A Bayesian functional data model for surveys collected under informative sampling with application to mortality estimation using NHANES.

Functional data are often extremely high-dimensional and exhibit strong dependence structures but can often prove valuable for both prediction and inference. The literature on functional data analysis is well developed; however, there has been very little work involving functional data in complex survey settings. Motivated by physical activity monitor data from the National Health and Nutrition Examination Survey (NHANES), we develop a Bayesian model for functional covariates that can properly account for the survey design. Our approach is intended for non-Gaussian data and can be applied in multivariate settings. In addition, we make use of a variety of Bayesian modeling techniques to ensure that the model is fit in a computationally efficient manner. We illustrate the value of our approach through two simulation studies as well as an example of mortality estimation using NHANES data.

Microinvasive glaucoma surgeries: critical summary of clinical trial data with and without phacoemulsification.

PURPOSE OF REVIEW: To critically summarize and examine published data from randomized controlled clinical trials (RCTs) investigating the safety and efficacy of microinvasive glaucoma surgeries (MIGS) with and without cataract surgery versus cataract surgery alone. RECENT FINDINGS: Three RCTs with standardized outcomes and rigorous methodology demonstrate superiority of the iStent (Glaukos), CyPass (Alcon), and Hydrus (Alcon) MIGS devices in combination with cataract surgery versus cataract surgery alone. The trials all involved medication washouts at baseline and also after 24 months of follow-up. In each of the trials, a greater proportion of participants randomized to the combined MIGS procedures achieved at least 20% unmedicated intraocular pressure (IOP) lowering compared with cataract surgery alone. With the exception of the CyPass device, which has been voluntarily withdrawn from the market, adverse events associated with MIGS were acceptable and consistent with routine intraocular surgeries. Follow-up studies demonstrate sustained efficacy, greater probabilities of visual field preservation, increased cost-effectiveness, and enhanced quality of life associated with MIGS procedures. SUMMARY: Data related to MIGS platforms for treatment of open-angle glaucoma with or without co-existing cataract supports their continued adoption in clinical practice. Future studies comparing various techniques and devices in a standardized fashion are needed.

Effect of special operational forces surgical resuscitation teams on combat casualty survival: A narrative review.

IMPORTANCE: The most common cause of preventable death on the conventional battlefield or on special operations force (SOF) missions is hemorrhage. SOF missions may take place in remote and austere locations. Many preventable deaths in combat occur within 30 min of wounding. Therefore, SOF damage control resuscitation (DCR) and damage control surgery (DCS) teams may improve combat casualty survival in the SOF environment. OBJECTIVE: To determine the effect of SOF DCR and DCS teams on combat casualty survival. Also, to describe commonalities in team structure, logistics, and blood product usage. DESIGN: A narrative review of the English literature used a Medline and Embase search strategy. The authors were contacted for more details as required. The risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Pooling of data was not done to the heterogeneity of studies. RESULTS: Weak evidence was identified showing a clinical benefit of SOF DCR and DCS teams. Conflicting evidence from less rigorous studies was also found. The overall risk of bias using ROBINS-I was serious to critical. Several commonalities in team structure, training, and logistics were found. CONCLUSIONS AND RELEVANCE: There is conflicting evidence regarding the effect SOF DCR and DCS teams have on combat casualty survival. There is no strong evidence that SOF DCR and DCS teams cause harm. More robust data collection is recommended to evaluate these teams.

PREOPERATIVE DOMED MACULAR CONTOUR CORRELATES WITH POSTOPERATIVE VISUAL GAIN AFTER VITRECTOMY FOR SYMPTOMATIC EPIRETINAL MEMBRANE.

PURPOSE: Evaluate macular features on preoperative ocular coherence tomography as indicators of postoperative visual gain following vitrectomy for epiretinal membrane (ERM). METHODS: A retrospective chart review of 66 eyes that underwent vitrectomy with membrane and internal limiting membrane peeling for symptomatic ERM. Inclusion criteria required a pre-op visual acuity of at least 20/200 and minimum follow-up of 1 year. In addition, 31 of these eyes with complete 5-line raster pre-op ocular coherence tomography had segmentation analysis which included noncentral ERM to inner nuclear layer and ERM to outer plexiform layer measurements. RESULTS: Eyes with "domed" pre-op macular contour had a mean preoperative acuity of 20/70 and gained a mean 2.4 lines at one year, compared with those with "flat" or "depressed" macular contour, having a 20/60 mean preoperative acuity and 0.6 lines gained (P = 0.02). Changes for other ocular coherence tomography features examined were not statistically significant. Paracentral ERM to inner nuclear layer measurements had moderate correlation, whereas paracentral ERM to outer plexiform layer measurements had weak correlation with gain in visual acuity. CONCLUSION: An inner macular-domed contour in eyes with ERM predicted better visual gain after vitrectomy with ERM and internal limiting membrane peeling compared with a flat or depressed contour.

