Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a highly prevalent, yet under-diagnosed condition. Due to its adverse impact on risk for cardiopulmonary disorders, there is interest in pro-active screening of OSA in hospitalized patients. We studied the long-term outcome of such screened patients who were initiated on positive airway pressure (PAP) therapy. METHODS: Hospitalized patients who screened positive for OSA and were confirmed with post-discharge polysomnography (PSG) were dichotomized by PAP adherence and followed for a period of 12 months to evaluate for the composite endpoint of hospital readmissions and emergency room (ED) visits for cardiopulmonary reasons. Cost analysis between the two groups was also conducted. RESULTS: 2042 hospitalized patients were assessed for OSA as part of a hospital sleep medicine program from August 2019 to June 2023. Of these, 293 patients were diagnosed with OSA and prescribed PAP therapy. Of these 293 patients, 108 were adherent to therapy and 185 were non-adherent. The overall characteristics of the groups included a mean (SD) age: 58 years (12.82), mean BMI (kg/m2): 39.72 (10.71), male sex: 57%, and apnea-hypopnea index (AHI): 25.49 (26). 78%, 41% and 43% had hypertension, congestive heart failure, and diabetes mellitus, respectively.The composite endpoint of hospital readmissions and ED visits for cardiovascular and pulmonary reasons was significantly higher in the non-adherent group as compared to the adherent group (HR: 1.24, 95% CI: 1-1.54) (p=0.03). The cost of care for both hospital billing (HB) as well as professional billing(PB) was higher for the non-adherent group ($1455.6 vs $1723.5, p = 0.004) in HB cost and $130.9 vs $144.7, p<0.001) in PB. Length of stay was higher for non-adherent patients (2.7 ± 5.1 days vs. 2.3 ± 5.9 days). CONCLUSIONS: Hospitalized patients diagnosed with OSA and adherent to therapy have reduced readmissions and ED visits for cardiopulmonary reasons 12 months after discharge. Adherent patients have reduced cost of health care and length of stay during hospitalizations.

A comparison of pre- and post-clinical education learning preferences among medical students who elected to dissect compared to those who did not during the COVID-19 pandemic.

Anatomy instructional methods varied widely during the COVID-19 pandemic and programs are assessing innovations for retention. Learning preferences were assessed among medical students dichotomized as elective dissectors (ED) or non-dissectors (ND) during the COVID-19 partial re-opening in 2020 (preclinical) and again in 2022 after clinical exposure (post-clinical) to assess the viability of elective dissection post-pandemic. A mixed-method approach was used for the assessment of test scores, learning preference surveys, learning activities rankings, and thematic analyses. No significant differences occurred in anatomy examination scores. Dissection was considered useful by both preclinical groups but significantly more so by ED, while the presence of an instructor was significantly preferred by ED although a majority of ND agreed. Elective dissection was significantly preferred by ND but also by a large minority of ED students. Pre- and post-clinical ND believed that elective dissection offered more academic flexibility, did not hinder clinical learning, and did not negatively impact medical education. The corresponding ED stated that confidence improved, clinical experiences were enhanced, and dissection was irreplaceable. Preclinical ND preferred self-learning, while ED students preferred online learning, but these differences largely disappeared post-clinically. Learning activity rankings were not significantly different among all groups (ND, ED, preclinical, and post-clinical). A hybrid laboratory with a virtual learning environment ranked highest across groups and preferences increased over time suggesting that students benefited from this instructional method during clinical exposure. The absence of laboratory experience ranked lowest, and preference decreased over time suggesting that anatomy dissection is valued.

Electronic structure in a transition metal dipnictide TaAs2.

The family of transition-metal dipnictides has been of theoretical and experimental interest because this family hosts topological states and extremely large magnetoresistance (MR). Recently,TaAs2, a member of this family, has been predicted to support a topological crystalline insulating state. Here, by using high-resolution angle-resolved photoemission spectroscopy (ARPES), we reveal both closed and open pockets in the metallic Fermi surface (FS) and linearly dispersive bands on the (2‾01) surface, along with the presence of extreme MR observed from magneto-transport measurements. A comparison of the ARPES results with first-principles computations shows that the linearly dispersive bands on the measured surface ofTaAs2are trivial bulk bands. The absence of symmetry-protected surface state on the (2‾01) surface indicates its topologically dark nature. The presence of open FS features suggests that the open-orbit fermiology could contribute to the extremely large MR ofTaAs2.

