Consensus guidelines on the bedside assistant skills required in robotic surgery.

BACKGROUND: While bedside assistants play a critical role in many robotic operations, substantial heterogeneity remains in bedside assistant training pathways. As such, this study aimed to develop consensus guidelines for bedside assistant skills required for team members in robotic operations. METHODS: We designed a study using the Delphi process to develop consensus guidelines around bedside assistant skills. We generated an initial list of bedside assistant skills from the literature, training materials, and expert input. We selected experts for the Delphi process based on prior scholarship in the area of robotic bedside assistant education and experience facilitating robotic bedside assistant training. For each item, respondents specified which robotic team members should have the skill from a list of "basic" bedside assistants, "advanced" bedside assistants, surgeons, surgical technologists, and circulating nurses. We conducted two rounds of the Delphi process and defined 80% agreement as sufficient for consensus. RESULTS: Fourteen experts participated in two rounds of the Delphi process. By the end of the second round, the group had reached consensus on 253 of 305 items (83%). The group determined that "basic" bedside assistants should have 52 skills and that "advanced" bedside assistants should have 60 skills. The group also determined that surgeons should have 54 skills, surgical technologists should have 25 skills, and circulating nurses should have 17 skills. Experts agreed that all participants should have certain communication skills and basic knowledge of aspects of the robotic system. CONCLUSIONS: We developed consensus guidelines on the skills required during robotic surgery by bedside assistants and other team members using the Delphi process. These findings can be used to design training around bedside assistant skills and assess team members to ensure that each team member has the appropriate skills. Hospitals can also use these guidelines to standardize expectations for robotic team members.

Electrical Stimulation Prevents Muscular Atrophy and the Decrease of Interleukin-6 in Paralyzed Muscles after Spinal Cord Injury in Rats.

Objective To analyze the muscle trophism and expression of interleukin-6 in the biceps brachii muscle of rats with incomplete cervical spinal cord injury treated with neuromuscular electrical stimulation (NMES). Methods Adult rats underwent C5-C7 spinal cord hemisection and a 5-week NMES protocol. Trophism of the biceps brachii was assessed using muscle weight/body weight ratio and histological analysis. Interleukin-6 expression from biceps brachii was measured using the enzyme-linked immunosorbent assay technique. Results Preservation of the biceps brachii muscle trophism was found in the NMES treated group, along with prevention of the reduction of interleukin-6 levels. Conclusion Spinal cord injury causes muscle atrophy and decreases interleukin-6 levels. These alterations are partially prevented by NMES. The results suggest a possible NMES action mechanism and underscore the clinical use of this therapeutic tool.

The novel HLA-A*23:140 allele was identified in a Brazilian bone marrow volunteer donor.

The HLA-A*23:140 allele differs from HLA-A*23:01:01 by one nucleotide substitution (G > A), position 1968 in exon 5.

Aldehydes alter TGF-ß signaling and induce obesity and cancer.

Obesity and fatty liver diseases-metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH)-affect over one-third of the global population and are exacerbated in individuals with reduced functional aldehyde dehydrogenase 2 (ALDH2), observed in approximately 560 million people. Current treatment to prevent disease progression to cancer remains inadequate, requiring innovative approaches. We observe that Aldh2-/- and Aldh2-/-Sptbn1+/- mice develop phenotypes of human metabolic syndrome (MetS) and MASH with accumulation of endogenous aldehydes such as 4-hydroxynonenal (4-HNE). Mechanistic studies demonstrate aberrant transforming growth factor ß (TGF-ß) signaling through 4-HNE modification of the SMAD3 adaptor SPTBN1 (ß2-spectrin) to pro-fibrotic and pro-oncogenic phenotypes, which is restored to normal SMAD3 signaling by targeting SPTBN1 with small interfering RNA (siRNA). Significantly, therapeutic inhibition of SPTBN1 blocks MASH and fibrosis in a human model and, additionally, improves glucose handling in Aldh2-/- and Aldh2-/-Sptbn1+/- mice. This study identifies SPTBN1 as a critical regulator of the functional phenotype of toxic aldehyde-induced MASH and a potential therapeutic target.

