Wireless Optofluidic Systems for Programmable In Vivo Pharmacology and Optogenetics.

In vivo pharmacology and optogenetics hold tremendous promise for dissection of neural circuits, cellular signaling, and manipulating neurophysiological systems in awake, behaving animals. Existing neural interface technologies, such as metal cannulas connected to external drug supplies for pharmacological infusions and tethered fiber optics for optogenetics, are not ideal for minimally invasive, untethered studies on freely behaving animals. Here, we introduce wireless optofluidic neural probes that combine ultrathin, soft microfluidic drug delivery with cellular-scale inorganic light-emitting diode (µ-ILED) arrays. These probes are orders of magnitude smaller than cannulas and allow wireless, programmed spatiotemporal control of fluid delivery and photostimulation. We demonstrate these devices in freely moving animals to modify gene expression, deliver peptide ligands, and provide concurrent photostimulation with antagonist drug delivery to manipulate mesoaccumbens reward-related behavior. The minimally invasive operation of these probes forecasts utility in other organ systems and species, with potential for broad application in biomedical science, engineering, and medicine.

Portfolio use in postgraduate medical education: a systematic scoping review.

BACKGROUND: Portfolios are increasingly commonplace in postgraduate medical education. However, poor understanding of and variations in their content, quality, and structure have hindered their use across different settings, thus dampening their efficacy. METHODS: This systematic scoping review on portfolios in postgraduate medical education utilized Krishna's Systematic Evidence Based Approach (SEBA). Braun and Clarke's thematic analysis and Hsieh and Shannon's directed content analysis were independently used to evaluate the data. RESULTS: In total, 12 313 abstracts were obtained, and 76 full-text articles included. Six key themes/categories were identified: (i) portfolio definitions and functions, (ii) platforms, (iii) design, (iv) implementation, (v) use in assessments, and (vi) evaluations of their usage. CONCLUSIONS: Portfolios allow for better appreciation and assessments of knowledge, skills, and attitudes in time-, learner-, and context-specific competencies through the establishment of smaller micro-competencies and micro-credentialling. Organized into three broad stages-development, implementation, and improvement-a six-step framework for optimizing and instituting portfolios in postgraduate medical education is offered.

A systematic scoping review of undergraduate medical ethics education programs from 1990 to 2020.

INTRODUCTION: Ensuring medical students are equipped with essential knowledge and portable skills to face complex ethical issues underlines the need for ethics education in medical school. Yet such training remains variable amidst evolving contextual, sociocultural, legal and financial considerations that inform training across different healthcare systems. This review aims to map how undergraduate medical schools teach and assess ethics. METHODS: Guided by the Systematic Evidence-Based Approach (SEBA), two concurrent systematic scoping reviews were carried out, one on ethics teaching and another on their assessment. Searches were conducted on PubMed, Embase, PsycINFO and ERIC between 1 January 1990 and 31 December 2020. Data was independently analysed using thematic and content analysis. RESULTS: Upon scrutinising the two sets of full-text articles, we identified 141 articles on ethics teaching and 102 articles on their assessments. 83 overlapped resulting in 160 distinct articles. Similar themes and categories were identified, these include teaching modalities, curriculum content, enablers and barriers to teaching, assessment methods, and their pros and cons. CONCLUSION: This review reveals the importance of adopting an interactive, multimodal and interdisciplinary team-teaching approach to ethics education, involving community resource partners and faculty trained in ethics, law, communication, professionalism, and other intertwining healthcare professions. Conscientious effort should also be put into vertically and horizontally integrating ethics into formal medical curricula to ensure contextualisation and application of ethics knowledge, skills and attitudes, as well as protected time and adequate resources. A stage-based multimodal assessment approach should be used to appropriately evaluate knowledge acquisition, application and reflection across various practice settings. To scaffold personalised development plans and remediation efforts, multisource evaluations may be stored in a centralised portfolio. Whilst standardisation of curricula content ensures cross-speciality ethical proficiency, deliberative curriculum inquiry performed by faculty members using a Delphi approach may help to facilitate the narrowing of relevant topics.

