Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault.

BACKGROUND: Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room. CASE REPORT: We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.

Grammatical Perspective-Taking in Comprehension and Production.

Language use in conversation requires conversation partners to consider each other's points-of-view, or perspectives. A large body of work has explored how conversation partners take into account differences in knowledge states when choosing referring expressions. This paper explores how well findings from perspective-taking in reference generalize to a relatively understudied domain of perspective: the processing of grammatical perspectival expressions like the motion verbs come and go in English. We re-visit findings from perspective-taking in reference that conversation participants are subject to egocentric biases: they are biased towards their own perspectives. Drawing on theoretical proposals for grammatical perspective-taking and prior experimental studies of perspective-taking in reference, we compare two models of grammatical perspective-taking: a serial anchoring-and-adjustment model, and a simultaneous integration model. We test their differing predictions in a series of comprehension and production experiments using the perspectival motion verbs come and go as a case study. While our comprehension studies suggest that listeners reason simultaneously over multiple perspectives, as in the simultaneous integration model, our production findings are more mixed: we find support for only one of the simultaneous integration model's two key predictions. More generally, our findings suggest a role for egocentric bias in production for grammatical perspective-taking as well as when choosing referring expressions.

Individual Differences in Cue Weighting in Sentence Comprehension: An Evaluation Using Approximate Bayesian Computation.

Cue-based retrieval theories of sentence processing assume that syntactic dependencies are resolved through a content-addressable search process. An important recent claim is that in certain dependency types, the retrieval cues are weighted such that one cue dominates. This cue-weighting proposal aims to explain the observed average behavior, but here we show that there is systematic individual-level variation in cue weighting. Using the Lewis and Vasishth cue-based retrieval model, we estimated individual-level parameters for reading speed and cue weighting using 13 published datasets; hierarchical approximate Bayesian computation (ABC) was used to estimate the parameters. The modeling reveals a nuanced picture of cue weighting: we find support for the idea that some participants weight cues differentially, but not all participants do. Only fast readers tend to have the predicted higher weighting for structural cues, suggesting that reading proficiency (approximated here by reading speed) might be associated with cue weighting. A broader achievement of the work is to demonstrate how individual differences can be investigated in computational models of sentence processing without compromising the complexity of the model.

Person-based prominence guides incremental interpretation: Evidence from obviation in Ojibwe.

Distinctions related to person and animacy have long been known to impact both the grammar and incremental processing in a way that can be described through "prominence" scales. We put the generalizability of these scales to the test by examining the processing effects of a typologically uncommon distinction known as obviation, which is found in Ojibwe, an Indigenous language of North America. Obviation contrasts the single most discourse-salient animate third person (proximate) with other non-salient third persons (obviative). Using a visual world paradigm, we show that obviation influences parsing and interpretation commitments under incremental ambiguity: Proximate nouns are assumed to be the agent of an action, while obviative nouns do not lead to strong incremental commitments. This result parallels previous findings in other languages with distinctions related to animacy and person, supporting a theory where the effect of prominence information in processing is the result of a common set of constraints derived from the alignment of scales related to person, syntactic position, and thematic role.

Artificial Intelligence Algorithm Improves Radiologist Performance in Skeletal Age Assessment: A Prospective Multicenter Randomized Controlled Trial.

Background Previous studies suggest that use of artificial intelligence (AI) algorithms as diagnostic aids may improve the quality of skeletal age assessment, though these studies lack evidence from clinical practice. Purpose To compare the accuracy and interpretation time of skeletal age assessment on hand radiograph examinations with and without the use of an AI algorithm as a diagnostic aid. Materials and Methods In this prospective randomized controlled trial, the accuracy of skeletal age assessment on hand radiograph examinations was performed with (n = 792) and without (n = 739) the AI algorithm as a diagnostic aid. For examinations with the AI algorithm, the radiologist was shown the AI interpretation as part of their routine clinical work and was permitted to accept or modify it. Hand radiographs were interpreted by 93 radiologists from six centers. The primary efficacy outcome was the mean absolute difference between the skeletal age dictated into the radiologists' signed report and the average interpretation of a panel of four radiologists not using a diagnostic aid. The secondary outcome was the interpretation time. A linear mixed-effects regression model with random center- and radiologist-level effects was used to compare the two experimental groups. Results Overall mean absolute difference was lower when radiologists used the AI algorithm compared with when they did not (5.36 months vs 5.95 months; P = .04). The proportions at which the absolute difference exceeded 12 months (9.3% vs 13.0%, P = .02) and 24 months (0.5% vs 1.8%, P = .02) were lower with the AI algorithm than without it. Median radiologist interpretation time was lower with the AI algorithm than without it (102 seconds vs 142 seconds, P = .001). Conclusion Use of an artificial intelligence algorithm improved skeletal age assessment accuracy and reduced interpretation times for radiologists, although differences were observed between centers. Clinical trial registration no. NCT03530098 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Rubin in this issue.

