Hospital transfers for evaluation and treatment of hand infections: Are all transfers necessary?

Background: Hand infections represent a common hand condition in the emergency department and one that frequently requires a hand specialist. The purpose of our study is to analyze hospital transfers for hand infections with a primary outcome being potential clinically avoidable transfers and to identify areas for improvement in the care of hand infections. Methods: Retrospective review of The Texas Healthcare Information Collection Database from 2015 to 2019. We analyzed all transfers for hand infections. Statistical analyses included: Transfer diagnosis, surgical interventions, length of stay (LOS), the day of the week that the transfer was initiated and whether or not the transfer or centralization was necessary or potentially avoidable. Results: A total of 3489 patients were transferred from one hospital to another for the management of a hand infection. 1628 (46.6 â€‹%) underwent at least one surgical intervention and 1861 (53.3 â€‹%) were treated non-operatively. Patients undergoing operative interventions had a lower LOS compared to those non-operatively. Transfers admitted during the weekend had decreased average LOS relative to non-weekend transfers, but a 94.7 â€‹% increased odds of receiving a relevant surgical intervention during the hospital admission. Nearly all patients were transferred to urban region hospitals. Of total, 1194 (34.22 â€‹%) were considered potentially avoidable centralizations, which we defined as transfer that resulted in no surgical intervention and discharge to home within 72 â€‹h. Conclusions: Although the reason for centralization was unknown, our analysis showed a high number of transfers that could have been potentially avoidable. We propose the development of specific guidelines, and perhaps the use of remote consultations for areas where hand specialist are not reliably available to help optimize the care of patient with hand infections.

Ultrafast Yttrium Hydride Chemistry at High Pressures via Non-equilibrium States Induced by an X-ray Free Electron Laser.

Controlling the formation and stoichiometric content of the desired phases of materials has become of central interest for a variety of fields. The possibility of accessing metastable states by initiating reactions by X-ray-triggered mechanisms over ultrashort time scales has been enabled by the development of X-ray free electron lasers (XFELs). Utilizing the exceptionally high-brilliance X-ray pulses from the EuXFEL, we report the synthesis of a previously unobserved yttrium hydride under high pressure, along with nonstoichiometric changes in hydrogen content as probed at a repetition rate of 4.5 MHz using time-resolved X-ray diffraction. Exploiting non-equilibrium pathways, we synthesize and characterize a hydride in a Weaire-Phelan structure type at pressures as low as 125 GPa, predicted using a crystal structure search, with a hydrogen content of 4.0-5.75 hydrogens per cation, that is enthalpically metastable on the convex hull.

Atrial Fibrillation and Older Age Predict Serum Brain-Derived Neurotrophic Factor Levels Among Patients With Heart Failure.

BACKGROUND: Predictors have not been determined of serum brain-derived neurotrophic factor (BDNF) levels among patients with heart failure (HF). OBJECTIVE: The primary purpose was to evaluate history of atrial fibrillation, age, gender, and left ventricular ejection fraction as predictors of serum BDNF levels at baseline, 10 weeks, and 4 and 8 months after baseline among patients with HF. METHODS: This study was a retrospective cohort analyses of 241 patients with HF. Data were retrieved from the patients' health records (coded history of atrial fibrillation, left ventricular ejection fraction), self-report (age, gender), and serum BDNF. Linear multiple regression analyses were conducted. RESULTS: One hundred three patients (42.7%) had a history of atrial fibrillation. History of atrial fibrillation was a significant predictor of serum BDNF levels at baseline (ß = -0.16, P = .016), 4 months (ß = -0.21, P = .005), and 8 months (ß = -0.19, P = .015). Older age was a significant predictor at 10 weeks (ß = -0.17, P = .017) and 4 months (ß = -0.15, P = .046). CONCLUSIONS: Prospective studies are needed to validate these results. Clinicians need to assess patients with HF for atrial fibrillation and include treatment of it in management plans.

Treatment of Lateral Epicondylitis: Is Surgery Still an Option?

