On the use of simulation in robotics: Opportunities, challenges, and suggestions for moving forward.

The last five years marked a surge in interest for and use of smart robots, which operate in dynamic and unstructured environments and might interact with humans. We posit that well-validated computer simulation can provide a virtual proving ground that in many cases is instrumental in understanding safely, faster, at lower costs, and more thoroughly how the robots of the future should be designed and controlled for safe operation and improved performance. Against this backdrop, we discuss how simulation can help in robotics, barriers that currently prevent its broad adoption, and potential steps that can eliminate some of these barriers. The points and recommendations made concern the following simulation-in-robotics aspects: simulation of the dynamics of the robot; simulation of the virtual world; simulation of the sensing of this virtual world; simulation of the interaction between the human and the robot; and, in less depth, simulation of the communication between robots. This Perspectives contribution summarizes the points of view that coalesced during a 2018 National Science Foundation/Department of Defense/National Institute for Standards and Technology workshop dedicated to the topic at hand. The meeting brought together participants from a range of organizations, disciplines, and application fields, with expertise at the intersection of robotics, machine learning, and physics-based simulation.

Microbial and molecular differences according to the location of head and neck cancers.

BACKGROUND: Microbiome has been shown to substantially contribute to some cancers. However, the diagnostic implications of microbiome in head and neck squamous cell carcinoma (HNSCC) remain unknown. METHODS: To identify the molecular difference in the microbiome of oral and non-oral HNSCC, primary data was downloaded from the Kraken-TCGA dataset. The molecular differences in the microbiome of oral and non-oral HNSCC were identified using the linear discriminant analysis effect size method. RESULTS: In the study, the common microbiomes in oral and non-oral cancers were Fusobacterium, Leptotrichia, Selenomonas and Treponema and Clostridium and Pseudoalteromonas, respectively. We found unique microbial signatures that positively correlated with Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways in oral cancer and positively and negatively correlated KEGG pathways in non-oral cancer. In oral cancer, positively correlated genes were mostly found in prion diseases, Alzheimer disease, Parkinson disease, Salmonella infection, and Pathogenic Escherichia coli infection. In non-oral cancer, positively correlated genes showed Herpes simplex virus 1 infection and Spliceosome and negatively correlated genes showed results from PI3K-Akt signaling pathway, Focal adhesion, Regulation of actin cytoskeleton, ECM-receptor interaction and Dilated cardiomyopathy. CONCLUSIONS: These results could help in understanding the underlying biological mechanisms of the microbiome of oral and non-oral HNSCC. Microbiome-based oncology diagnostic tool warrants further exploration.

Evaluation of Adherence to Emergency Department Point-of-Care Ultrasound Documentation and Billing Following Intervention.

Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%-63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%-74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.

Mitochondrial ATP synthase activity is impaired by suppressed O-GlcNAcylation in Alzheimer's disease.

Glycosylation with O-linked ß-N-acetylglucosamine (O-GlcNAc) is one of the protein glycosylations affecting various intracellular events. However, the role of O-GlcNAcylation in neurodegenerative diseases such as Alzheimer's disease (AD) is poorly understood. Mitochondrial adenosine 5'-triphosphate (ATP) synthase is a multiprotein complex that synthesizes ATP from ADP and Pi. Here, we found that ATP synthase subunit α (ATP5A) was O-GlcNAcylated at Thr432 and ATP5A O-GlcNAcylation was decreased in the brains of AD patients and transgenic mouse model, as well as Aß-treated cells. Indeed, Aß bound to ATP synthase directly and reduced the O-GlcNAcylation of ATP5A by inhibition of direct interaction between ATP5A and mitochondrial O-GlcNAc transferase, resulting in decreased ATP production and ATPase activity. Furthermore, treatment of O-GlcNAcase inhibitor rescued the Aß-induced impairment in ATP production and ATPase activity. These results indicate that Aß-mediated reduction of ATP synthase activity in AD pathology results from direct binding between Aß and ATP synthase and inhibition of O-GlcNAcylation of Thr432 residue on ATP5A.