Outcomes following adoption of a standardized protocol for abscess drain management in pediatric appendicitis.

BACKGROUND/PURPOSE: Though evidence-based clinical pathways for the diagnosis and treatment of pediatric appendicitis have been established, protocols guiding management of percutaneous abscess drains are lacking. We hypothesized a drain management protocol utilizing drain output and clinical factors instead of fluoroscopic drain studies would reduce interventional radiologic procedures without adversely impacting clinical outcomes. METHODS: A standardized protocol was uniformly adopted at a tertiary-care children's hospital in April 2016. A retrospective chart review included all cases of appendicitis requiring abscess drainage by interventional radiology three years pre- and postprotocol implementation. RESULTS: Fifty-eight patients (preprotocol = 39, postprotocol = 19) underwent percutaneous abscess drainage, of whom 52 (preprotocol = 34, postprotocol = 18) required a drain. Baseline demographics and clinical presentation were similar across groups. Following protocol implementation, total number of IR procedures decreased from 2.4 to 1.3 per patient (p = 0.004). There was no significant difference in the number of postprocedure diagnostic imaging studies, readmissions, or inpatient days, and there was a trend towards a decrease in number of drain days (10.7 to 5.7, p = 0.067). CONCLUSION: A standardized protocol for management of abscess drains for complicated appendicitis reduced the number of IR procedures without a negative impact on clinical outcomes or increase in alternative imaging studies. This approach may decrease radiation exposure, anesthetic administration, and resource utilization. TYPE OF STUDY: Treatment study (retrospective comparative study). LEVEL OF EVIDENCE: Level III.

Influence of Annealing and Biaxial Expansion on the Properties of Poly(l-Lactic Acid) Medical Tubing.

Poly-l-lactic acid (PLLA) is one of the most common bioabsorbable materials in the medical device field. However, its use in load-bearing applications is limited due to its inferior mechanical properties when compared to many of the competing metal-based permanent and bioabsorbable materials. The objective of this study was to directly compare the influence of both annealing and biaxial expansion processes to improve the material properties of PLLA. Results showed that both annealing and biaxial expansion led to an overall increase in crystallinity and that the crystallites formed during both processes were in the α' and α forms. 2D-WAXS patterns showed that the preferred orientation of crystallites formed during annealing was parallel to the circumferential direction. While biaxial expansion resulted in orientation in both axial and circumferential directions, with relatively equal sized crystals in both directions, Da (112 Å) and Dc (97 Å). The expansion process had the most profound effect on mechanical performance, with a 65% increase in Young's modulus, a 45% increase in maximum tensile stress and an 18-fold increase in strain at maximum load. These results indicate that biaxially expanding PLLA at a temperature above Tcc is possible, due to the high strain rates associated with stretch blow moulding.

Attachment and Concord of Temporal Adverbs: Evidence From Eye Movements.

The present study examined the processing of temporal adverbial phrases such as "last week," which must agree in temporal features with the verb they modify. We investigated readers' sensitivity to this feature match or mismatch in two eye-tracking studies. The main aim of this study was to expand the range of concord phenomena which have been investigated in real-time processing in order to understand how linguistic dependencies are formed during sentence comprehension (Felser et al., 2017). Under a cue-based perspective, linguistic dependency formation relies on an associative cue-based retrieval mechanism (Lewis et al., 2006; McElree, 2006), but how such a mechanism is deployed over diverse linguistic dependencies remains a matter of debate. Are all linguistic features candidate cues that guide retrieval? Are all cues given similar weight? Are different cues differently weighted based on the dependency being processed? To address these questions, we implemented a mismatch paradigm (Sturt, 2003) adapted for temporal concord dependencies. This paradigm tested whether readers were sensitive to a temporal agreement between a temporal adverb like last week and a linearly distant, but structurally accessible verb, as well as a linearly proximate but structurally inaccessible verb. We found clear evidence that readers were sensitive to feature match between the adverb and the linearly distant, structurally accessible verb. We found no clear evidence on whether feature match with the inaccessible verb impacted the processing of a temporal adverb. Our results suggest syntactic positional information plays an important role during the processing of the temporal concord relation.

The Influence of Low Shear Microbore Extrusion on the Properties of High Molecular Weight Poly(l-Lactic Acid) for Medical Tubing Applications.

