Outcomes of early treatment of radial dysplasia.

Purpose: Radial dysplasia, also termed radial club hand is an abnormality along the longitudinal axis of the hand characterized by hypoplasia or aplasia of radial structures. Surgery that centralize the wrist on the distal end of the ulna gives quite good results in terms of anatomical recovery but affecting range of motion of the wrist and fingers, limbs length. We conducted this study to evaluate the outcome of serial casting followed by centralization at our institution. Materials and methods: We conducted a prospective study involving 20 pediatric patients with 25 limbs affected by Bayne Types III and IV radial dysplasia, with an average follow-up period of 4.2 years. Each limb underwent progressive soft tissue stretching via serial casting, followed by centralization. Clinical and radio-graphic data were collected at surgery and during follow-up assessments. Results: The study achieved an average correction of 60° in radial deviation, with a decrease in wrist range of motion from 79° to 28° over the follow-up period. Finger mobility showed increased stiffness. Ulnar length recovery reached 57% of the normal contra-lateral side. Final results, based on the Bayne and Klug criteria, revealed that 24 out of 25 hands (96%) exhibited good or satisfactory outcomes. Conclusion: Early intervention employing gradual corrective casting followed by centralization is an effective treatment for radial dysplasia in children, consistently resulting in good or satisfactory outcomes. However, this approach entails a trade-off with reduced wrist and finger range of motion and potential implications for limb growth.

A Comparison of Surgical Subspecialty Match Rates in 2022 in the United States.

This paper examines the 2022 surgical subspecialty results within the Match hosted yearly by the National Resident Matching Program (NRMP) in the United States. It exists to place medical graduates with post-graduate training programs via an algorithm based on ranked lists provided by both residency programs and individual applicants around the world. This paper compares the match rates between allopathic medical graduates (MDs) and osteopathic medical graduates (DOs). Using published NRMP data and reports from Program Director surveys, we explored possible reasons for match rate differences between the two groups, hypothesizing that lower match rates among DOs could be explained by completion of less volunteerism, research, or curricular activities that may have affected their overall first-choice match rates in competitive surgical specialties. While the data showed that MDs consistently out-matched DOs, the cause was deemed multifactorial as the data did not provide concrete evidence to the contrary. We concluded that more data over time should be collected to understand why osteopathic students do not match as well as allopathic students in surgical specialties.

COVID-19 Vaccine Hesitancy in a Rural Primary Care Setting.

As the United States clamors with anti-vax protests, researchers seek to understand what social and behavioral values are keeping patients from electing to vaccinate themselves against the coronavirus disease 2019 (COVID-19) virus. Over the past year, the race to vaccinate has become less about developing working vaccines and more about finding ways to encourage vaccine uptake. This paper examines the question of vaccine hesitancy in rural Chemung County, NY. In identifying various psychosocial barriers to patient vaccination, which we hypothesize will be mostly political, we seek to understand the local mindset in the hope that our data guide the way to change it.

Core-shell microneedle patch for six-month controlled-release contraceptive delivery.

There is a tremendous need for simple-to-administer, long-acting contraception, which can increase access to improved family planning. Microneedle (MN) patches enable simple self-administration and have previously been formulated for 1-2 months' controlled release of contraceptive hormone using monolithic polymer/drug MN designs having first-order release kinetics. To achieve zero-order release, we developed a novel core-shell MN patch where the shell acts as a rate-controlling membrane to delay release of a contraceptive hormone, levonorgestrel (LNG), for 6 months. In this approach, LNG was encapsulated in a poly(lactide-co-glycolide) (PLGA) core surrounded by a poly(l-lactide) (PLLA) shell and a poly(D,L-lactide) (PLA) cap that were fabricated by sequential casting into a MN mold. Upon application to skin, the core-shell MNs utilized an effervescent interface to separate from the patch backing within 1 min. The core-shell design limited the initial 24 h burst release of LNG to 5.8 ± 0.5% and achieved roughly zero-order LNG release for 6.2 ± 0.1 months in vitro. A monolithic MN patch formulated with the same LNG and PLGA core, but without the rate-controlling PLLA shell and PLA cap had a larger LNG burst release of 22.6 ± 2.0% and achieved LNG release for just 2.1 ± 0.2 months. This study provides the first core-shell MN patch for controlled months-long drug release and supports the development of long-acting contraception using a simple-to-administer, twice-per-year MN patch.

Benefits of developing graduate medical education programs in community health systems.