Both targeted mass spectrometry and flow sorting analysis methods detected the decreased serum apolipoprotein E level in Alzheimer's disease patients.

Apolipoprotein E (ApoE) polymorphism has been appreciated as a valuable predictor of Alzheimer disease (AD), and the associated ε4 allele has been recognized as an indicator of susceptibility to this disease. However, serum ApoE levels have been a controversial issue in AD, due to the great variability regarding the different target detection methods, ethnicity, and the geographic variations of cohorts. The aim of this study was to validate serum ApoE levels in relation to AD, particularly using two distinct detection methods, liquid chromatography-selected reaction monitoring (SRM) mass spectrometry and microsphere-based fluorescence-activated cell sorting (FACS) analysis, to overcome experimental variations. Also, comparison of serum ApoE levels was performed between the level of protein detection by FACS and peptide level by SRM in both control and AD patients. Results from the two detection methods were cross-confirmed and validated. Both methods produced fairly consistent results, showing a significant decrease of serum ApoE levels in AD patients relative to those of a control cohort (43 control versus 45 AD, p < 0.0001). Significant correlation has been revealed between results from FACS and SRM (p < 0.0001) even though lower serum ApoE concentration values were measured in protein by FACS analysis than in peptide-level detections by SRM. Correlation study suggested that a decrease of the serum ApoE level in AD is related to the mini-mental state exam score in both results from different experimental methods, but it failed to show consistent correlation with age, gender, or clinical dementia rating.

A multi-looping chromatin signature predicts dysregulated gene expression in neurons with familial Alzheimer's disease mutations.

Mammalian genomes fold into tens of thousands of long-range loops, but their functional role and physiologic relevance remain poorly understood. Here, using human post-mitotic neurons with rare familial Alzheimer's disease (FAD) mutations, we identify hundreds of reproducibly dysregulated genes and thousands of miswired loops prior to amyloid accumulation and tau phosphorylation. Single loops do not predict expression changes; however, the severity and direction of change in mRNA levels and single-cell burst frequency strongly correlate with the number of FAD-gained or -lost promoter-enhancer loops. Classic architectural proteins CTCF and cohesin do not change occupancy in FAD-mutant neurons. Instead, we unexpectedly find TAATTA motifs amenable to binding by DLX homeodomain transcription factors and changing noncoding RNAPolII signal at FAD-dynamic promoter-enhancer loops. DLX1/5/6 mRNA levels are strongly upregulated in FAD-mutant neurons coincident with a shift in excitatory-to-inhibitory gene expression and miswiring of multi-loops connecting enhancers to neural subtype genes. DLX1 overexpression is sufficient for loop miswiring in wildtype neurons, including lost and gained loops at enhancers with tandem TAATTA arrays and singular TAATTA motifs, respectively. Our data uncover a genome structure-function relationship between multi-loop miswiring and dysregulated excitatory and inhibitory transcriptional programs during lineage commitment of human neurons homozygously-engineered with rare FAD mutations.

Sociobiome - Individual and neighborhood socioeconomic status influence the gut microbiome in a multi-ethnic population in the US.

Lower socioeconomic status (SES) is related to increased incidence and mortality due to chronic diseases in adults. Association between SES variables and gut microbiome variation has been observed in adults at the population level, suggesting that biological mechanisms may underlie the SES associations; however, there is a need for larger studies that consider individual- and neighborhood-level measures of SES in racially diverse populations. In 825 participants from a multi-ethnic cohort, we investigated how SES shapes the gut microbiome. We determined the relationship of a range of individual- and neighborhood-level SES indicators with the gut microbiome. Individual education level and occupation were self-reported by questionnaire. Geocoding was applied to link participants' addresses with neighborhood census tract socioeconomic indicators, including average income and social deprivation in the census tract. Gut microbiome was measured using 16SV4 region rRNA gene sequencing of stool samples. We compared α-diversity, ß-diversity, and taxonomic and functional pathway abundance by SES. Lower SES was significantly associated with greater α-diversity and compositional differences among groups, as measured by ß-diversity. Several taxa related to low SES were identified, especially an increasing abundance of Prevotella copri and Catenibacterium sp000437715, and decreasing abundance of Dysosmobacter welbionis in terms of their high log-fold change differences. In addition, nativity and race/ethnicity have emerged as ecosocial factors that also influence the gut microbiota. Together, these results showed that lower SES was strongly associated with compositional and taxonomic measures of the gut microbiome, and may contribute to shaping the gut microbiota.

