Remote Patient Monitoring Improves Patient Falls and Reduces Harm.

BACKGROUND: Minimizing patient falls and fall-related injuries within organizational constraints is a high priority for nurse leaders. The Centers for Medicare & Medicaid Services do not reimburse hospitals for fall-related expenditures. In-person sitters are used to prevent falls but are resource intensive and costly. Remote patient monitoring (RPM) may offer alternatives to in-person sitters to reduce fall-related harm. PURPOSE: The efficacy of RPM to reduce patient falls and fall-related injuries was explored. METHODS: Electronic health record data were extracted from a 13-hospital integrated health care system. Incidence rate ratios were used to analyze the impact of RPM technology on falls and fall-related injuries. RESULTS: When used in conjunction with standard fall precautions, RPM reduced falls 33.7% and fall-related injuries 47.4%. Fall-related expenditures decreased $304 400 with a combined estimated savings systemwide of $2 089 600 annually. CONCLUSIONS: RPM technology minimized falls and associated harm and improved patient safety, positively impacting hospital expenditures.

Neoadjuvant Chemotherapy and Endoprosthetic Reconstruction for Lower Extremity Sarcomas: Does Timing Impact Complication Rates?

INTRODUCTION: Sarcoma patients undergoing surgical resection and endoprosthetic reconstruction often receive neoadjuvant chemotherapy (NACT). The objective of the current study was to determine if the timing of NACT impacts the rates of surgical site infections (SSI) and reoperations. METHODS: This study was a secondary analysis of the recently published Prophylactic Antibiotic Regimens in Tumor Surgery trial. Patients who underwent NACT, tumor resection, and endoprosthetic reconstruction for a bone or soft tissue sarcoma were included. Multivariate Cox proportional hazards regression models were created to evaluate if NACT timing was predictive of SSI or reoperations. RESULTS: Overall, 216 patients from 39 clinical sites were included in the analysis. The most common diagnosis was osteosarcoma (75%), followed by Ewing's sarcoma (16%). The median time from completion of NACT to surgery was 24 days (interquartile range 15-42 days). Eighty-five (39%) patients underwent surgery within 3 weeks of completing NACT, 78 (36%) underwent surgery 3-6 weeks after completing NACT, and 53 (22%) patients underwent surgery > 6 weeks after completion of NACT. The timing of NACT did not impact SSI rates or reoperation rates. Longer operative time was an independent predictor of both SSI [hazard ratio (HR) per hour of 1.21, 95% confidence interval (CI) 1.07-1.40; p = 0.002] and reoperation rates (HR of 1.15 per hour, 95% CI 1.03-1.28; p = 0.014). CONCLUSION: The timing of surgery following NACT varied considerably. Chemotherapy timing did not impact SSI or reoperations in patients undergoing surgical resection and endoprosthetic reconstruction in sarcoma patients.

Deep evolutionary origin of limb and fin regeneration.

Salamanders and lungfishes are the only sarcopterygians (lobe-finned vertebrates) capable of paired appendage regeneration, regardless of the amputation level. Among actinopterygians (ray-finned fishes), regeneration after amputation at the fin endoskeleton has only been demonstrated in polypterid fishes (Cladistia). Whether this ability evolved independently in sarcopterygians and actinopterygians or has a common origin remains unknown. Here we combine fin regeneration assays and comparative RNA-sequencing (RNA-seq) analysis of Polypterus and axolotl blastemas to provide support for a common origin of paired appendage regeneration in Osteichthyes (bony vertebrates). We show that, in addition to polypterids, regeneration after fin endoskeleton amputation occurs in extant representatives of 2 other nonteleost actinopterygians: the American paddlefish (Chondrostei) and the spotted gar (Holostei). Furthermore, we assessed regeneration in 4 teleost species and show that, with the exception of the blue gourami (Anabantidae), 3 species were capable of regenerating fins after endoskeleton amputation: the white convict and the oscar (Cichlidae), and the goldfish (Cyprinidae). Our comparative RNA-seq analysis of regenerating blastemas of axolotl and Polypterus reveals the activation of common genetic pathways and expression profiles, consistent with a shared genetic program of appendage regeneration. Comparison of RNA-seq data from early Polypterus blastema to single-cell RNA-seq data from axolotl limb bud and limb regeneration stages shows that Polypterus and axolotl share a regeneration-specific genetic program. Collectively, our findings support a deep evolutionary origin of paired appendage regeneration in Osteichthyes and provide an evolutionary framework for studies on the genetic basis of appendage regeneration.