Long-term impact of add-on sequential triple combination therapy in pulmonary arterial hypertension: real world experience.

BACKGROUND: Sequential triple combination therapy is recommended for pulmonary arterial hypertension (PAH) patients who are not at therapeutic goal on dual therapy, but long-term data on efficacy and safety is scarce. OBJECTIVE: To assess the long-term impact of sequential triple combination therapy in patients with PAH who are not at goal on dual combination therapy. STUDY DESIGN AND METHODS: We performed a retrospective observational study in a racially/ethnically diverse cohort of consecutive PAH patients on a stable dual therapy regimen who remained in intermediate- or high-risk category and were subsequently initiated on sequential triple combination therapy. We studied interval change in functional, echocardiographic, and hemodynamic parameters, REVEAL 2.0 risk category and ERS/ESC 2022 simplified four-strata risk category. Multivariate logistic regression analysis was performed to identify independent predictors of successful risk reduction (achievement or maintenance of REVEAL 2.0 low-risk category). Kaplan-Meier survival curves were created to assess the effect of risk reduction on survival. RESULTS: Out of 414 PAH patients seen in our program, 55 patients received add-on sequential triple combination regimen and had follow-up hemodynamic data. The mean age was 57 years, with 85% women. The most common etiology of PAH was idiopathic/heritable (41.8%). Most patients were WHO functional class III (76.4%), and 34.5% of patients were in high-risk category (REVEAL 2.0). On a median follow-up of 68 weeks, there was a significant improvement in WHO Functional Class (p < 0.001), six-minute walk distance (35 m) with 61.8% of patients achieving low-risk status by REVEAL 2.0, and a 28% of patients' improvement in pulmonary vascular resistance. Female gender was identified as a strong predictor of successful risk reduction, whereas Hispanic ethnicity estimated right atrial pressure on echocardiogram and pericardial effusion predicted lower probability of risk reduction. Patients who achieved or maintained low-risk status had significantly improved survival. CONCLUSION: Add-on sequential triple combination therapy significantly increased functional, echocardiographic, and hemodynamic parameters with improvement in risk category and survival.

Effects of dosing non-toxigenic Clostridia on the bacterial populations and immunological responses in the intestinal tract of lactating dairy cows.

Understanding the effects of dosing non-toxigenic Clostridia to cows is rare and has received little attention so far. In the present study, a total of eight lactating dairy cows were divided in two groups: control (n = 4) or Clostridia challenged (oral supplementation of five diverse strains of Paraclostridium bifermentans, n = 4). Bacterial communities were analyzed by qPCR and next-generation sequencing (NGS) in the buccal mucosa as well as digesta and mucosal samples of the gastrointestinal (GI) tract from rumen to rectum (10 compartments), as well as fecal samples. Transcriptomic analysis of barrier and immune-related gene expression was performed on rumen, jejunum, and liver samples. We observed increased microbial populations with the Clostridial challenge in the buccal tissues and the proximal GI tract (forestomach), correlating with Clostridial loads in the feed. Otherwise, there were no significant differences in microbial populations (p > 0.05) throughout the distal part of the GI tract. The NGS approach, however, revealed that the Clostridial challenge changed the relative abundance of gut and fecal microbiota. In particular, in the challenge group, no Bifidobacterium was observed in the mucosa-associated microbiota and abundance of Pseudomonadota increased in the feces. These results indicated potential adverse effects of Clostridia to cow health. In general, immune responses to the Clostridial challenge were weak. However, transcriptional analysis revealed the down-regulation of junction adhesion molecule encoding gene (-1.44 of log2 fold-change), which might impact intestinal permeability.

Targeted electrochemical reduction of carcinogenic N-nitrosamines from emission control systems within CO2 capture plants.

