Unimolecular Kinetics of Stabilized CH3CHOO Criegee Intermediates: syn-CH3CHOO Decomposition and anti-CH3CHOO Isomerization.

The kinetics of the unimolecular decomposition of the stabilized Criegee intermediate syn-CH3CHOO has been investigated at temperatures between 297 and 331 K and pressures between 12 and 300 Torr using laser flash photolysis of CH3CHI2/O2/N2 gas mixtures coupled with time-resolved broadband UV absorption spectroscopy. Fits to experimental results using the Master Equation Solver for Multi-Energy well Reactions (MESMER) indicate that the barrier height to decomposition is 67.2 ± 1.3 kJ mol-1 and that there is a strong tunneling component to the decomposition reaction under atmospheric conditions. At 298 K and 760 Torr, MESMER simulations indicate a rate coefficient of 150-81+176 s-1 when tunneling effects are included but only 5-2+3 s-1 when tunneling is not considered in the model. MESMER simulations were also performed for the unimolecular isomerization of the stabilized Criegee intermediate anti-CH3CHOO to methyldioxirane, indicating a rate coefficient of 54-21+34 s-1 at 298 K and 760 Torr, which is not impacted by tunneling effects. Expressions to describe the unimolecular kinetics of syn- and anti-CH3CHOO are provided for use in atmospheric models, and atmospheric implications are discussed.

Airborne particulate concentration during non-thermal nano-pulse stimulation wart clearance is negligible compared to thermal modalities.

OBJECTIVES: As clinicians continue to implement safety protocols amid the global pandemic, considerations to mitigate potential viral transmission of airborne particulates (plume) generated from certain dermatologic procedures are of growing interest. This study intended to measure the change in airborne particulate matter using a non-thermal energy modality called nano-pulse stimulation (NPS) and compare levels of concentration to common thermal modalities (CO2 laser and electrocautery). NPS is a new non-thermal modality that applies nanosecond pulses of electrical energy to induce regulated cell death in cellular structures while sparing the surrounding acellular structure of the dermis. MATERIALS AND METHODS: The study used a Condensation Particle Counter during four types of dermatologic procedures: (1) using non-thermal NPS for the clearance of cutaneous, nongenital warts; (2) an electrocautery treatment of warts; (3) a CO2 laser for facial resurfacing; and (4) an electrocautery procedure for a facelift. Four subjects and a total of 11 warts were treated with NPS while a particle counter was used to detect the average particles per cubic centimeter once per second. The same particle counter was used, for comparison, during a wart removal procedure using electrocautery for comparison, and for control, during a skin resurfacing procedure with a CO2 laser and a facelift in which electrocautery was used. RESULTS: Only one of the 11 NPS wart procedures generated any detectable change in the particulate concentration and that change was negligible in comparison to the increase in particulate concentration measured during the CO2 laser resurfacing and the electrocautery use during a facelift procedure. CONCLUSIONS: Procedures using non-thermal NPS technology do not generate significant plume when applied to eliminate warts, suggesting it is unlikely that this new energy modality would release viral DNA into the air.

Synaptic Loss in Multiple Sclerosis Spinal Cord.

Disability in multiple sclerosis (MS) is considered primarily a result of axonal loss. However, correlation with spinal cord cross-sectional area-a predictor of disability-is poor, questioning the unique role of axonal loss. We investigated the degree of synaptic loss in postmortem spinal cords (18 chronic MS, 8 healthy controls) using immunohistochemistry for synaptophysin and synapsin. Substantial (58-96%) loss of synapses throughout the spinal cord was detected, along with moderate (47%) loss of anterior horn neurons, notably in demyelinating MS lesions. We conclude that synaptic loss is significant in chronic MS, likely contributing to disability accrual. ANN NEUROL 2020;88:619-625.

Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

Safety and Efficacy of Nanosecond Pulsed Electric Field Treatment of Seborrheic Keratoses.

