Silver and Copper Nitride Cooperate for CO Electroreduction to Propanol.

The need of carbon sources for the chemical industry, alternative to fossil sources, has pointed to CO2 as a possible feedstock. While CO2 electroreduction (CO2 R) allows production of interesting organic compounds, it suffers from large carbon losses, mainly due to carbonate formation. This is why, quite recently, tandem CO2 R, a two-step process, with first CO2 R to CO using a solid oxide electrolysis cell followed by CO electroreduction (COR), has been considered, since no carbon is lost as carbonate in either step. Here we report a novel copper-based catalyst, silver-doped copper nitride, with record selectivity for formation of propanol (Faradaic efficiency: 45 %), an industrially relevant compound, from CO electroreduction in gas-fed flow cells. Selective propanol formation occurs at metallic copper atoms derived from copper nitride and is promoted by silver doping as shown experimentally and computationally. In addition, the selectivity for C2+ liquid products (Faradaic efficiency: 80 %) is among the highest reported so far. These findings open new perspectives regarding the design of catalysts for production of C3 compounds from CO2 .

Perinatal Health Outcomes Across Rural and Nonrural Counties Within a Single Health System Catchment.

Background: Perinatal health outcomes are influenced by a variety of socioeconomic, behavioral, and economic factors that reduce access to health services. Despite these observations, rural communities continue to face barriers, including a lack of resources and the fragmentation of health services. Objective: To evaluate patterns in health outcomes, health behaviors, socioeconomic vulnerability, and sociodemographic characteristics across rural and nonrural counties within a single health system catchment area. Methods: Socioeconomic vulnerability metrics, health care access as determined by licensed provider metrics, and behavioral data were obtained from FlHealthCHARTS.gov and the County Health Rankings. County-level birth and health data were obtained from the Florida Department of Health. The University of Florida Health Perinatal Catchment Area (UFHPCA) was defined as all Florida counties where ≥5% of all infants were delivered at Shands Hospital between June 2011 and April 2017. Results: The UFHPCA included 3 nonrural and 10 rural counties that represented more than 64,000 deliveries. Nearly 1 in 3 infants resided in a rural county, and 7 out of 13 counties did not have a licensed obstetrician gynecologist. Maternal smoking rates (range 6.8%-24.8%) were above the statewide rate (6.2%). Except for Alachua County, breastfeeding initiation rates (range 54.9%-81.4%) and access to household computing devices (range 72.8%-86.4%) were below the statewide rate (82.9% and 87.9%, respectively). Finally, we found that childhood poverty rates (range 16.3%-36.9%) were above the statewide rate (18.5%). Furthermore, risk ratios suggested negative health outcomes for residents of counties within the UFHPCA for each measure, except for infant mortality and maternal deaths, which lacked sample sizes to adequately test. Conclusions: The health burden of the UFHPCA is characterized by rural counties with increased maternal death, neonatal death, and preterm birth, as well as adverse health behaviors that included increased smoking during pregnancy and lower levels of breastfeeding relative to nonrural counties. Understanding perinatal health outcomes across a single health system has potential to not only estimate community needs but also facilitate planning of health care initiatives and interventions in rural and low-resource communities.

Tumor Mutational Burden by Whole-Genome Sequencing in Resected NSCLC of Never Smokers.

