The Importance of Relationships in Political Advocacy.

Relationships in Advocacy form the basis for physicians to help their practices and patients navigate the challenges and complexities of the modern medical world. John Joyce, MD is the US Representative from Pennsylvania's 13th Congressional District. He serves as a member of the powerful Energy and Commerce Committee and has a leadership role on their Health Care Subcommittee. He is a member of the Doctors Caucus, a group of members from both parties with a health care background receiving weekly briefings on current health issues. He is a board-certified Dermatologist and spent many years in private practice in Central Pennsylvania. I have known him for over 30 years and serve as the AAOS Ambassador to Dr Joyce. Through an interview format Dr Joyce discusses the value of advocacy to him now that he is on the legislative side, how best for physicians to advocate for their patients and practices, and what strategies are most effective, and which are less effective or counterproductive. He shares what he has learned that would have benefitted him when he was a full time practicing private practice clinician about advocacy and relationships with legislators. His experience in both medicine and in Congress make him especially unique to educate us on the value of relationships in advocacy for physicians.

Peer feedback in graduate training: A phenomenological investigation of possibilities.

BACKGROUND: Whilst feedback is an essential component of clinical education, it is often lacking in clinical workplaces due to competing priorities. Peer feedback has been proposed as a potential solution but remains underexplored in terms of practicality and effects. We aimed to examine the experiences of peer feedback among paediatric trainees, and the associated feedback culture. METHODS: Following an Interpretative Phenomenological Analysis approach, the personal experiences of 12 paediatric trainees were explored using semi-structured interviews. Interpretive themes were developed between the transcripts using processes of abstraction, subsumption, contextualisation, and cross-case analysis. Themes were subsequently subjected to member checking and peer debriefing processes. RESULTS: We found that peer feedback was influenced by three contextual factors, namely, prevalent feedback culture, interpersonal consent, and the quality of relationships. Peer feedback culture was lacking in clinical workplaces. Feedback between peers was constrained by avoiding criticism and maintaining work relationships. Social and cultural norms inhibited constructive peer feedback without explicit consent. CONCLUSIONS: Enabling peer feedback in clinical settings requires attention to cultural, relational, and consent barriers. Potential approaches should include helping clinicians to develop greater cultural reflexivity, resident training in how to be peer educators, and enhancing institutional supports for peer feedback.

Robotic repair of vesicovaginal fistulas using fibrin sealant.

INTRODUCTION: Although infrequent, when encountered vesicovaginal fistulas (VVF) are a difficult condition for both patients and physicians alike. After the first robotic repair was described in 2005, this has been an increasingly common treatment modality. At our institution between 2009 and 2014, eleven of these patients were evaluated and treated with robotic repair. However, fibrin sealant was used in place of the traditional tissue flap. Included are six patients who had previously undergone operative repair. MATERIALS AND METHODS: After IRB approval was obtained, a retrospective study was undertaken to identify patients with VVF. Inclusion criteria were operative repair utilizing a da Vinci robotic system; there were no exclusion criteria. A total of eleven patients were identified, and in each case, a robot assisted laparoscopic approach was utilized and Tisseel fibrin sealant was used in lieu of tissue interposition. RESULTS: All patients underwent successful repair of their VVF without evidence of recurrence at a mean follow up of 15.6 months. CONCLUSIONS: Robotic vesicovaginal fistula repair with fibrin sealant seems to be a safe and viable alternative to the traditional repair utilizing a tissue flap.

Simultaneous DNA amplification and detection using a pH-sensing semiconductor system.

We developed an integrated chip for real-time amplification and detection of nucleic acid using pH-sensing complementary metal-oxide semiconductor (CMOS) technology. Here we show an amplification-coupled detection method for directly measuring released hydrogen ions during nucleotide incorporation rather than relying on indirect measurements such as fluorescent dyes. This is a label-free, non-optical, real-time method for detecting and quantifying target sequences by monitoring pH signatures of native amplification chemistries. The chip has ion-sensitive field effect transistor (ISFET) sensors, temperature sensors, resistive heating, signal processing and control circuitry all integrated to create a full system-on-chip platform. We evaluated the platform using two amplification strategies: PCR and isothermal amplification. Using this platform, we genotyped and discriminated unique single-nucleotide polymorphism (SNP) variants of the cytochrome P450 family from crude human saliva. We anticipate this semiconductor technology will enable the creation of devices for cost-effective, portable and scalable real-time nucleic acid analysis.