Paradoxical sleep deprivation and restriction promote castration-like effects and local inflammatory responses in male gerbil prostate.

Paradoxical sleep deprivation (PSD) presents different effects on metabolism and neurological functions. In addition, over long duration, sleep restriction (SR) can promote permanent changes. The prostate is an endocrine-dependent organ with homeostatic regulation directly related to hormone levels. Our study proposed to demonstrate the experimental prostatic effects of PSD (96 h), PSD with recovery (PSR - 96/96 h), and sleep restriction (SR - 30 PSD cycles/recovery). PSD and SR promoted decrease in serum testosterone and significant increase in serum and intraprostatic corticosterone. In agreement, androgen receptors (AR) were less expressed and glucocorticoid receptors (GR) were enhanced in PSR and SR. Thus, the prostate, especially under SR, demonstrates a castration-like effect due to loss of responsiveness and sensitization by androgens. SR triggered an important inflammatory response through enhancement of serum and intraprostatic pro- (IL-1α, IL-6, TNF-α) and anti-inflammatory (IL-10) cytokines. Furthermore, the respective receptors of anti-inflammatory cytokines (IL-1RI and TNF-R) were highly expressed in the prostatic epithelium and stroma. PSR can partially restore prostate homeostasis, as it restores testosterone and the prostate proliferation index, in addition to promoting balance in the inflammatory response that is considered protective. PSD and SR are key factors in the endocrine axis that coordinate prostatic homeostasis, and significant changes in these factors have consequences on prostate functionality.

Advances in silver nanoparticles: a comprehensive review on their potential as antimicrobial agents and their mechanisms of action elucidated by proteomics.

Nanoparticles play a crucial role in the field of nanotechnology, offering different properties due to their surface area attributed to their small size. Among them, silver nanoparticles (AgNPs) have attracted significant attention due to their antimicrobial properties, with applications that date back from ancient medicinal practices to contemporary commercial products containing ions or silver nanoparticles. AgNPs possess broad-spectrum biocidal potential against bacteria, fungi, viruses, and Mycobacterium, in addition to exhibiting synergistic effects when combined with certain antibiotics. The mechanisms underlying its antimicrobial action include the generation of oxygen-reactive species, damage to DNA, rupture of bacterial cell membranes and inhibition of protein synthesis. Recent studies have highlighted the effectiveness of AgNPs against various clinically relevant bacterial strains through their potential to combat antibiotic-resistant pathogens. This review investigates the proteomic mechanisms by which AgNPs exert their antimicrobial effects, with a special focus on their activity against planktonic bacteria and in biofilms. Furthermore, it discusses the biomedical applications of AgNPs and their potential non-preparation of antibiotic formulations, also addressing the issue of resistance to antibiotics.

Pediatric Solid Pseudopapillary Neoplasm of the Pancreas.

Background: Solid pseudopapillary neoplasm (SPN) of the pancreas in children is a rare tumor with low malignant potential. Some tumors, however, behave aggressively. There is very little literature on managing these variants, especially in children. We share our experience of managing large and recurrent SPN and explore the clinicopathological findings correlating to the risk of recurrence. Methods: This is a retrospective study of children treated for SPN between 2012 and 2022 at a tertiary care center in India. The clinicopathological features and management strategies in these children were evaluated. Results: Sixteen children with SPN were treated during this period (88% of girls). The median age of presentation was 12 years (interquartile range [IQR]: 9-14). All children presented with abdominal pain. Computed tomography gave a definitive diagnosis in 81% of cases. The tumor predominantly involved the head of the pancreas (n = 9, 56%). Eight of nine children classified as high-grade (HG) malignant had a benign course. One child had a recurrence of the tumor 4 years after the initial resection and further recurrence on chemotherapy. She required radiation therapy in addition to reoperation following which she was disease free for 77 months. The overall median follow-up was 46 months (IQR: 18-72 months). Conclusion: Complete resection of the tumor provides a cure in most patients with SPN. Recurrent tumors require a multi-modality approach. Long-term survival is good. There is a need for clear definitions of the components within the WHO criteria for HG malignancy.