Skeletal muscle, haematological and splenic volume characteristics of elite breath-hold divers.

PURPOSE: The aim of the study was to provide an evaluation of the oxygen transport, exchange and storage capacity of elite breath-hold divers (EBHD) compared with non-divers (ND). METHODS: Twenty-one healthy males' (11 EBHD; 10 ND) resting splenic volumes were assessed by ultrasound and venous blood drawn for full blood count analysis. Percutaneous skeletal muscle biopsies were obtained from the m. vastus lateralis to measure capillarisation, and fibre type-specific localisation and distribution of myoglobin and mitochondrial content using quantitative immunofluorescence microscopy. RESULTS: Splenic volume was not different between groups. Reticulocytes, red blood cells and haemoglobin concentrations were higher (+ 24%, p < 0.05; + 9%, p < 0.05; + 3%, p < 0.05; respectively) and mean cell volume was lower (- 6.5%, p < 0.05) in the EBHD compared with ND. Haematocrit was not different between groups. Capillary density was greater (+ 19%; p < 0.05) in the EBHD. The diffusion distance (R95) was lower in type I versus type II fibres for both groups (EBHD, p < 0.01; ND, p < 0.001), with a lower R95 for type I fibres in the EBHD versus ND (- 13%, p < 0.05). Myoglobin content was higher in type I than type II fibres in EBHD (+ 27%; p < 0.01) and higher in the type I fibres of EBHD than ND (+ 27%; p < 0.05). No fibre type differences in myoglobin content were observed in ND. Mitochondrial content was higher in type I than type II fibres in EBHD (+ 35%; p < 0.05), with no fibre type differences in ND or between groups. CONCLUSIONS: In conclusion, EBDH demonstrate enhanced oxygen storage in both blood and skeletal muscle and a more efficient oxygen exchange capacity between blood and skeletal muscle versus ND.

Improvised first aid techniques for terrorist attacks.

Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, Run, Hide, Tell, and in the USA, Fight Back This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount.

Predicting Profile Soil Properties with Reflectance Spectra via Bayesian Covariate-Assisted External Parameter Orthogonalization.

In situ, diffuse reflectance spectroscopy (DRS) profile soil sensors have the potential to provide both rapid and high-resolution prediction of multiple soil properties for precision agriculture, soil health assessment, and other applications related to environmental protection and agronomic sustainability. However, the effects of soil moisture, other environmental factors, and artefacts of the in-field spectral data collection process often hamper the utility of in situ DRS data. Various processing and modeling techniques have been developed to overcome these challenges, including external parameter orthogonalization (EPO) transformation of the spectra. In addition, Bayesian modeling approaches may improve prediction over traditional partial least squares (PLS) regression. The objectives of this study were to predict soil organic carbon (SOC), total nitrogen (TN), and texture fractions using a large, regional dataset of in situ profile DRS spectra and compare the performance of (1) traditional PLS analysis, (2) PLS on EPO-transformed spectra (PLS-EPO), (3) PLS-EPO with the Bayesian Lasso (PLS-EPO-BL), and (4) covariate-assisted PLS-EPO-BL models. In this study, soil cores and in situ profile DRS spectrometer scans were obtained to ~1 m depth from 22 fields across Missouri and Indiana, USA. In the laboratory, soil cores were split by horizon, air-dried, and sieved (<2 mm) for a total of 708 samples. Soil properties were measured and DRS spectra were collected on these air-dried soil samples. The data were randomly split into training (n = 308), testing (n = 200), and EPO calibration (n = 200) sets, and soil textural class was used as the categorical covariate in the Bayesian models. Model performance was evaluated using the root mean square error of prediction (RMSEP). For the prediction of soil properties using a model trained on dry spectra and tested on field moist spectra, the PLS-EPO transformation dramatically improved model performance relative to PLS alone, reducing RMSEP by 66% and 53% for SOC and TN, respectively, and by 76%, 91%, and 87% for clay, silt, and sand, respectively. The addition of the Bayesian Lasso further reduced RMSEP by 4⁻11% across soil properties, and the categorical covariate reduced RMSEP by another 2⁻9%. Overall, this study illustrates the strength of the combination of EPO spectral transformation paired with Bayesian modeling techniques to overcome environmental factors and in-field data collection artefacts when using in situ DRS data, and highlights the potential for in-field DRS spectroscopy as a tool for rapid, high-resolution prediction of soil properties.