Ethnic variations in compulsory detention and hospital admission for psychosis across four UK Early Intervention Services.

BackgroundSubstantial ethnic variations have been found in incidence, pathways to care and outcomes in psychosis. It is unknown whether these remain as marked in the presence of specialist Early Intervention Services (EIS) for psychosis. We present the first UK study exploring ethnic differences in compulsory detention and hospitalization rates for EIS patients. We investigated whether the excess rates of compulsory admission for people from Black groups have persisted following nationwide introduction of EIS. We also explored variations in compulsory admission for other ethnic groups, and differences by gender and diagnosis.MethodsFour inner-city London EIS teams gathered data from first-presentation psychosis patients between 2004¿2009 using the MiData audit tool. Clinical, sociodemographic and pathways to care data were recorded regarding adult patients from eight different ethnic groups at entry to EIS and one year later.ResultsBlack African EIS service users had odds of being detained and of being hospitalised three times greater than White British patients, even after adjustment for confounders. This was most marked in Black African women (seven to eight times greater odds than White British women). A post-hoc analysis showed that pathways to care and help-seeking behaviour partially explained these differences.ConclusionThese findings suggest EIS input in its current form has little impact on higher admission and detention rates in certain Black and minority groups. There is a need to tackle these differences and engage patients earlier, focusing on the needs of men and women from the most persistently affected groups.

Lack of association between pelvic outlet diameter and pelvic organ prolapse in squirrel monkeys.

INTRODUCTION AND HYPOTHESIS: The aim was to test the hypothesis that the pelvic outlet diameter (POD) is associated with pelvic organ prolapse (POP) in squirrel monkeys. METHODS: Magnetic resonance images (MRI) were obtained from 55 females with and without POP. Commercial software was used by two observers to measure the POD. POD, age, parity, and weight for the two groups were compared using Student's t test. Associations of age, parity, and body weight with POD were evaluated with linear regression analysis. Multiple regression analysis examined the relationships of age, parity, and POD with POP. Receiver operating curve methods were used to set thresholds. RESULTS: Observers concurred on measurements (Cronbach's alpha = 0.96 with lower 95% confidence limit of 0.94). POD was not related to parity (p = 0.10) or weight (p = 0.053), but was inversely related to age (p = 0.011). Animals with POP did not differ from those without POP with regard to age (p = 0.10), weight (p = 0.17), or POD (p = 0.99). The groups differed with regard to parity (p = 0.007) and multiple regression methods demonstrated that only parity had a significant relationship with POP (p = 0.002). Parity greater than 2 had 64% specificity and 89% sensitivity for POP. CONCLUSIONS: POD size does not contribute to POP in squirrel monkeys. This study confirms that among variables of age, body weight, POD, and parity, only parity appears as a risk factor for POP in squirrel monkeys.

Less Is More: Higher-Skilled Sim Racers Allocate Significantly Less Attention to the Track Relative to the Display Features than Lower-Skilled Sim Racers.

Simulated (sim) racing is an emerging esport that has garnered much interest in recent years and has been a relatively under-researched field in terms of expertise and performance. When examining expertise, visual attention has been of particular interest to researchers, with eye tracking technology commonly used to assess visual attention. In this study, we examined the overt visual attention allocation of high- and low-skilled sim racers during a time trial task using Tobii 3 glasses. In the study, 104 participants were tested on one occasion, with 88 included in the analysis after exclusions. Participants were allocated to either group according to their fastest lap times. Independent t-tests were carried out with sidak corrections to test our hypotheses. Our results indicate that when eye tracking metrics were normalised to the lap time and corner sector time, there was a difference in the relative length of overt attention allocation (fixation behaviour) as lower-skilled racers had significantly greater total fixation durations in laps overall and across corner sectors when normalised (p = 0.013; p = 0.018). Interestingly, high- and low-skilled sim racers differed in where they allocated their attention during the task, with high-skilled sim racers allocating significantly less overt attention to the track relative to other areas of the display (p = 0.003). This would allow for higher-skilled racers to obtain relatively more information from heads-up display elements in-game, all whilst driving at faster speeds. This study provides evidence that high-skilled sim racers appear to need significantly less overt attention throughout a fast lap, and that high- and low-skilled sim racers differ in where they allocate their attention while racing.

Usage of Padlock Over-the-Scope-Clip in Difficult-to-Control Recurrent Gastrointestinal Bleeding Due to a Gastric Dieulafoy Lesion.

