-investigated. METHODS: This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both pre- and post-intubation. Multivariable logistic regression analysis was performed to identify the modifiable and non-modifiable factors associated with PIH. RESULTS: 708 patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) and 71% were male. Median [IQR] arrival GCS was 7 [3-13]. Patients who developed PIH had a lower mean (SD) pre-intubation SBP (118 (46) vs. 138 (28), P<0.001) and higher median [IQR] ISS (27 [21-38] vs. 21 [9-26], P<0.001). Multivariable regression analysis identified BMI>25, increasing ISS, penetrating injury, spinal cord injury, Pre-intubation PRBC requirements, and diabetes mellitus as non-modifiable risk factors associated with increased odds of PIH. In contrast, pre-intubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH. CONCLUSION: More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and non-modifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival. LEVEL OF EVIDENCE: Level III, Prognostic Study.

Wind-Induced Vibration Monitoring of High-Mast Illumination Poles Using Wireless Smart Sensors.

This paper describes the use of wireless smart sensors for examining the underlying mechanism for the wind-induced vibration of high-mast illumination pole (HMIP) structures. HMIPs are tall, slender structures with low inherent damping. Video recordings of multiple HMIPs showed considerable vibrations of these HMIPs under wind loading in the state of Kansas. The HMIPs experienced cyclic large-amplitude displacements at the top, which can produce high-stress demand and lead to fatigue cracking at the bottom of the pole. In this study, the natural frequencies of the HMIP were assessed using pluck tests and finite element modeling, and the recorded vibration frequencies were obtained through computer vision-based video analysis. Meanwhile, a 30.48 m tall HMIP with three LED luminaires made of galvanized steel located in Wakeeney, Kansas, was selected for long-term vibration monitoring using wireless smart sensors to investigate the underlying mechanism for the excessive wind-induced vibrations. Data analysis with the long-term monitoring data indicates that while vortex-induced vibration occurs frequently at relatively low amplitude, buffeting-induced vibration was the leading cause of the excessive vibrations of the monitored HMIP. The findings provide crucial information to guide the design of vibration mitigation strategies for these HMIP structures.

Adapted large language models can outperform medical experts in clinical text summarization.

Analyzing vast textual data and summarizing key information from electronic health records imposes a substantial burden on how clinicians allocate their time. Although large language models (LLMs) have shown promise in natural language processing (NLP) tasks, their effectiveness on a diverse range of clinical summarization tasks remains unproven. Here we applied adaptation methods to eight LLMs, spanning four distinct clinical summarization tasks: radiology reports, patient questions, progress notes and doctor-patient dialogue. Quantitative assessments with syntactic, semantic and conceptual NLP metrics reveal trade-offs between models and adaptation methods. A clinical reader study with 10 physicians evaluated summary completeness, correctness and conciseness; in most cases, summaries from our best-adapted LLMs were deemed either equivalent (45%) or superior (36%) compared with summaries from medical experts. The ensuing safety analysis highlights challenges faced by both LLMs and medical experts, as we connect errors to potential medical harm and categorize types of fabricated information. Our research provides evidence of LLMs outperforming medical experts in clinical text summarization across multiple tasks. This suggests that integrating LLMs into clinical workflows could alleviate documentation burden, allowing clinicians to focus more on patient care.

Anthropogenic aerosols mask increases in US rainfall by greenhouse gases.

A comprehensive understanding of human-induced changes to rainfall is essential for water resource management and infrastructure design. However, at regional scales, existing detection and attribution studies are rarely able to conclusively identify human influence on precipitation. Here we show that anthropogenic aerosol and greenhouse gas (GHG) emissions are the primary drivers of precipitation change over the United States. GHG emissions increase mean and extreme precipitation from rain gauge measurements across all seasons, while the decadal-scale effect of global aerosol emissions decreases precipitation. Local aerosol emissions further offset GHG increases in the winter and spring but enhance rainfall during the summer and fall. Our results show that the conflicting literature on historical precipitation trends can be explained by offsetting aerosol and greenhouse gas signals. At the scale of the United States, individual climate models reproduce observed changes but cannot confidently determine whether a given anthropogenic agent has increased or decreased rainfall.

Zircons reveal the history of fluctuations in oxidation state of crustal magmatism and supercontinent cycle.