The assessment of neuromuscular fatigue during 120 min of simulated soccer exercise.

PURPOSE: This investigation examined the development of neuromuscular fatigue during a simulated soccer match incorporating a period of extra time (ET) and the reliability of these responses on repeated test occasions. METHODS: Ten male amateur football players completed a 120 min soccer match simulation (SMS). Before, at half time (HT), full time (FT), and following a period of ET, twitch responses to supramaximal femoral nerve and transcranial magnetic stimulation (TMS) were obtained from the knee-extensors to measure neuromuscular fatigue. Within 7 days of the first SMS, a second 120 min SMS was performed by eight of the original ten participants to assess the reliability of the fatigue response. RESULTS: At HT, FT, and ET, reductions in maximal voluntary force (MVC; -11, -20 and -27%, respectively, P ≤ 0.01), potentiated twitch force (-15, -23 and -23%, respectively, P < 0.05), voluntary activation (FT, -15 and ET, -18%, P ≤ 0.01), and voluntary activation measured with TMS (-11, -15 and -17%, respectively, P ≤ 0.01) were evident. The fatigue response was robust across both trials; the change in MVC at each time point demonstrated a good level of reliability (CV range 6-11%; ICC2,1 0.83-0.94), whilst the responses identified with motor nerve stimulation showed a moderate level of reliability (CV range 5-18%; ICC2,1 0.63-0.89) and the data obtained with motor cortex stimulation showed an excellent level of reliability (CV range 3-6%; ICC2,1 0.90-0.98). CONCLUSION: Simulated soccer exercise induces a significant level of fatigue, which is consistent on repeat tests, and involves both central and peripheral mechanisms.

Test-Retest Reliability of Physiological and Performance Responses to 120 Minutes of Simulated Soccer Match Play.

Harper, LD, Hunter, R, Parker, P, Goodall, S, Thomas, K, Howatson, G, West, DJ, Stevenson, E, and Russell, M. Test-retest reliability of physiological and performance responses to 120 minutes of simulated soccer match play. J Strength Cond Res 30(11): 3178-3186, 2016-This study investigated the test-retest reliability of physiological and performance responses to 120 minutes (90 minutes plus 30 minutes extra-time [ET]) of the soccer match simulation (SMS). Ten university-standard soccer players completed the SMS on 2 occasions under standardized conditions. Capillary and venous blood was taken pre-exercise, at half-time, and at 90 and 120 minutes, with further capillary samples taken every 15 minutes throughout the exercise. Core temperature (Tcore), physical (20- and 15-m sprint speeds and countermovement jump height), and technical (soccer dribbling) performance was also assessed during each trial. All variables except blood lactate demonstrated no systematic bias between trials (p > 0.05). During the last 15 minutes of ET, test-rest reliability (coefficient of variation %, Pearson's r, respectively) was moderate to strong for 20-m sprint speed (3.5%, 0.71), countermovement jump height (4.9%, 0.90), dribble speed (2.8%, 0.90), and blood glucose (7.1%, 0.93), and very strong for Tcore (1.2%, 0.99). Moderate reliability was demonstrated for 15-m sprint speed (4.6%, 0.36), dribble precision (11.5%, 0.30), plasma insulin (10.3%, 0.96), creatine kinase ([CK] 28.1%, 0.38), interleukin-6 (24%, 0.99), nonesterified fatty acids ([NEFA] 13.2%, 0.73), glycerol (12.5%, 0.86), and blood lactate (18.6%, 0.79). In the last 15 minutes of ET, concentrations of blood glucose and lactate and sprint and jump performances were reduced, whereas Tcore, NEFA, glycerol, and CK concentrations were elevated (p ≤ 0.05). The SMS is a reliable protocol for measuring responses across the full 120 minutes of soccer-specific exercise. Deleterious effects on performance and physiological responses occur during ET.

Delayed Presentation of Small Bowel Injury Following Extraperitoneal Ballistic Injury.

