Perovskite-silicon tandem solar cells with bilayer interface passivation.

Two-terminal monolithic perovskite-silicon tandem solar cells demonstrate huge advantages in power conversion efficiency (PCE) compared to their respective single-junction counterparts1,2. However, suppressing interfacial recombination at the wide-bandgap perovskite/electron transport layer interface, without compromising its superior charge transport performance, remains a significant challenge for perovskite-silicon tandem cells3,4. By exploiting the nanoscale discretely distributed LiF ultrathin layer followed by an additional deposition of diammonium diiodide molecule, we have devised a bilayer intertwined passivation strategy that combines efficient electron extraction with further suppression of nonradiative recombination. We constructed perovskite-silicon tandem devices on double-side textured Czochralski (CZ)-based silicon heterojunction cell, which featured a mildly-textured front surface and a heavily-textured rear surface, leading to simultaneously enhanced photocurrent and uncompromised rear passivation. The resulting perovskite-silicon tandem achieved an independently certified stabilized PCE of 33.89%, accompanied by an impressive fill factor (FF) of 83.0% and an open-circuit voltage (Voc) of nearly 1.97 volts. To our knowledge, this represents the first reported certified efficiency of a two-junction tandem solar cell exceeding the single-junction Shockley-Queisser limit of 33.7%.

Minimizing Voltage Losses via Synergistically Reducing Hetero-Interface Energy Offset for High Efficiency Perovskite Solar Cells.

The open circuit voltage (VOC) losses at multiple interfaces within perovskite solar cells (PSCs) limit the improvements in power conversion efficiency (PCE). Herein, a tailored strategy is proposed to reduce the energy offset at both hetero-interfaces within PSCs to decrease the VOC losses. For the interface of perovskite and electron transport layer where exists a mass of defects, it uses the pyromellitic acid to serve as a molecular bridge, which reduces non-radiative recombination and energy level offset. For the interface of perovskite and hole transport layer, which includes a passivator of PEAI, the detrimental effect (negative shift of work function) of PEAI passivation and optimizing the interface energy level alignment are neutralized by incorporating (2-(4-(bis(4-methoxyphenyl)amino)phenyl)-1-cyanovinyl)phosphonic acid. Owing to synergistically reduced hetero-interface energy offset, the PSCs achieve a PCE of 25.13%, and the VOC is increased from 1.134 to 1.174 V. In addition, the resulting PSCs possess enhanced stability, the unencapsulated PSCs can maintain ≈96% and ≈97% of their initial PCE after 2000 h of aging under ambient conditions and 210 h under operation conditions.

Efficient Inverted Perovskite Photovoltaics Through Surface State Manipulation.

Inverted perovskite solar cells (PSCs) are considered as the most promising avenue for the commercialization of PSCs due to their potential inherent stability. However, suboptimal interface contacts between electron transport layer (ETL) (such as C60) and the perovskite absorbing layer within inverted PSCs always result in reduced efficiency and poor stability. Herein, a surface state manipulation strategy has been developed by employing a highly electronegative 4-fluorophenethylamine hydrochloride (p-F-PEACl) to effectively address the issue of poor interface contacts in the inverted PSCs. The p-F-PEACl demonstrates a robust interaction with perovskite film through bonding of amino group and Cl- with I- and Pb2+ ions in the perovskite, respectively. As such, the surface defects of perovskite film can be significantly reduced, leading to suppressed non-radiative recombination. Moreover, p-F-PEACl also plays a dual role in enhancing the surface potential and improving energy-level alignment at the interfaces between the perovskite and C60 carrier transport layer, which directly contributes to efficient charge extraction. Finally, the open-circuit voltage (Voc) of devices increases from 1.104 V to 1.157 V, leading to an overall efficiency improvement from 22.34% to 24.78%. Furthermore, the p-F-PEACl-treated PSCs also display excellent stability.

Chalcogen Bonding Catalysis with Phosphonium Chalcogenide (PCH).

