Distinct Clinical Endpoints of Staphylococcus aureus Bacteraemia Complicate Assessment of Outcome.

BACKGROUND: We aimed to test the hypothesis that development of metastatic infection represents a distinct clinical endpoint from death due to Staphylococcus aureus bacteremia (SAB). METHODS: We conducted a retrospective observational study of adults with SAB between 20 December 2019 and 23 August st2022 (n = 464). Simple logistic regression, odds ratios, and z-scores were used to compare host, clinical, and microbiologic features. RESULTS: Co-occurrence of attributable mortality and metastatic infection was infrequent. Charlson Comorbidity Index and age were strongly associated with attributable mortality, but not metastatic infection. We compared patients with fatal SAB (without clinically-apparent metastatic complications, 14.4% of cohort), metastatic SAB (without attributable mortality, 22.2%), neither complication (56.7%), and overlapping fatal/metastatic SAB (6.7%). Compared to SAB without complications, fatal SAB was specifically associated with older age and multi-morbidity. Metastatic SAB was specifically associated with community acquisition, persistent fever, persistent bacteremia, and recurrence. Endocarditis was over-represented in the fatal/metastatic SAB overlap group, which shared patient characteristics with fatal SAB. In contrast to other (predominantly musculoskeletal) metastatic complications, endocarditis was associated with increased mortality, with death occurring in older multi-morbid patients later after SAB onset. CONCLUSIONS: Patients with SAB experience distinct clinical endpoints: (i) early death, associated with multi-morbidity and age; (ii) metastatic (predominantly musculoskeletal) SAB; (iii) endocarditis, associated with late death occurring in older people with multi-morbidity, and (iv) bacteraemia without complications. These distinctions could be important for selecting appropriate outcomes in clinical trials: different interventions might be required to reduce mortality versus improve clinical response in patients with metastatic SAB.

Emergence of novel methicillin resistant Staphylococcus pseudintermedius lineages revealed by whole genome sequencing of isolates from companion animals and humans in Scotland.

Staphylococcus pseudintermedius is an opportunistic pathogen in dogs, and infection in humans is increasingly found, often linked to contact with dogs. We conducted a retrospective genotyping and antimicrobial susceptibility testing study of 406 S. pseudintermedius isolates cultured from animals (dogs, cats and an otter) and humans across Scotland, from 2007 to 2020. Seventy-five sequence types (STs) were identified, among the 130 isolates genotyped, with 59 seen only once. We observed the emergence of two methicillin resistant Staphylococcus pseudintermedius (MRSP) clones in Scotland: ST726, a novel locally-evolving clone, and ST551, first reported in 2015 in Poland, possibly linked to animal importation to Scotland from Central Europe. While ST71 was the most frequent S. pseudintermedius strain detected, other lineages that have been replacing ST71 in other countries, in addition to ST551, were detected. Multidrug resistance (MDR) was detected in 96.4% of MRSP and 8.4% of MSSP. A single MRSP isolate was resistant to mupirocin. Continuous surveillance for the emergence and dissemination of novel MDR MRSP in animals and humans and changes in antimicrobial susceptibility in S. pseudintermedius is warranted to minimise the threat to animal and human health.

Investigating the Effects of Avatarization and Interaction Techniques on Near-field Mixed Reality Interactions with Physical Components.

Mixed reality (MR) interactions feature users interacting with a combination of virtual and physical components. Inspired by research investigating aspects associated with near-field interactions in augmented and virtual reality (AR & VR), we investigated how avatarization, the physicality of the interacting components, and the interaction technique used to manipulate a virtual object affected performance and perceptions of user experience in a mixed reality fundamentals of laparoscopic peg-transfer task wherein users had to transfer a virtual ring from one peg to another for a number of trials. We employed a 3 (Physicality of pegs) X 3 (Augmented Avatar Representation) X 2 (Interaction Technique) multi-factorial design, manipulating the physicality of the pegs as a between-subjects factor, the type of augmented self-avatar representation, and the type of interaction technique used for object-manipulation as within-subjects factors. Results indicated that users were significantly more accurate when the pegs were virtual rather than physical because of the increased salience of the task-relevant visual information. From an avatar perspective, providing users with a reach envelope-extending representation, though useful, was found to worsen performance, while co-located avatarization significantly improved performance. Choosing an interaction technique to manipulate objects depends on whether accuracy or efficiency is a priority. Finally, the relationship between the avatar representation and interaction technique dictates just how usable mixed reality interactions are deemed to be.