Point-of-care Ultrasound Identification of Hepatic Abscess in the Emergency Department.

CASE PRESENTATION: A 92-year-old female with past medical history of hypertension presented to the emergency department with pain in her right shoulder, right flank, and right upper quadrant of her abdomen. Point-of-care ultrasound (POCUS) and computed tomography imaging showed concerns for multiple large hepatic abscesses. Percutaneous drainage removed 240 millileters of purulent fluid that identified Fusobacterium nucleatum, a rare cause of pyogenic liver abscess. DISCUSSION: Emergency physicians should keep hepatic abscess on their differential for right upper quadrant abdominal pain and can use POCUS for expeditious diagnosis.

Developing and Applying an Urban Resilience Index for the Evaluation of Declining Areas: A Case Study of South Korea's Urban Regeneration Sites.

This study attempts to identify the direction of urban regeneration projects in declining areas by using the concept of urban resilience to cope with climate change and disaster. To this end, urban resilience was classified into a Green Resilient Infrastructure (GRI) and an Interactive Safety System (ISS), through a review of previous studies, and categorized into vulnerability, adaptability, and transformability. A total of 12 detailed indicators were derived and indexed using Euclidean distance. Using the indicators, three Korean urban regeneration targets, in Daegu, Mokpo, and Seosan, were selected to evaluate resilience before and after the urban regeneration plan. Consequently, the postplanning resilience index improved in all three target sites, compared to before the regeneration plan. Additionally, previously the regeneration plan showed lower index values in comparison to places not designated as urban regeneration areas. These results suggest that urban resilience needs to be considered in future urban regeneration projects, and that resilience indicators can be used as a means to set the direction of urban regeneration projects. To improve the overall resilience of a region, these indices can help local government establish a reference point for urban resilience in its region.

Using a Linear Probe Ultrasound for the Detection of First-Trimester Pregnancies in the Emergency Department.

Linear probe point-of-care ultrasound (LPUS) presents a less invasive alternative for identifying intrauterine pregnancies (IUPs) compared to usual practice (transabdominal (TAUS) or transvaginal (TVUS) ultrasound). TAUS and TVUS can be invasive or produce lower-resolution images than LPUS. The purpose of this study is to determine whether a linear probe alone can identify first-trimester IUPs. A convenience sample of 21 patients were enrolled at the University of California Irvine ED during a 7-month period. The inclusion criteria were English- or Spanish-speaking women (≥18 years) in their first trimester of pregnancy (≤12 weeks pregnant) with a body mass index (BMI) of <35. The exclusion criteria were psychiatric, incarcerated, or cognitively impaired patients. An ED physician performed LPUS and ordered a confirmatory ultrasound. The 21 patients enrolled had a mean age of 28.6 ± 6.60 years, BMI of 26.6 ± 5.03, and gestational age of 7.4 ± 2.69 weeks. Considering the 95% confidence interval, we are 97.5% confident that the sensitivity and specificity of LPUS to identify IUPs does not exceed 67.1% and 93.2%, respectively. Our pilot data did not demonstrate that LPUS can independently visualize IUPs in first-trimester patients.

Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

INTRODUCTION: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. METHODS: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. RESULTS: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). CONCLUSION: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

Sociobiome - Individual and neighborhood socioeconomic status influence the gut microbiome in a multi-ethnic population in the US.