ConspectusThe exploration of new catalysis concepts and strategies to drive chemical reactions is of vital importance for the sustainable development of organic synthesis. Recently, chalcogen bonding catalysis has emerged as a new concept for organic synthesis and has been demonstrated to be an important synthetic tool capable of addressing elusive reactivity and selectivity issues. This Account describes our progress in the research field of chalcogen bonding catalysis, including (1) the discovery of phosphonium chalcogenide (PCH) as highly efficient chalcogen bonding catalyst; (2) the development of "chalcogen-chalcogen bonding catalysis" and "chalcogen···π bonding catalysis" modes; (3) the demonstration that chalcogen bonding catalysis with PCH can activate hydrocarbons to achieve cyclization and coupling reactions of alkenes; (4) the discovery of unusual results that chalcogen bonding catalysis with PCH can solve elusive reactivity and selectivity issues that are inaccessible by classic catalysis approaches; and (5) the elucidation of chalcogen bonding mechanisms.With PCH catalysts, we systematically studied their chalcogen bonding properties, the relationship between structure and catalysis, and their application in facilitating a diverse array of reactions. Enabled by chalcogen-chalcogen bonding catalysis, an efficient assembly reaction of three molecules of ß-ketoaldehyde and one indole derivative in a single operation was realized, delivering heterocycles with a newly constructed seven-membered ring. In addition, a Se···O bonding catalysis approach achieved an efficient synthesis of calix[4]pyrroles. We developed a "dual chalcogen bonding catalysis" strategy to solve reactivity and selectivity issues in the Rauhut-Currier-type reactions and related cascade cyclizations, thus shifting conventionally covalent Lewis base catalysis to a cooperative Se···O bonding catalysis approach. This strategy enables the cyanosilylation of ketones to take place in the presence of a ppm-level amount of PCH catalyst loading. Furthermore, we established chalcogen···π bonding catalysis for catalytic transformation of alkenes. In the research field of supramolecular catalysis, the activation of hydrocarbons such as alkenes by weak interactions is a highly interesting unresolved topic. We showed that the Se···π bonding catalysis approach could efficiently activate alkenes to achieve both coupling and cyclization reactions. Chalcogen···π bonding catalysis with PCH catalysts is particularly highlighted by the capability of facilitating strong Lewis-acid inaccessible transformations, such as the controlled cross coupling of triple alkenes. Overall, this Account presents a panoramic view of our research on chalcogen bonding catalysis with PCH catalysts. The works described in this Account provide a significant platform to solve synthetic problems.

Development of a Predictive Nomogram for Circumferential Resection Margin in Rectal Cancer Surgery.

INTRODUCTION: Circumferential resection margin (CRM) is a key quality metric and predictor of oncologic outcomes and overall survival following surgery for rectal cancer. We aimed to develop a nomogram to identify patients at risk for a positive CRM in the preoperative setting. METHODS: We performed a retrospective evaluation of the National Cancer Database from 2010 to 2014 for patients with clinical stage I-III rectal cancer who underwent total mesorectal excision. Patients were excluded for emergency operation, resection for cancer recurrence, palliative resection, transanal resection, and missing CRM status. The primary outcome was positive CRM. Secondary outcomes included overall survival. RESULTS: There were 28,790 patients included. 2245 (7.8%) had a positive CRM. Higher tumor grade, lack of neoadjuvant chemotherapy, mucinous/signet tumor histology, open approach, abdominoperineal resection, higher T stage, lymphovascular invasion, and perineural invasion were all significantly associated with positive CRM (P < 0.05) and were included in the nomogram. The C-statistic was 0.703, suggesting a good predictive model. CONCLUSIONS: Positive CRM is associated with specific patient demographics and tumor characteristics. These factors can be used along with preoperative MRI to predict CRM positivity in the preoperative period and plan accordingly.

A comprehensive assessment of the prolonged febrile neutropenia evaluation in pediatric oncology patients.