The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.

Before/after intervention study to determine impact on life-cycle carbon footprint of converting from single-use to reusable sharps containers in 40 UK NHS trusts.

OBJECTIVES: To compare global warming potential (GWP) of hospitals converting from single-use sharps containers to reusable sharps containers (SSC, RSC). Does conversion to RSC result in GWP reduction? DESIGN: Using BS PAS 2050:2011 principles, a retrospective, before/after intervention quantitative model together with a purpose-designed, attributional 'cradle-to-grave' life-cycle tool, were used to determine the annual greenhouse gas (GHG) emissions of the two sharps containment systems. Functional unit was total fill line litres (FLL) of sharps containers needed to dispose of sharps for 1-year period in 40 trusts. Scopes 1, 2 and 3 emissions were included. Results were workload-normalised using National Health Service (NHS) national hospital patient-workload indicators. A sensitivity analysis examined areas of data variability. SETTING: Acute care hospital trusts in UK. PARTICIPANTS: 40 NHS hospital Trusts using RSC. INTERVENTION: Conversion from SSC to RSC. SSC and RSC usage details in 17 base line trusts immediately prior to 2018 were applied to the RSC usage details of the 40 trusts using RSC in 2019. PRIMARY OUTCOME MEASURE: The comparison of GWP calculated in carbon dioxide equivalents (CO2e) generated in the manufacture, transport, service and disposal of 12 months, hospital-wide usage of both containment systems in the 40 trusts. RESULTS: The 40 trusts converting to RSC reduced their combined annual GWP by 3267.4 tonnes CO2e (-83.9%); eliminated incineration of 900.8 tonnes of plastic; eliminated disposal/recycling of 132.5 tonnes of cardboard and reduced container exchanges by 61.1%. GHG as kg CO2e/1000 FLL were 313.0 and 50.7 for SSC and RSC systems, respectively. A sensitivity analysis showed substantial GHG reductions within unit processes could be achieved, however, their impact on relevant final GWP comparison varied <5% from base comparison. CONCLUSIONS: Adopting RSC is an example of a sustainable purchasing decision that can assist trusts meet NHS GHG reduction targets and can reduce GWP permanently with minimal staff behavioural change.

Recognizing postoperative nutritional complications of bariatric surgery in the primary care patient: a narrative review.

Bariatric surgery is an effective treatment for patients with morbid obesity. However, as safe and common as bariatric procedures have become, multiple complications can still result. These complications vary depending on the type of procedure performed (malabsorptive or restrictive) and are often nutritional derangements from the altered malabsorptive surface of the gastrointestinal tract and decreased capacity of the stomach. Deficiencies in vitamin D after malabsorptive procedures such as the Roux-en-Y gastric bypass can result in subsequent hypocalcemia and bone demineralization, and anemias can also present after surgery from inadequate vitamin B12 and iron absorption. Because of the prevalence of these deficiencies, baseline micronutrient testing and postoperative screening are recommended in many cases. Additionally, supplemental treatment often requires higher doses than those recommended for healthy adults. The purpose of this narrative review is to outline the various nutrient deficiencies that can result from bariatric procedures and report previously-published recommendations for screening and medical treatment of patients with these deficiencies. This review is directed toward primary care practitioners because of their unique position in delivering continuity of care and the frequency with which they will encounter patients who have undergone bariatric surgery and are seeking counseling regarding weight loss modalities.

Development and Field Validation of Lidocaine-Loaded Castration Bands for Bovine Pain Mitigation.

Castration is among the most common management procedures performed in the dairy and beef cattle industries and is mainly performed by surgery or elastic banding. Despite the various benefits of castration, all methods produce pain and distress. Castration by banding is simple, inexpensive, produces fewer complications, and can be performed in a high-throughput manner. Because lidocaine, a local anesthetic, can be delivered to trauma sites topically, we have formulated lidocaine-loaded castration bands (LLBs) to deliver local pain relief to calves during banded castration. The initial lidocaine content of three band types developed was between 80 and 200 mg per band. The transfer kinetics of lidocaine into tissue was determined in vitro, indicating a rapid release for the first 30 min, followed by a slow release lasting at least 48 h. Furthermore, the lidocaine delivery and pain mitigation effects of these LLBs were compared to standard lidocaine injections in vivo. Field studies indicated that LLBs performed at least as well as lidocaine injections for short-term lidocaine delivery into tissues and pain mitigation. Moreover, LLBs significantly outperformed lidocaine injections for long-term delivery and pain mitigation. The concentrations of lidocaine in the LLB-treated tissue samples were generally in the range of 0.5-3.5 mg of lidocaine per gram of tissue and were overall highest after 6 h. Lidocaine-loaded elastration bands deliver therapeutic quantities of lidocaine into scrotal tissues over a period of at least seven days in cattle. This approach would provide long-term pain mitigation to the animals and, by avoiding surgery or the administration of injections, would also decrease the time and handling costs for the producer.

