Assembly chaperone Nas6 selectively destabilizes 26S proteasomes with defective regulatory particle-core particle interfaces.

The 26S proteasome is a 66-subunit-chambered protease present in all eukaryotes that maintains organismal health by degrading unneeded or defective proteins. Defects in proteasome function or assembly are known to contribute to the development of various cancers, neurodegeneration, and diabetes. During proteasome biogenesis, a family of evolutionarily conserved chaperones assembles a hexameric ring of AAA+ family ATPase subunits contained within the proteasomal regulatory particle (RP) and guide their docking onto the surface of the proteolytic core particle (CP). This RP-CP interaction couples the substrate capture and unfolding process to proteolysis. We previously reported a mutation in the proteasome that promoted dissociation of the RP and CP by one of these chaperones, Nas6. However, the nature of the signal for Nas6-dependent proteasome disassembly and the generality of this postassembly proteasome quality control function for Nas6 remain unknown. Here, we use structure-guided mutagenesis and in vitro proteasome disassembly assays to demonstrate that Nas6 more broadly destabilizes 26S proteasomes with a defective RP-CP interface. We show that Nas6 can promote dissociation of mature proteasomes into RP and CP in cells harboring defects on either side of the RP-CP interface. This function is unique to Nas6 and independent from other known RP assembly chaperones. Further biochemical experiments suggest that Nas6 may exploit a weakened RP-CP interface to dissociate the RP from the CP. We propose that this postassembly role of Nas6 may fulfill a quality control function in cells by promoting the recycling of functional subcomplexes contained within defective proteasomes.

Looking Across the Drape: A Novel Quality Improvement Approach to Understanding Surgeon and Anesthesiologist Burnout.

OBJECTIVE: To identify well-being threats for surgeons and anesthesiologists and develop interventions using the Quality of Life Improvement (QOLI) approach. BACKGROUND: Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs. METHODS: Anesthesia and surgery faculty in eight perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live-voting to identify well-being priorities. RESULTS: 104 perioperative faculty completed the survey. Across specialties, higher MHC-SF scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded five areas for intervention: (1) Work culture, (2) Work environment/resources, (3) Sources of fulfillment, (4) Work/life harmony, (5) Financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were OR inefficiencies/delays and excessive workload, while anesthesiologists cited understaffing and unpredictable work hours. CONCLUSIONS: Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Recent advances in Surface Plasmon Resonance (SPR) biosensors for food analysis: a review.

Food safety is the prime area of concern that builds trust. With the prevailing advancements, it has become facile to ensure safety in almost all aspects. Technology has grown from tedious lab techniques to modern chromatographic techniques and immunoassays, progressed with more precise and rapid sensing through the advent of Biosensors. Biosensors provide an automated technology by presenting superfast, nondestructive and cost-effective detection in food analysis. SPR biosensor is an optical biosensor known for its versatility and has wider applications in food testing and analysis. It has an optical system for excitation and interrogation of surface plasmons, and a biomolecular recognition element to detect and seize the target analyte present in a sample. The optical signal detects the binding analyte, on the recognition element, which results in a change in refractive index at the surface and modifies the surface plasmons' propagation constant. SPR aids in label-free detection of various components such as adulterants, antibiotics, biomolecules, genetically modified foods, pesticides, insecticides, herbicides, microorganisms and microbial toxins in food and assures safety. The distinct advancements of SPR in food analysis have been found and discussed. The review also provides knowledge on the advantages and the key challenges encountered by SPR.

Shooting shadows: India's struggle to reduce the burden of anaemia.

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Tipping the scale: the role of a national nutritional supplementation programme for pregnant mothers in reducing low birth weight and neonatal mortality in India.

With over 1·3 million Anganwadi centres (AWC) (meaning 'courtyard shelter'), the Indian government runs a nationwide intervention providing nutrition supplement to pregnant mothers to improve the health of their children. Using two successive rounds of the nationally representative cross-sectional National Family Health Survey data (collected during 2005-2006 and 2015-2016) of India, we assessed whether nutrition supplements given to pregnant mothers through AWC were associated with select child health indicators - extremely low birth weight (ELBW), very low birth weight (VLBW), low birth weight (LBW) and neonatal mortality (death during day 0-27) stratified by death during day 0-1, day 2-6 and day 7-27. A total of 148 019 children and 205 593 children were eligible for analysing birth weight and neonatal mortality, respectively. OR with 95% CI, estimated from multivariate logistic regression models, suggest that receipt of nutrition supplements was associated with decreased risk of VLBW (OR: 0·73, 95% CI 0·63, 0·83, P < 0·001), LBW (OR: 0·92, 95% CI 0·88, 0·96, P < 0·001), but not ELBW (OR: 0·80, 95% CI 0·56, 1·15, P = 0·226). Women who always received nutrition supplements during their pregnancy saw lower risk of death of their neonates (OR: 0·67, 95% CI 0·61, 0·73, P < 0·001), including death on day 0-1 (OR: 0·66, 95% CI 0·58, 0·74, P < 0·001), day 2-6 (OR: 0·69, 95% CI 0·58, 0·82, P < 0·001) and day 7-27 (OR: 0·68, 95% CI 0·53, 0·87, P = 0·002). Therefore, nutritional supplementation to pregnant mothers appears to be helpful in deterring various stages of neonatal mortality, VLBW and LBW, though it might not be effective in mitigating ELBW. Findings were discussed considering possible limitations of the study.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Program for Supporting Frontline Improvement Projects in an Academic Radiology Department.

OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.

Absolute Temperature Thresholds for Detection of Skin Wetness and Dampness on the Hand and their Variation with Sex and Age.

The human body has dedicated receptors for sensing temperature and touch, but not wetness. How then is wetness perceived? To test if wetness perception arises from the sensory integration of touch and temperature, and to quantify its measurement in humans, we designed a wetness perception monitor (WPM) which enabled variation of temperature at the fingertips of participants while measuring the pressure exerted on a test surface in the controlled environment of a moisture-free chamber. Thirty randomly selected adults (18+ years) were tested for their perception of dampness/wetness using the WPM. Our data suggest that humans perceive dampness and wetness at average temperatures of 22 ± 0.4°C and 18 ± 0.5°C, respectively, and these sensations are extinguished at temperatures below 16 ± 1°C. Measurements were obtained at an average tactile pressure of 1.5 ± 0.3 kPa. Young adults (18-35 years) sensed wetness at significantly higher temperatures than middle-aged adults (36-55 years) or mature adults (56+ years), who sensed wetness at similar temperatures. We found a surprising sex difference in wetness perception, with females sensing wetness at higher temperatures than males. When the data were screened for outliers, we found that participants whose readings were outside normal ranges, self-reported sensory deficits suggesting that wetness perception could potentially be used as a noninvasive biomarker.

A life-cycle approach to food and nutrition security in India.

India's poor performance on critical food and nutrition security indicators despite substantial economic prosperity has been widely documented. These failings not only hamper national progress, but also contribute significantly to the global undernourished population, particularly children. While the recently passed National Food Security Act 2013 adopts a life-cycle approach to expand coverage of subsidized food grains to the most vulnerable households and address food security, there remains much to be desired in the legislation. Access to adequate food for 1.24 billion people is a multifaceted problem requiring an interconnected set of policy measures to tackle the various factors affecting food and nutrition security in India. In the present opinion paper, we discuss a fivefold strategy that incorporates a life-cycle approach, spanning reproductive health, bolstering citizen participation in existing national programmes, empowering women, advancing agriculture and better monitoring the Public Distribution System in order to fill the gaps in both access and adequacy of food and nutrition.

An At-Home Laparoscopic Curriculum for Junior Residents in Surgery, Obstetrics/Gynecology, and Urology.

Introduction: Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms. Methods: We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents. Results: Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28). Discussion: This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Examining the characteristics of visuospatial information processing in individuals with high-functioning autism.

Information processing in individuals with autism is marked by a unique interplay of strengths and weaknesses that in concert distinguishes social cognition in autism from individuals with typical-functioning brains. In autism, difficulties with higher cognitive processing and enhancement of low-level visuospatial processing, such as in visual search tasks, may lead to diminished central coherence, which has the potential to hinder how an individual functions in social interactions where integration of components such as intention, emotion, and context paints the global picture necessary for social processing. A more thorough understanding of the cognitive and neural processes in autism is important for the advancement of intervention programs. The intention of this review is to discuss the implications of neuroimaging and behavioral studies that have analyzed the higher cognitive functions in individuals with high-functioning autism, with a particular emphasis on studies that have investigated visuospatial processing.

Predicting obstructive sleep apnea severity from craniofacial images using ensemble machine learning models.

Obstructive sleep apnea (OSA) is a prevalent disease affecting 10 to 15% of Americans and nearly one billion people worldwide. It leads to multiple symptoms including daytime sleepiness; snoring, choking, or gasping during sleep; fatigue; headaches; non-restorative sleep; and insomnia due to frequent arousals. Although polysomnography (PSG) is the gold standard for OSA diagnosis, it is expensive, not universally available, and time-consuming, so many patients go undiagnosed due to lack of access to the test. Given the incomplete access and high cost of PSG, many studies are seeking alternative diagnosis approaches based on different data modalities. Here, we propose a machine learning model to predict OSA severity from 2D frontal view craniofacial images. In a cross-validation study of 280 patients, our method achieves an average AUC of 0.780. In comparison, the craniofacial analysis model proposed by a recent study only achieves 0.638 AUC on our dataset. The proposed model also outperforms the widely used STOP-BANG OSA screening questionnaire, which achieves an AUC of 0.52 on our dataset. Our findings indicate that deep learning has the potential to significantly reduce the cost of OSA diagnosis.