BACKGROUND: Pediatric oncology patients with prolonged (≥96 hours) febrile neutropenia (absolute neutrophil count < 500/µL) often undergo an evaluation for invasive fungal disease (IFD) and other infections. Current literature suggests that beta-D-glucan (BDG), galactomannan, bronchoalveolar lavage (BAL), and computed tomography (CT) scans (sinus, chest, and abdomen/pelvis) may help determine a diagnosis in this population. METHODS: In a retrospective cohort study of all cancer/stem cell transplant patients (diagnosed 2005-2019) from one pediatric hospital, all episodes with prolonged febrile neutropenia or IFD evaluations (defined as sending a fungal biomarker or performing a CT scan to assess for infection) were identified. RESULTS: In total, 503 episodes met inclusion criteria and 64% underwent IFD evaluations. In total, 36.4% of episodes documented an infection after initiation of prolonged febrile evaluation, most commonly Clostridioides difficile colitis (6.4%) followed by a true bacterial bloodstream infection (BSI) (5.2%), proven/probable IFD (4.8%), and positive respiratory pathogen panel (3.6%). There was no difference in sinus CTs showing sinusitis (74% vs 63%, p = 0.46), whereas 32% of abdomen/pelvis CTs led to a non-IFD diagnosis, and 25% of chest CTs showed possible pneumonia. On chest CT, the positive predictive value (PPV) for IFD was 19% for nodules and 14% for tree and bud lesions. BDG had a PPV of 25% for IFD and GM 50%. BAL diagnosed IFD once and pneumocystis jirovecii pneumonia twice. CONCLUSIONS: Chest CTs and abdomen/pelvis CTs provide clinically relevant information during the prolonged febrile neutropenia evaluation, whereas BDG, galactomannan, BAL, and sinus CTs have less certain utility.

Language-Based Disparities in Route of Hysterectomy for Benign Disease.

STUDY OBJECTIVE: To assess the association between patient primary language and route of hysterectomy. DESIGN: A retrospective cohort study was conducted using the Healthcare Cost and Utilization Project's State Inpatient Database (SID) and State Ambulatory Surgery and Services Database (SASD). SETTING: All inpatient and outpatient hysterectomies from the most recent year of available data (2020 - 2021) from the six states that record patient primary language in the SID and SASD (Indiana, Iowa, Maryland, Michigan, Minnesota, and New Jersey) were queried. PATIENTS OR PARTICIPANTS: Patients aged 18 and over undergoing an inpatient or ambulatory hysterectomy for benign indication. INTERVENTIONS: Minimally invasive hysterectomy compared to abdominal hysterectomy. MEASUREMENT AND MAIN RESULTS: The association between patient primary language (English vs non-English) and route of hysterectomy (abdominal vs minimally invasive) was evaluated. The cohort included 52,226 patients who met inclusion criteria. The majority of patients were non-Hispanic White (71%), with a median age of 46 years (IQR 40.0-53.0). 91.4% of patients spoke English as their primary language, 3.6% spoke Spanish, and 5.0% spoke another non-English language. Patients with a non-English primary language were significantly less likely to undergo minimally invasive hysterectomy compared to patients who spoke English (OR 0.60, 95% CI 0.56-0.64, p<0.001). This association remained significant following adjustments for age, race, insurance, median income, state, and fibroid, abnormal uterine bleeding, prolapse or endometriosis diagnosis (aOR 0.77, 95% CI 0.71-0.84). In a sensitivity analysis of English vs Spanish vs other non-English language, the association remained significant for other non-English languages (aOR 0.67, 95% CI 0.60-0.75) but not for Spanish (aOR 0.95, 95% CI 0.83-1.09). CONCLUSION: Patients who are non-English speaking are significantly less likely to receive a minimally invasive hysterectomy. Addressing language disparities may improve access to a minimally invasive route of surgery, a possible surrogate for improved surgical outcomes, for our gynecologic patients.

YOLOv7-Branch: A Jujube Leaf Branch Detection Model for Agricultural Robot.

The intelligent harvesting technology for jujube leaf branches presents a novel avenue for enhancing both the quantity and quality of jujube leaf tea, whereas the precise detection technology for jujube leaf branches emerges as a pivotal factor constraining its development. The precise identification and localization of jujube leaf branches using real-time object detection technology are crucial steps toward achieving intelligent harvesting. When integrated into real-world scenarios, issues such as the background noise introduced by tags, occlusions, and variations in jujube leaf morphology constrain the accuracy of detection and the precision of localization. To address these issues, we describe a jujube leaf branch object detection network based on YOLOv7. First, the Polarized Self-Attention module is embedded into the convolutional layer, and the Gather-Excite module is embedded into the concat layer to incorporate spatial information, thus achieving the suppression of irrelevant information such as background noise. Second, we incorporate implicit knowledge into the Efficient Decoupled Head and replace the original detection head, enhancing the network's capability to extract deep features. Third, to address the issue of imbalanced jujube leaf samples, we employ Focal-EIoU as the bounding box loss function to expedite the regression prediction and enhance the localization accuracy of the model's bounding boxes. Experiments show that the precision of our model is 85%, which is increased by 3.5% compared to that of YOLOv7-tiny. The mAP@0.5 value is 83.7%. Our model's recognition rate, recall and mean average precision are superior to those of other models. Our method could provide technical support for yield estimation in the intelligent management of jujube orchards.