Lack of peritoneal violation has been a strong tenet of nonoperative management for extraperitoneal penetrating injuries. There have been reports of intraperitoneal injuries without peritoneal violation in adult trauma literature. Such reports are scarce in pediatric trauma. We report delayed presentation of a small bowel injury in a 4-year-old male following extraperitoneal ballistic injury. No peritoneal violation was noted on wound exploration allowing conservative management. Patient developed abdominal distention on postoperative day 1, and radiologic imaging showed intraperitoneal air warranting an exploratory laparotomy. Intraperitoneal injuries without peritoneal violation have been attributed to the transmission of kinetic energy through the extraperitoneal tissue. Clinical judgment, physical exam, and radiologic adjuncts are of the utmost importance in management. Given our findings, extraperitoneal penetrating injuries certainly warrant extended observation of the patient.

Implementation of a pediatric trauma massive transfusion protocol: one institution's experience.

BACKGROUND: Massive transfusion protocols (MTPs) with fixed ratios of blood products may improve outcomes in coagulopathic adult trauma patients. However, there is a paucity of data on transfusion support protocols for pediatric trauma patients, whose mechanisms of injury may differ from those seen in adults. We hypothesized that an MTP would improve outcomes in children, through a balanced blood product resuscitation. STUDY DESIGN AND METHODS: A pediatric trauma MTP, with a fixed ratio of red blood cells (RBCs):fresh-frozen plasma (FFP):platelets:cryoprecipitate in quantities based on the patient's weight, was initiated at a pediatric hospital. Data on clinical status, resuscitation volumes, and hospital course were collected and compared to data from pre-MTP trauma patients requiring transfusion. RESULTS: Fifty-three patients were enrolled over a 15-month period and compared to 49 pre-MTP patients. Seventy-two percent of MTP patients had at least one coagulation value outside of the normal range upon emergency department (ED) arrival, and the median time to FFP transfusion decreased fourfold after MTP implementation (p<0.0001). A total of 49% of MTP patients received greater than 70 mL/kg blood products, and the 24-hour median FFP:RBC transfusion ratio was twofold higher in these patients than the pre-MTP cohort (median, 1:1.8 vs. 1:3.6; p=0.002). No improvement in mortality was observed after MTP implementation, taking into consideration injury severity, prothrombin time, and partial thromboplastin time. CONCLUSIONS: A pediatric trauma MTP is feasible and allows for rapid provision of balanced blood products for transfusion to coagulopathic children. Larger studies are warranted to determine whether such protocols will improve outcomes for pediatric trauma patients.

Open Retroperitoneal Inferior Vena Cava Cannulation for Distal Ventriculoatrial Shunt Catheter Placement.

Multiple alternative sites for distal ventriculoperitoneal shunts have been described including pleural, atrial, ureteral, fallopian, and gallbladder placement. In medically complex patients the sites for cerebrospinal fluid (CSF) diversion can be exhausted. We present a case where open retroperitoneal inferior vena cava cannulation was used for successful atrial catheter placement in a 17-month-old female. The patient had a complex abdominal, pulmonary, and vascular history precluding placement of the distal catheter in other sites or atrial placement through more peripheral venous cannulation. The patient underwent uncomplicated open retroperitoneal exposure of her inferior vena cava (IVC) with cannulation and placement of atrial catheter under fluoroscopic guidance. At the follow-up one year after surgery, the patient did not require revision with appropriate placement of the distal atrial catheter.

An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage.

BACKGROUND: Hemorrhage remains the main cause of preventable death on the modern battlefield. As Improvised Explosive Devices in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the windlass tourniquet to control distal hemorrhage after mid-thigh application. To evaluate the efficacy of the Combat Application Tourniquet (CAT) windlass tourniquet in comparison to the newer Emergency and Military Tourniquet (EMT) pneumatic tourniquet. METHODS: Serving soldiers were recruited from a military orthopedic outpatient clinic. Participants' demographics, blood pressure, and body mass index were recorded. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid-thigh level, and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally, the EMT tourniquet was applied to the first leg and popliteal pulse change Doppler recorded again. RESULTS: A total of 25 patients were recruited with 1 participant excluded. The self-applied CAT occluded popliteal flow in only four subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in two subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). This was a statistically significant difference at p < 0.001 for CAT versus EMT. CONCLUSION: This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid-thigh level. The EMT was successful in a significantly larger number of participants.

Undiagnosed Metachromatic Leukodystrophy Presenting as Severe Gastrointestinal Bleeding and Cholestasis from Hemobilia.