N-Nitrosamines are one of the environmentally significant byproducts from aqueous amine-based post-combustion carbon capture systems (CCS) due to their potential risk to human health. Safely mitigating nitrosamines before they are emitted from these CO2 capture systems is therefore a key concern before widescale deployment of CCS can be used to address worldwide decarbonization goals. Electrochemical decomposition is one viable route to neutralize these harmful compounds. The circulating emission control waterwash system, commonly installed at the end of the flue gas treatment trains to minimize amine solvent emissions, plays an important role to capture N-nitrosamines and control their emission into the environment. The waterwash solution is the last point where these compounds can be properly neutralized before becoming an environmental hazard. In this study, the decomposition mechanisms of N-nitrosamines in a simulated CCS waterwash with residual alkanolamines was investigated using several laboratory-scale electrolyzers utilizing carbon xerogel (CX) electrodes. H-cell experiments revealed that N-nitrosamines were decomposed through a reduction reaction and are converted into their corresponding secondary amines thereby neutralizing their environmental impact. Batch-cell experiments statistically examined the kinetic models of N-nitrosamine removal by a combined adsorption and decomposition processes. The cathodic reduction of the N-nitrosamines statistically obeyed the first-order reaction model. Finally, a prototype flow-through reactor using an authentic waterwash was used to successfully target and decompose N-nitrosamines to below the detectable level without degrading the amine solvent compounds allowing them to be return to the CCS and lower the system operating costs. The developed electrolyzer was able to efficiently remove greater than 98% of N-nitrosamines from the waterwash solution without producing any additional environmentally harmful compounds and offers an effective and safe route to mitigate these compounds from CO2 capture systems.

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use.

INTRODUCTION: Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use. METHODS: This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022. RESULTS: Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7). CONCLUSIONS: Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

iSleepFirst: burnout, fatigue, and wearable-tracked sleep deprivation among residents staffing the medical intensive care unit.

PURPOSE: This study aimed to evaluate the relationship between sleep, burnout, and psychomotor vigilance in residents working in the medical intensive care unit (ICU). METHODS: A prospective cohort study of residents was implemented during a consecutive 4-week. Residents were recruited to wear a sleep tracker for 2 weeks before and 2 weeks during their medical ICU rotation. Data collected included wearable-tracked sleep minutes, Oldenburg burnout inventory (OBI) score, Epworth sleepiness scale (ESS), psychomotor vigilance testing, and American Academy of Sleep Medicine sleep diary. The primary outcome was sleep duration tracked by the wearable. The secondary outcomes were burnout, psychomotor vigilance (PVT), and perceived sleepiness. RESULTS: A total of 40 residents completed the study. The age range was 26-34 years with 19 males. Total sleep minutes measured by the wearable decreased from 402 min (95% CI: 377-427) before ICU to 389 (95% CI: 360-418) during ICU (p < 0.05). Residents overestimated sleep, logging 464 min (95% CI: 452-476) before and 442 (95% CI: 430-454) during ICU. ESS scores increased from 5.93 (95% CI: 4.89, 7.07) to 8.33 (95% CI: 7.09,9.58) during ICU (p < 0.001). OBI scores increased from 34.5 (95% CI: 32.9-36.2) to 42.8 (95% CI: 40.7-45.0) (p < 0.001). PVT scores worsened with increased reaction time while on ICU rotation (348.5 ms pre-ICU, 370.9 ms post-ICU, p < 0.001). CONCLUSIONS: Resident ICU rotations are associated with decreased objective sleep and self-reported sleep. Residents overestimate sleep duration. Burnout and sleepiness increase and associated PVT scores worsen while working in the ICU. Institutions should ensure resident sleep and wellness checks during ICU rotation.

Effects of COVID-19 Acute Respiratory Distress Syndrome Intensive Care Unit Survivor Telemedicine Clinic on Patient Readmission, Pain Perception, and Self-Assessed Health Scores: Randomized, Prospective, Single-Center, Exploratory Study.