BACKGROUND: Nanosecond pulsed electric field technology (also known as Nano-Pulse Stimulation or NPS) is a nonthermal, drug-free, energy-based technology that has demonstrated effects on cellular structures of the dermis and epidermis in previous clinical studies. OBJECTIVE: To evaluate the safety and efficacy of a single NPS treatment for clearing seborrheic keratoses (SKs). MATERIALS AND METHODS: This study was a prospective, randomized, open-label, multisite, nonsignificant risk trial in which each subject served as their own control. Fifty-eight subjects had 3 of 4 confirmed SK lesions treated, resulting in 174 total treated lesions. Subjects returned for 5 to 6 follow-up evaluations and photographs. RESULTS: At 106 days after NPS treatment, 82% of treated seborrheic keratoses were rated clear or mostly clear by the assessing physician. Seventy-one percent of lesions were rated clear or mostly clear by the 3 independent reviewers based on the 106-day photographs. All treated subjects returned for all study visits, and 78% of the subjects were satisfied or mostly satisfied with the outcome of the treatment. No adverse events were reported. CONCLUSION: The NPS procedure was well tolerated and effective in the removal of SKs.

Safety and Efficacy of Nanosecond Pulsed Electric Field Treatment of Sebaceous Gland Hyperplasia.

BACKGROUND: Nanosecond pulsed electric field (nsPEF) technology involves delivery of ultrashort pulses of electrical energy and is a nonthermal, drug-free technology that has demonstrated favorable effects on cellular structures of the dermis and epidermis. OBJECTIVE: Determine the tolerability and effectiveness of nsPEF treatment of sebaceous gland hyperplasia (SGH). METHODS: This study was a prospective, randomized, open-label, multisite, nonsignificant risk trial in which each subject served as their own control. After injection of local anesthetic, high-intensity, ultrashort pulses of electrical energy were used to treat 72 subjects resulting in a total of 222 treated lesions. Subjects returned for 3 to 4 follow-up evaluations with photographs. RESULTS: At the final study visit, 99.6% of treated SGH lesions were rated clear or mostly clear and 79.3% of the subjects were satisfied or mostly satisfied with the outcome. At 60 days after nsPEF treatment, 55% of the lesions were judged to have no hyperpigmentation and 31% exhibited mild post-treatment hyperpigmentation. At the last observation for all lesions, 32% of the 222 lesions were noted as having slight volume loss. CONCLUSION: Nanosecond pulsed electric field procedure is well tolerated and is very effective in the removal of SGHs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03612570.

A dose-response study of nanosecond electric energy pulses on facial skin.

Nanosecond pulsed electric fields, also known as Nano-Pulse Stimulation or NPS, can trigger regulated cell death to clear skin lesions that are cellular in nature. Before treating facial lesions, it is important to demonstrate the effects of these pulses on normal facial skin. Here we have applied a range of NPS energies to the epidermis and dermis of normal facial skin scheduled for excision to establish a safe dose range of energies prior to use in clinical applications. This was an open-label, non-randomized study under the direction of a single Principal Investigator. The time course of the treated tissue changes was determined by histological analysis. All energy settings generated a delayed epidermal loss followed by re-epithelialization by day 7 and a normal course of healing. One day after NPS treatment, the cellular membranes of the treated epidermis were intact, but their nuclei no longer stained with H&E, resulting in a hollow appearance that has been referred to as "ghost cells." Cellular structures in the dermis, such as sebaceous glands and melanocytes, exhibited regulated cell death observed by 1 day post treatment. Melanocytes recovered to their normal density within 7 days. The 60-day samples indicated that epidermis, hair follicles, and eccrine glands appeared normal. The selective effect of NPS treatment on cellular structures in the epidermal and dermal layers suggests that this non-thermal modality of energy delivery is ideal for treating cellular targets including benign and malignant skin lesions. NPS skin treatments provide a promising method for clearing skin lesions with a cellular basis.

Effect of Pause Procedures on Participant Reflection and Commitment-to-Change in Continuing Medical Education.