We apply a zircon redox index to a global compilation of detrital zircons to track the variation of oxidation state, expressed as ΔFMQ, through Earth's history. Those from I-type rocks, which comprise mantle and crustal igneous protoliths, including tonalite-trondhjemite-granodiorites (TTGs), generally have a high oxidation state (ΔFMQ > 0). In contrast, zircons from igneous rocks derived from supracrustal source rocks (S-type) are commonly reduced (ΔFMQ < 0). With the probability density function derived from the Gaussian-Kernel-Density-Estimation, we use the maximum likelihood estimation (MLE) to distinguish S-type from I-type zircons through Earth's history using zircon redox. Voluminous S-type magma production shows a ca. 600 Ma cyclicity that is closely related to the supercontinent cycle. We link a cyclic drop in redox values after 2.6 Ga to periodic S-type magma generation associated with burial and melting of metasedimentary rocks during supercontinent assembly and amalgamation. The ΔFMQ of the detrital zircons rise at ∼3.5 Ga followed by a consistent average ΔFMQ > 0 over the last 3 Ga. Given that the redox state of magmas is independent of crustal thickness and silica variation, and elevated values are likely more closely related to tectonic setting, we suggest that the consistent average ΔFMQ > 0 from ca. 3.5 Ga onwards relates to recycling of oceanic lithosphere back into the mantle in what eventually became established as subduction zones. The more reduced magmas associated with sedimentary sources, became established at 2.6 Ga, presumably in response to continental rocks rising above sea-level, and follow peaks of productivity associated with the supercontinent cycle.

Clinical Text Summarization: Adapting Large Language Models Can Outperform Human Experts.

Sifting through vast textual data and summarizing key information from electronic health records (EHR) imposes a substantial burden on how clinicians allocate their time. Although large language models (LLMs) have shown immense promise in natural language processing (NLP) tasks, their efficacy on a diverse range of clinical summarization tasks has not yet been rigorously demonstrated. In this work, we apply domain adaptation methods to eight LLMs, spanning six datasets and four distinct clinical summarization tasks: radiology reports, patient questions, progress notes, and doctor-patient dialogue. Our thorough quantitative assessment reveals trade-offs between models and adaptation methods in addition to instances where recent advances in LLMs may not improve results. Further, in a clinical reader study with ten physicians, we show that summaries from our best-adapted LLMs are preferable to human summaries in terms of completeness and correctness. Our ensuing qualitative analysis highlights challenges faced by both LLMs and human experts. Lastly, we correlate traditional quantitative NLP metrics with reader study scores to enhance our understanding of how these metrics align with physician preferences. Our research marks the first evidence of LLMs outperforming human experts in clinical text summarization across multiple tasks. This implies that integrating LLMs into clinical workflows could alleviate documentation burden, empowering clinicians to focus more on personalized patient care and the inherently human aspects of medicine.

Right Ventricular Dysfunction Patterns among Patients with COVID-19 in the Intensive Care Unit: A Retrospective Cohort Analysis.

Rationale: Right ventricular (RV) dysfunction is common among patients hospitalized with coronavirus disease (COVID-19); however, its epidemiology may depend on the echocardiographic parameters used to define it. Objectives: To evaluate the prevalence of abnormalities in three common echocardiographic parameters of RV function among patients with COVID-19 admitted to the intensive care unit (ICU), as well as the effect of RV dilatation on differential parameter abnormality and the association of RV dysfunction with 60-day mortality. Methods: We conducted a retrospective cohort study of ICU patients with COVID-19 between March 4, 2020, and March 4, 2021, who received a transthoracic echocardiogram within 48 hours before to at most 7 days after ICU admission. RV dysfunction and dilatation, respectively, were defined by guideline thresholds for tricuspid annular plane systolic excursion (TAPSE), RV fractional area change, RV free wall longitudinal strain (RVFWS), and RV basal dimension or RV end-diastolic area. Association of RV dysfunction with 60-day mortality was assessed through logistic regression adjusting for age, prior history of congestive heart failure, invasive ventilation at the time of transthoracic echocardiogram, and Acute Physiology and Chronic Health Evaluation II score. Results: A total of 116 patients were included, of whom 69% had RV dysfunction by one or more parameters, and 36.3% of these had RV dilatation. The three most common patterns of RV dysfunction were the presence of three abnormalities, the combination of abnormal RVFWS and TAPSE, and isolated TAPSE abnormality. Patients with RV dilatation had worse RV fractional area change (24% vs. 36%; P = 0.001), worse RVFWS (16.3% vs. 19.1%; P = 0.005), higher RV systolic pressure (45 mm Hg vs. 31 mm Hg; P = 0.001) but similar TAPSE (13 mm vs. 13 mm; P = 0.30) compared with those with normal RV size. After multivariable adjustment, 60-day mortality was significantly associated with RV dysfunction (odds ratio, 2.91; 95% confidence interval, 1.01-9.44), as was the presence of at least two parameter abnormalities. Conclusions: ICU patients with COVID-19 had significant heterogeneity in RV function abnormalities present with different patterns associated with RV dilatation. RV dysfunction by any parameter was associated with increased mortality. Therefore, a multiparameter evaluation may be critical in recognizing RV dysfunction in COVID-19.