Functional Outcomes After Localized Prostate Cancer Treatment.

Importance: Adverse outcomes associated with treatments for localized prostate cancer remain unclear. Objective: To compare rates of adverse functional outcomes between specific treatments for localized prostate cancer. Design, Setting, and Participants: An observational cohort study using data from 5 US Surveillance, Epidemiology, and End Results Program registries. Participants were treated for localized prostate cancer between 2011 and 2012. At baseline, 1877 had favorable-prognosis prostate cancer (defined as cT1-cT2bN0M0, prostate-specific antigen level <20 ng/mL, and grade group 1-2) and 568 had unfavorable-prognosis prostate cancer (defined as cT2cN0M0, prostate-specific antigen level of 20-50 ng/mL, or grade group 3-5). Follow-up data were collected by questionnaire through February 1, 2022. Exposures: Radical prostatectomy (n = 1043), external beam radiotherapy (n = 359), brachytherapy (n = 96), or active surveillance (n = 379) for favorable-prognosis disease and radical prostatectomy (n = 362) or external beam radiotherapy with androgen deprivation therapy (n = 206) for unfavorable-prognosis disease. Main Outcomes and Measures: Outcomes were patient-reported sexual, urinary, bowel, and hormone function measured using the 26-item Expanded Prostate Cancer Index Composite (range, 0-100; 100 = best). Associations of specific therapies with each outcome were estimated and compared at 10 years after treatment, adjusting for corresponding baseline scores, and patient and tumor characteristics. Minimum clinically important differences were 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritation, and 4 to 6 for bowel and hormone function. Results: A total of 2445 patients with localized prostate cancer (median age, 64 years; 14% Black, 8% Hispanic) were included and followed up for a median of 9.5 years. Among 1877 patients with favorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -12.1 [95% CI, -16.2 to -8.0]), but not worse sexual function (adjusted mean difference, -7.2 [95% CI, -12.3 to -2.0]), compared with active surveillance. Among 568 patients with unfavorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -26.6 [95% CI, -35.0 to -18.2]), but not worse sexual function (adjusted mean difference, -1.4 [95% CI, -11.1 to 8.3), compared with external beam radiotherapy with androgen deprivation therapy. Among patients with unfavorable prognosis, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel (adjusted mean difference, -4.9 [95% CI, -9.2 to -0.7]) and hormone (adjusted mean difference, -4.9 [95% CI, -9.5 to -0.3]) function compared with radical prostatectomy. Conclusions and Relevance: Among patients treated for localized prostate cancer, radical prostatectomy was associated with worse urinary incontinence but not worse sexual function at 10-year follow-up compared with radiotherapy or surveillance among people with more favorable prognosis and compared with radiotherapy for those with unfavorable prognosis. Among men with unfavorable-prognosis disease, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel and hormone function at 10-year follow-up compared with radical prostatectomy.

Drought Stress Induced Different Response Mechanisms in Three Dendrobium Species under Different Photosynthetic Pathways.

Many Dendrobium species, which hold a high status and value in traditional Chinese medicine, grow on barks and rocks in the wild, often encountering harsh environments and facing droughts. However, the molecular mechanisms underlying the shift in the photosynthetic pathway induced by drought remain unclear. To address this issue, three Dendrobium species with different photosynthetic pathways were selected for sequencing and transcriptome data analysis after drought treatment. The findings included 134.43 GB of sequencing data, with numerous Differentially Expressed Genes (DEGs) exhibiting different response mechanisms under drought stress. Gene Ontology (GO)-KEGG-based enrichment analysis of DEGs revealed that metabolic pathways contributed to drought tolerance and alterations in photosynthetic pathways. Phosphoenolpyruvate Carboxylase (PEPC) was subjected to phylogenetic tree construction, sequence alignment, and domain analysis. Under drought stress, variations were observed in the PEPC gene structure and expression among different Dendrobium species; the upregulation of Dc_gene2609 expression may be caused by dof-miR-384, which resulted in the shift from C3 photosynthesis to CAM, thereby improving drought tolerance in Dendrobium. This study revealed the expression patterns and roles of PEPC genes in enhancing plant drought tolerance and will provide an important basis for in-depth research on Dendrobium's adaptation mechanisms in arid environments.