Ring finger metacarpal fracture iatrogenic rotation using an ulnar gutter splint: A cadaveric study.

STUDY DESIGN: Cohort cadaveric study. INTRODUCTION: Ring finger metacarpal fractures are often treated with ulnar gutter orthoses incorporating the ring and small fingers. Iatrogenic pronation of the distal metacarpal fragment may occur from overzealous orthotic "molding", resulting in a crossover deformity of the ring finger over the small finger. PURPOSE OF THE STUDY: The goal of this cadaveric study is to determine whether including the middle finger in an ulnar gutter orthotic could lessen the chances of iatrogenic ring finger metacarpal fracture rotation. METHODS: Transverse ring finger metacarpal shaft fractures were created in 24 cadaver hands. The ring and small fingers were then placed into an intrinsic plus position, simulating the application of an ulnar gutter orthotic. Weights of 2.5, 5, and 10 pounds were applied to the ring and small fingers to simulate iatrogenic-induced fracture pronation. The amount of rotational displacement at the fracture was measured, and the protocol was repeated, including the middle finger in the intrinsic plus position. Mann-Whitney-Wilcoxon test was used for statistical analysis. RESULTS: There was an increase in distal fragment rotation with increasing weight. Fracture displacement was greater with the 2-finger position than the 3-finger at all weight levels; this reached statistical significance at 10 lbs (2.8 vs 1.8 mm). CONCLUSIONS: Application of an ulnar gutter orthotic including only ring and small fingers can rotate the distal fragment of a ring finger metacarpal shaft fracture such that overlap could occur with the small finger. Including the middle finger in ulnar gutter splints will mitigate against the rotation of the ring finger metacarpal shaft fracture.

Goals of care discussions: perceptions of radiation and medical oncologists.

BACKGROUND: Goals of care discussions (GOCD) are essential when counseling patients with cancer. Respective roles of radiation oncologists (RO) and medical oncologists (MO) in GOCD can be unclear. This study aims to clarify the dynamics and barriers to GOCD. METHODS: Five hundred and fifty-four ROs and 1604 MOs at NCI-designated comprehensive cancer centers were sent an anonymous electronic survey regarding demographics, opinions, training in GOCD, GOCD frequency, and three vignettes. Response formats were Yes/No, Likert-type, and free response. Chi-square and Wilcoxon rank-sum tests were performed. Likert-type scores were reported as median [interquartile range]. RESULTS: There were 76 (13.7%) RO and 153 (9.5%) MO who completed surveys. Sixty-three percent of RO and 66% of MO reported GOCD with > 50% of patients (p = 0.90). GOCD were initiated for declining performance status (74%) and poor life expectancy (69%). More MO (42%) received formal GOCD training compared to RO (18%) (p < 0.01). MO were more comfortable conducting GOCD than RO (p < 0.01). RO-conducted GOCD were rated to be less important by MO compared to RO (p < 0.05). Thirty-six percent of MO reported being "not at all" or "somewhat" comfortable with RO-conducted GOCD. RO-initiated GOCD with new patients were rated less appropriate by RO compared to MO perceptions of RO-initiated GOCD (p < 0.01). CONCLUSIONS: While MO and RO conduct GOCD with similar frequency, MO are more comfortable conducting GOCD and are more likely to have formal training. MO rate importance of RO involvement lower than RO. Further research is needed to understand interdisciplinary dynamics that may impact GOCD and subsequent patient care outcomes.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk.

PURPOSE: The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome. METHODS: The 2012-2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions. RESULTS: A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%). CONCLUSION: This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

Postgraduate ethics training programs: a systematic scoping review.

BACKGROUND: Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum. METHODS: With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review. RESULTS: The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF). CONCLUSIONS: Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.

Changes in Brain Activation Associated with Spontaneous Improvization and Figural Creativity After Design-Thinking-Based Training: A Longitudinal fMRI Study.