Problem: Conferences are the most common form of continuing medical education (CME), but their effect on clinician practice is inconsistent. Reflection is a critical step in the process of practice change among clinicians and may lead to improved outcomes following conference-based CME. However, reflection requires time to process newly-learned material. Adequate time for reflection may be noticeably absent during many conference presentations. Intervention: The pause procedure is a 90-second 'pause' during a 30-minute presentation so learners can review and discuss content. The goal of the pause procedure is to stimulate learners' active engagement with newly learned material which will, in turn, promote learner reflection. Context: Fifty-six presentations at two hospital medicine CME conferences were assigned to the pause procedure or control. Study outcomes provided by conference participants were validated reflection scores and commitment-to-change (CTC) statements for each presentation. A post-hoc survey of the intervention group was conducted to assess presenters' experiences with the pause procedure. Impact: A total of 527 conference participants completed presentation evaluations (response rate 72.7%). Presentations incorporating the pause procedure failed to lead higher participant reflection scores (percentage 'top box' score; intervention: 39.2% vs. control: 41.7%, p = 0.40) or participant CTC rates (median [IQR]; intervention: 4.64 [3.04, 10.57] vs. control: 8.16 [5.28, 17.12], p = 0.13) than control presentations. However, the majority of presenters (16 out of 17 survey respondents) had never before used the intervention and little active engagement among learners was noted during the pause procedure. Lessons Learned: Adding the pause procedure to CME presentations did not lead to greater reflection or CTC among clinician learners. However, presenters had limited experience with the intervention, which may have reduced their fidelity to the educational principles of the pause procedure. Faculty development may be necessary when planning a new educational intervention that is to be implemented by conference presenters.

Patient Length of Stay Under the Two-Midnight Rule: Assessing the Accuracy of Providers' Predictions.

EXECUTIVE SUMMARY: We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Cardiovascular Disease and Triathlon-Related Deaths in the United Kingdom.

INTRODUCTION: Triathlon is one of the fastest growing sports in the United Kingdom. However, in recent years several deaths have occurred. The intention of this study is to identify these cases and examine the role cardiovascular disease played in these deaths. METHODS: An extensive online search was performed to identify triathlon-related deaths (TRDs) in the United Kingdom and UK citizens who died during or as a result of competing in triathlons abroad. British Triathlon provided the number of participants who took part in UK-based events. Coroners provided information on all those who died. RESULTS: Between 2009 and 2015, 991,186 participants took part in British Triathlon-sanctioned events. Five TRDs in the United Kingdom were identified. The mortality rate was 0.5 per 100,000 participants. Deaths occurred during or after the swim (3), cycle (1), and run (1) events. During the same period, 5 TRDs were identified among UK citizens competing abroad. These deaths occurred during or after the swim (2), cycle (1), and run (2) events. Cardiovascular pathology was cited as a cause or contributing factor in half of the fatalities. Four deaths were referred to a specialist cardiac pathology service for autopsy. CONCLUSIONS: Cardiovascular disease was found to be the most common cause of TRD. Further research is needed to determine the underlying cardiac pathology that triggers TRDs. With this information it may be possible to develop screening tools that can prevent similar fatalities from occurring in the future.

Multicenter Efficacy Trial of a Percutaneous Radiofrequency System for the Reduction of Glabellar Lines.

BACKGROUND: Bipolar percutaneous radiofrequency (RF) is an established method for ablation of distal peripheral branches of the facial nerve to produce weakness of the corrugator muscle. Recent developments to the Serene RF system (Serene Medical, Inc., Pleasanton, CA) allowing for safer and more predictable results highlighted a need for prospective clinical data. OBJECTIVES: The authors sought to assess the ability of percutaneous RF to safely improve the appearance of dynamic glabellar lines for a minimum of 3 months and up to 1 year. METHODS: This prospective study enrolled 78 patients across 5 centers in the United States. The most distal branches of the medial and lateral facial nerve innervation to the brow depressor/corrugator complex were treated. Follow-up was at 3 days by telephone and in-office at 7 days and 3, 6, 9, and 12 months posttreatment. Patients were evaluated employing the Merz scale for dynamic glabellar lines. RESULTS: At 3 months, 93.6% of patients had a ≥1-point Merz scale improvement in dynamic glabellar lines based on independent, blinded review. Sustained ≥2-point improvement was present in 60% and 20% of patients at 3 and 12 months, respectively. Overall satisfaction remained >60% through 6 months and >50% at 12 months. All device- or procedure-related adverse events were mild (90%) or moderate (10%) and resolved without medical intervention. CONCLUSIONS: Bipolar percutaneous RF may be adopted in conjunction with surgery or as an office-based procedure where it can serve as a minimally invasive alternative to, or in concert with, Botulinum Toxin A therapy.

Commercial trials evaluating the novel use of ethyl formate for in-transit fumigation of shipping containers.