Determination of operation parameters for magnesium-air fuel cell to recover nitrogen and phosphorus from wastewater.

Recovering phosphorus (P) and nitrogen (N) from wastewater not only contributes to environmental protection but also aligns with sustainable development goals. This study employed a magnesium-air fuel cell (Mg-O2-FC) to extract P and N from wastewater in the form of struvite (MgNH4·6H2O), based on the removal efficiency of ammonia and phosphate, electricity generation capacity and struvite purity to determine the optimal operation parameters. These parameters included hydraulic retention time (HRT), service life of magnesium sheet, and precipitation discharge frequency. The results showed that the removal efficiency of ammonia from 0 to 4h was 55.99%, and that from 4 to 12h was only 15.74%. The phosphate removal efficiency in the initial cycle was 97.68% but decreased to 63.25% after 24h. The phosphate removal rate in 2 min increased by 145% when the precipitation discharge frequency increased from 4 h/time to 24 h/time. Consequently, the HRT, service life of the magnesium sheet, and precipitation discharge frequency were selected as 4 h, 24 h, and 24 h/time. These optimized conditions provide valuable insights for the practical implementation of Mg-O2-FC in recovering N and P from wastewater.

Exploration and future trends on spatial correlation of green innovation efficiency in strategic emerging industries under the digital economy: A social network analysis.

With digital technological change and the increasing frequency of interregional innovation links, the spatial correlation and diversity of strategic emerging industries' green innovation efficiency (SEI-GIE) need to be explored in depth. This paper innovatively constructs the SEI-GIE input-output index system under digital economy. The proposed grey model FINGBM(1,1) with ω-order accumulation and weighted initial value optimization realizes effective prediction of 7 input-output indicators of 30 provinces in China from 2021 to 2025. Super-SBM-DEA, gravity model, and social network analysis are applied to explore spatial network structure's dynamic process of SEI-GIE from 12th to 14th Five-Year-Plan period (2011-2025). Empirical results show that (1) Under the effect of digital economy, the SEI-GIE in China generally shows a U-shaped fluctuation trend, in which the growth trend in the central region is obvious, and the western region shows significant fluctuations. (2) The spatial correlation network of SEI-GIE presents a complex and stable center-periphery circle. Particularly, the overall increase in network efficiency highlights the strong small-world characteristics. (3) Beijing, Shanghai, Zhejiang and Jiangsu have always been in the leading core position, with strong influence and control; And Tianjin's core position in the network will decline. Additionally, Guangxi and Chongqing have great potential, but Guangdong needs to strengthen its radiation effect. (4) Block model shows that plate-I (Beijing, Tianjin) receive spatial spillovers from others, while plates-III,IV have significant spillover effects. This study provides theoretical reference for policymakers from a network perspective to promote development of China's SEI-GIE.

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy.

BACKGROUND: To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications. METHODS: A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2). RESULTS: Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications. CONCLUSION: Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

TITLE: Trainees Involvement in MyomectomyThe goal of our study was to determine the association of trainees involvement with surgical outcomes of fibroid excision surgery or myomectomy. We conducted a study of abdominal and laparoscopic myomectomies using an international surgical database. We found that trainees involvement in myomectomy was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy. However, trainees involvement did not impact surgical outcomes for laparoscopic myomectomy.

Cascade Reaction in Organic Hole Transport Layer Enables Efficient Perovskite Solar Cells.