Biodegradable polymers play a crucial role in the medical device field, with a broad range of applications such as suturing, drug delivery, tissue engineering, scaffolding, orthopaedics, and fixation devices. Poly-l-lactic acid (PLLA) is one of the most commonly used and investigated biodegradable polymers. The objective of this study was to determine the influence low shear microbore extrusion exerts on the properties of high molecular weight PLLA for medical tubing applications. Results showed that even at low shear rates there was a considerable reduction in molecular weight (Mn = 7-18%) during processing, with a further loss (Mn 11%) associated with resin drying. An increase in melt residence time from ~4 mins to ~6 mins, translated into a 12% greater reduction in molecular weight. The degradation mechanism was determined to be thermal and resulted in a ~22-fold increase in residual monomer. The differences in molecular weight between both batches had no effect on the materials thermal or morphological properties. However, it did affect its mechanical properties, with a significant impact on tensile strength and modulus. Interestingly there was no effect on the elongational proprieties of the tubing. There was also an observed temperature-dependence of mechanical properties below the glass transition temperature.

The grammaticality asymmetry in agreement attraction reflects response bias: Experimental and modeling evidence.

Memory access mechanisms such as cue-based retrieval have come to dominate theories of the processing of linguistic dependencies such as subject-verb agreement. One phenomenon that has been regarded as demonstrating the role of such mechanisms is the grammaticality asymmetry in agreement attraction, which is the observation that nouns other than the grammatical controller of agreement can influence the computation of subject-verb agreement in ungrammatical, but not grammatical, sentences. This asymmetry is most often accounted for via the dynamics of retrieval interference. We challenge this interpretation, arguing that the asymmetry largely reflects response bias. Three forced-choice judgment experiments show that neutralizing response bias results in a decrease in the size of the grammaticality asymmetry, or its elimination altogether. Together with the response time patterns in these experiments, this result favors an account that attributes attraction effects to a continuous and equivocal representation of number, rather than to the dynamics of retrieval interference. We implement a model of grammaticality judgments that links a continuous representation of number to the rate of evidence accumulation in a diffusion process. This model accounts for the presence or absence of the grammaticality asymmetry through shifts in the decisional starting point (i.e. response bias), and highlights the importance of monitoring for response bias effects in judgment tasks.

A new argument for co-active parses during language comprehension.

One perennially important question for theories of sentence comprehension is whether the human sentence processing mechanism is parallel (i.e., it simultaneously represents multiple syntactic analyses of linguistic input) or serial (i.e., it constructs only a single analysis at a time). Despite its centrality, this question has proven difficult to address for both theoretical and methodological reasons (Gibson & Pearlmutter, 2000; Lewis, 2000). In the present study, we reassess this question from a novel perspective. We investigated the well-known ambiguity advantage effect (Traxler, Pickering, & Clifton, 1998) in a speeded acceptability judgment task. We adopted a signal detection theoretic approach to these data, with the goal of determining whether speeded judgment responses were conditioned on one or multiple syntactic analyses. To link these results to incremental parsing models, we developed formal models to quantitatively evaluate how serial and parallel parsing models should impact perceived sentence acceptability in our task. Our results suggest that speeded acceptability judgments are jointly conditioned on multiple parses of the input, a finding that is overall more consistent with parallel parsing models than serial models. Our study thus provides a new, psychophysical argument for coactive parses during language comprehension. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Processing of Norwegian complex verbs: Evidence for early decomposition.

We examined the processing of Norwegian complex verbs-compounds consisting of a prepositional prefix and a verbal root-to investigate the lexical decomposition of such morphologically complex compounds. In an eyetracking-while-reading study, we tested whether reading time measures were significantly predicted by a compound verb's whole-word frequency, its root family frequency, or some combination thereof. The results suggest that whole-word and root family frequencies make independent contributions to first-fixation durations. Subsequent reading time measures were better predicted by either whole-word frequency, root family frequency, or both in tandem. We interpret these results as providing support for hybrid models of lexical representation, in which complex verbs are associated with an atomic (whole-word) representation linked to the lexical entries for the compound's constituent morphemes.

Growing and Learning When Consumption Is Seasonal: Long-Term Evidence From Tanzania.

This article shows that the seasonality of food consumption during childhood, conditional on average consumption, affects long-run human capital development. We develop a model that distinguishes differences in average consumption levels, seasonal fluctuations, and idiosyncratic shocks, and estimate the model using panel data from early 1990s Tanzania. We then test whether the mean and seasonality of a child's consumption profile affect height and educational attainment in 2010. Results show that the negative effects of greater seasonality are 30 % to 60 % of the magnitudes of the positive effects of greater average consumption. Put differently, children expected to have identical human capital based on annualized consumption measures will have substantially different outcomes if one child's consumption is more seasonal. We discuss implications for measurement and policy.