Background: The prevailing trend for the treatment of lateral epicondylitis (LE) is nonsurgical. Although many providers consider LE surgery controversial, others consider surgical intervention in patients with recalcitrant symptoms. The purpose of this study is to analyze epidemiological changes in LE surgery over a 9-year period prior to the coronavirus pandemic in 2019. Methods: A cross-sectional analysis of the Texas health care database from 2010 to 2018 was performed. We analyzed all procedures performed for LE during the set time period using Current Procedure Terminology (CPT) codes. Statistical analyses included procedures performed, patient demographics, zone of residence, and insurance designation. Results: There were a total of 12802 records of LE with 1 or more associated surgical procedures. Lateral epicondylar debridement (with/without tendon repair) was the most common procedure recorded, followed by arthroscopic procedures and tendon lengthening. Overall incidence remained low and did not significantly change during the studied period; however, surgical case volumes were significantly higher in metropolitan areas and increased at a faster rate when compared with those of more rural regions. Commercial insurance was the most prevailing form of payment. The incidence was significantly higher in the age group between 45 and 64 years old and most commonly performed in Caucasian females. Conclusions: The benefit of surgery for the treatment of LE has yet to be completely elucidated; however, surgical intervention continues to be offered. Although the incidence of surgery for the treatment of LE remained low over the study period, the volume of cases in metropolitan areas increased at a fast rate between 2010 and 2018. The results of this study found that surgery is still a treatment option in some patients despite the controversy. Level of Evidence: Economic/Decision Analysis, Level IV.

Maintaining the quality of vaccines through the use of standards: Current challenges and future opportunities.

An international hybrid meeting held 21-22 June 2023 in Ottawa, Canada brought together regulators, scientists, and industry experts to discuss a set of principles and best practices in the development and implementation of standards. Although the use of international standards (ISs) and international units (IUs) has been an essential part of ensuring human and animal vaccine quality in the past decades, the types and uses of standards have expanded with technological advances in manufacture and testing of vaccines. The needs of stakeholders are evolving in response to the ever-increasing complexity, diversity, and number of vaccine products as well as increasing efforts to replace animal-based potency tests with in vitro assays that measure relevant quality attributes. As such, there must be a concomitant evolution in the design and implementation of both international and in-house standards. Concomitantly, greater harmonization of regulatory expectations must be achieved through collaboration with standard-setting organizations, national control laboratories and manufacturers. Stakeholders provided perspectives on challenges and several recommendations emerged as essential to advancing agreed upon objectives.

'Everything would have gone a lot better if someone had listened to me': A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan.

Australians with a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan may at times require emergency care due to the fluctuating nature of their physical and mental health conditions or when their supports have become insufficient. This nationwide study investigated the experiences of people presenting to an emergency department (ED) who have a PSD and an NDIS plan. The objective was to understand current care and communication practices and to provide recommendations for service integration. Twenty-four interviews were conducted with people who had a PSD and an NDIS plan. Participants were asked semi-structured questions about their experiences when engaging with NDIS processes and when engaging with the ED as an NDIS recipient and how communication practices could be improved between the two services. A qualitative, descriptive thematic analysis approach was used. A lived experience advisory group participated in the research and provided commentary. The findings of this study indicate that the NDIS, as a personalised budget scheme, presents challenges for people with complex PSD and physical needs. ED clinicians appear to be unclear about what the NDIS provides and communication between the two systems is fragmented and inconsistent. The themes identified from the analysed transcripts are: (a) People with PSD experience distress when dealing with the NDIS; (b) There's a blame game between the ED and the NDIS; and (c) Inadequate service integration between the ED and NDIS. Recommendations to assist with service integration include building service capacity, providing overlapping care and bridging the diverse biomedical, psychosocial and disability care services.

Retraction: Carbon content drives high temperature superconductivity in a carbonaceous sulfur hydride below 100 GPa.

Retraction of 'Carbon content drives high temperature superconductivity in a carbonaceous sulfur hydride below 100 GPa' by G. Alexander Smith et al., Chem. Commun., 2022, 58, 9064-9067, https://doi.org/10.1039/D2CC03170A.

I have not come here because I have nothing better to do: The lived experience of presenting to the emergency department for people with a psychosocial disability and an NDIS plan-A qualitative study.

Almost 60 000 people have a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan. As PSD can be a fluctuating condition, people with a PSD and an NDIS plan, at times, may require crisis care and present to the emergency department (ED). This national study explored the experiences of people with a PSD and an NDIS plan when presenting to the ED. To understand the unique lived experience of people with a PSD and an NDIS plan, semi-structured interviews were conducted with 24 people between March and November 2022 and were analysed thematically. A lived experience advisory group was engaged as part of the research team. Participants were asked about their experiences in the ED including barriers to therapeutic care and what worked well. Participants reported emotional distress caused by receiving a biomedical rather than a person-centred mental health response. A previous mental health history overshadowed diagnostic decisions and most participants interviewed stated they would not choose to return to the ED. Half of the participants spoke of one presentation only where needs were met. Four main themes emerged from the data: (a) Diagnostic overshadowing; (b) Judgement and stigma; (c) Waiting without hope; and (d) If things went well. This study provides evidence of the unique lived experience of people with a PSD and an NDIS plan when presenting to the ED. The results highlight the need for clinicians in the ED to understand the complexity and nuances of supporting people with a PSD. Recommendations for a person-centred care approach are provided. Alternative support options for this group of people need to be explored.