BACKGROUND: Data are scarce about tumor mutational burden (TMB) as a biomarker in never smokers with non-small cell lung cancer (NSCLC). METHODS: TMB was assessed by whole-genome sequencing (WGS) and compared with in silico reduced whole-exome sequencing (WES) and targeted commercial next-generation sequencing (NGS) gene panels in 92 paired tumor-normal samples from never smokers who underwent NSCLC resection with curative intent. Analyses were performed to test for association with survival after surgery and to identify the optimal prognostic TMB cutoff. RESULTS: Tumors of never smokers with NSCLC had low TMB scores (median 1.57 mutations/Mb; range, 0.13-17.94). A TMB cutoff of 1.70 mutations/Mb was associated with a 5-year overall survival of 58% in the high-TMB (42% of cases) compared with 86% in low-TMB patients (Wald P = 0.0029). TMB scores from WGS and WES were highly correlated (Spearman ρ = 0.93, P < 2.2e-16). TMB scores from NGS panels demonstrated high intraindividual fluctuations and identified high-TMB patients with 65% concordance in average compared with WGS. CONCLUSIONS: In resected NSCLC of never smokers, high TMB was associated with worse prognosis. WES provided a good estimate of TMB while targeted NGS panels seem to lack adequate depth and resolution in the setting of low mutation burden. IMPACT: TMB is a prognostic indicator of survival in resected NSCLC from individuals who never smoked. In this setting of low mutation counts, TMB can be accurately measured by WGS or WES, but not NGS panels.

Doula Perspectives on Lactation Education and Breastfeeding Support for Diverse, Low-income Women: A Field Report.

Women living below the federal poverty level have low breastfeeding rates and historically have lacked access to doula care. This disparity is particularly evident among African American women. The objective of this pilot study was to assess doulas' experiences delivering lactation education to racially/ethnically diverse, primarily Medicaid-eligible pregnant women and describe doulas' perceptions of client barriers to breastfeeding. We also wanted to understand doulas' views of infant feeding and lactation education during their participation in a quality improvement intervention that trained doulas to provide lactation education and breastfeeding support at 4 clinics serving low-income clients. Two focus groups were conducted with 7 doulas. Focus group data were transcribed, coded, and analyzed using qualitative thematic analysis. Doulas reported close relationships with their clients and provided consistent breastfeeding support and education to women in prenatal, birth, and postpartum phases of care. Doulas emphasized the need for more lactation education, especially to overcome clients' perceived milk insufficiency and early termination due to breastfeeding barriers. Doula-led breastfeeding education and support may improve breastfeeding outcomes for diverse women from underserved areas.

Management of cauda equina syndrome during pregnancy and postpartum.

Cauda equina syndrome (CES) is a rare condition that occurs from multiple nerve root compression. It is considered a surgical emergency because it can lead to permanent neurological damage. There is limited literature regarding management and prognosis of CES for pregnant patients, leaving providers with many questions when encountering patients with this condition. We describe the case of a patient who developed CES during pregnancy. She presented at 30 weeks gestation and successfully underwent surgical decompression in prone position. She later delivered via elective caesarean at term. This case highlights management considerations for pregnant patients with CES, including positioning during surgery and use of regional anaesthesia.

A cautionary tale for health education initiatives in vulnerable populations: Improving nutrition in Haiti prisons.

Introduction: Prisons in low-income countries have barriers to providing adequate nutrition to the incarcerated. This perspective discusses a quality improvement program with health education to improve nutrition provided to men in two prisons in Haiti. Methods: Incarcerated men in the National Penitentiary in Port Au Prince and the prison in Mirebalais were the focus of the program. A culturally competent educational intervention was delivered to the prison cooks. Program evaluation included a baseline and a follow-up assessment in 2021 and 2022 in both prisons. Calories, body composition, and nutrition were assessed at both time points. Results: Among 1,060 men assessed in the baseline time period, the mean number of calories per day was 571. Further, 62.5% had a vitamin C intake insufficient to prevent scurvy and 91.6% had vitamin B1 insufficient to prevent beriberi. In the follow-up period, caloric intake decreased to a mean of 454 per day (p < 0.001). The proportion of incarcerated men who had insufficient vitamin C and vitamin B1 to prevent disease increased in the follow-up period. Discussion: The caloric and nutritional intake of incarcerated men in Haitian prisons is poor and is getting worse. The educational intervention with the cooks was not successful due to civil and political strife in the low-income country of Haiti. Standard interventions to improve nutrition need to consider the social context for accessing food.

Obstetric rectal laceration in the absence of an anal sphincter injury.