Metachromatic leukodystrophy (MLD) is a neurodegenerative disorder caused by the accumulation of lipids called sulfatides throughout the nervous system. Sulfatides can also collect in other organs throughout the body including the gallbladder where they form polyps. Gallbladder polyps rarely have been found to bleed in patients with known MLD, presumably due to polyp shearing. Here we present a case of a child with autism presenting with severe gastrointestinal bleeding and direct hyperbilirubinemia, requiring significant resuscitation and biliary drain placement to tamponade ongoing bleeding. Subsequent neurologic and genetic investigation led to the diagnosis of MLD, with laparoscopic cholecystectomy revealing extensive, elongated gallbladder polyps. Clinicians who care for patients with MLD, including gastroenterologists who manage their progressive oropharyngeal dysphagia, should be aware of the risk for this life-threatening complication. Moreover, pediatric gastroenterologists and hepatologists should maintain a high index of suspicion for MLD in new patients presenting with developmental regression and gastrointestinal bleeding.

Exploring the use of WhatsApp in out-of-hours pharmacy services: A multi-site qualitative study.

BACKGROUND: WhatsApp is an instant messaging application that has grown in popularity over the last decade. The literature has focused on the use of WhatsApp in medical, surgical and nursing disciplines, with little work exploring pharmacists' experiences of using WhatsApp to provide services. OBJECTIVE(S): The aim of this research was to explore pharmacists' experiences of using WhatsApp to support delivery of out-of-hours pharmacy services. METHODS: A qualitative design was underpinned by a phenomenological philosophy. Focus groups and an extract of the WhatsApp transcript were thematically analysed using NVivo. RESULTS: Over three hundred communication events (1580 messages) were analysed in the WhatsApp transcript. Message type was classified as follows; handover (26%, n = 410), procedural queries (26%, n = 410), laptop location (18%, n = 284), whole staff communication (24%, n = 379), clinical queries (5%, n = 79), and administrative communications (1%, n = 16). A total of five focus groups were conducted between October and November 2017 with 27 participants that included pharmacists with different levels of experience. The findings suggest that WhatsApp improved communication between junior and senior pharmacists, particularly during the global cyber crisis, and provided an opportunity to share best practice. Concerns were raised regarding the encroachment of work activities into personal time. Additionally, the tacit approval by senior pharmacists to group information sharing and solution development, despite the potential for non-active participation, highlighted the issue of collective complicity. CONCLUSIONS: WhatsApp can be a useful platform to support the delivery of out-of-hours services through professional development, improving communication and supporting relationships. This paper demonstrates that service managers must consider multiple ethico-legal and social frameworks when developing or allowing the organic development of such communication methods within healthcare provider organisations.

Novel Essential Amino Acid Supplements Following Resistance Exercise Induce Aminoacidemia and Enhance Anabolic Signaling Irrespective of Age: A Proof-of-Concept Trial.

We investigated the effects of ingesting a leucine-enriched essential amino acid (EAA) gel alone or combined with resistance exercise (RE) versus RE alone (control) on plasma aminoacidemia and intramyocellular anabolic signaling in healthy younger (28 ± 4 years) and older (71 ± 3 years) adults. Blood samples were obtained throughout the three trials, while muscle biopsies were collected in the postabsorptive state and 2 h following RE, following the consumption of two 50 mL EAA gels (40% leucine, 15 g total EAA), and following RE with EAA (combination (COM)). Protein content and the phosphorylation status of key anabolic signaling proteins were determined via immunoblotting. Irrespective of age, during EAA and COM peak leucinemia (younger: 454 ± 32 µM and 537 ± 111 µM; older: 417 ± 99 µM and 553 ± 136 µM) occurred ~60-120 min post-ingestion (younger: 66 ± 6 min and 120 ± 60 min; older: 90 ± 13 min and 78 ± 12 min). In the pooled sample, the area under the curve for plasma leucine and the sum of branched-chain amino acids was significantly greater in EAA and COM compared with RE. For intramyocellular signaling, significant main effects were found for condition (mTOR (Ser2481), rpS6 (Ser235/236)) and age (S6K1 (Thr421/Ser424), 4E-BP1 (Thr37/46)) in age group analyses. The phosphorylation of rpS6 was of similar magnitude (~8-fold) in pooled and age group data 2 h following COM. Our findings suggest that a gel-based, leucine-enriched EAA supplement is associated with aminoacidemia and a muscle anabolic signaling response, thus representing an effective means of stimulating muscle protein anabolism in younger and older adults following EAA and COM.