Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL). METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects. RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events. CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.

Clinically Applicable Assessment of Tisagenlecleucel CAR T Cell Treatment by Digital Droplet PCR for Copy Number Variant Assessment.

Chimeric antigen receptor (CAR) T cell therapy is an innovative immunotherapy for treating cancers in both children and adults with proven utility in numerous clinical trials. Significantly, some CAR T cell therapies have now been approved by relevant national regulatory bodies across numerous countries for clinical therapeutic use outside of clinical trials. One such recently licensed product is tisagenlecleucel, a CAR T therapy approved for the treatment of B-cell acute lymphoblastic leukemia (B-ALL) using autologous T cells from the patient. The genetically engineered T cells target a protein called CD19, common to B cells, through a CAR incorporating a 4-1BB costimulatory domain to improve response. Since tisagenlecleucel is now a standard of care treatment for B-ALL, it is clinically essential to be able to accurately monitor these CAR T cells in patients. Assessment of the copy number variant (CNV) of the CAR T cell products allows this within a clinically acceptable timeframe for optimal patient benefit. However, no standardized method with high reproducibility and efficiency has been described within a routine clinical laboratory setting. Here, we demonstrated a novel digital droplet PCR (ddPCR)-based methodology for the study of CNV (ddPCR-CNV) in 4-1BB CD19-specific CAR T cells with universal applicability across clinical diagnostic laboratories.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy.

BACKGROUND: Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications. MATERIALS AND METHODS: The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described. RESULTS: Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively. CONCLUSION: Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.

Species richness declines and biotic homogenisation have slowed down for NW-European pollinators and plants.

Concern about biodiversity loss has led to increased public investment in conservation. Whereas there is a widespread perception that such initiatives have been unsuccessful, there are few quantitative tests of this perception. Here, we evaluate whether rates of biodiversity change have altered in recent decades in three European countries (Great Britain, Netherlands and Belgium) for plants and flower visiting insects. We compared four 20-year periods, comparing periods of rapid land-use intensification and natural habitat loss (1930-1990) with a period of increased conservation investment (post-1990). We found that extensive species richness loss and biotic homogenisation occurred before 1990, whereas these negative trends became substantially less accentuated during recent decades, being partially reversed for certain taxa (e.g. bees in Great Britain and Netherlands). These results highlight the potential to maintain or even restore current species assemblages (which despite past extinctions are still of great conservation value), at least in regions where large-scale land-use intensification and natural habitat loss has ceased.

Comparing postinduction hypoxemia between ramped and supine position endotracheal intubations with apneic oxygenation in the emergency department.

INTRODUCTION: Ramped position and apneic oxygenation are strategies to mitigate hypoxemia; however, the benefits of these strategies when utilized together remain unclear. Therefore, we compared first-attempt, postinduction hypoxemia between adult emergency department (ED) endotracheal intubations performed with apneic oxygenation in the ramped versus supine positions. METHODS: We used the National Emergency Airway Registry (NEAR), a multicenter registry of data on ED intubations from 25 academic and community sites. We included first-attempt intubations with direct (DL) and video (VL) laryngoscopy in subjects ≥ 18 years old with nontrauma indications receiving apneic oxygenation. We examined patient characteristics (e.g., sex, obesity) and key intubation outcomes, including hypoxemia (primary outcome), first-pass success, and other adverse events (e.g., bradycardia). In addition, we examined unadjusted odds ratios (OR) and adjusted ORs (aOR) for key variables and stratified by laryngoscope type. RESULTS: We included 210 ramped cases and 1,820 supine cases in the DL cohort and 202 ramped and 1,626 supine cases in the VL cohort. Rates of postinduction hypoxemia were similar between supine and ramped position in both the DL cohort (supine 6.5% and ramped 7.6%, aOR [95% CI] = 0.96 [0.55 to 1.67]) and the VL cohort (supine 10.1% and ramped 12.4%, aOR [95% CI] = 0.97 [0.60 to 1.56]). Other outcomes were also similar between groups. CONCLUSION: Using this large national data set, we did not identify a difference in postinduction hypoxemia between ramped and supine positions in this cohort of ED intubations with apneic oxygenation.

Early warning signs of bulking in an activated sludge system through interpretation of ATP data in a systems analysis context.

A research project was undertaken at an integrated thermomechanical pulp and paper mill in Canada to evaluate the use of adenosine triphosphate (ATP) monitoring methods in order to identify the potential for operational problems related to microbiological aspects of activated sludge. The specific filamentous bulking ATP (fbATP) ratio is an emerging measurement technique that measures the proportion of flocs that have bulking potential by filtering a sample through a 250 microm mesh and measuring the ATP in the retentate. For the host mill in this study, the specific fbATP measurement provides early warning signs of bulking, at 1.0 to 1.5 times the sludge age, before poor settling occurs. A possible bulking scenario was identified in which the initiator was the overflow of an upstream tank containing high BOD whitewater, resulting in spikes of organic acids to the treatment and promoting the proliferation of certain types of filamentous bacteria. A storage response by filamentous bacteria to these high readily biodegradable substrate conditions was monitored with fbATP. By predicting the onset of bulking conditions, this technique can potentially assist operators to make corrective actions proactively.

Modeling thermomechanical pulp and paper activated sludge treatment plants to gain insight to the causes of bulking.