Diagnostic accuracy of an uncorrected native T1 mapping sequence for liver fibrosis and inflammation in autoimmune hepatitis: a prospective study using histopathology as reference standard.

PURPOSE: There is an unmet clinical need for non-invasive imaging biomarkers that could replace liver biopsy in the management of patients with autoimmune hepatitis (AIH). In this study, we sought to evaluate the diagnostic accuracy of a simple uncorrected, non-contrast T1 mapping for detecting fibrosis and inflammation in AIH patients using histopathology as a reference standard. MATERIAL AND METHODS: Over 3 years, 33 patients with AIH were prospectively studied using a multiparametric liver MRI protocol which included T1 mapping. Biopsies were performed up to 3 months before imaging, and a standardized histopathological score for fibrosis (F0-F4) and inflammatory activity (PPA0-4) was used as a reference. Statistical analysis included independent t test, Mann-Whitney U-test, and ROC (receiver operating characteristic) analysis. RESULTS: T1 mapping values were significantly higher in patients with advanced fibrosis (F0-2 vs. F3-4; p < 0.015), significant fibrosis (F0-1 vs. F2-4; p < 0.005), and significant inflammatory activity (PPA 0-1 vs. PPA 2-4 p = 0.048). Moreover, the technique demonstrated a good diagnostic performance in detecting significant (AUC 0.856) and advanced fibrosis (AUC 0.835), as well as significant inflammatory activity (AUC 0.763). CONCLUSION: A rapid, simple, uncorrected, non-contrast T1 mapping sequence showed satisfactory diagnostic performance in comparison with histopathology for detecting significant tissue inflammation and fibrosis in AIH patients, being a potential non-invasive imaging biomarker for monitoring disease activity in such individuals.

Elucidating metformin action on the ovary and fertility in healthy mice.

Metformin is a hypoglycemic drug, widely used in type-2-diabetes (T2D) patients. In the last years, this drug has been suggested as a treatment for gestational diabetes and recommended to women with PCOS to increase the chances of pregnancy or avoid early miscarriages. However, the exact effects of metformin on the female reproductive tract in general, and on the ovary in particular, are still not completely understood. In this study, we analyzed the effect of metformin on fertility and ovarian physiology in healthy female mice. We found that this drug altered the estrous cycle, early follicular development, serum estradiol and progesterone levels, and ovarian steroidogenic enzyme expression. Moreover, ovarian angiogenesis was lower in metformin treated animals compared with untreated ones, whereas natural or gonadotropin-induced fertilization rates remained unchanged. However, offspring of metformin-treated animals displayed decreased body weight at birth. In this work, we unraveled the main effects of metformin on the ovary, isolated from other conditions such as hyperglycemia and hyperandrogenism, which is essential for a better understanding of metformin's mechanisms of action on reproduction and fertility.

Intraperitoneal Administration of 17-DMAG as an Effective Treatment against Leishmania braziliensis Infection in BALB/c Mice: A Preclinical Study.

BACKGROUND: Leishmaniasis is a significant global public health issue that is caused by parasites from Leishmania genus. With limited treatment options and rising drug resistance, there is a pressing need for new therapeutic approaches. Molecular chaperones, particularly Hsp90, play a crucial role in parasite biology and are emerging as promising targets for drug development. OBJECTIVE: This study evaluates the efficacy of 17-DMAG in treating BALB/c mice from cutaneous leishmaniasis through in vitro and in vivo approaches. MATERIALS AND METHODS: We assessed 17-DMAG's cytotoxic effect on bone marrow-derived macrophages (BMMΦ) and its effects against L. braziliensis promastigotes and intracellular amastigotes. Additionally, we tested the compound's efficacy in BALB/c mice infected with L. braziliensis via intraperitoneal administration to evaluate the reduction in lesion size and the decrease in parasite load in the ears and lymph nodes of infected animals. RESULTS: 17-DMAG showed selective toxicity [selective index = 432) towards Leishmania amastigotes, causing minimal damage to host cells. The treatment significantly reduced lesion sizes in mice and resulted in parasite clearance from ears and lymph nodes. It also diminished inflammatory responses and reduced the release of pro-inflammatory cytokines (IL-6, IFN-γ, TNF) and the regulatory cytokine IL-10, underscoring its dual leishmanicidal and anti-inflammatory properties. CONCLUSIONS: Our findings confirm the potential of 17-DMAG as a viable treatment for cutaneous leishmaniasis and support further research into its mechanisms and potential applications against other infectious diseases.