Lower socioeconomic status (SES) is related to increased incidence and mortality due to chronic diseases in adults. Association between SES variables and gut microbiome variation has been observed in adults at the population level, suggesting that biological mechanisms may underlie the SES associations; however, there is a need for larger U.S. studies that consider individual- and neighborhood-level measures of SES in racially diverse populations. In 825 participants from a multi-ethnic cohort, we investigated how SES shapes the gut microbiome. We determined the relationship of a range of several individual- and neighborhood-level SES indicators with the gut microbiome. Individual education level and occupation were self-reported by questionnaire. Geocoding was applied to link participants' addresses with neighborhood census tract socioeconomic indicators, including average income and social deprivation in the census tract. Gut microbiome was measured using 16SV4 region rRNA gene sequencing of stool samples. We compared α-diversity, ß-diversity, and taxonomic and functional pathway abundance by socioeconomic status. Lower SES was significantly associated with greater α-diversity and compositional differences among groups, as measured by ß-diversity. Several taxa related to low SES were identified, especially an increasing abundance of Genus Catenibacterium and Prevotella copri. The significant association between SES and gut microbiota remained even after considering the race/ethnicity in this racially diverse cohort. Together, these results showed that lower socioeconomic status was strongly associated with compositional and taxonomic measures of the gut microbiome, suggesting that SES may shape the gut microbiota.

Asp664 cleavage of amyloid precursor protein induces tau phosphorylation by decreasing protein phosphatase 2A activity.

Caspase cleavage of amyloid precursor protein (APP) has been reported to be important in amyloid beta protein (Aß)-mediated neurotoxicity. However, the underlying mechanisms are not clearly understood. In this study, we explored the effect of caspase cleavage of APP on tau phosphorylation in relation to Aß. We found that Asp664 cleavage of APP increased tau phosphorylation at Thr212 and Ser262 in N2A cells and primary cultured hippocampal neurons. Compared with wild-type APP, protein phosphatase 2A (PP2A) activity was significantly increased when Asp664 cleavage was blocked by the D664A point mutation. Furthermore, we found that over-expression of C31 reduced PP2A activity. C31 binds directly to the PP2A catalytic subunit, through the asparagine, proline, threonine, tyrosine (NPTY) motif, which is essential for C31-induced tau hyperphosphorylation. However, it appears that the other fragment produced by Asp664 cleavage, Jcasp, modulates neither PP2A activity nor tau hyperphosphorylation. Asp664 cleavage and accompanying tau hyperphosphorylation were remarkably diminished by blockage of Aß production using a γ-secretase inhibitor. Taken together, our results suggest that Asp664 cleavage of APP leads to tau hyperphosphorylation at specific epitopes by modulating PP2A activity as a downstream of Aß. Direct binding of C31 to PP2A through the C31-NPTY domain was identified as a mechanism underlying this effect.

A Two-Part Approach Distinguishing the Occurrence and Frequency of Self-reported Attentional Failures During Driving to Predict Crash Risks Among Older Drivers.

OBJECTIVES: With advancing age, older drivers experience greater fatal crash risks due to age-related declines in cognitive and physical capabilities. Being informed of the age-related increased risks could help older drivers form compensatory strategies and determine when to seek further help to stay on the road safely for longer. Using a self-report assessment tool, the Attentional Failure during Driving Questionnaire (AFDQ), we examined older drivers' experience of various attentional failures during daily driving and how the measures could predict their crash risks. METHODS: We used a new methodological approach distinguishing the occurrences of attentional failures during driving and the frequency of those occurrences. The individuals' AFDQ occurrence and frequency scores were compared with prior driving outcomes and simulated driving performance. RESULTS: Unlike middle-aged drivers, frequency rather than occurrence of attentional failures was a significant predictor of prior traffic violations and crashes among older drivers. Also, attentional failures, but not chronological age, predicted older drivers' crash risks. AFDQ frequency was also associated with older drivers' poorer performance in simulated driving. DISCUSSION: The findings suggest that the self-report assessment for attention-related driving failures can predict older drivers' crash risks. Furthermore, the two-part approach of AFDQ provides an opportunity to do a more comprehensive investigation of the associations between attentional declines and crash risks among older drivers.