Spatial Sequencing: A Perspective.

Fluorescent spatial sequencing brings next-generation sequencing into a new realm capable of identifying nucleic acids in the cell's natural environment. For the first time, scientists are able to multiplex the assignment of specific locations to hundreds of transcriptional targets and lay the foundation for understanding how genetic changes control the fate of each cell within the tissue microenvironment. In this perspective, we discuss the capabilities of fluorescent spatial sequencing in the context of other spatial imaging technologies and describe how these new technologies offer a data-rich, multiomic solution to many research applications. Fluorescent spatial sequencing has opened options for exploring many fundamental questions in biology, helping us gain a better understanding of cell and tissue development and disease progression.

Long-acting reversible contraception by effervescent microneedle patch.

To increase access to long-acting contraception, we developed a reversible contraceptive microneedle patch that is simple-to-administer, slowly releases contraceptive hormone (levonorgestrel) for >1 month, and generates no biohazardous sharps waste. After manually pressing the patch to skin for 1 min, microneedles rapidly separate from the patch within the skin due to effervescence triggered by contact with skin's interstitial fluid, as demonstrated in rats and human participants. Long-acting contraception is achieved by formulating microneedles with a biodegradable polymer [poly(lactic-co-glycolic) acid] that slowly releases levonorgestrel for ~1 month in vitro. In rats, the patch maintained levonorgestrel concentration above the human contraceptive threshold level for >1 month, and a placebo microneedle patch was well-tolerated in human participants. Women of reproductive age in three continents demonstrated interest in and preference for long-acting contraception by microneedle patch. These studies indicate that an effervescent microneedle patch could facilitate greater access to long-acting contraception.

Rapidly separable microneedle patch for the sustained release of a contraceptive.

Women often have limited access to contraception, and barrier methods have low acceptance and a high failure rate, mostly due to incorrect use, which can result in unplanned pregnancies. Sustained-release formulations of contraceptive hormones are available, yet typically require their administration by trained personnel. Here, we report the design of a microneedle patch with rapidly separable biodegradable polylactic acid and polylactic-co-glycolic acid needles, and its application for the continuous release of levonorgestrel-a contraceptive hormone. Bubble structures between each microneedle and the patch backing allow the microneedles to efficiently penetrate skin under compression, and to snap off under shear within five seconds after patch administration. In rats, the microneedle patch was well tolerated, leaving little visible evidence of use, and maintained plasma concentrations of the hormone above the human therapeutic level for one month. Further development of the rapidly separable microneedle patch for self-administered, long-acting contraception could enable women to better control their fertility.

Polymer Coated Urea in Turfgrass Maintains Vigor and Mitigates Nitrogen's Environmental Impacts.

Polymer coated urea (PCU) is a N fertilizer which, when added to moist soil, uses temperature-controlled diffusion to regulate N release in matching plant demand and mitigate environmental losses. Uncoated urea and PCU were compared for their effects on gaseous (N2O and NH3) and aqueous (NO3(-)) N environmental losses in cool season turfgrass over the entire PCU N-release period. Field studies were conducted on established turfgrass sites with mixtures of Kentucky bluegrass (Poa pratensis L.) and perennial ryegrass (Lolium perenne L.) in sand and loam soils. Each study compared 0 kg N ha(-1) (control) to 200 kg N ha(-1) applied as either urea or PCU (Duration 45CR®). Application of urea resulted in 127-476% more evolution of measured N2O into the atmosphere, whereas PCU was similar to background emission levels from the control. Compared to urea, PCU reduced NH3 emissions by 41-49% and N2O emissions by 45-73%, while improving growth and verdure compared to the control. Differences in leachate NO3(-) among urea, PCU and control were inconclusive. This improvement in N management to ameliorate atmospheric losses of N using PCU will contribute to conserving natural resources and mitigating environmental impacts of N fertilization in turfgrass.

Nitrous oxide emissions from anhydrous ammonia, urea, and polymer-coated urea in illinois cornfields.