The Effects of Secondary Task Demands on Cybersickness in Active Exploration Virtual Reality Experiences.

Active exploration in virtual reality (VR) involves users navigating immersive virtual environments, going from one place to another. While navigating, users often engage in secondary tasks that require attentional resources, as in the case of distracted driving. Inspired by research generally studying the effects of task demands on cybersickness (CS), we investigated how the attentional demands specifically associated with secondary tasks performed during exploration affect CS. Downstream of this, we studied how increased attentional demands from secondary tasks affect spatial memory and navigational performance. We discuss the results of a multi-factorial between-subjects study, manipulating a secondary task's demand across two levels and studying its effects on CS in two different sickness-inducing levels of an exploration experience. The secondary task's demand was manipulated by parametrically varying $n$ in an aural $n$-back working memory task and the provocativeness of the experience was manipulated by varying how frequently users experienced a yaw-rotational reorientation effect during the exploration. Results revealed that increases in the secondary task's demand increased sickness levels, also resulting in a higher temporal onset rate, especially when the experience was not already highly sickening. Increased attentional demand from the secondary task also vitiated navigational performance and spatial memory. Overall, increased demands from secondary tasks performed during navigation produce deleterious effects on the VR experience.

Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review.

OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence.

The Effects of Auditory, Visual, and Cognitive Distractions on Cybersickness in Virtual Reality.

Cybersickness (CS) is one of the challenges that has hindered the widespread adoption of Virtual Reality (VR). Consequently, researchers continue to explore novel means to mitigate the undesirable effects associated with this affliction, one that may require a combination of remedies as opposed to a solitary stratagem. Inspired by research probing into the use of distractions as a means to control pain, we investigated the efficacy of this countermeasure against CS, studying how the introduction of temporally time-gated distractions affects this malady during a virtual experience featuring active exploration. Downstream of this, we discuss how other aspects of the VR experience are affected by this intervention. We discuss the results of a between-subjects study manipulating the presence, sensory modality, and nature of periodic and short-lived (5-12 seconds) distractor stimuli across 4 experimental conditions: (1) no-distractors (ND); (2) auditory distractors (AD); (3) visual distractors (VD); (4) cognitive distractors (CD). Two of these conditions (VD and AD) formed a yoked control design wherein every matched pair of 'seers' and 'hearers' was periodically exposed to distractors that were identical in terms of content, temporality, duration, and sequence. In the CD condition, each participant had to periodically perform a 2-back working memory task, the duration and temporality of which was matched to distractors presented in each matched pair of the yoked conditions. These three conditions were compared to a baseline control group featuring no distractions. Results indicated that the reported sickness levels were lower in all three distraction groups in comparison to the control group. The intervention was also able to both increase the amount of time users were able to endure the VR simulation, as well as avoid causing detriments to spatial memory and virtual travel efficiency. Overall, it appears that it may be possible to make users less consciously aware and bothered by the symptoms of CS, thereby reducing its perceived severity.

How Virtual Hand Representations Affect the Perceptions of Dynamic Affordances in Virtual Reality.

User representations are critical to the virtual experience, and involve both the input device used to support interactions as well as how the user is virtually represented in the scene. Inspired by previous work that has shown effects of user representations on the perceptions of relatively static affordances, we attempt to investigate how end-effector representations affect the perceptions of affordances that dynamically change over time. Towards this end, we empirically evaluated how different virtual hand representations affect users' perceptions of dynamic affordances in an object retrieval task wherein users were tasked with retrieving a target from a box for a number of trials while avoiding collisions with its moving doors. We employed a 3 (virtual end-effector representation) X 13 (frequency of moving doors) X 2 (target object size) multi-factorial design, manipulating the input modality and its concomitant virtual end-effector representation as a between-subjects factor across three experimental conditions: (1) Controller (using a controller represented as a virtual controller); (2) Controller-hand (using a controller represented as a virtual hand); (3) Glove (using a hand tracked hi-fidelity glove represented as a virtual hand). Results indicated that the controller-hand condition produced lower levels of performance than both the other conditions. Furthermore, users in this condition exhibited a diminished ability to calibrate their performance over trials. Overall, we find that representing the end-effector as a hand tends to increase embodiment but can also come at the cost of performance, or an increased workload due to a discordant mapping between the virtual representation and the input modality used. It follows that VR system designers should carefully consider the priorities and target requirements of the application being developed when choosing the type of end-effector representation for users to embody in immersive virtual experiences.