Sub-Tenon Triamcinolone and Anti-HIV Medication-Induced Cushing Syndrome.

This case report describes a diagnosis of iatrogenic Cushing syndrome as a result of sub-Tenon triamcinolone injection in a patient receiving treatment for HIV who presented with decreased visual acuity in both eyes.

Fc-engineered antibodies promote neutrophil-dependent control of Mycobacterium tuberculosis.

Mounting evidence indicates that antibodies can contribute towards control of tuberculosis (TB). However, the underlying mechanisms of humoral immune protection and whether antibodies can be exploited in therapeutic strategies to combat TB are relatively understudied. Here we engineered the receptor-binding Fc (fragment crystallizable) region of an antibody recognizing the Mycobacterium tuberculosis (Mtb) capsule, to define antibody Fc-mediated mechanism(s) of Mtb restriction. We generated 52 Fc variants that either promote or inhibit specific antibody effector functions, rationally building antibodies with enhanced capacity to promote Mtb restriction in a human whole-blood model of infection. While there is likely no singular Fc profile that universally drives control of Mtb, here we found that several Fc-engineered antibodies drove Mtb restriction in a neutrophil-dependent manner. Single-cell RNA sequencing analysis showed that a restrictive Fc-engineered antibody promoted neutrophil survival and expression of cell-intrinsic antimicrobial programs. These data show the potential of Fc-engineered antibodies as therapeutics able to harness the protective functions of neutrophils to promote control of TB.

Navigating a "Good Death" During COVID-19: Understanding Real-Time End-of-Life Care Structures, Processes, and Outcomes through Clinical Notes.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic severely disrupted hospice care, yet there is little research regarding how widespread disruptions affected clinician and family decision-making. We aimed to understand how the pandemic affected structures, processes, and outcomes of end-of-life care. RESEARCH DESIGN AND METHODS: Retrospective narrative chart review of electronic health records of 61 patients referred and admitted to hospice from three New York City geriatrics practices who died between March 1, 2020-March 31, 2021. We linked longitudinal, unstructured medical and hospice electronic health record notes to create a real-time, multi-perspective trajectory of patients' interactions with providers using directed content analysis. RESULTS: Most patients had dementia and were enrolled in hospice for 11 days. Care processes were shaped by structural factors (staffing, supplies, and governmental/institutional policies), and outcomes were prioritized by care teams and families (protecting safety, maintaining high-touch care, honoring patient values, and supporting patients emotionally and spiritually). Processes used to achieve these outcomes were decision-making, care delivery, supporting a "good death", and emotional and spiritual support. DISCUSSION AND IMPLICATIONS: Care processes were negotiated throughout end-of-life, with clinicians and families making in-the-moment decisions. Some adaptations were effective but also placed extraordinary pressure on paid and family caregivers. Health care teams' and families' goals to meet patients' end-of-life priorities can be supported by ongoing assessment of patient goals and process changes needed to support them, stronger structural supports for paid and family caregivers, incentivizing relationships across primary care and hospice teams, and extending social work and spiritual care.

"When You're in It, It Feels Like It's Everything": Medical Students' Experience of Failure and Remediation in the United States and the Netherlands.