Creativity is widely recognized as an essential skill for entrepreneurial success and adaptation to daily-life demands. However, we know little about the neural changes associated with creative capacity enhancement. For the first time, using a prospective, randomized control design, we examined longitudinal changes in brain activity associated with participating in a five-week design-thinking-based Creative Capacity Building Program (CCBP), when compared with Language Capacity Building Program (LCBP). Creativity, an elusive and multifaceted construct, is loosely defined as an ability to produce useful/appropriate and novel outcomes. Here, we focus on one of the facets of creative thinking-spontaneous improvization. Participants were assessed pre- and post-intervention for spontaneous improvization skills using a game-like figural Pictionary-based fMRI task. Whole-brain group-by-time interaction revealed reduced task-related activity in CCBP participants (compared with LCBP participants) after training in the right dorsolateral prefrontal cortex, anterior/paracingulate gyrus, supplementary motor area, and parietal regions. Further, greater cerebellar-cerebral connectivity was observed in CCBP participants at post-intervention when compared with LCBP participants. In sum, our results suggest that improvization-based creative capacity enhancement is associated with reduced engagement of executive functioning regions and increased involvement of spontaneous implicit processing.

Multiplexed Molecular Imaging of Fresh Tissue Surfaces Enabled by Convection-Enhanced Topical Staining with SERS-Coded Nanoparticles.

There is a need for intraoperative imaging technologies to guide breast-conserving surgeries and to reduce the high rates of re-excision for patients in which residual tumor is found at the surgical margins during postoperative pathology analyses. Feasibility studies have shown that utilizing topically applied surface-enhanced Raman scattering (SERS) nanoparticles (NPs), in conjunction with the ratiometric imaging of targeted versus untargeted NPs, enables the rapid visualization of multiple cell-surface biomarkers of cancer that are overexpressed at the surfaces of freshly excised breast tissues. In order to reliably and rapidly perform multiplexed Raman-encoded molecular imaging of large numbers of biomarkers (with five or more NP flavors), an enhanced staining method has been developed in which tissue surfaces are cyclically dipped into an NP-staining solution and subjected to high-frequency mechanical vibration. This dipping and mechanical vibration (DMV) method promotes the convection of the SERS NPs at fresh tissue surfaces, which accelerates their binding to their respective biomarker targets. By utilizing a custom-developed device for automated DMV staining, this study demonstrates the ability to simultaneously image four cell-surface biomarkers of cancer at the surfaces of fresh human breast tissues with a mixture of five flavors of SERS NPs (four targeted and one untargeted control) topically applied for 5 min and imaged at a spatial resolution of 0.5 mm and a raster-scanned imaging rate of >5 cm2 min-1 .

Extra-Articular Base Fractures of the Proximal Phalanx in Adults: A Systematic Review.

Background: Extra-articular proximal phalanx base fractures are common in adults and can lead to permanent finger stiffness and joint contractures. The purpose of this review is to summarise the evidence for operative and non-operative management of this fracture type. Methods: The MedLine, Embase, PubMed, Scopus and Cochrane Library databases were searched using the following key terms: 'proximal phalanx', 'base', 'fracture', 'repair' and 'fixation'. A total of 2,889 unique records were extracted. All studies with primary data on the management of extra-articular proximal phalangeal base fractures in adults were included for initial review. Results: Eleven studies met inclusion criteria with a total of 441 extra-articular proximal phalanx base fractures. Outcomes were determined by final total active range of motion. 182 extra-articular proximal phalangeal base fractures were treated non-operatively, with excellent or good outcomes attained in 80% of cases. Another 259 extra-articular proximal phalangeal base fractures were treated operatively, including 236 with Kirschner wires (K-wires), 18 with plates, and five with intramedullary screws. Case-level data were available in 186 fractures managed by K-wire fixation, with excellent or good outcomes achieved in 79% of cases. Excellent or good outcomes were achieved in 35% of cases treated by plates, and 80% of five cases treated by intramedullary screw fixation. Three (1.6%) patients managed conservatively required surgery after reduction loss. No patients managed with K-wires required re-operation for reduction loss; tenolysis/capsulotomy was required in 11 (4.5%) cases for stiffness, and pin site infections occurred in eight (3.5%) cases. Complex regional pain syndrome occurred in five cases (28%) of plate fixation. Conclusions: In summary, excellent or good results may be achieved by K-wire pinning or conservative management. Current evidence is limited for plate or intramedullary screw fixation. Prospective trials and outcomes standardisation are needed to improve the evidence base. Level of Evidence: Level III (Therapeutic).