The use of shipping containers for cargo transportation has the potential to transport insect pests from infested to non-infested areas. Therefore, fumigation is required as an appropriate biosecurity measure to exterminate these pests. In-transit fumigation trials were conducted in two 20 ft shipping containers during a two-day journey in both September and December 2017. Ethyl formate (90 g m-3) was purged with nitrogen (EF + N2) into the containers. Ethyl formate concentration inside containers and the surrounding environment were monitored at timed intervals throughout the journey. Fumigation achieved sufficient concentration × time (Ct) products in the containers during the journey, which can exterminate all stages of most common insect pests. The Ct products in-transit were greater than those in a shipping container being fumigated in a stationary position at a dose rate of 90 g m-³ for 24 hours exposure. Levels of EF in the environment between 1-15 m downwind from the containers and driver's cabin were less than 0.5 ppm at each of the timed intervals, 200 times below 100 ppm of EF Threshold Limit Value (TLV). Our study indicates that in-transit EF + N2 technology has the potential to deliver cost savings in the fumigation process through reduction of the Labor cost, elimination of the time a container and cargo must remain stationary in a fumigation yard and a significant decrease in total supply chain time (between container packing and receival).

Medical moulages of farm accidents.

Although popular for displaying dermatologic conditions before the advent of photography, the medical moulage has also illustrated injuries and accidents. Explored here are three farm accidents and the moulages based on them that occurred in rural Minnesota in the early 20th century. Besides being an object of historical interest, the medical moulage also provides a valuable learning and training opportunity, and can even be thought of as the predecessor of three dimensional printing.

Somali Cultural Competency among Students in One Minnesota Medical School.

Minnesota has the largest Somali population in the United States. Thus, students in the state's medical schools are likely exposed to Somali patients during their training. We assessed baseline knowledge of and attitudes about Somali patients among students at one medical school in the state. We then exposed those students to an educational intervention and reassessed their knowledge and attitudes afterward. We found students' baseline knowledge was poor (65% of questions answered correctly, on average), but improved (80% answered correctly, on average) post-intervention. The majority of students also felt the quality of care they could provide Somali patients would be compromised because of their lack of cultural understanding. Although the results were not statistically significant due to low power, this study represents a meaningful attempt to assess students' baseline knowledge as well as a proof-of-concept intervention to highlight ways to improve cultural competency training in Minnesota's medical schools.

Riboflavin and ultraviolet light for pathogen reduction of murine cytomegalovirus in blood products.

BACKGROUND: Two studies were performed to test the effectiveness of riboflavin and ultraviolet (UV) light treatment (Mirasol PRT, Terumo BCT) against murine cytomegalovirus (MCMV). The first study utilized immune-compromised mice to measure the reduction of cell-free MCMV. A second study used a murine model to evaluate the ability of Mirasol PRT to prevent transfusion-transmitted (TT)-MCMV infection. STUDY DESIGN AND METHODS: Human plasma was inoculated with MCMV and then treated with Mirasol PRT. The viral titer was measured using an infectious dose 50% assay in nude mice. Mice were euthanized on Day 10 posttransfusion, and their spleens were tested for the presence of MCMV DNA using polymerase chain reaction (PCR). Mirasol PRT was also evaluated to determine its effectiveness in preventing TT-MCMV in platelets (PLTs) stored in PLT additive solution. PLTs were inoculated with either cell-associated MCMV or cell-free MCMV and then treated with Mirasol PRT. Mice were transfused with treated or untreated product and were euthanized 14 days posttransfusion. Blood and spleens were assayed for MCMV DNA by real-time-PCR. RESULTS: Using nude mice to titer MCMV, a modest 2.1-log reduction was observed in plasma products after Mirasol PRT treatment. TT-MCMV was not observed in the mouse transfusion model when either cell-free or cell-associated MCMV was treated with Mirasol PRT; MCMV transmission was uniformly observed in mice transfused with untreated PLTs. CONCLUSIONS: These results suggest that using riboflavin and UV light treatment may be able to reduce the occurrence of transmission of human CMV from infectious PLTs and plasma units.

Effects of storage-aged red blood cell transfusions on endothelial function in hospitalized patients.