PURPOSE: Medical training institutions worldwide must be prepared to remediate struggling learners, but there is little empirical evidence around learners' perspectives on remediation efforts. Research shows that emotion has a significant effect on learning, but it has not been well studied in remediation in medical education. Given the high stakes of remediation, understanding more about learners' emotional experience could lead to improvements in remediation programs. This study aimed to explore medical students' emotional experience of failure and remediation to offer opportunities to improve remediation. METHOD: This study is a thematic analysis of data collected from July to September 2022 from one-to-one interviews with students from 4 institutions (2 in the United States and 2 in the Netherlands) who had not met expectations on 1 or more medical school assessment(s). Interview questions explored students' experiences with learning of and responding to a performance that was below expected standards, with probes around any mentions of emotions. RESULTS: Fourteen students participated: 9 from schools in the United States and 5 from schools in the Netherlands. The students perceived the failure and remediation event to be highly significant, reflecting negatively on their suitability for a career as a physician. We identified 5 themes: (1) shame was pervasive and only retrospectively perceived as unwarranted; (2) self-doubt was common and weighty; (3) resentment, blame, and other external-facing emotions were present but softened over time; (4) worry and stress related to perceived career effect differed across countries; and (5) students had mixed emotional reactions to the remediation process. CONCLUSIONS: Medical students have strong emotional responses to failure and remediation. Expecting and considering emotions such as shame, self-doubt, and anger could help educators design better remediation programs. Differences across countries may be at least partially explained by different degrees of time variability and flexibility within the curricula.

Comparing observed and preferred instruction in robotic surgery.

BACKGROUND: The unique setup of robotic surgery challenges the traditional instructional dynamic between surgical learners and teachers. Previous studies have posited difficulties such as reliance on observational learning and ease of takeover. However, we lack understanding of how these instructional challenges manifest and are perceived by learners. Improving instruction has the potential to optimize education and performance in robotic surgery. METHODS: In this qualitative study, we conducted robotic case observations and learner interviews focusing on instruction in robotic surgery. We deductively generated codes in a theory-informed manner after review of the instructional literature in surgery, medicine, and other fields. We applied these codes in a rigorous directed content analysis of field notes and transcripts to identify themes. RESULTS: Thirty-eight faculty, fellows, and residents participated in 10 robotic cases and 20 semistructured interviews. Observed practices on the basis of case observations differed substantially from preferred practices on the basis of interview data. Using 37 codes, we identified 4 main themes related to instruction in robotic surgery: contextualization, individualization, autonomy, and multimodality. We contrasted observed and preferred instruction in each of these areas to generate instructional considerations that may better align preferences and practices. CONCLUSIONS: We observed several suboptimal instructional practices that contradicted preferred ways of learning. We suggested robotic-specific instructional considerations such as using multimodality to promote active learning and to reduce ambiguity. We also provided considerations applicable to all types of surgery, such as to include rationale to promote learning consolidation and to frame operative steps to allow trainees to plan their participation.

Performance and acceptability of the STREAM Disinfectant Generator for infection prevention and control practices in primary health care facilities in Uganda.

BACKGROUND: Effective infection prevention and control programs can positively influence quality of care, increase patient safety, and protect health care providers. Chlorine, a widely used and effective chemical disinfectant, is recommended for infection prevention and control in health care settings. However, lack of consistent chlorine availability limits its use. Electrolytic chlorine generators can address limited chlorine supply and stockouts by enabling onsite production of readily usable, high-quality chlorine cost-effectively. We report the feasibility (i.e., performance, acceptability, chlorine availability, and cost) of the electrolytic STREAM Disinfectant Generator (Aqua Research, New Mexico, USA) device for infection prevention and control in primary health care facilities in Uganda. METHODS: We installed STREAM devices in 10 primary health care facilities in central and western Uganda. Commercial chlorine inventory records (stock cards) were reviewed in each facility to calculate average liters of chlorine received and used per month. These values were compared with actual STREAM chlorine production volumes over the study period to determine its impact on chlorine availability. We collected acceptability data from a purposive sample of device users (n = 16), hospital administrators (n = 10), and district health officers (n = 6) who had been directly involved in the operation or supervision of the STREAM device. We descriptively analyzed the acceptability data by user group and evaluated qualitative responses manually using a thematic approach. Cost data were normalized and modeled to determine a break-even and cost-savings analysis across a five-year period (the minimum expected lifespan of the STREAM device). RESULTS: Chlorine was consistently available without any reported stockouts during the evaluation period. STREAM chlorine production resulted in a 36.9 percent cost-savings over a five-year period compared to commercial chlorine. User acceptability of the STREAM device was high among STREAM operators, hospital administrators, and district health officers, with all respondents reporting that STREAM moderately or significantly improved infection prevention and control practices in the health facility. Overall, 88 percent of device users and 100 percent of hospital administrators wished to continue using the STREAM device instead of commercial chlorine products. CONCLUSION: The STREAM device has demonstrated significant potential to strengthen infection prevention and control practices in health care facilities in Uganda. Based on the preliminary results, the STREAM device should be considered a promising tool for district hospitals and large health centers facing infection prevention and control challenges in Uganda and elsewhere, provided water and electricity are available. Going forward, implementation of the STREAM device could also be considered in smaller health care facilities in Uganda and elsewhere.