Orthopedic Surgery Residents: How Much Do They Know About Occupational Therapy?

Background Orthopedic hand surgeons rely on occupational therapy (OT) as a crucial part of rehabilitation following injury or surgery. Therefore, orthopedic surgeons should understand the full range of OT services. There is limited prior research on orthopedic residents' understanding of OT in the United States. The main goal of this study is to examine how well orthopedic surgery residents grasp and perceive the role of OT, particularly in hand surgery, as integrated into their educational curriculum. Methods The study included all orthopedic surgery residents from a single institution (Columbia University, New York) during 2022-2023. We obtained permission from the Institutional Review Board, Department Chair, and Program Director to recruit participants. Eligible residents who agreed to participate completed questionnaires regarding their understanding of the role of OT in orthopedic surgery. Results Thirty subjects met the inclusion criteria. The total response rate from the residents was 14/30 (47%). The residents reported a mediocre level of familiarity with OT while also rating 4.5/5 the importance of OT in hand surgery without significant difference between postgraduate year groups. 11/14 residents reported no formal training concerning the role of OT in hand surgery. 12/14 residents reported that it would be helpful to spend time with an occupational therapist. Conclusions This study revealed the lack of confidence residents expressed regarding occupational therapists' roles. All residents recognized the importance of OT in hand surgery and expressed interest in shadowing occupational therapists. Residents of all levels acknowledge the crucial partnership between orthopedists and occupational therapists but lack formal education about the therapist's scope and role.

Flexor Tendon Zone II Repair.

Background: Flexor-tendon injury is a historically challenging problem for orthopaedic surgeons. Much research has been dedicated to finding solutions that offer balance in terms of the strength and ease of the repair versus the rate of complications such as adhesions. The number of core sutures, distance from the tendon edge, and use of an epitendinous stitch have been shown to affect repair strength1-4. A number of configurations have been described for the placement of the suture; however, none has been identified as a clear gold standard5. This article will highlight the preferred tendon repair technique of the senior author (R.J.S.), the Strickland repair with a simple running epitendinous stitch. Relevant anatomy, indications, operative technique, and postoperative management will be discussed. Description: The flexor tendon is typically accessed via extension of the laceration that caused the initial injury. After the neurovascular structures and pulleys are assessed, the tendon is cleaned and prepared for repair. A 3-0 braided nylon suture is utilized for the 4-core strand repair and placed in the Strickland fashion. A 5-0 polypropylene suture is then utilized for the simple running epitendinous stitch. Alternatives: Multiple alternative techniques have been described. These vary in the number of core strands, the repair configuration, the suture caliber, and the use of an epitendinous or other suture. Nonoperative treatment is typically reserved for partial flexor-tendon laceration, as complete tendon discontinuity will not heal and requires surgical intervention. Rationale: The 4-core strand configuration has been well established to increase the strength of the repair as compared with 2-core strand configurations, while also being easier to accomplish and with less suture burden than other techniques1. The presently described technique has excellent repair strength and can allow for early active range of motion, which is critical to reduce the risk of postoperative adhesions and stiffness. Expected Outcomes: Excellent outcomes have been demonstrated for primary flexor-tendon repair if performed soon after the injury1,2,6,7. Delayed repair may lead to adhesions and poor tendon healing8. Early postoperative rehabilitation is vital for success9. There are advocates for either active or passive protocols10-12. The protocol at our institution is to begin early active place-and-hold therapy at 3 to 5 days postoperatively, which has been shown in the literature to provide improved finger motion as compared with passive-motion therapy13-16.Important Tips:: The proximal end of the tendon may need to be retrieved via a separate incision if it is not accessible through the flexor-tendon sheath.The proximal end of the tendon may be held in place with a 25-gauge needle in order to best place sutures into both ends of the tendon.The epitendinous suture is run around the back wall before the core sutures are tied down, in order to prevent the tendon and repair from bunching up and becoming overly bulky.The entire A4 pulley and the distal A2 pulley can be divided for exposure if necessary.Up to 2 cm of the flexor-tendon sheath can be divided.If there are concomitant digital nerve injuries, repair these after the tendon, in order to avoid damaging the more delicate nerve repair while manipulating the tendon for repair.The most common major complications following tendon repair are formation of adhesions and rerupture. Acronyms and Abbreviations:: FDS = flexor digitorum superficialisFDP = flexor digitorum profundusMCP = metacarpophalangealPIP = proximal interphalangealDIP = distal interphalangeal.