Give Me a Hand: Improving the Effectiveness of Near-field Augmented Reality Interactions By Avatarizing Users' End Effectors.

Inspired by previous works showing promise for AR self-avatarization - providing users with an augmented self avatar, we investigated whether avatarizing users' end-effectors (hands) improved their interaction performance on a near-field, obstacle avoidance, object retrieval task wherein users were tasked with retrieving a target object from a field of non-target obstacles for a number of trials. We employed a 3 (Augmented hand representation) X 2 (density of obstacles) X 2 (size of obstacles) X 2 (virtual light intensity) multi-factorial design, manipulating the presence/absence and anthropomorphic fidelity of augmented self-avatars overlaid on the user's real hands, as a between subjects factor across three experimental conditions: (1) No-Augmented Avatar (using only real hands); (2) Iconic-Augmented Avatar; (3) Realistic Augmented Avatar. Results indicated that self-avatarization improved interaction performance and was perceived as more usable regardless of the anthropomorphic fidelity of avatar. We also found that the virtual light intensity used in illuminating holograms affects how visible one's real hands are. Overall, our findings seem to indicate that interaction performance may improve when users are provided with a visual representation of the AR system's interacting layer in the form of an augmented self-avatar.

Can I Squeeze Through? Effects of Self-Avatars and Calibration in a Person-Plus-Virtual-Object System on Perceived Lateral Passability in VR.

With the popularity of Virtual Reality (VR) on the rise, creators from a variety of fields are building increasingly complex experiences that allow users to express themselves more naturally. Self-avatars and object interaction in virtual worlds are at the heart of these experiences. However, these give rise to several perception based challenges that have been the focus of research in recent years. One area that garners most interest is understanding the effects of self-avatars and object interaction on action capabilities or affordances in VR. Affordances have been shown to be influenced by the anthropometric and anthropomorphic properties of the self-avatar embodied. However, self-avatars cannot fully represent real world interaction and fail to provide information about the dynamic properties of surfaces in the environment. For example, pressing against a board to feel its rigidity. This lack of accurate dynamic information can be further amplified when interacting with virtual handheld objects as the weight and inertial feedback associated with them is often mismatched. To investigate this phenomenon, we looked at how the absence of dynamic surface properties affect lateral passability judgments when carrying virtual handheld objects in the presence or absence of gender matched body-scaled self-avatars. Results suggest that participants can calibrate to the missing dynamic information in the presence of self-avatars to make lateral passability judgments, but rely on their internal body schema of a compressed physical body depth in the absence of self-avatars.

Objects May Be Farther Than They Appear: Depth Compression Diminishes Over Time with Repeated Calibration in Virtual Reality.

Prior research in depth perception and perceptuo-motor calibration have primarily focused on participants completing experiments in single sessions and therefore do not empirically evaluate changes over time. Further, these studies do not typically take into account the amount of experience that the participants have in virtual reality (VR) prior to participation, the role of experience during participation, or calibration that may occur throughout the experiment session. In this contribution, we conducted a novel empirical evaluation of how calibration affects perception-action coordination over time. We recruited novice VR users and they completed eight sessions of a depth perception reaching experiment over the course of 12 weeks. During these experiments, we examined how participants' ability to estimate depth in a virtual environment changed as they gradually gained experience. While previous literature has shown that participants tend to underestimate distances, we found that this underestimation diminished over time as they gained experience in the virtual environment. Our study highlights the need for carrying out VR studies over time and the influence that longitudinal calibration can have on spatial perception in long-term VR experiences.

A single centre experience using internal traction sutures in managing long gap oesophageal atresia.