Rectal laceration in the absence of concurrent anal sphincter injury at the time of parturition is not a frequently reported finding. This rarely encountered injury is also referred to as a buttonhole injury. It is a disruption of the vaginal and rectal tissue with resultant disruption of the anal epithelium in the setting of an intact external anal sphincter. A 30-year-old gravida 1 para 0 at 39 weeks presented for induction of labour due to chronic hypertension. During her labour course, she developed with superimposed preeclampsia with severe features and magnesium sulfate was initiated. She underwent a spontaneous vaginal delivery of an infant weighing 3840 g. Following delivery, stool was visualised in the vagina. A rectal examination revealed a rectovaginal defect separate from the second-degree perineal laceration, which extended proximally to the cervix. The anal sphincter was noted to be intact with good tone. Both defects were repaired, and she had an uncomplicated recovery.

Idiopathic granulomatous mastitis diagnosed during pregnancy associated with successful breastfeeding experience.

Idiopathic granulomatous mastitis (IGM) is a rare benign breast condition with a course that is often rapidly progressive and slow to resolve. There is no consensus on management, especially during pregnancy and lactation. A 30-year-old at 33 weeks presented with mastalgia, induration and galactorrhoea in the left breast. There was no improvement with antibiotics. Initial workup was negative, and a core needle biopsy showed findings consistent with the diagnosis of IGM. She was treated with steroids antepartum. She was co-managed by rheumatology and her obstetrician/breastfeeding medicine specialist postpartum. She was treated with azathioprine, breastfed exclusively for 6 months and continued breastfeeding through the first year. A multidisciplinary team approach is crucial in diagnosing, treating, and facilitating successful breastfeeding in patients with IGM.

Mechanisms behind TB, HBV, and HIV chronic infections.

Immune evasion is critical for pathogens to maintain their presence within hosts, giving rise to chronic infections. Here, we examine the immune evasion strategies employed by three pathogens with high medical burden, namely, tuberculosis, HIV and HBV. Establishment of chronic infection by these pathogens is a multi-step process that involves an interplay between restriction factor, innate immunity and adaptive immunity. Engagement of these host defences is intimately linked with specific steps within the pathogen replication cycles. Critical host factors are increasingly recognized to regulate immune evasion and susceptibility to disease. Fuelled by innovative technology development, the understanding of these mechanisms provides critical knowledge for rational design of vaccines and therapeutic immune strategies.

Causes and outcomes of markedly elevated C-reactive protein levels.

OBJECTIVE: To characterize the causes of marked elevation of C-reactive protein (CRP) levels, investigate patient outcomes, and examine factors that might influence the CRP response. DESIGN: Health records were used to retrospectively determine patient characteristics, diagnoses, and outcomes over a 2-year period (2012 to 2013). SETTING: A large referral centre in Moncton, NB. PARTICIPANTS: Adult inpatients and outpatients with a CRP level above 100 mg/L. MAIN OUTCOME MEASURES: Differences among the CRP distributions of various diagnosis categories were examined using Kruskal-Wallis tests, and factors affecting outcomes were examined using Fisher exact tests. RESULTS: Over the 2-year period, 1260 CRP levels (839 patients; 3.1% of all tests) were above 100 mg/L (range 100.1 to 576.0 mg/L). The mean age was 63 years (range 18 to 101) and 50.2% of patients were men. Infection was the most prevalent cause (55.1%), followed by rheumatologic diseases (7.5%), multiple causes (5.6%), other inflammatory conditions (5.4%), malignancy (5.1%), drug reactions (1.7%), and other conditions (2.0%). A diagnosis could not be established in 17.6% of cases. On average, infections caused higher peak CRP levels (W = 34 519, P < .001) and infection was present in 88.9% of cases with CRP levels greater than 350 mg/L. Rheumatologic causes were associated with only 5.6% of CRP levels above 250 mg/L. The overall mortality was 8.6% and was higher in patients with malignancy (37.0%), multiple diagnoses (21.0%), and leukopenia (20.7%, P = .002). CONCLUSION: Most patients had infections and the proportion of patients with infections increased with the level of CRP, although many diagnoses were associated with markedly elevated CRP levels. These data could help guide health care professionals in the evaluation and management of these patients.