The continued effects of COVID-19 on the lives and livelihoods of vegetable farmers in India.

India experienced a rapid rise in COVID-19 infections from March 2021. States imposed varying levels of lockdowns and curfews to curb the spread of the disease. These restrictions severely affected the functioning of food systems. The objective of this study was to analyze how COVID-19 continues to affect agricultural production, food security and household diets of vegetable farmers. A phone-based survey was conducted with 595 vegetable farmers in the states of Andhra Pradesh, Assam, Jharkhand, Karnataka and Odisha, 60% of whom had been interviewed a year earlier. Overall, 60% of farmers experienced decreased vegetable production; over 80% reported a reduction in consumption of at least one food group; and 45% reported some level of food insecurity between May 2020 and May 2021. Farmers who reported decreased staples production, difficulty accessing seeds/seedlings, or reduced their household spending were more likely to report decreased vegetable production. Vegetable consumption was positively associated with receipt of COVID-19 relief benefits, borrowing money, or having home gardens. Farmers who received public agricultural assistance, or had reduced expenses, were more likely to have lower vegetable consumption. Greater severity of food insecurity was associated with farmers belonging to underprivileged social groups, non-Hindus, or those who experienced decrease in livestock production, weather related disruptions or received COVID-19 assistance. This is one of few studies that have conducted a longitudinal assessment of the impacts across multiple waves of COVID-19. COVID-19 is seen to be one among several shocks experienced by farm households, and exacerbated existing issues within agriculture and food security. There is a need for public policy support to strengthen both production and consumption of vegetables.

Physical and chemical characterization of smokeless tobacco products in India.

The rapid proliferation of smokeless tobacco (SLT) in India has occurred without adequate information on the possible dangers and toxicity of these products. Tobacco flavors as well as nicotine (both protonated and un-protonated) are responsible for health dangers and addiction. The study aimed to offer information on the physical characteristics of commonly used smokeless tobacco products (including microscopic analysis), along with nicotine content (both total and un-protonated), pH, moisture, and flavors. The Standard Operating Procedures (SOPs) validated by the World Health Organization (WHO) recognized Tobacco Testing Laboratory TobLabNet) were applied for the analysis of various constituents of the SLTs. The microscopic analysis indicated that some of the SLT products like khaini were finely processed and available in filter pouches for users' convenience and prolonged use leading to prolonged retention and addiction potential. Nicotine absorption and availability (both protonated and un-protonated) are affected by moisture and pH. Essences provide a pleasant aroma and flavor, with an increased risk of misuse and other health problems. Few chewing tobacco and Zarda had the lowest levels of un-protonated nicotine (0.10-0.52% and 0.15-0.21%, respectively), whereas Gul, Gudhaku, and Khaini had the highest levels, ranging from 95.33 to 99.12%. Moisture and pH ranged from 4.54 to 50.19% and 5.25-10.07 respectively. Menthol (630.74-9681.42 µg/g) was the most popular flavour, followed by Eucalyptol (118.16-247.77 µg/g) and camphor (148.67 and 219.317 µg/g). SLT's health concerns and addiction dangers are exacerbated by the high proportion of bioavailable nicotine coupled with flavors. The findings of this study have important implications for the regulation and use of SLT in countries where use of SLT is prevalent.

Factors associated with minimum dietary diversity failure among Indian children.

Recognising the importance of infant and young child feeding practices during the first 2 years of life, the World Health Organization's Global Nutrition Monitoring Framework developed a minimum dietary diversity (MDD) indicator for feeding children aged 6-23 months. MDD is defined as the consumption of food items from five or more groups out of a total of eight food groups. Food intake from less than five food groups is considered minimum dietary diversity failure (MDDF). Using the nationally representative National Family Health Survey (NFHS) dataset, the present study assessed the trend in MDDF between 2005-6 and 2015-16 and the factors associated with MDDF among children aged 6-23 months during 2015-16. The NFHS conducted in 2005-6 and 2015-16 covered a sample of 14 419 and 74 078 children aged 6-23 months, respectively. Overall, the MDDF reduced from 87⋅4  % (95  % confidence interval (95  % CI) 86⋅8  %, 87⋅9  %) in 2005-6 to 80⋅6  % (95  % CI 80⋅1  %, 81⋅0  %) in 2015-16. Multivariable logistic regression analysis revealed that increased child's age, second and third birth order children, higher maternal age and education, mass media exposure of mothers and more than four antenatal care visits had a negative association with the MDDF. Children living in rural areas and residing in high-focus states of India were observed with higher odds of experiencing MDDF. Exposure to community healthcare services was negatively associated with MDDF, and anaemic children were more likely to have MDDF. Socioeconomic status of mothers and children and encouragement of maternal and child healthcare use could be helpful in devising context-specific intervention to mitigate MDDF.