Relationship between backpack load location, sex, anthropometric and body composition factors with postural sway in healthy young adults.

Objective: Evaluate the effect of backpack load location on postural sway and correlate sway path length (PL) to anthropometrics and body composition. Methods: Fifteen participants aged 18-25 stood on a force plate with backpack load located high (LH), low (LL) or without backpack (NL). Body composition and anthropometric variables were correlated to PL. Results: Load increased PL, 95% confidence ellipse, and mean velocity while it reduced mediolateral SampEn (p<0.05). Females had increased mean velocity and PL of sway (p<0.05). Larger phase angles correlated with reduced PL under NL. Taller individuals correlated with reduced PL under LL. Greater mass correlated with reduced PL under LH. Conclusions: Load carriage regardless of load location increased postural sway metrics except mediolateral SampEn. Females had greater PL and mean velocity compared to males. Select anthropometric and body composition variables correlated with postural sway under different load conditions.

Objectif: Évaluer l'effet de la position de la charge du sac à dos sur le balancement postural et corréler la longueur du chemin du balancement (PL) aux facteurs anthropométriques et à la composition corporelle. Méthodologie: Quinze participants âgés de 18 à 25 ans se sont tenus debout sur une plateforme biomécanique, la charge du sac à dos étant placée à un niveau élevé (LH), bas (LL) ou sans sac à dos (NL). La composition corporelle et les variables anthropométriques ont été corrélées à la PL. Résultats: La charge a augmenté la PL, l'ellipse de confiance à 95 % et la vitesse moyenne tout en réduisant la SampEn (entropie d'échantillon) médio-latérale (p<0,05). Les femmes avaient une vitesse moyenne et une PL de balancement plus élevées (p<0,05). Les angles de phase plus importants sont en corrélation avec une réduction de la PL sous NL. Les personnes plus grandes étaient en corrélation avec une réduction de la PL sous LL. Une masse plus importante est en corrélation avec une réduction de la PL sous LH. Conclusions: Le port de charge, quelle que soit la position de la charge, a augmenté les paramètres du balancement postural, à l'exception de la SampEn médio-latérale. Les femmes avaient une PL et une vitesse moyenne plus élevées que les hommes. Certaines variables anthropométriques et de composition corporelle sont en corrélation avec le balancement postural dans différentes conditions de charge.

Retraction: Colossal Density-Driven Resistance Response in the Negative Charge Transfer Insulator MnS_{2} [Phys. Rev. Lett. 127, 016401 (2021)].

Retraction of DOI: 10.1103/PhysRevLett.127.016401.

Stable and metastable structures of tin (IV) oxide at high pressure.

We have analysed [Formula: see text] with a combination of synchrotron X-ray diffraction and X-ray absorption spectroscopy across a pressure range of [Formula: see text] GPa with thermal annealing by a [Formula: see text] laser allowing access to all of the known high-density polymorphs of [Formula: see text], and here report their crystallographic information. The metastability of the post-rutile [Formula: see text]-[Formula: see text] and [Formula: see text] structures in [Formula: see text] are investigated by experiment and PW-DFT simulations, revealing a complex energetic landscape and suggesting a significant dependence of the observed phases on the pressure-temperature pathway taken in experiment. This article is part of the theme issue 'Exploring the length scales, timescales and chemistry of challenging materials (Part 1)'.

Effects of simulated hypo-gravity on lower limb kinematic and electromyographic variables during anti-gravitational treadmill walking.