Prenatal diagnosis of aortopulmonary window associated with aberrant subclavian artery.

Aortopulmonary window is a rare cardiac developmental anomaly characterised by a communication between the ascending aorta and the pulmonary artery. Aortopulmonary window may be isolated or associated with cardiac defects such as ventricular septal defect, atrial septal defect, interrupted aortic arch, and tetralogy of Fallot. We report a case of aortopulmonary window associated with aberrant subclavian artery based on fetal two-dimensional echocardiogram. The mother was referred for fetal echocardiography because of multiple fetal anomalies. Prenatal echocardiography at 30 weeks of gestation revealed a defect between the main and right pulmonary arteries and the ascending aorta (type III). The patient was born at 38 weeks of gestation via caesarean delivery, and was admitted to the neonatal intensive care unit because of respiratory failure and multiple congenital anomalies. Postnatal echocardiogram and cardiac MRI confirmed the prenatal findings. In addition, this patient had severe Dandy-Walker malformation and renal anomalies with poor prognosis. The family decided to withdraw respiratory care support on day of life 4, and the neonate passed away shortly after.

Menstrual management and reproductive concerns in adolescent and young adult women with underlying hematologic or oncologic disease.

PURPOSE OF REVIEW: Heavy menstrual bleeding is common among adolescent and young adult women, and can affect health-related quality of life. The cause of heavy menstrual bleeding is not uncommonly because of an underlying hematologic or oncologic disease process, which substantially influences the way patients are counseled and treated. RECENT FINDINGS: Options for menstrual management are more numerous today than ever before and range from minimizing monthly blood loss to suppressing the cycle altogether. However, an underlying bleeding disorder or malignancy can introduce many nuances and limits in individual patient care, which this review highlights. Additionally, because survival rates for adolescent and young adult cancers are improving, more of these patients are planning for lives after their disease, which may include starting or adding to a family. Options for fertility preservation during cancer therapy regimens are solidifying and both primary practitioners and subspecialists should be aware of the possibilities. SUMMARY: Patients with underlying hematologic or oncologic disease require management of menstrual bleeding, but also deserve a comprehensive evaluation and counseling regarding their individualized contraceptive needs and fertility preservation options during their reproductive years. This review employs the latest evidence from current literature to help guide clinicians caring for this unique demographic.

Involved LEEP excision margins as predictor of residual/recurrent disease in HIV-positive and HIV-negative women in a low-resource setting.

OBJECTIVE: To describe the accuracy of the diagnosis of involved excision margins after loop electrosurgical excision procedure (LEEP) in a low-resource setting. STUDY DESIGN: Cross-sectional study of 176 LEEPs indicated for a cytological report of high-grade squamous intraepithelial lesion (HGSIL). A total of 72 HIV-positive and 104 HIV-negative women with cervical intraepithelial neoplasia (CIN) ≥ 2 on their LEEP histology report with involved excision margins were enrolled in the study. All patients underwent either a repeat LEEP or a hysterectomy. The specimens were evaluated for residual/recurrent CIN ≥ 2 or less. RESULTS: Persistent/recurrent CIN ≥ 2 was diagnosed in 139 (79.4%) instances and microinvasive squamous cell carcinoma in 6 (3.4%). Thirty (17.2%) showed CIN1. The persistence/recurrence rate was 72.2% and 88.5% in HIV-positive and HIV-negative women, respectively (χ2 = 7.5, p = 0.006). CONCLUSION: In > 80% the diagnosis of involved excision margins was confirmed, a positive predictive value of 82.4%. In the absence of more accurate follow-up methods such as HPV testing or co-testing with cytology, a correct diagnosis of margin status, especially when involved, is an important guide to further management and follow-up.

Histometry of high-grade cervical intraepithelial neoplasia and LEEP excision margin in HIV-infected and uninfected women.