BACKGROUND: Post-intensive care syndrome (PICS) affects up to 50% of intensive care unit (ICU) survivors, leading to long-term neurocognitive, psychosocial, and physical impairments. Approximately 80% of COVID-19 pneumonia ICU patients are at elevated risk for developing acute respiratory distress syndrome (ARDS). Survivors of COVID-19 ARDS are at high risk of unanticipated health care utilization postdischarge. This patient group commonly has increased readmission rates, long-term decreased mobility, and poorer outcomes. Most multidisciplinary post-ICU clinics for ICU survivors are in large urban academic medical centers providing in-person consultation. Data are lacking on the feasibility of providing telemedicine post-ICU care for COVID-19 ARDS survivors. OBJECTIVE: We explored the feasibility of instituting a COVID-19 ARDS ICU survivor telemedicine clinic and examined its effect on health care utilization post-hospital discharge. METHODS: This randomized, unblinded, single-center, parallel-group, exploratory study was conducted at a rural, academic medical center. Study group (SG) participants underwent a telemedicine visit within 14 days of discharge, during which a 6-minute walk test (6MWT), EuroQoL 5-Dimension (EQ-5D) questionnaire, and vital signs logs were reviewed by an intensivist. Additional appointments were arranged as needed based on the outcome of this review and tests. The control group (CG) underwent a telemedicine visit within 6 weeks of discharge and completed the EQ-5D questionnaire; additional care was provided as needed based on findings in this telemedicine visit. RESULTS: Both SG (n=20) and CG (n=20) participants had similar baseline characteristics and dropout rate (10%). Among SG participants, 72% (13/18) agreed to pulmonary clinic follow-up, compared with 50% (9/18) of CG participants (P=.31). Unanticipated visits to the emergency department occurred for 11% (2/18) of the SG compared with 6% (1/18) of the CG (>.99). The rate of pain or discomfort was 67% (12/18) in the SG compared with 61% (11/18) in the CG (P=.72). The anxiety or depression rate was 72% (13/18) in the SG versus 61% (11/18; P=.59) in the CG. Participants' mean self-assessed health rating scores were 73.9 (SD 16.1) in the SG compared with 70.6 (SD 20.9) in the CG (P=.59). Both primary care physicians (PCPs) and participants in the SG perceived the telemedicine clinic as a favorable model for postdischarge critical illness follow-up in an open-ended questionnaire regarding care. CONCLUSIONS: This exploratory study found no statistically significant results in reducing health care utilization postdischarge and health-related quality of life. However, PCPs and patients perceived telemedicine as a feasible and favorable model for postdischarge care among COVID-19 ICU survivors to facilitate expedited subspecialty assessment, decrease unanticipated postdischarge health care utilization, and reduce PICS. Further investigation is warranted to determine the feasibility of incorporating telemedicine-based post-hospitalization follow-up for all medical ICU survivors that may show improvement in health care utilization in a larger population.

Evaluating Gender-based Differences in Clinical Outcomes for Patients Undergoing Left Atrial Appendage Occlusion: A Single Centre Experience.

There is emerging recent data that has shown women to be more prone to in-hospital major adverse events after trans catheter left atrial appendage occlusion. Institutional LAAO registry at West Virginia University (WVU) was reviewed from January 2016 to October 2021 to identify 271 women and 293 men who underwent successful LAAO device implantation. Patients were evaluated for gender-based differences in baseline characteristics, CHA2DS2-VASc Score, HAS-BLED score, procedural data, in-hospital, and follow-up outcomes. Compared to men, women had lower baseline comorbidities including coronary artery disease (135 (49.6%) vs 172 (58.7%), P = 0.03), myocardial infarction (MI) (56 (20.5%) vs 85 (29%), P = 0.02) and coronary artery bypass surgery (10 (3.6%) vs 27 (9.2%), P = 0.008). Women were noted to have a higher CHA2DS2-VASc Score (5.3 ± 1.4 vs 4.4 ± 1.4, P < 0.001), and left ventricular ejection fraction (57.9 ± 7.7 vs 52.7 ± 12.4, P < 0.001). Women were noted to have a significantly higher rate of in-hospital composite adverse events (74 (27.2%) vs 58 (19.8%), P = 0.03); bleeding events (38 (10.2%) vs 19 (6.4%), P = 0.003) and associated blood transfusion (6 vs 0, P = 0.001) compared with men. No statistically significant differences were noted between both genders regarding the follow-up outcome. Our single center study shows women to have higher in-hospital composite adverse events as well as higher bleeding events during the index hospital admission.

Extended reality veterinary medicine case studies for diagnostic veterinary imaging instruction: Assessing student perceptions and examination performance.