The doped organic hole transport layer (HTL) is crucial for achieving high-efficiency perovskite solar cells (PSCs). However, the traditional doping strategy undergoes a time-consuming and environment-dependent oxidation process, which hinders the technology upgrades and commercialization of PSCs. Here, we reported a new strategy by introducing a cascade reaction in traditional doped Spiro-OMeTAD, which can simultaneously achieve rapid oxidation and overcome the erosion of perovskite by 4-tert-butylpyridine (tBP) in organic HTL. The ideal dopant iodobenzene diacetate was utilized as the initiator that can react with Spiro to generate Spiro⋅+ radicals quickly and efficiently without the participation of ambient air, with the byproduct of iodobenzene (DB). Then, the DB can coordinate with tBP through a halogen bond to form a tBP-DB complex, minimizing the sustained erosion from tBP to perovskite. Based on the above cascade reaction, the resulting Spiro-based PSCs have a champion PCE of 25.76 % (certificated of 25.38 %). This new oxidation process of HTL is less environment-dependent and produces PSCs with higher reproducibility. Moreover, the PTAA-based PSCs obtain a PCE of 23.76 %, demonstrating the excellent applicability of this doping strategy on organic HTL.

Highly Pathogenic Avian Influenza Virus (H5N1) Clade 2.3.4.4b Introduced by Wild Birds, China, 2021.

Highly pathogenic avian influenza (HPAI) subtype H5N1 clade 2.3.4.4b virus has spread globally, causing unprecedented large-scale avian influenza outbreaks since 2020. In 2021, we isolated 17 highly pathogenic avian influenza H5N1 viruses from wild birds in China. To determine virus origin, we genetically analyzed 1,529 clade 2.3.4.4b H5N1 viruses reported globally since October 2020 and found that they formed 35 genotypes. The 17 viruses belonged to genotypes G07, which originated from eastern Asia, and G10, which originated from Russia. The viruses were moderately pathogenic in mice but were highly lethal in ducks. The viruses were in the same antigenic cluster as the current vaccine strain (H5-Re14) used in China. In chickens, the H5/H7 trivalent vaccine provided complete protection against clade 2.3.4.4b H5N1 virus challenge. Our data indicate that vaccination is an effective strategy for preventing and controlling the globally prevalent clade 2.3.4.4b H5N1 virus.

Applying a risk prediction model for bloodstream infection in a febrile, nonseverely neutropenic cohort of pediatric stem cell transplant patients.

BACKGROUND: The optimal management of febrile stem cell transplant (SCT) patients presenting without severe neutropenia (absolute neutrophil count [ANC] ≥ 500/µL) is unclear. The authors have developed iterative risk prediction models (Esbenshade Vanderbilt [EsVan] models) that reliably predict bloodstream infections (BSIs) in the febrile general pediatric oncology population without severe neutropenia, but SCT-specific data are limited. METHODS: All SCTs occurring from May 2005 to November 2019 at a single institution were identified. Episodes of fever with a central venous catheter and ANC values ≥ 500/µL were abstracted. All previous versions of the EsVan model were applied to the SCT data, and c-statistics were generated. The models were additionally applied to each type of transplant (autologous/allogeneic), and a new allogeneic model that further adjusted for metrics of immunosuppression, Esbenshade Vanderbilt Allogeneic SCT Model (EsVanAlloSCT), was developed and internally validated. RESULTS: For 429 SCT episodes (221 autologous and 208 allogeneic), the BSI incidence was 19.6% (84 of 429), and it was higher in allogeneic transplant patients (25.5%) than autologous transplant patients (14.0%; p < .01). All versions of the EsVan model performed well for the overall SCT cohort (c-statistics, 0.759-0.795). The EsVan models performed better for the autologous episodes (c-statistics, 0.869-0.881) than the allogeneic SCT episodes (c-statistics, 0.678-0.717). The new allogeneic transplant-specific model, EsVanAlloSCT, which added an adjustment for the extent of immunosuppression, yielded a c-statistic of 0.792 (bootstrap-corrected, 0.750). CONCLUSIONS: The EsVan models work exceptionally well when they are applied to autologous SCT, but they work less well for allogeneic SCT. EsVanAlloSCT appears to improve the predictive ability in allogeneic SCT, but it will need additional external validation.

Chalcogen Bonding Catalysis of the Cloke-Wilson Rearrangement.