Introduction: This study investigated kinematic and EMG changes in gait across simulated gravitational unloading levels between 100% and 20% of normal body weight. This study sought to identify if each level of unloading elicited consistent changes-particular to that percentage of normal body weight-or if the changes seen with unloading could be influenced by the previous level(s) of unloading. Methods: 15 healthy adult participants (26.3 ± 2.5 years; 53% female) walked in an Alter-G anti-gravity treadmill unloading system (mean speed: 1.49 ±0.37 mph) for 1 min each at 100%, 80%, 60%, 40% and 20% of normal body weight, before loading back to 100% in reverse order. Lower-body kinematic data were captured by inertial measurement units, and EMG data were collected from the rectus femoris, biceps femoris, medial gastrocnemius, and anterior tibialis. Data were compared across like levels of load using repeated measures ANOVA and statistical parametric mapping. Difference waveforms for adjacent levels were created to examine the rate of change between different unloading levels. Results: This study found hip, knee, and ankle kinematics as well as activity in the rectus femoris, and medial gastrocnemius were significantly different at the same level of unloading, having arrived from a higher, or lower level of unloading. There were no significant changes in the kinematic difference waveforms, however the waveform representing the change in EMG between 100% and 80% load was significantly different from all other levels. Discussion: This study found that body weight unloading from 100% to 20% elicited distinct responses in the medial gastrocnemius, as well as partly in the rectus femoris. Hip, knee, and ankle kinematics were also affected differentially by loading and unloading, especially at 40% of normal body weight. These findings suggest the previous level of gravitational load is an important factor to consider in determining kinematic and EMG responses to the current level during loading and unloading below standard g. Similarly, the rate of change in kinematics from 100% to 20% appears to be linear, while the rate of change in EMG was non-linear. This is of particular interest, as it suggests that kinematic and EMG measures decouple with unloading and may react to unloading uniquely.

An angiotensin converting enzyme homolog is required for volatile pheromone detection, odorant binding protein secretion and normal courtship behavior in Drosophila melanogaster.

In many arthropods, including insects responsible for transmission of human diseases, behaviors that include mating, aggregation, and aggression are triggered by detection of pheromones. Extracellular odorant binding proteins are critical for pheromone detection in many insects and are secreted into the fluid bathing the olfactory neuron dendrites. In Drosophila melanogaster, the odorant binding protein LUSH is essential for normal sensitivity to the volatile sex pheromone, 11-cis vaccenyl acetate (cVA). Using a genetic screen for cVA pheromone insensitivity, we identified ANCE-3, a homolog of human angiotensin converting enzyme that is required for detection of cVA pheromone. The mutants have normal dose-response curves for food odors, although olfactory neuron amplitudes are reduced in all olfactory neurons examined. ance-3 mutants have profound delays in mating, and the courtship defects are primarily but not exclusively due to loss of ance-3 function in males. We demonstrate that ANCE-3 is required in the sensillae support cells for normal reproductive behavior, and that localization of odorant binding proteins to the sensillum lymph is blocked in the mutants. Expression of an ance-3 cDNA in sensillae support cells completely rescues the cVA responses, LUSH localization, and courtship defects. We show the courtship latency defects are not due to effects on olfactory neurons in the antenna nor mediated through ORCO receptors, but instead stem from ANCE-3-dependent effects on chemosensory sensillae in other body parts. These findings reveal an unexpected factor critical for pheromone detection with profound influence on reproductive behaviors.

Comprehensive review of a large cohort of outpatient versus inpatient open renal and bladder surgery in children.

INTRODUCTION: Outpatient surgery and pediatric ambulatory surgery centers continue to have increasing popularity among pediatric urologist for minor surgeries. Past studies have shown that open renal and bladder surgeries (i.e. nephrectomy, pyeloplasty and ureteral reimplantation) can also be done in an outpatient setting. With health care costs continuing to rise, it may be reasonable to explore performing these surgeries as an outpatient and consider performing them in a pediatric ambulatory surgery center. OBJECTIVE: Our study assesses the safety and utility of outpatient open renal and bladder surgeries in children compared to those done as inpatients. STUDY DESIGN: IRB-approved chart review was performed on patients undergoing nephrectomy, ureteral reimplantation, complex ureteral reimplantation, and pyeloplasty by a single pediatric urologist between January 2003-March 2020. Procedures were performed at a freestanding pediatric surgery center (PSC) and a children's hospital (CH). Demographics, type of procedures, American Society of Anesthesiologists score, operative times, time to discharge, ancillary procedures, readmission or ER visits within 72 h were reviewed. Home zip codes were used to determine the distance from pediatric surgery center and children's hospital. RESULTS: 980 procedures were evaluated. Of these, 94% procedures were performed as an outpatient and 6% procedures were performed as inpatients. 40% of patients underwent ancillary procedures. Outpatients had a significantly lower age, ASA score, operative time, and readmission or return to ER within 72 h (1.5% vs. 6.2%). Twelve patients were readmitted (9 outpatient, 3 inpatient) and six returned to the ER (5 outpatient, 1 inpatient). 15/18 of these patients underwent reimplantations. Four required early reoperation on postoperative day (POD)2-3. Only one outpatient reimplant was admitted one day later. PSC patients lived farther away. DISCUSSION: Outpatient open renal and bladder surgery was found to be safely performed in our patients. In addition, it did not matter whether the operation was done in the children's hospital or pediatric ambulatory surgery center. Since outpatient surgery has been shown to be significantly less expensive than inpatient surgery, it is reasonable for pediatric urologist to consider performing these operations in the outpatient setting. CONCLUSIONS: Our experience shows that an outpatient approach to open renal and bladder procedures is safe and should be considered when counseling families about treatment options.