Educational technologies in veterinary medicine aim to train veterinarians faster and improve clinical outcomes. COVID-19 pandemic, shifted face-to-face teaching to online, thus, the need to provide effective education remotely was exacerbated. Among recent technology advances for veterinary medical education, extended reality (XR) is a promising teaching tool. This study aimed to develop a case resolution approach for radiographic anatomy studies using XR technology and assess students' achievement of differential diagnostic skills. Learning objectives based on Bloom's taxonomy keywords were used to develop four clinical cases (3 dogs/1 cat) of spinal injuries utilizing CT scans and XR models and presented to 22 third-year veterinary medicine students. Quantitative assessment (ASMT) of 7 questions probing 'memorization', 'understanding and application', 'analysis' and 'evaluation' was given before and after contact with XR technology as well as qualitative feedback via a survey. Mean ASMT scores increased during case resolution (pre 51.6% (±37%)/post 60.1% (± 34%); p < 0.01), but without significant difference between cases (Kruskal-Wallis H = 2.18, NS). Learning objectives were examined for six questions (Q1-Q6) across cases (C1-4): Memorization improved sequentially (Q1, 2 8/8), while Understanding and Application (Q3,4) showed the greatest improvement (26.7%-76.9%). Evaluation and Analysis (Q5,6) was somewhat mixed, improving (5/8), no change (3/8) and declining (1/8).Positive student perceptions suggest that case studies' online delivery was well received stimulating learning in diagnostic imaging and anatomy while developing visual-spatial skills that aid understanding cross-sectional images. Therefore, XR technology could be a useful approach to complement radiological instruction in veterinary medicine.

Extended reality visualization of medical museum specimens: Online presentation of conjoined twins curated by Dr. Jacob Henle between 1844-1852.

Background: The purpose of this study is to characterize a full-term conjoined twins' cadaver curated by Dr. Jacob Henle sometime between 1844 and 1852 and demonstrate digital distribution of an old and rare medical museum specimen using an extended reality (XR) model workflow. Methods: The cadaver (Preparation 296) is in the Department of Anatomy and Cell Biology at the University of Heidelberg. An XR display workflow comprises image capture, segmentation, and visualization using CT/MR scans derived from the cadaver. Online radiology presentation to medical students focuses on diagnostic characteristics of anatomical systems depicted with XR models. Results: Developmental defects in Preparation 296 include duplicated supradiaphragmatic structures and abnormal osteological features. Subdiaphragmatically, the gut is continuous on the right, but terminates at the distal esophagus on the left. One large liver occupies the abdomen with one spleen located on the left side. Observations suggest duplication of the primitive streak and separate notochords rostrally. Duplication occurs near the yolk sac and involves midgut formation while secondary midline fusion of the upper extremities and ribs likely results from the proximity of the embryos during development. Medical students access the model with device agnostic software during the curricular topic "Human Body Plan" that includes embryology concepts covering mechanisms of twinning. Conclusions: The workflow enables ease-of-access XR visualizations of an old and rare museum specimen. This study also demonstrates digital distribution and utilization of XR models applicable to embryology education.

Hospice Emergency Planning and COVID-19.

Objectives: Centers for Medicare and Medicaid Services requirements for Emergency Preparedness Planning (EPP) by hospice organizations significantly increased in 2017. This study seeks to assess the involvement of various hospice personnel in EPP before and since the onset of the novel coronavirus disease COVID-19 pandemic. Methods: A link to an anonymous online survey was sent to members of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association, targeting members involved in hospice care in the United States. A descriptive analysis of the data was performed. Results: Prior to the pandemic, 39.8% of respondents were "moderately" or "very" involved with the development and revisions of the Emergency Preparedness Plan. Since the beginning of the pandemic, this increased to 59%, which largely occurred among physicians. Clinical Nurse and Nurse Practitioner involvement in development/revisions remained low. Approximately 30% of respondents desired more involvement across the areas of EPP. Conclusion: The involvement of personnel of various disciplines is varied and the involvement of physicians appears to have increased with the onset of the COVID-19 pandemic. A notable portion of personnel desired more involvement across all aspects of EPP. More research is needed in this important but little-understood area.

Case-based radiological anatomy instruction using cadaveric MRI imaging and delivered with extended reality web technology.