Exploring access cavity through non-carious cervical lesions: Impacts on instrumentation, obturation, and fracture resistance in mandibular incisors.

AIM: To compare the effects of Cervical Access Cavity (CervAC) and Traditional Access Cavity (TradAC) on root canal preparation, root canal filling, and fracture resistance in mandibular incisors. METHODOLOGY: Twenty recently extracted and intact mandibular incisors were initially scanned using a micro-CT device. The specimens were anatomically matched to create two groups (n = 10). A wedge-shaped non-carious cervical lesion (NCCL) was created on the buccal aspect of all teeth using a double-faced segmented diamond disc. In group 1, a TradAC was prepared, whilst in group 2, access was created through the simulated NCCL using a round diamond bur 1012. After root canal preparation with Rotate instruments sizes 15/0.04, 20/0.04, and 25/0.04, the teeth were scanned again and evaluated for root canal volume and surface area, static voxels, volume of removed dental tissue, and dentine thickness. After that, the root canals were filled using the single-cone technique, teeth were restored with composite resin, and subsequently rescanned to calculate the volume of filling materials and voids. Then, the restored teeth were subjected to fracture resistance tests using a universal testing machine. Statistical comparisons between groups were performed with the Mann-Whitney test or the Student's t-test, with a statistical significance level of 5%. RESULTS: Statistical comparisons indicated no significant differences between groups in terms of root canal volume, surface area, static voxels, removed root dentine, root canal filling volume, percentage of voids, or fracture resistance load (p > .05). Conversely, teeth prepared with TradAC showed a significantly higher percentage of dental tissue removed from the crown (p = .001) and a greater volume of filling material remnants in the pulp chamber (p < .001) compared to the CervAC group. A significantly lower percentage reduction in dentine thickness was observed only on the mesial aspect of root at Level 1 in TradAC group (p = .008). CONCLUSIONS: CervAC can be considered a viable alternative approach in the presence of NCCL in mandibular incisors.

Building Interprofessional Competencies Through a Collaborative Prescribing Activity With Osteopathic, Pharmacy, and Physician Assistant Students.

Introduction: Medication errors can lead to significant adverse events. Nearly 50% of medication errors occur during the prescription-writing stage of the medication use process, and effective interprofessional collaboration and communication are key to reducing error in this process. Methods: We developed a three-part, 60-minute, interprofessional education activity providing medical, physician assistant, and pharmacy students the opportunity to practice collegial interprofessional communication surrounding prescribing practices. Learners met virtually initially as a large group and divided into small groups facilitated by a health professional. Part 1 involved reviewing two prescriptions prepared by learners; part 2 was a discussion about the education, roles, and responsibilities of each profession; and part 3 focused on identifying prescription errors in examples provided by faculty. Students completed a post-pre survey measuring their perception of learning the Interprofessional Collaborative Competency Attainment Survey (ICCAS) areas. Results: Of 317 participants (151 doctor of osteopathy, 68 master of physician assistant studies, and 98 doctor of pharmacy students), 286 completed the post-pre survey, for a 90% response rate. Students reported statistically significant (p < .001) increases in all 20 questions spanning the six ICCAS areas. Discussion: The virtual format allowed multiple institutions to participate from various locations. It broadened the learners' experience by fostering interaction among those with varied perspectives and allowed collaboration between locations and programs that otherwise could not have participated. The activity introduced students to virtual collaboration and key telehealth skills, enhancing their confidence and familiarity with virtual interactions in a professional setting.