Rational arguments for regulatory acceptance of consistency testing: benefits of non-animal testing over in vivo release testing of vaccines.

INTRODUCTION: There are rational arguments to replace existing in vivo potency and safety assays for batch release testing of vaccines with more advanced non-animal techniques to measure critical quality attributes. However, the introduction of in vitro alternatives to replace in vivo release assays of authorized vaccines is challenging. AREAS COVERED: This report describes the hurdles encountered in substituting in vivo assays and ways to overcome these and provides arguments why more advanced in vitro alternatives are superior, not only as a tool to monitor the quality of vaccines but also from a practical, economical, and ethical point of view. The rational arguments provided for regulatory acceptance can support a strategy to replace/substitute any in vivo batch release test if an appropriate non-animal testing strategy is available. EXPERT OPINION: For several vaccines, in vivo release assays have been replaced leading to an optimized control strategy. For other vaccines, new assays are being developed that can expect to be introduced within 5-10 years. From a scientific, logistical, and animal welfare perspective, it would be beneficial to substitute all existing in vivo batch release assays for vaccines. Given the challenges related to development, validation, and acceptance of new methods, and considering the relatively low prices of some legacy vaccines, this cannot be done without government incentives and supportive regulatory authorities from all regions.

Healthcare Associated Infections, Nurse Staffing, and Financial Performance.

Healthcare associated infections (HAIs) are a concern to patients, hospital administrators and policymakers. For over than a decade, efforts have been made to hold hospitals accountable for the costs of HAIs. This study uses contingency theory as a framework to examine the association between HAIs and hospital financial performance. We use publicly available data on 2059 hospitals in 2014 to 2016 that include HAIs, staffing financial performance, and hospital and hospital market characteristics. The key independent variables are available infection rates and nurse staffing. The dependent variables are indicators of financial performance: operating margin, total margin, and days cash on hand. We find nearly identical negative direct associations between infections and operating margins and total margins (-0.07%), and positive associations between the interaction of infections and nurse staffing (0.05%). A 10% higher infection rate would be predicted to be associated with only a 0.2% lower profit margin. The associations between HAIs, nurse staffing and days cash on hand were insignificantly different from zero.

Evaluating depressive symptoms, BDNF Val66Met, and APOE-ε4 as moderators of response to computerized cognitive training in heart failure.

BACKGROUND: Depressive symptoms, brain-derived neurotrophic factor (BDNF) Val66Met, and apolipoprotein (APOE)-ε4 may moderate response to computerized cognitive training (CCT) interventions among patients with heart failure (HF). OBJECTIVES: The purpose of this study was to examine moderators of intervention response to CCT over 8 months among patients with HF enrolled in a 3-arm randomized controlled trial. Outcomes were memory, serum BDNF, working memory, instrumental activities of daily living (IADLs), and health-related quality of life (HRQL). METHODS: 256 patients with HF were randomized to CCT, computerized crossword puzzles active control, and usual care control groups for 8 weeks. Data were collected at enrollment, baseline, 10 weeks, and 4 and 8 months. Mixed effects models were computed to evaluate moderators. RESULTS: As previously reported, there were no statistically significant group by time effects in outcomes among the 3 groups over 8 months. Tests of moderation indicated that depressive symptoms and presence of BDNF Val66Met and APOE-ε4 were not statistically significant moderators of intervention response in outcomes of delayed recall memory, serum BDNF, working memory, IADLs, and HRQL. In post hoc analysis evaluating baseline global cognitive function, gender, age, and HF severity as moderators, no significant effects were found. HF severity was imbalanced among groups (P = .049) which may have influenced results. CONCLUSIONS: Studies are needed to elucidate biological mechanisms of cognitive dysfunction in HF and test novel interventions to improve memory, serum BDNF, working memory, IADLs and HRQL. Patients may need to be stratified or randomized by HF severity within intervention trials.