Bio-physical determinants of sediment accumulation on an offshore coral reef: A snapshot study.

Sediments are found on all coral reefs around the globe. However, the amount of sediment in different reservoirs, and the rates at which sediments move between reservoirs, can shape the biological functioning of coral reefs. Unfortunately, relatively few studies have examined reef sediment dynamics, and associated bio-physical drivers, simultaneously over matching spatial and temporal scales. This has led to a partial understanding of how sediments and living reef systems are connected, especially on clear-water offshore reefs. To address this problem, four sediment reservoirs/sedimentary processes and three bio-physical drivers were quantified across seven different reef habitats/depths at Lizard Island, an exposed mid-shelf reef on the Great Barrier Reef. Even in this clear-water reef location a substantial load of suspended sediment passed over the reef; a load theoretically capable of replacing the entire standing stock of on-reef turf sediments in just 8 h. However, quantification of actual sediment deposition suggested that just 2 % of this passing sediment settled on the reef. The data also revealed marked spatial incongruence in sediment deposition (sediment trap data) and accumulation (TurfPod data) across the reef profile, with the flat and back reef emerging as key areas of both deposition and accumulation. By contrast, the shallow windward reef crest was an area of deposition but had a limited capacity for sediment accumulation. These cross-reef patterns related to wave energy and reef geomorphology, with low sediment accumulation on the ecologically important reef crest aligning with substantial wave energy. These findings reveal a disconnect between patterns of sediment deposition and accumulation on the benthos, with the 'post-settlement' fate of sediments dependent on local hydrodynamic conditions. From an ecological perspective, the data suggests key contextual constraints (wave energy and reef geomorphology) may predispose some reefs or reef areas to high-load turf sediment regimes.

Dynamic Fracture and Crack Arrest Toughness Evaluation of High-Performance Steel Used in Highway Bridges.

Impact energy tests are an efficient method of verifying adequate toughness of steel prior to it being put into service. Based on a multitude of historical correlations between impact energy and fracture toughness, minimum impact energy requirements that correspond to desired levels of fracture toughness are prescribed by steel bridge design specifications. Research characterizing the fracture behavior of grade 485 and 690 (70 and 100) high-performance steel utilized impact, fracture toughness, and crack arrest testing to verify adequate performance for bridge applications. Fracture toughness results from both quasi-static and dynamic stress intensity rate tests were analyzed using the most recently adopted master curve methodology. Both impact and fracture toughness tests indicated performance significantly greater than the minimum required by material specifications. Even at the AASHTO Zone III service temperature, which is significantly colder than prescribed test temperatures, minimum average impact energy requirements were greatly exceeded. All master curve reference temperatures, both for quasi-static and dynamic loading rates, were found to be colder than the Zone III minimum service temperature. Three correlations between impact energy and fracture toughness were evaluated and found to estimate reference temperatures that are conservative by 12 to 50 °C (22 to 90 °F) on average for the grades and specimen types tested. The evaluation of two reference temperature shifts intended to account for the loading rate was also performed and the results are discussed.

The Transverse Turbinate Line: A Reliable Landmark for the Maxillary Sinus Natural Ostium.

OBJECTIVES: Approximating the maxillary sinus natural ostium's (MSNO) natural position during anterograde surgery is challenging, as only a single visual "landmark," the maxillary line, is routinely offered to guide the identification of the MSNO in three-dimensional space. Despite almost 40 years of endoscopic sinus surgery (ESS) experience in North America, maxillary recirculation and discontinuity between the natural and surgical ostia are commonly encountered during revision ESS. Consequently, we feel an additional visual landmark would assist in localizing the MSNO with or without image guidance. In this study, we aim to provide a second reliable landmark in the sinonasal cavity. METHODS: We present a cadaveric anatomical landmark series that provides a second visual landmark for the MSNO, which we have labeled the transverse turbinate line (TTL): a 2-millimeter zone of confidence for the craniocaudal positioning of the MSNO that can be combined with the anteroposterior (AP) landmark of the maxillary line. RESULTS: In our study, 40 cadaveric sinuses were dissected, and the TTL was found to correspond consistently with the zone between the superior and inferior aspects of the MSNO. CONCLUSION: We anticipate that this second relational landmark may decrease the time required for anterograde access to the MSNO in trainees, increase the accuracy of identification, and translate to lower long-term recirculation and maxillary surgery failure rates. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3285-3291, 2023.