The Activated Sludge Model No. 1 was chosen as the basis for model development and was modified to take into account the specific characteristics of pulp and paper effluents. The model was incorporated to the GPS-X simulation environment (Hydromantis, Hamilton, Ontario, Canada) to study operating deficiencies and nutrient transformations, particularly in relation to bulking. The results show that the process of ammonification is not significant at the studied mill and that the process of phosphatification (transformation of soluble organic phosphorus into orthophosphates) seems to be related to settling problems, as indicated by the sludge volume index. The phosphatification rate and the standard oxygen-transfer efficiency were found to decrease as the system entered a bulking state. Understanding the behavior of pulp and paper activated sludge can be improved by the incorporation of industry-specific processes and components to comprehensive models. These models then can be used to gain insight to the causes of bulking.

Functional Characterization of the Osteoarthritis Genetic Risk Residing at ALDH1A2 Identifies rs12915901 as a Key Target Variant.

OBJECTIVE: To identify the functional single-nucleotide polymorphisms (SNPs) and mechanisms conferring increased risk of hand osteoarthritis (OA) at the ALDH1A2 locus, which is a retinoic acid regulatory gene. METHODS: Tissue samples from 247 patients with knee, hip, or hand OA who had undergone joint surgery were included. RNA-sequencing analysis was used to investigate differential expression of ALDH1A2 and other retinoic acid signaling pathway genes in cartilage. Expression of ALDH1A2 in joint tissues obtained from multiple sites was quantified using quantitative reverse transcription-polymerase chain reaction. Allelic expression imbalance (AEI) was measured by pyrosequencing. The consequences of ALDH1A2 depletion by RNA interference were assessed in primary human chondrocytes. In silico and in vitro analyses were used to pinpoint which, among 62 highly correlated SNPs, could account for the association at the locus. RESULTS: ALDH1A2 expression was observed across multiple joint tissue samples, including osteochondral tissue from the hand. The expression of ALDH1A2 and of several retinoic acid signaling genes was different in diseased cartilage compared to non-diseased cartilage, with ALDH1A2 showing lower levels in OA cartilage. Experimental depletion of ALDH1A2 resulted in changes in the expression levels of a number of chondrogenic markers, including SOX9. In addition, reduced expression of the OA risk-conferring allele was witnessed in a number of joint tissues, with the strongest effect in cartilage. The intronic SNP rs12915901 recapitulated the AEI observed in patient tissues, while the Ets transcription factors were identified as potential mediators of this effect. CONCLUSION: The ALDH1A2 locus seems to increase the risk of hand OA through decreased expression of ALDH1A2 in joint tissues, with the effect dependent on rs12915901. These findings indicate a mechanism that may now be targeted to modulate OA risk.

Analysis of hydrodilatation as part of a combined service for stiff shoulder.

BACKGROUND: Adhesive capsulitis is a common cause of stiff shoulder and may result in pain and restriction of movement. The study aimed to investigate the role of hydrodilatation of the glenohumeral joint in the management of adhesive capsulitis. METHODS: Patients referred from the shoulder clinic underwent hydrodilatation under ultrasound guidance. Of 209 referred for hydrodilatation, 163 underwent the procedure and attended follow-up physiotherapy. Outcome measures were available for 118 patients (58 men and 60 women). Mean age of the study group was 52.6 years. RESULTS: There was a statistically significant improvement in both Oxford Shoulder Score (OSS) and Disability Arm Shoulder Hand Scores (Quick DASH) in the first 4 weeks after the procedure, which was maintained but not improved to the end of the study period. Patients presenting with pain, those who had a history of steroid injections and older patients all had worse functional scores at presentation. Diabetes (both Type I and II), previous physiotherapy, length of history and whether pain or stiffness, or both, were the predominant symptom did not have any statistical significance at presentation. These factors were not predictors of any statistically significant improvement in functional scores. CONCLUSIONS: Hydrodilatation results in a significant improvement of symptoms in patients with adhesive capsulitis.

Financial Capability in Early Social Work Practice: Lessons for Today.

During the profession's first decades, social workers tried to improve their clients' financial capability (FC). This article describes the methods used by early social workers who attempted to enhance the FC of their clients, based on contemporary descriptions of their practice. Social workers initially emphasized thrift, later adding more sophisticated consideration of the cost of foods, rent, and other necessities. Social work efforts were furthered by home economists, who served as specialists in nutrition, clothing, interior design, and other topics related to homemaking. Early home economists included specialists in nutrition and family budgeting; these specialists worked with social services agencies to provide a financial basis for family budgets and assisted clients with family budgeting. Some agencies engaged home economists as consultants and as direct providers of instruction on home budgets for clients. By the 1930s, however, social work interest in family budget problems focused on the psychological meaning of low income to the client, rather than in measures to increase client FC. Consequently, social workers' active engagement with family budget issues­engagement that characterized earlier decades­faded. These early efforts can inform contemporary practice as social workers are once again concerned about improving their clients' FC.

Key variables analysis of a novel continuous biodrying process for drying mixed sludge.

A novel continuous biodrying process has been developed whose goal is to increase the dry solids content of the sludge to economic levels rendering it suitable for a safe and economic combustion operation in a biomass boiler. The sludge drying rates are enhanced by the metabolic bioheat produced in the matrix of mixed sludge. The goal of this study was to systematically analyze the continuous biodrying reactor. By performing a variable analysis, it was found that the outlet relative humidity profile was the key variable in the biodrying reactor. The influence of different outlet relative humidity profiles was then evaluated using biodrying efficiency index. It was found that by maintaining the air outlet relative humidity profile at 85/85/96/96% in the four compartments of the reactor, the highest biodrying efficiency index can be achieved, while economic dry solids level (>45%w/w) are guaranteed.