The Cloke-Wilson rearrangement is an important method to construct heterocycles which was conventionally facilitated by strong Lewis acids, Brønsted acids and Lewis bases. A weak interaction catalysis approach to the Cloke-Wilson rearrangement remains a challenging topic and yet no example is reported. Herein, a chalcogen bonding catalysis method to achieve the Cloke-Wilson rearrangement is described that involves activation of carbonyl cyclopropanes by double Se⋅⋅⋅O interactions. This chalcogen bonding catalysis approach afforded a wide range of dihydrofurans with good yields, thus establishing an alternative strategy to catalyze the Cloke-Wilson rearrangement.

Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients.

BACKGROUND: Racial and socioeconomic disparities, exacerbated during the COVID-19 pandemic and surrounding socio-political polarization, affect access to, delivery of, and patient perception of healthcare. Perioperatively, the bedside nurse carries the greatest responsibility of direct care, which includes pain reassessment, a metric tracked for compliance. OBJECTIVE: This study aimed to critically assess disparities in obstetrics and gynecology perioperative care and how these have changed since March 2020 using nursing pain reassessment compliance within a quality improvement framework. STUDY DESIGN: A retrospective cohort of 76,984 pain reassessment encounters from 10,774 obstetrics and gynecology patients at a large, academic hospital from September 2017 to March 2021 was obtained from Tableau: Quality, Safety and Risk Prevention platform. Noncompliance proportions were analyzed by patient race across service lines; a sensitivity analysis was performed excluding patients who were of neither Black nor White race. Secondary outcomes included analysis by patient ethnicity, body mass index, age, language, procedure, and insurance. Additional analyses were performed by temporally stratifying patients into pre- and post-March 2020 cohorts to investigate potential pandemic and sociopolitical effects on healthcare disparities. Continuous variables were assessed with Wilcoxon rank test, categorical variables were assessed with chi-squared test, and multivariable logistic regression analyses were performed (P<.05). RESULTS: Noncompliance proportions of pain reassessment did not differ significantly between Black and White patients as an aggregate of all obstetrics and gynecology patients (8.1% vs 8.2%), but greater differences were found within the divisions of Benign Subspecialty Gynecologic Surgery (Minimally Invasive Gynecologic Surgery + Urogynecology) (14.9% vs 10.70%; P=.03) and Maternal Fetal Medicine (9.5% vs 8.3%; P=.04). Black patients admitted to Gynecologic Oncology experienced lower noncompliance proportions than White patients (5.6% vs 10.4%; P<.01). These differences persisted after adjustment for body mass index, age, insurance, timeline, procedure type, and number of nurses attending to each patient with multivariable analyses. Noncompliance proportions were higher for patients with body mass index ≥35 kg/m2 within Benign Subspecialty Gynecology (17.9% vs 10.4%; P<.01). Non-Hispanic/Latino patients (P=.03), those ≥65 years (P<.01), those with Medicare (P<.01), and those who underwent hysterectomy (P<.01) also experienced greater noncompliance proportions. Aggregate noncompliance proportions differed slightly pre- and post-March 2020; this trend was seen across all service lines except Midwifery and was significant for Benign Subspecialty Gynecology after multivariable analysis (odds ratio, 1.41; 95% confidence interval, 1.02-1.93; P=.04). Though increases in noncompliance proportions were seen for non-White patients after March 2020, this was not statistically significant. CONCLUSION: Significant race, ethnicity, age, procedure, and body mass index-based disparities were identified in the delivery of perioperative bedside care, especially for those admitted to Benign Subspecialty Gynecologic Services. Conversely, Black patients admitted to Gynecologic Oncology experienced lower levels of nursing noncompliance. This may be in part be related to the actions of a Gynecologic Oncology nurse practioner at our institution who helps coordinate care for the division's postoperative patients. Noncompliance proportions increased after March 2020 within Benign Subspecialty Gynecologic Services. Although this study was not designed to establish causation, possible contributing factors include implicit or explicit biases regarding pain experience across race, body mass index, age, or surgical indication, discrepancies in pain management across hospital units, and downstream effects of healthcare worker burnout, understaffing, increased use of travelers, or sociopolitical polarization since March 2020. This study demonstrates the need for ongoing investigation of healthcare disparities at all interfaces of patient care and provides a way forward for tangible improvement of patient-directed outcomes by utilizing an actionable metric within a quality improvement framework.