Zombie Cruise Ship Virtual Escape Room for POCUS Pulmonary: Scan Your Way Out.

Audience: Targeted audience could be learners in medical field with basic knowledge of point-of-care ultrasound (POCUS), pulmonary and emergency medicine for example, medical students, emergency medicine residents (1st-3rd year), emergency physicians at all level of trainings, or emergency medicine physician's assistants. Introduction: Point-of-care ultrasound (POCUS) is rapidly becoming an essential part of emergency medicine and patient care .1,2 POCUS can provide more detailed clinical information when used in conjunction with a physical examination, overall aiding clinicians' decision-making capacity.3 POCUS also proves a cost-effective tool in reducing the number of advanced imaging studies ordered and unnecessary patient radiation exposure.3,4 Performing POCUS has also proved beneficial for patient satisfaction because it increases the amount of face-to-face time spent with the patient while also providing live imaging interpretation during the emergency department visits .3,5,6 POCUS-Pulmonary can also create a safer environment for both medical staff and patients during the COVID-19 pandemic.6 Performing POCUS-Pulmonary on suspected COVID-19 patients can limit the number of patients receiving thoracic CT studies to confirm COVID-19 related pneumonia.6,7 Performing POCUS-Pulmonary reduces the number of patients transferred between the radiology department and the emergency department, significantly reduces overall possible COVID-19 exposures, and reduces equipment cleaning time.6 Given the overall reduction of advanced imaging studies ordered, CT scanners would be more readily available for critical care patients, such as trauma or other hemodynamic instability.6 Emergency providers practicing in rural areas with limited resources may benefit from the use of POCUS -Pulmonary, facilitating better patient care at decreased exposure-rate, cleaning cost, and overall increase in patient satisfaction given more bedside patient-provider communication.6-8 POCUS-Pulmonary is a crucial clinical skill for emergency medicine providers everywhere.6,8 Clinicians should be able to perform POCUS-Pulmonary, interpret image findings, and develop a treatment plan promptly.9. Educational Objectives: By the end of performing the Zombie Cruise Ship Virtual Escape Room, learners will be able to: 1) recognize sonographic signs of A-line, B-line, Barcode sign, Bat sign, Seashore Sign, Plankton sign, Jellyfish Sign, Lung point, lung lockets, and Lung pulse; 2) differentiate sonographic findings of pneumothorax, hemothorax, pneumonia, COVID 19 pneumonia, pulmonary edema, and pleural effusion from normal lung findings; 3) distinguish pneumonia from atelectasis by recognizing dynamic air bronchogram; and 4) recognize indications for performing POCUS pulmonary such as dyspnea, blunt trauma, fall, cough and/or heart failure. Educational Methods: This group-based learning program was designed for use in virtual meetings, lectures, and in small-group learning activities, such as didactic and EM conferences. A Google form was used to create a virtual escape room for learners in which they had to take quizzes to advance to the next level. Learners may enact teamwork through discussion and group effort, or respond individually to ultrasound pulmonary questions. Research Methods: Learners will take pre and post-test assessment to compare the learners POCUS-Pulmonary knowledge before and after small group, virtual escape room learning. All participants in the virtual escape room game are given a pre and post-test assessment comprised of seventeen total questions: two questions asking the participant's training level, and fifteen POCUS-Pulmonary questions. Pre and Post-test questions are identical; however, the participants' answers to the pre-test assessment are not revealed to them on completion. Instead, participants receive a letter grade on completing the pre-test assessment. Participants complete the pre and post-test assessments over fifteen minutes allotted before and after the virtual escape room. Upon completing the post-test assessment, a letter grade and the correct answers were given to the participants. Results: Twenty-four emergency medicine resident physicians (PGY 1-3)) participated in the Zombie Cruise Ship Escape Room pre-test, while a total of twenty-three resident physicians participated in the post-test assessment. The pre-test data showed an average of 10.33 points, compared to post-test data, which showed 11.91 points. There was an improvement of two points on the median score with a median pre-test score of 10 vs. the post-test median of 12. Discussion: The virtual zombie cruise ship experience proved a practical and useful tool in increasing overall participants' interest in POCUS pulmonary during the COVID-19 pandemic. Participants had higher retention after actively discussing and researching the most up-to-date clinical information during the virtual and inperson small group meetings. The game encouraged participants to make decisions quickly. This pace created a fun competition between participants who genuinely enjoyed the learning experience even during the COVID-19 pandemic via Zoom/Google Meet virtual conferences. By creating a virtual escape learning tool, learners can experience teamwork-based learning without concern for group size limitations during the pandemic. Topics: Sonographic findings of pneumothorax, hemothorax, pneumonia, COVID-19 pneumonia, pulmonary edema, pleural effusion, normal lung, A-line, lack of A-line, presence of B-line, Lung sliding, M mode, dynamic air bronchogram, lung rockets, Bar code Sign, Bat Sign, lung pulse, lung point, hepatization, Seashore Sign, Plankton Sign, Jellyfish Sign, and subpleural pulmonary consolidation.