Anatomic Risks with Overpenetration of the Volar Locking Plates' Proximal Holes.

Background Volar locking plate fixation (VLP) is commonly used to treat distal radius fractures (DRF). Risk of dorsal compartment injury with distal screw hole fixation has been studied; however, the risk with proximal screw hole fixation is not well studied. Purpose The goal of this study was to investigate the risk of dorsal structure injury from the screw holes proximal to the two distal rows. Methods Nine cadaveric forearms were used. After volar distal radius exposure, a long VLP was applied. Kirschner wires were placed through the most proximal holes into the dorsal compartments. The extensor structures penetrated were noted and tagged with hemoclips. The distance from the dorsal cortex to the structures was measured. Results The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bodies were only penetrated; no tendons were penetrated. Proportion of muscle penetration increased with the more proximal screw holes. EPB was more likely to be penetrated distally and APL proximally; both were injured at holes 2 and 3. The extensors were 2 mm from the dorsal cortex of the radius on average; this did not decrease with compression of the forearm. Conclusions This is the first study to examine the anatomic risk of extensor structure injury with VLP proximal screw hole penetration. No extensor tendons were penetrated by these proximal screw holes; first dorsal compartment muscle bellies may be irritated with overpenetration. Our findings suggest that proximal VLP screws do not need to be downsized if they are not over 2 mm prominent.

Systematic Review and Meta-Analysis of the Influence of Genetic Variation on Ototoxicity in Platinum-Based Chemotherapy.

OBJECTIVE: The objective of this meta-analysis is to evaluate the impact of genetic polymorphisms on platinum-based chemotherapy (PBC)-induced ototoxicity. DATA SOURCES: Systematic searches of PubMed, Embase, Cochrane, and Web of Science were conducted from the inception of the databases to May 31, 2022. Abstracts and presentations from conferences were also reviewed. REVIEW METHODS: Four investigators independently extracted data in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Differences in the prevalence of PBC-induced ototoxicity between reference and variant (i) genotypes and (ii) alleles were analyzed. The overall effect size was presented using the random-effects model as an odds ratio (OR) with a 95% confidence interval (CI). RESULTS: From 32 included articles, 59 single nucleotide polymorphisms on 28 genes were identified, with 4406 total unique participants. For allele frequency analysis, the A allele in ACYP2 rs1872328 was positively associated with ototoxicity (OR: 2.61; 95% CI: 1.06-6.43; n = 2518). Upon limiting to cisplatin use only, the T allele of COMT rs4646316 and COMT rs9332377 revealed significant results. For genotype frequency analysis, the CT/TT genotype in ERCC2 rs1799793 demonstrated an otoprotective effect (OR: 0.50; 95% CI: 0.27-0.94; n = 176). Excluding studies using carboplatin or concomitant radiotherapy revealed significant effects with COMT rs4646316, GSTP1 rs1965, and XPC rs2228001. Major sources of variations between studies include differences in patient demographics, ototoxicity grading systems, and treatment protocols. CONCLUSION: Our meta-analysis presents polymorphisms that exert ototoxic or otoprotective effects in patients undergoing PBC. Importantly, several of these alleles are observed at high frequencies globally, highlighting the potential for polygenic screening and cumulative risk evaluation for personalized care.

Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review.

OBJECTIVES: Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation. DESIGN: Krishna's Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment. DATA SOURCES: PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases. ELIGIBILITY CRITERIA: Articles published between 1 January 2000 and 31 December 2020 were included. DATA EXTRACTION AND SYNTHESIS: The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion. RESULTS: 12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations. CONCLUSIONS: This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.

Foliar nutrient concentrations of six northern hardwood species responded to nitrogen and phosphorus fertilization but did not predict tree growth.

Foliar chemistry can be useful for diagnosing soil nutrient availability and plant nutrient limitation. In northern hardwood forests, foliar responses to nitrogen (N) addition have been more often studied than phosphorus (P) addition, and the interactive effects of N and P addition have rarely been described. In the White Mountains of central New Hampshire, plots in ten forest stands of three age classes across three sites were treated annually beginning in 2011 with 30 kg N ha-1 y-1 or 10 kg P ha-1 y-1 or both or neither-a full factorial design. Green leaves of American beech (Fagus grandifolia Ehrh.), pin cherry (Prunus pensylvanica L.f.), red maple (Acer rubrum L.), sugar maple (A. saccharum Marsh.), white birch (Betula papyrifera Marsh.), and yellow birch (B. alleghaniensis Britton) were sampled pre-treatment and 4-6 years post-treatment in two young stands (last cut between 1988-1990), four mid-aged stands (last cut between 1971-1985) and four mature stands (last cut between 1883-1910). In a factorial analysis of species, stand age class, and nutrient addition, foliar N was 12% higher with N addition (p < 0.001) and foliar P was 45% higher with P addition (p < 0.001). Notably, P addition reduced foliar N concentration by 3% (p = 0.05), and N addition reduced foliar P concentration by 7% (p = 0.002). When both nutrients were added together, foliar P was lower than predicted by the main effects of N and P additions (p = 0.08 for N × P interaction), presumably because addition of N allowed greater use of P for growth. Foliar nutrients did not differ consistently with stand age class (p ≥ 0.11), but tree species differed (p ≤ 0.01), with the pioneer species pin cherry having the highest foliar nutrient concentrations and the greatest responses to nutrient addition. Foliar calcium (Ca) and magnesium (Mg) concentrations, on average, were 10% (p < 0.001) and 5% lower (p = 0.01), respectively, with N addition, but were not affected by P addition (p = 0.35 for Ca and p = 0.93 for Mg). Additions of N and P did not affect foliar potassium (K) concentrations (p = 0.58 for N addition and p = 0.88 for P addition). Pre-treatment foliar N:P ratios were high enough to suggest P limitation, but trees receiving N (p = 0.01), not P (p = 0.64), had higher radial growth rates from 2011 to 2015. The growth response of trees to N or P addition was not explained by pre-treatment foliar N, P, N:P, Ca, Mg, or K.

Extensor Tendon Injury After Volar Locking Plating for Distal Radius Fractures: A Systematic Review.

Distal radius fractures are common orthopedic injuries. Treatment has varied historically, but volar locking plating currently predominates. Although flexor tendon injury is a well-studied complication of this operation, extensor tendon injury is less well studied. The purpose of this review is to search the literature and present the epidemiology, presentation, and treatment of this complication. The Cochrane, EMBASE, PubMed, and SCOPUS databases were searched for the terms "volar" + "radius" + ("plate" OR "plating") + "extensor." Ninety final studies were included for analysis in this review. The incidence of extensor tendon rupture varies from 0% to 12.5%; the extensor pollicis longus is most commonly ruptured. The presentation and management of extensor tendon injury after injury, intraoperatively, and postoperatively are summarized. Radiographic views are described to detect screw prominence and minimize intraoperative risk. Extensor tendon injury after volar locking plate for distal radius fractures is an uncommon injury with several risk factors including dorsal screw prominence and fracture fragments. Removal of hardware and tendon transfers or reconstruction may be necessary to prevent loss of extensor mechanism.