Dieulafoy's lesions (DLs) are a rare cause of acute gastrointestinal bleeds (GIBs). Here we describe Over-the-Scope Clip Padlock System (OTSC-P) use to treat a gastric fundus DL with recurrent bleeding despite other interventions. The OTSC-P was created for full-thickness defect closure in the event of a perforation, but use has expanded to treatment of GIB. They consist of metal clips mounted on transparent caps, delivered via endoscope. Their size allows control of larger bleeding lesions, provides enhanced tissue stability and the firmer clip grasp reduces rebleeding or clip dislodgement.

A Rare Case of Primary B-Cell Lymphoma of the Pancreas.

Primary pancreatic lymphomas (PPLs) are a subgroup of gastrointestinal (GI) lymphomas. They are an exceedingly rare entity, both in terms of pancreatic malignancies and also extranodal lymphomas. Epidemiological investigations have been challenging to do because of their rarity. This has resulted in a lack of clarity on the clinicopathological characteristics, differential diagnosis, best course of treatment, and prognosis of PPL. Because the clinical signs are frequently non-specific, it can lead to a diagnostic hazard for the unwary physician. Preoperatively, it is imperative to distinguish between adenocarcinoma and PPL, as they present similarly, but have vastly different treatment modalities and prognosis. We herein present a case of an elderly man who presented with obstructive jaundice and was found to have PPL.

Comparing the cognitive performance of action video game players and age-matched controls following a cognitively fatiguing task: A stage 2 registered report.

Recent work demonstrates that those who regularly play action video games (AVGs) consistently outperform non-gamer (NG) controls on tests of various cognitive abilities. AVGs place high demands on several cognitive functions and are often engaged with for long periods of time (e.g., over 2 h), predisposing players to experiencing cognitive fatigue. The detrimental effects of cognitive fatigue have been widely studied in various contexts where accurate performance is crucial, including aviation, military, and sport. Even though AVG players may be prone to experiencing cognitive fatigue, this topic has received little research attention to date. In this study, we compared the effect of a cognitively fatiguing task on the subsequent cognitive performance of action video game players and NG control participants. Our results indicated AVGs showed superior spatial working memory and complex attention abilities while showing no difference from NGs on simple attention performance. Additionally, we found that our cognitive fatigue and control interventions did not differentially affect the cognitive performance of AVGs and NGs in this study. This pre-registered study provides evidence that AVGs show superior cognitive abilities in comparison to a non-gaming population, but do not appear more resilient to cognitive fatigue.

Hatchery supplementation provides a demographic boost but alters age composition of sockeye salmon in Auke Lake, Southeast Alaska.

Evaluating salmon hatchery supplementation programs requires assessing not only program objectives but identifying potential risks to wild populations as well. Such evaluations can be hampered by difficulty in distinguishing between hatchery- and wild-born returning adults. Here, we conducted 3 years (2011-2013) of experimental hatchery supplementation of sockeye salmon in Auke Lake, Juneau, Alaska where a permanent weir allows sampling and genotyping of every returning adult (2008-2019). We identified both hatchery- and wild-born returning adults with parentage assignment, quantified the productivity (adult offspring/spawner) of hatchery spawners relative to that of wild spawners, and compared run timing, age, and size at age between hatchery- and wild-born adults. Hatchery-spawning females produced from approximately six to 50 times more returning adults than did naturally spawning females. Supplementation had no discernable effect on run timing and limited consequences for size at age, but we observed a distinct shift to younger age at maturity in the hatchery-born individuals in all three brood years. The shift appeared to be driven by hatchery-born fish being more likely to emigrate after one, rather than two, years in the lake but the cause is unknown. In cases when spawning or incubation habitat is limiting sockeye salmon production, hatchery supplementation can be effective for enhancing the number of returning adult fish but not without the risk of phenotypic change in the recipient population, which can be an undesired outcome of hatchery supplementation. This study adds to a growing body of evidence suggesting that phenotypic change within a single generation of captive spawning might be widespread in salmon hatchery programs.

Fine-scale temporal adaptation within a salmonid population: mechanism and consequences.