Prevalence of gender-based and sexual harassment within orthopedic surgery in Canada.

BACKGROUND: Gender-based and sexual harassment are prevalent in the medical profession. We aimed to quantify the prevalence of such behaviours within orthopedic surgery in Canada and to identify any risk factors for experiencing gender-based or sexual harassment in the workplace. METHODS: In collaboration with the Canadian Orthopaedic Association, we conducted a Canada-wide email questionnaire survey in June 2019 of all orthopedic surgeons registered with the Canadian Orthopaedic Association and the Canadian Orthopaedic Residents' Association. The development of our questionnaire was informed by a review of the literature and published surveys on gender-based and sexual harassment, and consultation with researchers in intimate partner violence. We conducted a multivariable logistic regression analysis to identify risk factors for harassment. RESULTS: Of the 1783 surgeons invited to participate, 465 returned the questionnaire (response rate 26.1%); the response rate was 48.1% for females and 22.1% for males. Overall, 331/433 respondents (76.4%, 95% confidence interval [CI] 72%-80%) and 315/423 respondents (74.5%, 95% CI 70%-78%) reported having experienced at least 1 occurrence of gender-based and sexual harassment, respectively. Women were significantly more likely than men to have experienced both gender-based and sexual harassment (odds ratio [OR] 16.2, 95% CI 4.8-54.0, and OR 2.2, 95% CI 1.2-4.0, respectively). Respondents who identified as nonwhite were significantly less likely than those who identified as white to have experienced gender-based harassment (OR 0.5, 95% CI 0.3-0.99). CONCLUSION: The prevalence of gender-based and sexual harassment is high within Canadian orthopedic surgery, and women are at highest risk for experiencing harassment. The results may provide the impetus for orthopedic societies to develop action plans and to re-examine and enforce policies to address these damaging behaviours appropriately.

Targeting Poison Exons to Treat Developmental and Epileptic Encephalopathy.

Developmental and epileptic encephalopathies (DEEs) describe a subset of neurodevelopmental disorders categorized by refractory epilepsy that is often associated with intellectual disability and autism spectrum disorder. The majority of DEEs are now known to have a genetic basis with de novo coding variants accounting for the majority of cases. More recently, a small number of individuals have been identified with intronic SCN1A variants that result in alternative splicing events that lead to ectopic inclusion of poison exons (PEs). PEs are short highly conserved exons that contain a premature truncation codon, and when spliced into the transcript, lead to premature truncation and subsequent degradation by nonsense-mediated decay. The reason for the inclusion/exclusion of these PEs is not entirely clear, but research suggests an autoregulatory role in gene expression and protein abundance. This is seen in proteins such as RNA-binding proteins and serine/arginine-rich proteins. Recent studies have focused on targeting these PEs as a method for therapeutic intervention. Targeting PEs using antisense oligonucleotides (ASOs) has shown to be effective in modulating alternative splicing events by decreasing the amount of transcripts harboring PEs, thus increasing the abundance of full-length transcripts and thereby the amount of protein in haploinsufficient genes implicated in DEE. In the age of personalized medicine, cellular and animal models of the genetic epilepsies have become essential in developing and testing novel precision therapeutics, including PE-targeting ASOs in a subset of DEEs.

Class II malocclusion correction with Invisalign: Is it possible?