Acute Limb Ischemia in an 8-Year-Old Patient: A Case Report.

We report the case of an 8-year-old patient with a history of nephrotic syndrome, who presented to the emergency department with right foot pain. The patient's mother described intermittent pain that woke her son from sleep and was accompanied by the foot turning purple and becoming cold to touch. Physical examination revealed capillary refill of over 10 seconds in the right and less than 2 seconds in the left foot. Ankle-brachial indices (ABIs) were 0.0 on the right and 0.96 on the left. The patient was admitted and started on therapeutic intravenous heparin. After consultation with his parents, right lower extremity angiography and thrombolysis was performed over 2 days. He subsequently underwent fasciotomy and amputation of the tip of all 5 toes. Eighteen months later, there is no leg length discrepancy, he is walking with foot inserts and has normal ABIs bilaterally.

Protection by and maintenance of CD4 effector memory and effector T cell subsets in persistent malaria infection.

Protection at the peak of Plasmodium chabaudi blood-stage malaria infection is provided by CD4 T cells. We have shown that an increase in Th1 cells also correlates with protection during the persistent phase of malaria; however, it is unclear how these T cells are maintained. Persistent malaria infection promotes protection and generates both effector T cells (Teff), and effector memory T cells (Tem). We have previously defined new CD4 Teff (IL-7Rα-) subsets from Early (TeffEarly, CD62LhiCD27+) to Late (TeffLate, CD62LloCD27-) activation states. Here, we tested these effector and memory T cell subsets for their ability to survive and protect in vivo. We found that both polyclonal and P. chabaudi Merozoite Surface Protein-1 (MSP-1)-specific B5 TCR transgenic Tem survive better than Teff. Surprisingly, as Tem are associated with antigen persistence, Tem survive well even after clearance of infection. As previously shown during T cell contraction, TeffEarly, which can generate Tem, also survive better than other Teff subsets in uninfected recipients. Two other Tem survival mechanisms identified here are that low-level chronic infection promotes Tem both by driving their proliferation, and by programming production of Tem from Tcm. Protective CD4 T cell phenotypes have not been precisely determined in malaria, or other persistent infections. Therefore, we tested purified memory (Tmem) and Teff subsets in protection from peak pathology and parasitemia in immunocompromised recipient mice. Strikingly, among Tmem (IL-7Rαhi) subsets, only TemLate (CD62LloCD27-) reduced peak parasitemia (19%), though the dominant memory subset is TemEarly, which is not protective. In contrast, all Teff subsets reduced peak parasitemia by more than half, and mature Teff can generate Tem, though less. In summary, we have elucidated four mechanisms of Tem maintenance, and identified two long-lived T cell subsets (TemLate, TeffEarly) that may represent correlates of protection or a target for longer-lived vaccine-induced protection against malaria blood-stages.

Percutaneous Ultrasound-Guided Cryoablation for Symptomatic Plantar Fibromas.

PURPOSE: Here, we report our experience in treating painful plantar fibromas with percutaneous cryoablation. METHODS: We retrospectively identified patients with symptomatic plantar fibromas who underwent percutaneous ultrasound-guided cryoablation between June 2014 and June 2015. In total, four patients (two male, two female) with five plantar fibromas undergoing a total of seven ablation procedures were identified. Each procedure was performed under general anesthesia using a single freeze-thaw cycle. The electronic medical record, procedure reports, and pain scores from a brief pain inventory administered before and after treatment were reviewed. Average and worst pain in 24 h, and time to peak symptom improvement post-procedure were compared. Complications were reviewed using the SIR classification. RESULTS: Five plantar fibromas were treated (mean size 2.2 ± 1.6 cm). Four of five lesions were present for more than 6 years, and 1/5 was present for less than 1 year. Surgical excision was previously performed on 3/5 lesions, all with short-term recurrence. Mean worst pain score in 24 h and average pain score in 24 h (scale of 10) at initial evaluation were 7.1 ± 1.8 and 5.8 ± 1.9, reduced after cryoablation to 0.8 ± 0.8 and 0.4 ± 0.6, respectively. Average time to symptom improvement was 2.8 ± 0.98 weeks (range 2-4 weeks). All patients reported improved ambulation and weight-bearing, and complete cessation of pain medication after treatment. The improvement was sustained on follow-up at 12 months. No major complications occurred. Minor complications occurred in 3/5 patients. CONCLUSIONS: Early experience with percutaneous ultrasound-guided cryoablation to treat painful plantar fibromas suggests that it is a safe and effective treatment option, with early and near-complete symptom improvement.