The utilization of atrial sensing dipole in single lead implantable cardioverter defibrillator for detection of new-onset atrial high-rate episodes or subclinical atrial fibrillation: A systematic review and meta-analysis.

This meta-analysis aims to evaluate the performance of atrial sensing dipole in single lead implantable cardioverter defibrillator (VDD-ICD) recipients in particular diagnosing new-onset atrial high-rate episodes (AHREs) defined as rate threshold of 200 beats per minute, or subclinical atrial fibrillation (SCAF) defined as device-detected AF without symptoms. We comprehensively searched PubMed, Embase, and ClinicalTrials.gov. Studies comparing contemporary single- and dual-chamber ICD (VVI-/DDD-ICD) versus VDD-ICD were included. Restricted maximum likelihood method for random effect model and Mantel-Haenszel method for fixed effect model were used to estimate the effect size of new-onset AHREs, or SCAF detection in each group. Three prospective studies were identified and total of 991 participants were included. There were 330 (33.3%) in VDD-ICD and 661 (66.7%) in VVI-/DDD-ICD. Most (78%) participants were men. Median follow-up was from 365 days to 847 days. VDD-ICD has a higher likelihood of detecting AHREs or SCAF as compared to VVI-/DDD-ICD [(OR random effect : 2.6; 95% CI: 1.2, 5.8; p = .018); I-squared = 67.8%, p = .019]. This difference was more apparently seen in the comparison between VDD-ICD and VVI-ICD [(OR random effect: 3.8; 95% CI: 2.1, 6.6, p < .001), I-squared = 0.0%, p = .518]. The result is same as fixed effect. Rate of AHREs detection observed in VDD-ICD was not statistically different when compared to the only group with DDD-ICD from SENSE trial. In conclusion, this meta-analysis reveals that the use of floating atrial sensing dipole in VDD-ICD increases the detection of new-onset AHREs or SCAF when compared to VVI-ICD, with similar atrial sensing performance to DDD-ICD.

Minimum 2-Year Analysis of S2-Alar-Iliac Screw Fixation for Adult Spinal Deformity.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine the rate and risk factors for S2AI screw-related pain after adult spinal deformity surgery with a minimum 2-year follow-up. METHODS: A consecutive 83 spinal deformity patients undergoing surgical treatment between August 2015 and December 2017 with minimum 2-year follow-up for S2AI screw complication and screw-related pain were included. Linear regression was performed on various risk factors and postoperative S2AI screw-related pain. Subset analysis of 53 patients was performed on preoperative and postoperative SRS and ODI scores, operative data, and radiographic data. RESULTS: The overall proportion of S2AI screw-related pain was 9.6%. An S2AI screw complication was identified radiographically in 10.8% of patients; among these, 22.2% experienced S2AI screw-related pain. 3.4% of all patients underwent S2A1 screw removal. The SRS, ODI, sagittal vertical axis (SVA), and coronal alignment scores/measurements improved following treatment in all patients. However, the mean difference for the pre and postoperative SRS function score (1.2 ± 0.5 vs 0.9 ± 0.8) and SVA (4.0 ± 4.9 cm vs 2.1 ± 4.8 cm) were higher for the pain group. CONCLUSIONS: A minimum 2-year analysis of S2AI screw fixation in adult spinal deformity patients showed that 9.6% of patients experienced S2AI screw-related pain and 3.4% of patients had S2A1 screws removed. The size and the number of S2AI screws did not predict postoperative pain, nor were radiographic findings correlated with clinical outcomes. The patient outcome scores, coronal alignment, and SVA improved for all patients, but within the pain group there was an overall larger change in the SVA and SRS function score.

Spinal Deformity Surgery in Pediatric Patients With Cerebral Palsy: A National-Level Analysis of Inpatient and Postdischarge Outcomes.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy. METHODS: A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission. RESULTS: A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5). CONCLUSIONS: Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.