INTRODUCTION: This research aimed to determine whether Class II malocclusion can be treated with clear aligners after completing treatment with the initial set of aligners. METHODS: A sample of 80 adult patients were divided into Group 1 with Class I molar malocclusions (n = 40 [11 men and 29 women]; 38.70 ± 15.90 years) and Group 2 with Class II molar malocclusions (n = 40 [11 men and 29 women]; 35.25 ± 15.21 years). All patients had finished treatment with the initial set of Invisalign aligners (Align Technology, Santa Jose, Calif) without known centric occlusion-centric relation discrepancies, issues of compliance, or overcorrection. The 7 measurements using the American Board of Orthodontics (ABO) Model Grading System and millimetric measurements for anteroposterior (AP) and vertical dimensions were assessed and compared between the 2 groups at pretreatment, posttreatment ClinCheck (Align Technology) prediction, and posttreatment. RESULTS: No improvements were observed in the AP correction. The amount of AP correction in patients with Class II malocclusion was 6.8% of the predicted amount. The amount of overbite correction achieved was 28.8% and 38.9% of the predicted amounts in patients with Class I and Class II malocclusion, respectively. Significant improvements in alignment and interproximal contact scores were observed, with only slight improvements in total ABO scores. An increase in mean occlusal contacts score was observed after treatment. No patient with Class II malocclusions would meet the ABO standards after Invisalign treatment. CONCLUSIONS: The Invisalign system successfully achieves certain tooth movements but fails to achieve other movements predictably. No significant Class II correction or overjet reduction was observed with elastics for an average of 7-month duration in the adult population. Additional refinements may be necessary to address problems created during treatment, as evidenced by a posterior open bite incidence.

Esthetic perception of clear aligner therapy attachments using eye-tracking technology.

INTRODUCTION: The purpose of this research was to assess and compare esthetic perceptions of clear aligner therapy with attachments and esthetic brackets by measuring differences in eye fixations using eye-tracking technology. METHODS: The sample involved 250 adult subjects. The subjects gave verbal consent, then viewed photographs showing 4 variations of orthodontic appliances: clear aligner control with minimal attachments, clear aligner with anterior and posterior attachments, esthetic brackets, and clear aligner with posterior attachments. Images were displayed for 6 seconds each on a computer monitor. Location and time to first fixation, total fixation duration, and total visit count and duration for each type of appliance were measured. Subjects were then asked to complete an online survey. RESULTS: Participants spent the least amount of time looking at the photograph of the control, followed by those of the ceramic brackets, posterior attachments, and anterior and/or posterior attachments. The anterior and/or posterior image had the least number of visits but garnered the longest visit duration (1.32 visits averaging 0.74 seconds per visit). This was followed by the images of the posterior attachments (1.40 visits, 0.70 seconds per visit), ceramic brackets (1.43 visits, 0.65 seconds per visit), and minimal attachments control (1.45 visits, 0.61 seconds per visit). The hierarchy of most preferred appliances across all 250 respondents was as follows: minimal attachments control, ceramic brackets, posterior attachments, and anterior and/or posterior attachments. Overall, 88.4% of subjects would compromise appliance esthetics during treatment for a better outcome (n = 221). CONCLUSIONS: Eye-tracking data show that time to the first fixation was negatively correlated with its survey ranking and that an increase in attachments led to an increase in total fixation duration. There is a general desire for clear aligners without attachments and ceramic brackets over clear aligners with multiple attachments. Survey data suggest that although respondents viewed appliance esthetics as highly important, nearly all would compromise appliance esthetics during treatment if it resulted in a better outcome.

Seasonal changes in the song control nuclei of the Rufous-bellied Thrush, Turdus rufiventris (Oscine, Passeriformes, and Turdidae).

In vocal learning birds, memorization and song production rely on a set of telencephalic nuclei referred to as the song control system. Seasonal changes in song production are correlated with changes in the volume of the song control nuclei and are influenced by photoperiodic conditions and hormonal cues. The seasonal volume changes in the avian brain that controls singing are thought to involve regulation of neuronal replacement, which is a striking example of neuronal plasticity. The Rufous-bellied Thrush (Turdus rufiventris) is a seasonally breeding bird that actively sings during the spring and summer (breeding season) and is relatively silent in the fall, yet possible mechanisms behind the periodic changes in song production remain unknown. Here, we have examined two song control nuclei: High vocal center (HVC) and robust nucleus of arcopallium (RA) in fall males, spring males, and fall females of Rufous-bellied Thrush. The cytoarchitectonic organization was analyzed and quantified from Nissl-stained sections, and gene expression of song nuclei markers was examined by in situ hybridization during breeding and nonbreeding seasons. We observed a reduction in HVC volume and reductions in parvalbumin, and RGS4 expression in HVC and RA in males during the nonbreeding season. These findings provide evidence of seasonal changes in the song system of a representative tropical-breeding Turdidae species that does not maintain territories or mate bonding, setting the histological and molecular groundwork for future studies aimed at better understanding of song nuclei changes in seasonally breeding songbirds.