Effects of Mechanical Complications on Radiation Exposure During Fluoroscopically Guided Gastrojejunostomy Exchange in the Pediatric Population.

The purpose of the article is to evaluate the effects of mechanical complications, such as clogging or coiling, of gastrojejunostomy tubes on radiation exposure during exchange in the pediatric population. In this HIPAA-compliant and IRB-approved study, we retrospectively reviewed procedural records for patients undergoing gastrojejunostomy (GJ) tube exchange during a 4-month period in 2014. Success of the procedure, specifications of the tube, age, and sex of the patient as well as radiation exposure during the procedure were included. Radiation exposure was measured in fluoroscopy time and cumulative air kerma. Complications encountered during exchange were also recorded, if available. Patients presenting for gastrostomy to GJ conversions or combined procedures were excluded from the study. Ordinary and mixed effect linear regression models were used to test associations between GJ tube parameters, presence of mechanical complications, and fluoroscopy time and radiation dose. 146 patients undergoing 285 GJ exchanges met inclusion criteria over the 4-month study period (M:F 82:64). All exchanges were successful with 85 demonstrating a form of mechanical complication (44 coiled, 41 clogged). Of the reported GJ tube specifications, only tube length was significantly associated with mechanical complications (p < 0.001). The presence of mechanical complication was significantly associated with increased radiation exposure and fluoroscopy time (p < 0.0001). Mechanical complications of gastrojejunostomy tubes, such as clogging or coiling, are associated with increased radiation exposure during exchange. Strategies to decrease these complications, including re-siting the gastrostomy tract or placement of a surgical jejunostomy in the event of repeated coiling of a tube should be strongly considered.

Early Inhibition of Fatty Acid Synthesis Reduces Generation of Memory Precursor Effector T Cells in Chronic Infection.

Understanding the mechanisms of CD4 memory T cell (Tmem) differentiation in malaria is critical for vaccine development. However, the metabolic regulation of CD4 Tmem differentiation is not clear, particularly in persistent infections. In this study, we investigated the role of fatty acid synthesis (FAS) in Tmem development in Plasmodium chabaudi chronic mouse malaria infection. We show that T cell-specific deletion and early pharmaceutical inhibition of acetyl CoA carboxylase 1, the rate limiting step of FAS, inhibit generation of early memory precursor effector T cells (MPEC). To compare the role of FAS during early differentiation or survival of Tmem in chronic infection, a specific inhibitor of acetyl CoA carboxylase 1, 5-(tetradecyloxy)-2-furoic acid, was administered at different times postinfection. Strikingly, the number of Tmem was only reduced when FAS was inhibited during T cell priming and not during the Tmem survival phase. FAS inhibition during priming increased effector T cell (Teff) proliferation and strongly decreased peak parasitemia, which is consistent with improved Teff function. Conversely, MPEC were decreased, in a T cell-intrinsic manner, upon early FAS inhibition in chronic, but not acute, infection. Early cure of infection also increased mitochondrial volume in Tmem compared with Teff, supporting previous reports in acute infection. We demonstrate that the MPEC-specific effect was due to the higher fatty acid content and synthesis in MPEC compared with terminally differentiated Teff. In conclusion, FAS in CD4 T cells regulates the early divergence of Tmem from Teff in chronic infection.

Together They Stand: Interpreting Not-At-Issue Content.

Potts unified the account of appositives, parentheticals, expressives, and honorifics as 'Not- At-Issue' (NAI) content, treating them as a natural class semantically in behaving like root (unembedded) structures, typically expressing speaker commitments, and being interpreted independently of At-Issue content. We propose that NAI content expresses a complete speech act distinct from the speech act of the containing utterance. The speech act hypothesis leads us to expect the semantic properties Potts established. We present experimental confirmation of two intuitive observations made by Potts: first that speech act adverbs should be acceptable as NAI content, supporting the speech act hypothesis; and second, that when two speech acts are expressed as successive sentences, the comprehender assumes they are related by some discourse coherence relation, whereas an NAI speech act need not bear a restrictive discourse coherence relation to its containing utterance, though overall sentences containing relevant content are rated more acceptable than those that do not. The speech act hypothesis accounts for these effects, and further accounts for why judgments of syntactic complexity or evaluations of whether or not a statement is true interact with the at-issue status of the material being judged or evaluated.