OBJECTIVE: To investigate whether the size of the lesion correlates with the completeness of excision, and whether human immunodeficiency virus (HIV) infection was a risk factor for incompleteness of excision. We investigated the size of high-grade cervical intraepithelial lesions of loop electrosurgical excision procedure (LEEP) specimens to assess its effect on the status of the excision margins. Because of the possible negative effect of HIV infection on the completeness of excision, we compared HIV-positive with HIV-negative cases. STUDY DESIGN: Cross-sectional study of 226 consecutive LEEP specimens with cervical intraepithelial neoplasia (CIN). There were 126 CINs > or = 2; 59 (46.8%) were HIV positive. We measured the linear surface, the number of involved crypts, and the number of step sections involved by CIN > or = 2. RESULTS: The excision margins were involved in 65.1%. The measurable linear extent and the average number of involved crypts and sections were significantly higher with incomplete excision (p < 0.0001, p = 0.001, and p = 0.02, respectively). The endocervical excision margin was involved in 52.4% of incomplete excisions. The excision was incomplete in 43.9% of HIV-infected and 56.1% of HIV-uninfected cases (chi2 = 0.03, p = 0.88). CONCLUSION: It appears that instead of the linear surface involvement, it is rather the location in the endocervix and the extension inside the crypts that affects the excision margin status. HIV infection did not affect the completeness of excision.

Influence of knowledge of human immunodeficiency virus serostatus on accuracy of cervical cytologic diagnosis.

BACKGROUND: Women who are infected with the human immunodeficiency virus (HIV) are at high risk of human papillomavirus-persistent infections. Invasive cervical cancer is listed among the illnesses associated with the acquired immunodeficiency syndrome. The objective of the current study was to investigate whether, in South Africa, the accuracy of abnormal cytology confirmed by a histological diagnosis using loop electrosurgical excision procedure (LEEP) is affected by knowledge of the woman's HIV serostatus. METHODS: Of 7648 biopsy specimens, 941 were LEEPs indicated by a cytology report of low-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. A total of 618 specimens (65.7%) were from HIV-uninfected women and 323 specimens (34.3%) were from HIV-infected women. Those women with an unknown pre-LEEP cytological diagnosis were excluded from the study. RESULTS: The total prevalence of HIV infection among the 7648 patients was 18.6%, reflecting its prevalence in the general population of women aged 15 to 49 years. The rate of HIV infection among 3462 women with invasive cervical cancer was 10.7%. The overall prevalence of preinvasive lesions was 73.9% in HIV-infected women compared with 50.3% in women not infected with HIV (P<.0001). The concordance and discordance rates between cytology and histology were similar in uninfected and infected women (P =.93 and P =.18, respectively). Among HIV-infected women, 79.1% of discordant results were due to cytological overdiagnosis; among HIV-negative women, 86.5% of discordant results were due to underdiagnosis (P<.0001). CONCLUSIONS: It appears that the finding of a higher prevalence of preinvasive lesions combined with the knowledge of a patient's HIV-positive serostatus prompts more cytological overdiagnosis, thereby resulting in avoidable LEEP interventions.

Screening and brief intervention for alcohol and other abuse.