PURPOSE: Extended reality (XR) technology enhances learning in medical education. The purpose of this study was to develop and apply a case-based approach for teaching radiological anatomy utilizing XR technology for improved student exploration and engagement. METHODS: The workflow consisted of MRI scanning cadavers followed by radiological, pathological, and anatomical assessment, and finally case presentation based on XR visualizations and student interaction. Case information (Subject, History, and Physical Exam) was presented to student groups who generated and recorded hypotheses using Google Forms. RESULTS: Use of all components of the system was voluntary and a total of 74 students responded to the survey request (response rate = 95%). Assessment of the experience was conducted through a qualitative survey comprising four Likert scale questions (1-5, 1 lowest), three binary questions, and open-ended comments. Mean, standard deviation, and overall agreement (mean ± SD, OA) showed that students found MRI scans of cadavers to be helpful for dissections (4.14 ± 1.1, 74.3%) and provided an understanding of relevant anatomy (4.32 ± 0.9, 79.7%), while 78.4% of students used the DICOM viewer to visualize scans of cadavers. The difficulty of use was found to be average (2.90 ± 1.0, 23%). zSpace visualizations were used by 40.5% of students, generally agreeing that an understanding of spatial relationships improved as a result (3.60 ± 1.0, 43.2%). More case-based sessions were favored by 97.3% of students. CONCLUSIONS: Results suggest that cadaveric MRI radiological visualization and XR technology enhance understanding of case-based anatomical dissections and encourage student exploration and engagement.

Effects of postweaning supplementation of immunomodulatory feed ingredient on circulating cytokines and microbial populations in programmed fed beef heifers.

The objective was to determine the effects of an immunomodulatory feed ingredient following weaning on cytokine expression and fecal microbial populations of heifers. Commercial Angus heifers (n = 72) were weaned (227 ± 7 d of age), blocked by BW (n = 9 blocks), and randomly assigned to one of two pens per block. Pens within weight block (four heifers per pen) were then randomly assigned to treatments. Heifers were fed twice daily from days 0 to 60 (to gain 0.75 kg/d) and top dressed with either 18 g/heifer/d of the immunomodulatory feed ingredient (Celmanax; Arm and Hammer Animal Nutrition, Princeton, NJ; CEL) or corn-germ meal (CON). Blood samples were collected on days 0, 15, 30, 45, 60 and fecal grab samples on day 0 of the feeding trial. After day 60, two heifers per pen (n = 32) were randomly selected for a transportation challenge. Serum samples were collected at hours 0, 4, 8, 12 and fecal grab samples at hours -24, 0, 24 and 7 d postchallenge. Blood samples were analyzed for interferonγ (IFNγ), interleukin-8 (IL-8), and haptoglobin (HP) using commercially available ELISA kits and qRT-PCR for genes of interest associated with cytokine expression. Fecal samples were enumerated for Clostridia and E. coli using selective media (≤5 isolates from each media/sample), tested to determine whether they were Clostridium perfringens or pathogenic E. coli, and then enriched for detection of Salmonella. Data were analyzed via ANOVA. During the feeding trial, HP was reduced (P = 0.018) in CEL compared with CON at days 15, 45, and 60, whereas IFNγ and IL-8 did not differ (P > 0.080) between treatments. All cytokines were decreased (P < 0.001) in CEL compared with CON during the challenge. During the feeding trial, HP mRNA was increased (P = 0.045) in CEL compared with CON at days 30 and 60. Similarly, IFNγ mRNA was increased (P = 0.040) in CEL compared with CON; however, other genes of interest did not differ (P > 0.172). Both C. perfringens and total E. coli counts were decreased (P = 0.036) in CEL compared with CON at 24 h after the start of the transportation challenge. Clostridia and pathogenic E. coli counts did not differ (P = 0.941) between treatments. Total Clostridia and E. coli counts were increased (P < 0.014) 24 h postchallenge. All microbial populations, except pathogenic E. coli, observed decreased (P ≤ 0.009) counts from 24 h to 7 d postchallenge. Overall, Celmanax supplementation decreased circulating cytokines, and altered microbial populations and gene expression, thus, may serve a role in preparing animals to better cope with immunological challenges.

With consumers wanting less antibiotic usage in cattle production, the need for natural feed ingredients that have positive effects on animal health are needed. The feeding of a yeast-based feed product decreased cytokines in the blood and their mRNA expression in white blood cells that act on stimulating an inflammatory response. When an animal has an inflammatory response, their immune system is working harder than necessary. This means they are using energy that could otherwise be used for growth, which decreases efficiency and performance. The feeding of this yeast-based feed ingredient also reduced the amount of harmful bacteria in the feces of the heifers. Having lower amounts of harmful bacteria (such as Salmonella) in the feces decreases the chance of carcass contamination. For consumers, this means less instances of food-borne illnesses.