Evaluation of advanced curve speed warning system to prevent fire truck rollover crashes.

INTRODUCTION: A disproportionately high number of deadly crash-incidents involve fire-tanker rollovers during emergency response driving. Most of these rollover incidents occur at dangerous horizontal curves ("curves") due to unsafe speed. This study examined the effects of a curve speed warning system (CSWS) on fire tanker drivers' emergency response behavior to develop system improvement suggestions. METHOD: Twenty-four firefighters participated in driving tests using a simulator. A fire tanker model, carrying a full tank of water, was used in emergency driving tests performed with and without CSWS. The CSWS was designed using the algorithm for passenger vehicles with a few initial modifications considering the unique requirements of heavy fire tanker and emergency driving. RESULTS: The results indicated that the CSWS was effective in issuing preemptive warnings when the drivers were approaching curves with unsafe speed during emergency response. Warnings occurred more frequently at curves with smaller radius. Although the CSWS improved driving performance, it did not significantly reduce the number of rollover events. A detailed analysis of the rollover events provided suggestions for improvement of CSWS algorithms. CONCLUSIONS: To further improve the CSWS algorithm, the following may be considered: including increased safety speed margin below the rollover critical speed, moving the speed warning trigger from the curve apex to the curve entry point, extending the safe speed-control zone to cover the entire curve, and employing artificial intelligence to accommodate individual driving styles. PRACTICAL APPLICATIONS: Fire tankers continue to be at increased risk of rollover during emergency response due to unsafe negotiation of dangerous curves. Development and use of advanced driver assist systems such as CSWS evaluated in this study may be an effective strategy to prevent deadly rollover crash-incidents. The knowledge generated by this study will be useful for system designers to improve the CSWS specifically designed for heavy emergency vehicles.

Risk stratification of patients with right-sided colorectal cancer based on the tumor-infiltrating M1 macrophage.

The homing of M1 and M2 macrophages may play distinct roles in the tumor microenvironment (TME). However, these roles of macrophages in the TME remain unclear. We downloaded RNA sequencing data from The Cancer Genome Atlas (TCGA) database for patients with CRC. Subsequently, Kaplan-Meier survival curves were generated to assess the differential infiltration of M1 and M2 macrophages based on CRC location. Differentially expressed gene (DEG) and functional analyses were performed to screen the roles of DEGs. Critical prognostic genes were identified using least absolute shrinkage and selection operator regression. The risk scores were calculated for each patient. In patients with right-sided CRC, reduced M1 macrophage infiltration was associated with poor prognosis. M1 macrophage infiltration positively correlated with CD8+ T cell infiltration. A risk model was developed and validated for performance using GSE103479 and GSE72970. Nine genes were identified as independent prognostic genes that could be potential biomarkers for effectively predicting survival in patients with right-sided CRC. Kaplan-Meier curves for overall survival and progression-free survival analyses revealed that the high-risk group of patients with right-sided CRC had a poor prognosis. This novel M1 macrophage-related risk model may provide a gene signature for predicting the survival outcomes of patients with right-sided CRC and facilitate further studies examining the relationship between infiltration of M1 macrophages and the prognosis of such patients.