Improving patient safety in the endoscopy unit: utilization of remote video auditing to improve time-out compliance.

BACKGROUND AND AIMS: Patient and procedure verification, or the time-out process (TOP), is considered one of the most vital components of patient safety. It has long been a focus of intervention in the surgical community and recently was incorporated into the American Society for Gastrointestinal Endoscopy guidelines for safety in the GI endoscopy unit. The TOP has had limited attention in the endoscopy literature but remains an area for improvement in clinical endoscopy practice. The aim of this study was to identify barriers and improve TOP compliance rates in our endoscopy unit using remote video auditing (RVA). METHODS: This was a single-center, prospective, pilot initiative in an endoscopy unit at a tertiary care academic medical center. Video cameras with offsite monitoring were installed in each procedure room in our endoscopy suite in November 2016. Baseline TOP compliance rates were audited with RVA over a 2-month period. A multidisciplinary quality improvement team reviewed the data, identified barriers to the TOP, and implemented actionable items in January 2017. TOP compliance rates were again monitored via RVA, and data were collected through October 2018. Pre- and postintervention TOP compliance rates were compared. RESULTS: Over the baseline period, 692 procedures were audited and TOP compliance documented. Baseline TOP compliance rate was 69.6%. Identifiable barriers to TOP compliance included a lack of designated team member to lead TOP, inconsistent documentation of TOP, irrelevant safety checklist items not applicable to endoscopic procedures, and lack of patient safety culture. Actionable items implemented in response to these barriers included designation of a TOP leader, visual indication of initiation of TOP, creation of a concise endoscopy-specific safety checklist, and formal notification/education of the entire endoscopy team. Postintervention TOP compliance rates were then audited from January 2017 to October 2018 and included 12,008 procedures. The mean TOP compliance rate significantly improved from baseline (95.3% vs 69.6%; 95% confidence interval, 22.4-29.3; P < .0001). Additionally, the improvement was maintained throughout the entire postintervention observation period. CONCLUSIONS: TOP compliance rates significantly improved in our endoscopy unit through the use of RVA and implementation of 4 actionable items. Future studies should evaluate the reproducibility of this method in other endoscopy units.

Published intimate partner violence studies often differ from their trial registration records.

INTRODUCTION: Registering study protocols in a trial registry is important for methodologic transparency and reducing selective reporting bias. The objective of this investigation was to determine whether published studies of intimate partner violence (IPV) that had been registered matched the registration record on key study design elements. METHODS: We systematically searched three trial registries to identify registered IPV studies and the published literature for the associated publication. Two authors independently determined for each study whether key study elements in the registry matched those in the published paper. RESULTS: We included 66 studies published between 2006 and 2017. Nearly half (29/66, 44%) were registered after study completion. Many (26/66, 39%) had discrepancies regarding the primary outcome, and nearly two-thirds (42/66, 64%) had discrepancies in secondary outcomes. Discrepancies in study design were less frequent (13/66, 20%). However, large changes in sample size (26/66, 39%) and discrepancies in funding source (28/66, 42%) were frequently observed. CONCLUSIONS: Trial registries are important tools for research transparency and identifying and preventing outcome switching and selective outcome reporting bias. Published IPV studies often differ from their records in trial registries. Researchers should pay close attention to the accuracy of trial registry records.

Interdisciplinary Rounds on a Hospitalist Service: Impact on Palliative Care Measures, Quality, and Utilization Outcomes.