The use of alternative N sources relative to conventional ones could mitigate soil-surface NO emissions. Our objective was to evaluate the effect of anhydrous ammonia (AA), urea, and polymer-coated urea (ESN) on NO emissions for continuous corn ( L.) production. Corn received 110 kg N ha in 2009 and 180 kg N ha in 2010 and 2011. Soil NO fluxes were measured one to three times per week early in the growing season and less frequently later, using vented non-steady state closed chambers and a gas chromatograph. Regardless of N source, NO emissions were largest immediately after substantial (>20 mm) rains, dropping to background levels thereafter. Averaged across N sources, 2.85% of the applied N was lost as NO. Emission differences for treatments only occurred in 2010, the year with maximum NO production. In the 2010 growing season, cumulative emissions (in kg NO-N ha) were lowest for the check (2.21), followed by ESN (9.77), and ESN was lower than urea (14.07) and AA (16.89). Emissions in 2010 based on unit of corn yield produced followed a similar pattern, and NO emissions calculated as percent of applied N showed that AA losses were 1.9 times greater than ESN. Across years, relative to AA, ESN reduced NO emissions, emissions per unit of corn yield, and emissions per unit of N applied, whereas urea produced intermediate values. The study indicates that, under high N loss potential (wet and warm conditions), ESN could reduce NO emissions more that urea and AA.

Fluorescent in situ sequencing (FISSEQ) of RNA for gene expression profiling in intact cells and tissues.

RNA-sequencing (RNA-seq) measures the quantitative change in gene expression over the whole transcriptome, but it lacks spatial context. In contrast, in situ hybridization provides the location of gene expression, but only for a small number of genes. Here we detail a protocol for genome-wide profiling of gene expression in situ in fixed cells and tissues, in which RNA is converted into cross-linked cDNA amplicons and sequenced manually on a confocal microscope. Unlike traditional RNA-seq, our method enriches for context-specific transcripts over housekeeping and/or structural RNA, and it preserves the tissue architecture for RNA localization studies. Our protocol is written for researchers experienced in cell microscopy with minimal computing skills. Library construction and sequencing can be completed within 14 d, with image analysis requiring an additional 2 d.

Forests, fields, and the edge of sustainability at the ancient Maya city of Tikal.

Tikal has long been viewed as one of the leading polities of the ancient Maya realm, yet how the city was able to maintain its substantial population in the midst of a tropical forest environment has been a topic of unresolved debate among researchers for decades. We present ecological, paleoethnobotanical, hydraulic, remote sensing, edaphic, and isotopic evidence that reveals how the Late Classic Maya at Tikal practiced intensive forms of agriculture (including irrigation, terrace construction, arboriculture, household gardens, and short fallow swidden) coupled with carefully controlled agroforestry and a complex system of water retention and redistribution. Empirical evidence is presented to demonstrate that this assiduously managed anthropogenic ecosystem of the Classic period Maya was a landscape optimized in a way that provided sustenance to a relatively large population in a preindustrial, low-density urban community. This landscape productivity optimization, however, came with a heavy cost of reduced environmental resiliency and a complete reliance on consistent annual rainfall. Recent speleothem data collected from regional caves showed that persistent episodes of unusually low rainfall were prevalent in the mid-9th century A.D., a time period that coincides strikingly with the abandonment of Tikal and the erection of its last dated monument in A.D. 869. The intensified resource management strategy used at Tikal-already operating at the landscape's carrying capacity-ceased to provide adequate food, fuel, and drinking water for the Late Classic populace in the face of extended periods of drought. As a result, social disorder and abandonment ensued.

Highly multiplexed subcellular RNA sequencing in situ.

Understanding the spatial organization of gene expression with single-nucleotide resolution requires localizing the sequences of expressed RNA transcripts within a cell in situ. Here, we describe fluorescent in situ RNA sequencing (FISSEQ), in which stably cross-linked complementary DNA (cDNA) amplicons are sequenced within a biological sample. Using 30-base reads from 8102 genes in situ, we examined RNA expression and localization in human primary fibroblasts with a simulated wound-healing assay. FISSEQ is compatible with tissue sections and whole-mount embryos and reduces the limitations of optical resolution and noisy signals on single-molecule detection. Our platform enables massively parallel detection of genetic elements, including gene transcripts and molecular barcodes, and can be used to investigate cellular phenotype, gene regulation, and environment in situ.