Prevalence of and Risk Factors for Emergency Department Visits After Outpatient Gynecologic Surgery.

STUDY OBJECTIVE: To identify the prevalence of and risk factors for emergency department (ED) visits within 30 days of outpatient gynecologic surgery. DESIGN: Retrospective cohort study. SETTING: Tertiary academic medical institution. PATIENTS: Adult patients who underwent outpatient surgery (≤1 midnight in the hospital) between January 2018 and September 2019 (N = 2373). INTERVENTIONS: Scheduled outpatient gynecologic surgery for a benign indication. MEASUREMENTS AND MAIN RESULTS: A total of 109 patients (5%) visited the ED within 30 days of surgery. Patients who visited the ED were significantly younger (median age 37 years vs 42 years, p = .02) and had a higher prevalence of abdominal surgical history (67% vs 56%, p = .02) and cardiopulmonary comorbidities (53% vs 40%, p = .007). They were more likely to have undergone a hysterectomy (26% vs 20%) and less likely to have undergone prolapse surgery (4% vs 12%, p = .05). Pain related to the surgical site (42% of ED visits), nausea and/or vomiting (14%), and fever (12%) were the most common surgery-related reasons for ED visits. Medical issues not directly related to surgery accounted for 31% of ED visits. A total of 36% of ED visits resulted in admission. When adjusted for age, insurance status, American Society of Anesthesiologists class, chronic pain and cardiopulmonary comorbidities, abdominal surgical history, primary procedure performed, and surgical route, the following factors were associated with significantly increased risk of visiting the ED: decreasing age (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1-1.3, p <.001), history of abdominal surgery (aOR 1.7, 95% CI 1.1-2.6, p = .017), cardiopulmonary comorbidities (aOR 1.9, 95% CI 1.2-3.0, p = .003), undergoing hysterectomy (aOR 2.0, 95% CI 1.1-3.8, p = .032), and a vulvovaginal surgical route as opposed to abdominal surgical route (aOR 2.4, 95% CI 1.2-5.1, p = .015). CONCLUSION: ED visits after outpatient gynecologic surgery were uncommon, although approximately one-third of visits resulted in admission. Strategies that target our identified risk factors of younger patient age and cardiopulmonary comorbidities may help reduce the ED burden generated by patients undergoing gynecologic surgery.

Preoperative Hematocrit Level and Associated Risk of Transfusion for Myomectomy Based on Myoma Burden and Surgical Route.

STUDY OBJECTIVE: To determine the association between preoperative hematocrit level and risk of blood transfusion for laparotomic and laparoscopic myomectomy based on myoma burden and surgical route. DESIGN: A cohort study of prospectively collected data. SETTING: American College of Surgeons National Surgical Quality Improvement Program participating institutions. PATIENTS: A total of 26 229 women who underwent a laparotomic or laparoscopic myomectomy from 2010 to 2020. INTERVENTIONS: The primary outcome assessed was the risk of transfusion based on preoperative hematocrit level. This was evaluated with respect to myoma burden and surgical route. MEASUREMENTS AND MAIN RESULTS: There were 26 229 women who underwent a myomectomy during the study interval, 2345 women (9%) of whom required a blood transfusion. Compared with patients who did not require transfusion, those who did had lower median preoperative hematocrit levels (34.7 vs 38.2). Patients were stratified by surgical approach (laparotomic vs laparoscopic) and myoma burden (1-4 myomas/weight ≤250 g or ≥5 myomas/weight >250 g) using Current Procedural Terminology codes (58140, 58146, 58545, 58546). In all categories, there was an inverse relationship between blood transfusion and preoperative hematocrit level with increasing risk depending on preoperative hematocrit range. The odds ratios comparing hematocrit level of 29% with 39% were 6.16 (95% confidence interval [CI], 5.15-7.36), 4.92 (95% CI, 4.19-5.78), 4.85 (95% CI, 3.72-6.33), and 5.2 (95% CI, 3.63-7.43) for patients with laparotomic (1-4 myomas/≤250 g, ≥5 myomas/>250 g) and laparoscopic myomectomy (1-4 myomas/≤250 g, 5 myomas/>250 g), respectively. CONCLUSION: Incremental increases in hematocrit result in a significantly decreased risk of blood transfusion at the time of myomectomy.