BACKGROUND: Despite growth in service availability, palliative care (PC) referrals are often underutilized or delayed, which may compromise patient outcomes. LOCAL PROBLEM: Underutilized or delayed PC referrals among hospitalized adults prompted this project aimed at improving PC measures, quality, and utilization outcomes. METHODS: Data extracted from the electronic medical record were used to identify needed improvements in PC. INTERVENTION: Interdisciplinary rounds (IDRs) were implemented on the hospitalist service in a nonintensive care setting. RESULTS: Following implementation, median time to PC referral decreased by 2 days. Length of stay (LOS), direct cost, and 30-day mortality also decreased. Postintervention patients were more likely to transition home compared with another facility. CONCLUSIONS: Results support IDRs as a mechanism to improve time to PC referral, decrease LOS, direct cost, and 30-day mortality among hospitalized adults. A more objective method of identifying patients with unmet PC needs may be warranted.

Impact of a Restraint Management Bundle on Restraint Use in an Intensive Care Unit.

Restraint use has been linked to longer lengths of stay and other undesirable outcomes. This evidence-based project explored the impact of a restraint management bundle on restraint use, quality, and safety outcomes. Results indicated that the proportion of intensive care unit patients restrained decreased significantly (24.3% vs 20.9%) following program implementation. Project results suggest that the restraint management bundle may provide a framework for guiding the process to reduce restraint use, minimize harm, and improve patient safety.

Comparative mitogenomic analyses of Amazona parrots and Psittaciformes.

Amazon parrots are long-lived birds with highly developed cognitive skills, including vocal learning. Several parrot mitogenomes have been sequenced, but important aspects of their organization and evolution are not fully understood or have limited experimental support. The main aim of the present study was to describe the mitogenome of the blue-fronted Amazon, Amazona aestiva, and compare it to other mitogenomes from the genus Amazona and the order Psittaciformes. We observed that mitogenomes are highly conserved among Amazon parrots, and a detailed analysis of their duplicated control regions revealed conserved blocks. Population level analyses indicated that the specimen analyzed here seems to be close to A. aestiva individuals from Bahia state. Evolutionary relationships of 41 Psittaciformes species and three outgroups were inferred by BEAST. All relationships were retrieved with high support.

Eye development in the four-eyed fish Anableps anableps: cranial and retinal adaptations to simultaneous aerial and aquatic vision.

The unique eyes of the four-eyed fish Anableps anableps have long intrigued biologists. Key features associated with the bulging eye of Anableps include the expanded frontal bone and the duplicated pupils and cornea. Furthermore, the Anableps retina expresses different photoreceptor genes in dorsal and ventral regions, potentially associated with distinct aerial and aquatic stimuli. To gain insight into the developmental basis of the Anableps unique eye, we examined neurocranium and eye ontogeny, as well as photoreceptor gene expression during larval stages. First, we described six larval stages during which duplication of eye structures occurs. Our osteological analysis of neurocranium ontogeny revealed another distinctive Anablepid feature: an ossified interorbital septum partially separating the orbital cavities. Furthermore, we identified the onset of differences in cell proliferation and cell layer density between dorsal and ventral regions of the retina. Finally, we show that differential photoreceptor gene expression in the retina initiates during development, suggesting that it is inherited and not environmentally determined. In sum, our results shed light on the ontogenetic steps leading to the highly derived Anableps eye.

The non-visual opsins: eighteen in the ancestor of vertebrates, astonishing increase in ray-finned fish, and loss in amniotes.

Non-visual opsins were discovered in the early 1990s. These genes play roles in circadian rhythm in mammals, seasonal reproduction in birds, light avoidance in amphibian larvae, and neural development in fish. However, the interpretation of such studies and the success of future work are compromised by the fact that non-visual opsin repertoires have not been properly characterized in any of these lineages. Here, we show that non-visual opsins from tetrapods and ray-finned fish are distributed among 18 monophyletic subfamilies. An amphibian sequence occurs in every subfamily, whereas mammalian orthologs occur in only seven. Species in the major ray-finned fish lineages, Holostei, Osteoglossomorpha, Otomorpha, Protacanthopterygii, and Neoteleostei, have large numbers of non-visual opsins (22-32 genes) as a result of gene duplication events including, but not limited to, the teleost genome duplication (TGD). In contrast to visual opsins, where lineage-specific duplication is common, the ray-finned fish non-visual opsin repertoire appears to have stabilized shortly after the TGD event and consequently even distantly related species have repertoires of similar size and composition. Most non-visual opsins have been named without the benefit of a phylogenetic perspective and, accordingly, major revisions are proposed.