Transitioning from epicutaneous to oral peanut immunotherapy.

Introduction: Epicutaneous immunotherapy (EPIT) has been tested in clinical trials for children with peanut allergy (PA) for its safety and efficacy in inducing desensitization. Aside from peanut avoidance and symptom management, oral immunotherapy (OIT) is another option for PA patients. However, OIT can be associated with adverse events and pose safety concerns to children and their caregivers. Methods: This study assessed 27 children who successfully completed a peanut EPIT trial. 18 of them transitioned to peanut OIT with starting doses ranging from 10-600 mg of peanut protein. Our aim was to learn more about the EPIT to OIT experience through descriptive survey responses and to gather information that may support the sequential use of the two immunotherapies for safe and positive outcomes that may not be achieved by either alone. Results: Overall, children and their caregivers had less anxiety about starting OIT after having had peanut exposure through EPIT. Most children who transitioned from EPIT to OIT had no or minor symptoms initially, with symptoms lessening later in OIT. Most were also able to maintain or increase their peanut dose over time, achieving maintenance doses of 60-2,000 mg. Discussion: In comparison with current literature on OIT for PA in children, the reported symptoms appeared less severe and less prevalent in the EPIT to OIT group. However, there were 3 participants who withdrew from OIT due to the development of intolerable symptoms. This study provides initial data in support of EPIT to OIT, and larger randomized controlled trials assessing effectiveness of the two therapies together are warranted.

AAV Vector Mediated Delivery of NG2 Function Neutralizing Antibody and Neurotrophin NT-3 Improves Synaptic Transmission, Locomotion, and Urinary Tract Function after Spinal Cord Contusion Injury in Adult Rats.

NG2 is a structurally unique transmembrane chondroitin sulfate proteoglycan (CSPG). Its role in damaged spinal cord is dual. NG2 is considered one of key inhibitory factors restricting axonal growth following spinal injury. Additionally, we have recently detected its novel function as a blocker of axonal conduction. Some studies, however, indicate the importance of NG2 presence in the formation of synaptic contacts. We hypothesized that the optimal treatment would be neutralization of inhibitory functions of NG2 without its physical removal. Acute intraspinal injections of anti-NG2 monoclonal antibodies reportedly prevented an acute block of axonal conduction by exogenous NG2. For prolonged delivery of NG2 function neutralizing antibody, we have developed a novel gene therapy: adeno-associated vector (AAV) construct expressing recombinant single-chain variable fragment anti-NG2 antibody (AAV-NG2Ab). We examined effects of AAV-NG2Ab alone or in combination with neurotrophin NT-3 in adult female rats with thoracic T10 contusion injuries. A battery of behavioral tests was used to evaluate locomotor function. In vivo single-cell electrophysiology was used to evaluate synaptic transmission. Lower urinary tract function was assessed during the survival period using metabolic chambers. Terminal cystometry, with acquisition of external urethral sphincter activity and bladder pressure, was used to evaluate bladder function. Both the AAV-NG2Ab and AAV-NG2Ab combined with AAV-NT3 treatment groups demonstrated significant improvements in transmission, locomotion, and bladder function compared with the control (AAV-GFP) group. These functional improvements associated with improved remyelination and plasticity of 5-HT fibers. The best results were observed in the group that received combinational AAV-NG2Ab+AAV-NT3 treatment.SIGNIFICANCE STATEMENT We recently demonstrated beneficial, but transient, effects of neutralization of the NG2 proteoglycan using monoclonal antibodies delivered intrathecally via osmotic mini-pumps after spinal cord injury. Currently, we have developed a novel gene therapy tool for prolonged and clinically relevant delivery of a recombinant single-chain variable fragment anti-NG2 antibody: AAV-rh10 serotype expressing scFv-NG2 (AAV-NG2Ab). Here, we examined effects of AAV-NG2Ab combined with transgene delivery of Neurotrophin-3 (AAV-NT3) in adult rats with thoracic contusion injuries. The AAV-NG2Ab and AAV-NG2Ab+AAV-NT3 treatment groups demonstrated significant improvements of locomotor function and lower urinary tract function. Beneficial effects of this novel gene therapy on locomotion and bladder function associated with improved transmission to motoneurons and plasticity of axons in damaged spinal cord.