We demonstrate a clear example of local adaptation of seasonal timing of spawning and embryo development. The consequence is a population of pink salmon that is segmented into spawning groups that use the same limited habitat. We synthesize published observations with results of new analyses to demonstrate that genetic variation of these traits results in survival differentials related to that variation, and that density-dependent embryo mortality and seasonally variable juvenile mortality are a mechanism of selection. Most examples of local adaptation in natural systems depend on observed correlations between environments and fitness traits, but do not fully demonstrate local adaptation: that the trait is genetically determined, exhibits different fitness in common environments or across different environments, and its variation is mechanistically connected to fitness differences. The geographic or temporal scales of local adaptation often remain obscure. Here, we show that heritable, fine-scale differences of timing of reproductive migration in a pink salmon (Oncorhynchus gorbuscha) resulted in temporal structure that persisted several generations; the differences enable a density-dependent population to pack more spawners into limited spawning habitat, that is, enhance its fitness. A balanced trade-off of survivals results because embryos from early-migrating fish have a lower freshwater survival (harsh early physical conditions and disturbance by late spawners), but emigrant fry from late-migrating fish have lower marine survivals (timing of their vernal emergence into the estuarine environment). Such fine-scale local adaptations increase the genetic portfolio of the populations and may provide a buffer against the impacts of climate change.

Imaging the three-dimensional Fermi-surface pairing near the hidden-order transition in URu2Si2 using angle-resolved photoemission spectroscopy.

We report angle-resolved photoemission spectroscopy experiments probing deep into the hidden-order state of URu(2)Si(2), utilizing tunable photon energies with sufficient energy and momentum resolution to detect the near Fermi-surface (FS) behavior. Our results reveal (i) the full itinerancy of the 5f electrons, (ii) the crucial three-dimensional k-space nature of the FS and its critical nesting vectors, in good comparison with density-functional theory calculations, and (iii) the existence of hot-spot lines and pairing of states at the FS, leading to FS gapping in the hidden-order phase.

Ethnic variations in pathways into early intervention services for psychosis.

BACKGROUND: Ethnic variations have previously been identified in the duration of untreated psychosis (DUP) and pathways into psychiatric services. These have not been examined in the context of early intervention services, which may alter these trajectories. AIMS: To explore ethnic differences in the nature and duration of pathways into early intervention services. METHOD: In a naturalistic cohort study, data were collected for 1024 individuals with psychotic disorders accepted for case management by eight London early intervention services. RESULTS: Duration of untreated psychosis was prolonged in the White British group compared with most other ethnic groups. White British individuals were more likely to make contact with their general practitioner and less likely to be seen within emergency medical services. All Black patient groups were more likely than their White British counterparts to experience involvement of criminal justice agencies. CONCLUSIONS: Variations continue to exist in how and when individuals from different ethnic groups access early intervention services. These may account for disparities in DUP.

Increased TMEM16A-encoded calcium-activated chloride channel activity is associated with pulmonary hypertension.

Pulmonary artery smooth muscle cells (PASMCs) are more depolarized and display higher Ca(2+) levels in pulmonary hypertension (PH). Whether the functional properties and expression of Ca(2+)-activated Cl- channels (Cl(Ca)), an important excitatory mechanism in PASMCs, are altered in PH is unknown. The potential role of Cl(Ca) channels in PH was investigated using the monocrotaline (MCT)-induced PH model in the rat. Three weeks postinjection with a single dose of MCT (50 mg/kg ip), the animals developed right ventricular hypertrophy (heart weight measurements) and changes in pulmonary arterial flow (pulse-waved Doppler imaging) that were consistent with increased pulmonary arterial pressure and PH. Whole cell patch experiments revealed an increase in niflumic acid (NFA)-sensitive Ca(2+)-activated Cl(-) current [I(Cl(Ca))] density in PASMCs from large conduit and small intralobar pulmonary arteries of MCT-treated rats vs. aged-matched saline-injected controls. Quantitative RT-PCR and Western blot analysis revealed that the alterations in I(Cl(Ca)) were accompanied by parallel changes in the expression of TMEM16A, a gene recently shown to encode for Cl(Ca) channels. The contraction to serotonin of conduit and intralobar pulmonary arteries from MCT-treated rats exhibited greater sensitivity to nifedipine (1 µM), an l-type Ca(2+) channel blocker, and NFA (30 or 100 µM, with or without 10 µM indomethacin to inhibit cyclooxygenases) or T16A(Inh)-A01 (10 µM), TMEM16A/Cl(Ca) channel inhibitors, than that of control animals. In conclusion, augmented Cl(Ca)/TMEM16A channel activity is a major contributor to the changes in electromechanical coupling of PA in this model of PH. TMEM16A-encoded channels may therefore represent a novel therapeutic target in this disease.