Evolutionary Developmental Biology (Evo-Devo) Research in Latin America.

Famous for its blind cavefish and Darwin's finches, Latin America is home to some of the richest biodiversity hotspots of our planet. The Latin American fauna and flora inspired and captivated naturalists from the nineteenth and twentieth centuries, including such notable pioneers such as Fritz Müller, Florentino Ameghino, and Léon Croizat who made a significant contribution to the study of embryology and evolutionary thinking. But, what are the historical and present contributions of the Latin American scientific community to Evo-Devo? Here, we provide the first comprehensive overview of the Evo-Devo laboratories based in Latin America and describe current lines of research based on endemic species, focusing on body plans and patterning, systematics, physiology, computational modeling approaches, ecology, and domestication. Literature searches reveal that Evo-Devo in Latin America is still in its early days; while showing encouraging indicators of productivity, it has not stabilized yet, because it relies on few and sparsely distributed laboratories. Coping with the rapid changes in national scientific policies and contributing to solve social and health issues specific to each region are among the main challenges faced by Latin American researchers. The 2015 inaugural meeting of the Pan-American Society for Evolutionary Developmental Biology played a pivotal role in bringing together Latin American researchers eager to initiate and consolidate regional and worldwide collaborative networks. Such networks will undoubtedly advance research on the extremely high genetic and phenotypic biodiversity of Latin America, bound to be an almost infinite source of amazement and fascinating findings for the Evo-Devo community.

Moving Forward Through Consensus: A Modified Delphi Approach to Determine the Top Research Priorities in Orthopaedic Oncology.

BACKGROUND: Several challenges presently impede the conduct of prospective clinical studies in orthopaedic oncology, including limited financial resources to support their associated costs and inadequate patient volume at most single institutions. This study was conducted to prioritize research questions within the field so that the Musculoskeletal Tumor Society (MSTS), and other relevant professional societies, can direct the limited human and fiscal resources available to address the priorities that the stakeholders involved believe will have the most meaningful impact on orthopaedic oncology patient care. QUESTIONS/PURPOSES: The purpose of this study was to use a formal consensus-based approach involving clinician-scientists and other stakeholders to identify the top priority research questions for future international prospective clinical studies in orthopaedic oncology. METHODS: A three-step modified Delphi process involving multiple stakeholder groups (including orthopaedic oncologists, research personnel, funding agency representation, and patient representation) was conducted. First, we sent an electronic questionnaire to all participants to solicit clinically relevant research questions (61 participants; 54% of the original 114 individuals invited to participate returned the questionnaires). Then, participants rated the candidate research questions using a 5-point Likert scale for five criteria (60 participants; 53% of the original group participated in this portion of the process). Research questions that met a priori consensus thresholds progressed for consideration to an in-person consensus meeting, which was attended by 44 participants (39% of the original group; 12 countries were represented at this meeting). After the consensus panel's discussion, members individually assigned scores to each question using a 9-point Likert scale. Research questions that met preset criteria advanced to final ranking, and panel members individually ranked their top three priority research questions, resulting in a final overall ranking of research priorities. RESULTS: A total of 73 candidate research questions advanced to the consensus meeting. In the end, the consensus panel identified four research priorities: (1) Does less intensive surveillance of patients with sarcoma affect survival? (2) What are the survival outcomes over time for orthopaedic oncology implants? (3) Does resection versus stabilization improve oncologic and functional outcomes in oligometastatic bone disease? (4) What is the natural history of untreated fibromatosis? CONCLUSIONS: The results of this study will assist in developing a long-term research strategy for the MSTS and, possibly, the orthopaedic oncology field as a whole. Furthermore, the results of this study can assist researchers in guiding their research efforts and in providing a justified rationale to funding agencies when requesting the resources necessary to support future collaborative research studies that address the identified orthopaedic oncology priorities.