Impact of intraoperative wound dressing on post-tracheostomy pressure injuries.

OBJECTIVE: Determine the efficacy of a team-based approach to reduce tracheostomy-related skin breakdown by creating a standardized intraoperative dressing and nursing wound care protocol. METHODS: Prospective data collection of pediatric tracheostomy outcomes before and after interventions consisting of intraoperative wound dressing and standardized nursing wound care bundles. RESULTS: Before intervention, the incidence of skin breakdown within the first-week post-tracheostomy was 52% (13/25). Among patients who received an intraoperative wound dressing and nursing wound care bundles, the incidence of skin breakdown was reduced to 6.1% (3/49). CONCLUSION: The adoption of intraoperative wound dressings and nursing wound care bundles has nearly eliminated the incidence of skin breakdown in the first week post-tracheostomy among patients 0-12 years of age.

Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis.

INTRODUCTION: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. METHODS: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. RESULTS: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.

Initiating daily acute intermittent hypoxia (dAIH) therapy at 1-week after contusion spinal cord injury (SCI) improves lower urinary tract function in rat.

Spinal cord injury (SCI) above the level of the lumbosacral spinal cord produces lower urinary tract (LUT) dysfunction, resulting in impairment of urine storage and elimination (voiding). While spontaneous functional recovery occurs due to remodeling of spinal reflex micturition pathways, it is incomplete, indicating that additional strategies to further augment neural plasticity following SCI are essential. To this end, acute intermittent hypoxia (AIH) exposure has been proposed as a therapeutic strategy for improving recovery of respiratory and other somatic motor function following SCI; however, the impact of AIH as a therapeutic intervention to improve LUT dysfunction remains to be determined. Therefore, we examined the effects of daily AIH (dAIH) on both spontaneous micturition patterns and reflex micturition event (rME) behaviors in adult female Sprague-Dawley rats with mid-thoracic moderate contusion SCI. For these experiments, dAIH gas exposures (five alternating 3 min 12% O2 and 21% O2 episodes) were delivered for 7 consecutive days beginning at 1-week after SCI, with awake micturition patterns being evaluated weekly for 2-3 sessions before and for 4 weeks after SCI and rME behaviors elicited by continuous infusion of saline into the bladder being evaluated under urethane anesthesia at 4-weeks after SCI; daily normoxia (dNx; 21% O2 episodes) served as a control. At 1-week post-SCI, both an areflexic phenotype (i.e., no effective voiding events) and a functional voiding phenotype (i.e., infrequent voiding events with large volumes) were observed in spontaneous micturition patterns (as expected), and subsequent dAIH, but not dNx, treatment led to recovery of spontaneous void frequency pattern to pre-SCI levels; both dAIH- and dNx-treated rats exhibited slightly increased void volumes. At 4-weeks post-SCI, rME behaviors showed increased effectiveness in voiding in dAIH-treated (compared to dNx-treated) rats that included an increase in both bladder contraction pressure (delta BP; P = 0.014) and dynamic voiding efficiency (P = 0.018). Based on the voiding and non-voiding bladder contraction behaviors (VC and NVC, respectively) observed in the BP records, bladder dysfunction severity was classified into mild, moderate, and severe phenotypes, and while rats in both treatment groups included each severity phenotype, the primary phenotype observed in dAIH-treated rats was mild and that in dNx-treated rats was moderate (P = 0.044). Taken together, these findings suggest that 7-day dAIH treatment produces beneficial improvements in LUT function that include recovery of micturition pattern, more efficient voiding, and decreased NVCs, and extend support to the use of dAIH therapy to treat SCI-induced LUT dysfunction.

A snapshot of sediment dynamics on an inshore coral reef.

Sediments are ubiquitous on coral reefs. However, studies of reef sediments have largely focused on isolated reservoirs, or processes, and rarely consider hydrodynamic drivers. We therefore provide a quantitative snapshot of sediment dynamics on a coral reef. Across a depth profile, we simultaneously examined: suspended sediments, sediment deposition and accumulation, and hydrodynamic and biological movement processes. We reveal the marked potential for the water column to deliver sediments. Currents carried 12.6 t of sediment over the 2,314 m2 study area in 6 days. Sediment traps suggested that a surprisingly high percentage of this sediment was potentially deposited (5.2%). Furthermore, wave-driven resuspension and reworking by parrotfishes separated a highly dynamic sediment regime on the shallow reef flat (3 m), from a more stagnant reef slope (4.5 m-12 m). This study provides a comprehensive model of how hydrodynamic forces and on-reef processes may shape sediment dynamics on a coral reef.