The G-Force Conundrum in Platelet-Rich Fibrin Generation: Management of a Problem Hidden in Plain Sight.

Aim: A force of 400 g at 2700 revolutions per minute (RPM) results in an optimum leukocyte and platelet-rich fibrin (L-PRF). Most of centrifuges with varying characteristics generate a g-force in excess of 700 g at 2700 RPM. In this context, the study explores the effect of the original centrifugation protocol and a modified protocol tailor-made to lower the RPM to generate a g-force of ~ 400 g on platelet concentration, clot size and growth factors release in L-PRF prepared in two different commercially available centrifuges. Materials and Methods: Twenty five subjects each were assigned to the following groups; R1 and R2 where L-PRF was obtained from two laboratory swing-out centrifuges (Remi 8C® and Remi C854®, Mumbai, India), respectively. PRF was obtained from each subject within a group using two protocols; Original (O) protocol: conforming to the original centrifugation cycle (2700 RPM for 12 min) and Modified (M) protocol. Clot size, growth factor estimation, and platelet counts were measured at 20, 40, and 60 min from all the L-PRF clots, respectively. Results: At the third time period (40-60 min), there were no significant differences in clot sizes with the original protocol (P = 0.09), but a highly significant difference was noticed with the modified protocol in both the centrifuges (P = 0.001). Our results showed an increased concentration of vascular endothelial growth factor and epidermal growth factor with modified protocol than with original protocol with both the centrifuges (P = 0.001). By the end of second and third time periods, more platelet concentration was observed with modified protocol than with the original protocol in both the centrifuges (P = 0.001). Conclusion: This study infers that the centrifuge type and relative centrifugal force can affect the quality and quantity of cells and growth factors and an optimum relationship between g-force and RPM should be maintained to obtain L-PRF with adequate cell viability and optimum growth factor release.

Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is an under-recognized condition that results in morbidity and mortality. Postoperative complications, including medical emergency team activation (META), are disproportionally increased among surgical patients at risk for OSA. A systematic approach is needed to improve provider recognition and treatment, but protocols that demonstrate improvement in META are lacking. As part of a multidisciplinary quality improvement project, DOISNORE50 (DIS), a sleep apnea questionnaire and proactive safety measure, was algorithmically applied to all perioperative patients. METHODS: Consecutive sleep screening was conducted among perioperative patients. Of the 49,567 surgical navigation center patients, 11,932 had previous diagnosis of OSA. Of the 37,572 (96%) patients screened with DIS, 25,171 (66.9%) were Low Risk (DIS < 4), 9,211 (24.5%) were At Risk (DIS ≥ 4), and 3,190 (8.5%) were High Risk (DIS ≥ 6) for OSA, respectively. High Risk patients received same-day sleep consultation. On the day of surgery, patients with Known OSA, At Risk, and High Risk for OSA received an "OSA Precaution Band." An electronic chart reminder alerted admission providers to order postoperative continuous positive airway pressure (CPAP) machine and sleep consult for patients High Risk for OSA. RESULTS: Implementation of a comprehensive program was associated with increased sleep consultation, sleep testing, and inpatient CPAP use (P < .001). For every 1,000 surgical patients screened, 30 fewer META, including rapid responses, reintubation, code blues, and code strokes, were observed. However, inpatient sleep consultation and inpatient CPAP use were not independently associated with reduced META. In the subgroup of patients hospitalized longer than 3 days, inpatient CPAP use was independently associated with reduced META. CONCLUSIONS: In this single-center, institution-wide, multidisciplinary-approach, quality improvement project, a comprehensive OSA screening process and treatment algorithm with appropriate postoperative inpatient CPAP therapy and inpatient sleep consultations was associated with increased CPAP use and reduced META. Further prospective studies are needed to assess cost, feasibility, and generalizability of these findings. CITATION: Namen AM, Forest D, Saha AK, et al. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):1953-1965.

A Case of Severe Hyponatremia in a Patient With Primary Adrenal Insufficiency.

Primary adrenal insufficiency leads to the decreased production of cortisol and aldosterone. Patients develop an electrolyte imbalance, which can be severe and life-threatening. It is more common in women, usually between the second and fourth decades. We present the case of a 58-year-old female who was admitted due to laboratory findings of severe hyponatremia. Further workup revealed the underlying cause to be primary adrenal insufficiency. Our case report highlights that profound hyponatremia can present with minimal non-specific symptoms and the absence of any neurological manifestations. Correction of hyponatremia, treatment with hydrocortisone and fludrocortisone, and water restriction in the management of this patient resulted in full clinical recovery.