Substance use is the most common health risk behavior among adolescents and is one of the greatest threats to their current and future health. Universal screening of adolescents in general medical settings can be instrumental in identifying substance use early, before further problems develop and when BIs are more likely to be effective. Screening in and of itself may have some therapeutic effect. Brief screening tools feasible for use by busy medical offices to quickly and reliably assess adolescent risk for a substance use disorder now are available. A recent study found that a physician-conducted CRAFFT screen interview required an average of 74 seconds to complete, whereas a computer self-administered version took an average of 49 seconds. The CRAFFT and AUDIT tools currently have the most evidence for validity among adolescents, whereas the validity of other widely used tools such as DAST-10, NIDA-modified ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), and ultra-brief screens (AUDIT-C, single-item screens) has yet to be established for adolescents. Studies are needed to identify effective strategies to promote universal adolescent screening and the use of valid screening tools in general medical settings. One statewide (Massachusetts) study found that although most (86%) primary care physicians seeing adolescents reported screening adolescents for substance use annually, only 1 in 3 reported using a validated tool (the CRAFFT). The remaining physicians reporting using informal screening procedures, their own questionnaire, or the CAGE. Computerization of screening and integration into the electronic health record appear to be promising strategies to promote universal screening and standardized use of valid screening tools. Increasing adolescent screening rates necessitates supporting physicians' ability to respond effectively to the screen results. To that end, recent evidence-informed practice guides from the AAP and NIAAA provide a structured algorithm for specific recommended responses based on level of risk. Adolescents who are at low or moderate risk for a substance use disorder, who constitute most of those seen in general medical settings, may be effectively counseled with a few minutes of brief advice, particularly after being primed with screening, feedback, and education before seeing their physician. High-risk patients (screen-positives) should receive a brief follow-up assessment to determine the appropriate level of care needed and a BI, using MI principles, to enhance motivation for behavioral change and help-seeking. Indications of acute danger or addiction may necessitate breaking confidentiality to protect patient safety and begin RT. Our review shows a small but growing body of research on the effectiveness of opportunistic BIs following screening of adolescents in clinical settings. Studies to date have largely tested brief alcohol-focused MI-based interventions with adolescents in the ED or trauma care settings; however, the number of studies conducted in primary health care settings is increasing. The strongest BI effects found in these studies tend to be related to harm reduction, such as reduction of substance-related driving/riding, alcohol-related injuries, unplanned sex, and other negative consequences of use. Effects on substance use have been more modest and tend to be stronger at shorter (< or = 6 months) rather than longer follow-up (> or = 12 months). However, many of these studies compared BI to active control conditions, which often included elements of BI (eg, assessment, brief advice, informational handouts). Significant reductions in substance use and related harms were also seen in these control groups, likely making detection ofa BI effect more difficult. A few studies have shown initial support for a prevention effect of BI among abstinent adolescents. At the opposite end of the spectrum, little is known about the effects of BI for adolescents with dependence and needing RT because of a lack of studies. Other areas needing additional research are the effect of BI on adolescent drug use, particularly on use of drugs other than cannabis; the mediators and moderators of BI effects; ways to reinforce and sustain effects over time; and how best to increase SBI implementation in general medical settings and to effectively train physicians. The effect of efforts such as the Substance Abuse and Mental Health Services Administration-funded physician residency SBIRT training programs remain to be determined. There has been increasing investigation into the potential of interactive computer technologies to aid SBIRT delivery to adolescents and young adults. A more detailed review of this area of research is beyond the scope of this article, but computer technology is proving to be an acceptable and effective tool in the delivery of BIs to young people, both as physician "extenders" in clinical settings and in the form of stand-alone self-guided programs. Computer technologies likely will play a critical role in promoting the expansion of SBIRT implementation for youth in general medical settings.

Cervical preneoplasia biomarkers: a conundrum for the community based gynecologic surgical pathologist.

The integration of high-risk (HR) human papillomavirus (HPV) in the cell genome is an essential step in the oncogenic pathway of lower ano-genital HPV-related squamous preinvasive and invasive lesions. The expression of HR-HPV surrogate biomarkers of HR-HPV integration by immunohistocytochemistry (IHC) serves as a diagnostic and/or a prognostic tool of cervical preinvasive lesions. IHC is claimed to decrease the interobserver variability in the diagnosis of histomorphologically equivocal lesions, and to be helpful in evaluating the potentiality of regression, persistence or progression. The most common biomarkers used in cervical pathology are p16(INK4a), Ki-67, the HPV capsid L1 antigen, and ProEXc. Critical review of the literature shows a great variability in the diagnostic accuracy, risk evaluation, and relative distribution of these biomarkers in low and high grade preinvasive lesions. Review of the literature suggests that currently dual IHC with p16 and L1 provide the best diagnostic and prognostic evaluation of lesions diagnosed histomorphologically as low and high-grade.