BACKGROUND: Clinical and animal studies indicate that transfusions of older stored red blood cells (RBCs) impair clinical outcomes as compared to fresh RBC transfusions. It has been suggested that this effect is due to inhibition of nitric oxide (NO)-mediated vasodilation after transfusion of older RBC units. However, to date this effect has not been identified in human transfusion recipients. STUDY DESIGN AND METHODS: Forty-three hospitalized patients with transfusion orders were randomly assigned to receive either fresh (<14 days) or older stored (>21 days) RBC units. Before transfusion, and at selected time points after the start of transfusion, endothelial function was assessed using noninvasive flow-mediated dilation assays. RESULTS: After transfusion of older RBC units, there was a significant reduction in NO-mediated vasodilation at 24 hours after transfusion (p = 0.045), while fresh RBC transfusions had no effect (p = 0.231). CONCLUSIONS: This study suggests for the first time a significant inhibitory effect of transfused RBC units stored more than 21 days on NO-mediated vasodilation in anemic hospitalized patients. This finding lends further support to the hypothesis that deranged NO signaling mediates adverse clinical effects of older RBC transfusions. Future investigations will be necessary to address possible confounding factors and confirm these results.

Successful endovascular treatment of duodenal obstruction caused by large abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) causing duodenal obstruction is not a common presentation. Our literature review demonstrated that open surgery was often used to treat such problem. Here, we describe the first case of an endovascular approach to treat acute duodenal obstruction caused by a massive infrarenal AAA. CASE REPORT: An 84-year-old man presented with acute abdominal pain and distension, vomiting, decreasing appetite, and weight loss. Computed tomography scan confirmed a large infrarenal AAA causing duodenal obstruction. The patient was started on total parenteral nutrition, and the aneurysm treated by endovascular aneurysm repair (EVAR). Postoperatively, the patient's symptoms of duodenal obstruction gradually resolved. CONCLUSIONS: EVAR is a viable treatment option for patients presenting with duodenal obstruction caused by AAA.

Ethyl Formate: A Potential Disinfestation Treatment for Eucalyptus Weevil (Gonipterus platensis) (Coleoptera: Curculionidae) in Apples.

Export of Pink Lady apples from Australia has been significantly affected by infestations of adult eucalyptus weevils (Gonipterus platensis Marelli). These weevils cling tenaciously to the pedicel of apple fruit when selecting overwintering sites. As a result, apples infested with live G. platensis adults lead to rejection for export. Since the Montreal Protocol restricted use of methyl bromide as postharvest treatment, it was necessary to consider alternative safer fumigants for disinfestation of eucalyptus weevil. Laboratory experiments were conducted using concentrations of 5, 10, 15, 20, 25, 30, 40, and 80 mg/liter of ethyl formate. Complete control (100% mortality) was achieved at 25-30 mg/liter of ethyl formate at 22-24°C for 24-h exposure without apples. However, with 90-95% of the volume full of apples, complete control was achieved at 40 mg/liter of ethyl formate at 22-24°C for 24-h exposure. No phytotoxicity was observed and after one day aeration, residue of ethyl formate declined to natural levels (0.05-0.2 mg/kg). Five ethyl formate field trials were conducted in cool storages (capacity from 250-900 tons) and 100% kill of eucalyptus weevils were achieved at 50-55 mg/liter at 7-10°C for 24 h. Ethyl formate has great potential for preshipment treatment of apples. Its use is considerably cheaper and safer than already existing fumigants like methyl bromide and phosphine.

Towards an understanding of maltreatment in football.

Introduction: This study explored the understanding of maltreatment from the perspective of various personnel working in roles related to safeguarding and welfare in English professional and semi-professional football. Method: Through a social constructivist position, the present study was able to explore multiple understandings and perceptions of maltreatment in football. Individual semi-structured interviews (MDuration = 68.00 minutes, SD = 9.05 minutes) were conducted with 19 participants working across league structures ranging from the English Premier League (EPL) to the English Northern Premier League Division One, as well as individuals working with some of the principal organizations in English professional football. Results: Through reflexive thematic analysis, three general dimensions were highlighted: "current understanding of maltreatment in football," "constituents of maltreatment," and "signs and symptoms of maltreatment." Findings from those working in a safeguarding capacity mirror the research literature around understanding the components of maltreatment but also demonstrate how wrongdoing is nuanced by the football context, in that certain forms of maltreatment are driven by the unique nature of this environment. Discussion: From an applied perspective, the findings also outline how to distinguish both the more overt and covert signs and symptoms of maltreatment, whilst also highlighting the impact of maltreatment on individuals' mental health and their sense of self. Overall, the findings provide a platform for practitioners and researchers to consider in the design of safeguarding and welfare provision by highlighting the need to raise knowledge and awareness of maltreatment whilst intervening to challenge the prevailing workplace culture within professional football.