Effect of spin-orbit coupling on the actinide dioxides AnO2 (An=Th, Pa, U, Np, Pu, and Am): a screened hybrid density functional study.

We present a systematic comparison of the lattice structures, electronic density of states, and band gaps of actinide dioxides, AnO(2) (An=Th, Pa, U, Np, Pu, and Am) predicted by the Heyd-Scuseria-Ernzerhof screened hybrid density functional (HSE) with the self-consistent inclusion of spin-orbit coupling (SOC). The computed HSE lattice constants and band gaps of AnO(2) are in consistently good agreement with the available experimental data across the series, and differ little from earlier HSE results without SOC. ThO(2) is a simple band insulator (f(0)), while PaO(2), UO(2), and NpO(2) are predicted to be Mott insulators. The remainders (PuO(2) and AmO(2)) show considerable O2p/An5f mixing and are classified as charge-transfer insulators. We also compare our results for UO(2), NpO(2), and PuO(2) with the PBE+U, self interaction correction (SIC), and dynamic mean-field theory (DMFT) many-body approximations.

Down syndrome and the eye: Ocular characteristics and ocular assessment.

The trisomy of chromosome 21, the smallest autosome, is associated with significant systemic manifestations in addition to intellectual disability. The triplication of this chromosome, known as Down syndrome (DS) is also associated with several manifestations in the eye, and ocular adnexae. People with DS have a variety of ophthalmic conditions, some of which require intervention. The variable systemic and ophthalmic presentations in DS can make the delivery of eye care challenging. We highlight common ophthalmic presentations in people with DS, as well as the practical implications of delivering eye examinations for this complex needs population. We aim to aid clinicians involved in the ophthalmic care of people with DS in both clinical and research settings.

A Complicated Case of COVID-19-Induced Inferolateral Wall Myocardial Infarction Successfully Treated With Streptokinase.

The treatment of myocardial infarction (MI) in coronavirus disease 2019 (COVID-19)-positive patients is both controversial and challenging, particularly in a healthcare setup unable to fulfill COVID-19 protocols. In this report, we describe a case of a COVID-19-positive patient admitted with COVID-19 pneumonia treated symptomatically with a non-rebreathing mask, dexamethasone, remdesivir, and low-molecular-weight heparin (LMWH). On day two of the hospital stay, the patient developed inferolateral wall myocardial infarction (MI) without hemodynamic instability. He was treated successfully with thrombolytic (streptokinase) with no severe complications. However, his hospital stay was further complicated by decreasing oxygen saturation and rising inflammatory markers including procalcitonin and IL-6, suggesting superimposed bacterial infection. Thereafter, he was placed on BiPAP oxygen, and aggressive antibiotic therapy including tigecycline along with clindamycin and moxifloxacin was initiated. He showed gradual daily improvements and was discharged after a prolonged hospital stay. To decrease the exposure and spread of COVID-19 infection among the healthcare workers, when there is a deficiency in medical staff, and no negative-pressure catheterization laboratory, thrombolytic can be used for treatment in low-risk, hemodynamically stable MI during this pandemic. However, this needs further research.

Parent experience of Beads of Courage program in a neonatal intensive care unit.

AIM: The neonatal intensive care unit can be a stressful environment for parents. The Beads of Courage program is an arts-in-medicine, psychosocial intervention, designed to strengthen and support children and families who are coping with serious or life-threatening illness. We hypothesised that the program would improve the parent experience in the neonatal unit. METHODS: Infants less than 32 weeks' gestation were eligible for enrolment on the program. The study was conducted from 2016 to 2018. A 13 point questionnaire was sent to participating parents post discharge from the unit including a combination of Likert scale and open-ended questions. RESULTS: During the study period 123 infants were enrolled. Mean gestational age was 27.7(±2.2) weeks and median length of stay was 49 days (lower quartile 34; upper quartile 76). All respondents rated the program as "helpful and enjoyable" with 72.5% rating it "extremely helpful and enjoyable", 85% felt the program made their stay in the neonatal unit easier. CONCLUSION: The Beads of Courage program was found to be an extremely popular initiative for parents in a neonatal unit setting and was found to be a useful adjunct to communication and inclusion of parents in the care of their infants. SUMMARY: The Beads of Courage program in a NICU setting was found to be very helpful for parents in improving awareness of procedures and understanding overall care of their infants. Parents felt their journey was made easier with the additional engagement and communication with being in the program.