Dental Anesthesia for Medical Providers: A Novel Interprofessional Course.

PURPOSE: To limit the use of opioids for nontraumatic dental conditions in emergency settings, the physician assistant (PA) and dental faculty at A.T. Still University designed a course that teaches PA students to administer dental anesthesia. METHODS: Dental faculty and teacher assistants taught PA students proper dental anesthesia. The course consisted of a recorded, prelaboratory lecture and in-person lab. During the laboratory, students rotated through 3 stations where they reviewed dental anatomy, practiced injections on dental anesthesia manikins, and simulated injections on student volunteers using the Safe-D-Needle. Students completed verbal and hands-on assessments. RESULTS: Ninety-seven percent of students passed the assessments on their first attempt. Course evaluations suggested the course had a positive effect on students' attitudes toward oral pain management. CONCLUSION: This educational model allowed PAs to expand their emergency medicine toolbox. In the future, this model should be adapted to incorporate other healthcare professionals as well.

Are We Overradiating Patients with Irritable Bowel Syndrome?

INTRODUCTION: Protracted exposures to small doses of radiation, even cumulative effective doses (CED) as low as 50-100 mSv, may increase the risk for malignancy. Medical radiation exposure has not been rigorously examined for patients with irritable bowel syndrome (IBS). We examined medical radiation exposure in patients with IBS at a tertiary care center in the USA. METHODS: Patients diagnosed with IBS at our institute from 2009 to 2018 were included in a retrospective cohort study. Medical charts were examined to calculate total and annual CED. RESULTS: 221 patients were included; mean CED was 40.32 mSv (SD: 54.36). Fifty-nine participants (26.7%) received >50 mSv of CED with 27 participants (12.2%) exceeding 100 mSv. Conventional imaging, nuclear medicine, and fluoroscopy accounted for 74.08, 12.93, and 12.98% of total CED, respectively. CT scans contributed to 66.61% of total CED. Outpatient orders accounted for 37.96% of total CED, while 31.4% of total CED was ordered in the emergency department. Population-specific high total CED was calculated as 105.65 mSv. Multivariable binomial logistic regression model found that comorbid anxiety, chronic pain medication use, and diarrhea-predominant IBS were independently positively associated with population-specific high CED exposure. No significant temporal trend in peri-diagnostic mean CED was found. CONCLUSION: Patients with IBS receive high amounts of medical radiation, with 1 in 4 patients reaching at-risk levels of 50 mSv or more. Usage of pain medication at home, comorbid anxiety, and IBS-D are independently linked to an increased risk of high CED.

Delays in lumbar puncture are independently associated with mortality in cryptococcal meningitis: a nationwide study.

BACKGROUND: Cryptococcal meningitis (CM) is the most serious presentation of invasive cryptococcosis. Seen in patients with and without HIV infection, CM is associated with significant morbidity and mortality. Early lumbar puncture is a cornerstone of treatment in cryptococcal meningitis. We present findings from a nationwide analysis of patients admitted with CM in the United States between 2007 and 2016, with the aim of determining the impact of delays in lumbar puncture on inpatient outcomes. METHODS: The national inpatient sample (NIS) database was queried for all inpatient visits for cryptococcal meningitis between January 2007 and December 2016. Logistic regression models were used to determine risk factors for inpatient mortality, prolonged admissions, and delays in obtaining an initial lumbar puncture. RESULTS: The annual number of admissions for CM decreased during the study interval, from 3590 in 2007 to 2830 in 2016. Mortality did not change over this period (9.9%); however, length of stay and inpatient cost significantly increased. The proportion of patients with HIV declined from 70.7% to 54.0%. Delay in lumbar puncture beyond the first 24 h was independently associated with mortality (OR = 1.55, CI = 1.31-1.82, p-value <.001). Patients admitted on a weekend, those of African-American ethnicity, and those without a known history of HIV were more likely to have delays in obtaining an early LP. HIV patients had a lower risk of mortality (OR = 0.77, CI = 0.68-0.86, p-value <.001). CONCLUSION: We found an independent association of delay in early lumbar puncture with worsened patient outcomes. Inpatient mortality for patients with CM continues to remain high, with an increasing proportion of patients without underlying HIV infection. There were significant deviations in management of CM from Infectious Diseases Society of America (IDSA) guidelines.