Impact of the COVID-19 Pandemic on Emergency Department Transfers to a Higher Level of Care.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, a reduction in emergency department (ED) visits was seen nationally according to the US Centers for Disease Control and Prevention. However, no data currently exists for the impact of ED transfers to a higher level of care during this same time period. The primary objective of the study was to determine whether the COVID-19 pandemic affected the rate of non-COVID-19 transfers from a rural community ED. METHODS: We completed a retrospective chart review of all ED patients who presented to Kingman Regional Medical Center in Kingman, Arizona, from March 1-June 31, 2019 and March 1-June 31, 2020. To ensure changes were not due to seasonal trends, we examined transfer rates from the same four-month period in 2019 and 2020. Patients were included in the study if they were transferred to an outside facility for a higher level of care not related to COVID-19. RESULTS: Between the time periods studied there was a 25.33% (P = 0.001) reduction in total ED volume and a 21.44% (P = 0.009) reduction in ED transfers to a higher level of care. No statistical difference was noted in ED transfer volume following adjustment for decreased ED volumes. Transfers for gastroenterology (45%; P = 0.021), neurosurgery (29.2%; P = 0.029), neurology (76.3%; P < 0.001), trauma (37.5%; P = 0.039), urology (41.8%; P = 0.012), and surgery (56.3%; P = 0.028) all experienced a decrease in transfer rates during the time period studied. When gender was considered, males exhibited an increased rate of transfers to psychiatric facilities (P = 0.018). CONCLUSION: Significant reductions in both ED volume and transfers have coincided with the emergence of the COVID-19 pandemic. Further research is needed to determine how the current pandemic has affected patient care.

Splenic Injury Following Colonoscopy: A Case Report.

INTRODUCTION: Colonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur. CASE REPORT: A 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs. CONCLUSION: Splenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted.

Incidence of Non-thrombotic Diagnoses Following Venous Duplex Ultrasound at a Community Emergency Department.

BACKGROUND:  When used as a diagnostic aid for diagnosing deep vein thrombosis (DVT), venous duplex ultrasound (US) may reveal non-thrombotic findings in those with acute extremity pain. The objective of this study was to determine the prevalence and predictors of non-thrombotic findings on venous duplex US at a community emergency department. METHODS: A retrospective chart review of all adult patients who presented to a community emergency department who underwent either an upper or lower extremity venous duplex US for the evaluation of DVT from June 1, 2019, to September 15, 2020. All US studies were completed by certified sonographers and interpreted by board-certified radiologists. Two trained research assistants manually abstracted patient demographics and US findings. Data were analyzed using the chi-square statistic for categorical variables and the student's independent t-test for continuous variables. Multivariate binomial regression was used to identify independent predictors of non-thrombotic results on venous duplex US. RESULTS: A total of 1,448 venous duplex US were obtained during the study period with 126 DVTs being diagnosed. A total of 1071 US had no acute abnormality and 252 had non-thrombotic findings. All non-thrombotic findings were found in the lower extremity. Of those with non-thrombotic findings, the most common diagnoses included edema (34.9%, 88/252), Baker's cyst (22.6%, 57/252), and an unspecified fluid collection (16.3%, 41/252). Patients with non-thrombotic findings were more likely to have a history of atrial fibrillation (p=0.001) or hypertension (p=0.001), be older than the age of 70 (p=0.042), or have a history of using illicit drugs (p=0.003). Females were less likely to have non-thrombotic findings. CONCLUSION: In this single-site study, non-thrombotic findings were present in 23.5% of all venous duplex US completed at a community emergency department. These findings are more common in the elderly, those with cardiovascular disorders, and those who have used illicit drugs.