AIM: Thoracoscopically placed internal traction sutures (ITS) for the initial management of long gap oesophageal atresia (LGOA), not amenable to primary anastomosis, was first described in 2015. Here we describe our experience using ITS both thoracoscopically and at thoracotomy where the gap between upper and lower oesophagus is too wide for primary anastomosis. METHOD: The case notes of all infants treated with ITS for oesophageal atresia (01/10/2015 to 01/12/2019) were reviewed. Gaps considered too wide for an anastomosis had ITS placed between the two pouches as described by Patkowski in 2015. All patients were gastrostomy fed.  Patients returned to theatre with an expectation to complete the anastomosis or re-tighten the traction sutures. RESULTS: Seven patients (4 OA, 1 OA with proximal fistula, 2 OA/distal TOF) median birthweight 2.28 kg (1.2-3.6 kg) were managed using ITS. Median gap length 4.5 (3-9) vertebral bodies.  ITS were placed thoracoscopically in 5 cases and at thoracotomy in 2 at median 46 days (1-120) old. In all cases, ITS was associated with significant intra-thoracic adhesions. Five patients leaked from the traction sutures. Four patients had a delayed primary anastomosis performed at thoracotomy and 3 required a cervical oesophagostomy. The median length of stay was 159 days (98-282).  All patients started thoracoscopically eventually required thoracotomy. CONCLUSION: The use of ITS in our department was associated with significant complications, particularly intra-thoracic leaks and adhesions.  In our hands ITS did not improve the feasibility of thoracoscopic repair for LGOA and has been abandoned by us. LEVEL OF EVIDENCE: Level IV Case Series.

Did I Hit the Door? Effects of Self-Avatars and Calibration in a Person-Plus-Virtual-Object System on Perceived Frontal Passability in VR.

The availability of new and improved display, tracking and input devices for Virtual Reality experiences has facilitated the use of partial and full body self-avatars in interaction with virtual objects in the environment. However, scaling the avatar to match the user's body dimensions remains to be a cumbersome process. Moreover, the effect of body-scaled self-avatars on size perception of virtual handheld objects and related action capabilities has been relatively unexplored. To this end, we present an empirical evaluation investigating the effect of the presence or absence of body-scaled self-avatars and visuo-motor calibration on frontal passability affordance judgments when interacting with virtual handheld objects. The self-avatar's dimensions were scaled to match the participant's eyeheight, arms length, shoulder width and body depth along the mid section. The results indicate that the presence of body-scaled self-avatars produce more realistic judgments of passability and aid the calibration process when interacting with virtual objects. Also, participants rely on the visual size of virtual objects to make judgments even though the kinesthetic and proprioceptive feedback of the object is missing or mismatched.

Using Virtual Reality to Compare Design Alternatives Using Subjective and Objective Evaluation Methods.

OBJECTIVE: This study sought to develop a method that supports a more evidence-based approach to evaluating multiple design options in virtual reality (VR), combining subjective insights gathered using traditional approaches and objective feedback gathered using the VR platform. Additionally, this study sought to understand how objective data garnered from the VR platform could be used to compliment traditional evaluation strategies. BACKGROUND: VR can be a viable research platform for supporting evidence-based design practices. Prior studies have predominately utilized experiential user feedback. While able to provide valuable subjective insights, these approaches are less effective in making objective comparisons between multiple designs alternatives. METHOD: A repeated measures study was conducted with nursing faculty. User feedback was captured through surveys, interviews, and the VR platform. RESULTS: The survey, interview, and the objective VR data converged in terms of identifying the highest performing design option. Survey data showed that Room 2 performed best in terms of perceived physical access to supplies, unobstructed movement, and availability of space to accommodate additional equipment. VR data showed that participants in Room 2 had significantly higher visibility to both patient and care partners throughout their simulated interaction. CONCLUSION: Simulation-based evaluations in VR that use a combination of users' subjective insights and objective data obtained from VR can be an effective tool for helping designers evaluate multiple design options. The use of scenario-based simulations provided a structured and clinically relevant approach to comparing three preoperative rooms, supporting a more robust assessment of users' physical response to a simulated healthcare environment.

Isolation and genome sequencing of Staphylococcus schleiferi subspecies coagulans from Antarctic and North Sea seals.

Reports on the commensal organism and opportunistic pathogen Staphylococcus schleiferi have largely considered isolates from humans and companion dogs. Two subspecies are recognized: the coagulase-negative S. schleiferi ssp. schleiferi, typically seen in humans, and the coagulase-positive S. schleiferi ssp. coagulans, typically seen in dogs. In this study, we report the isolation, genome sequencing and comparative genomics of three S. schleiferi ssp. coagulans isolates from mouth samples from two species of healthy, free-living Antarctic seals, southern elephant seals (Mirounga leonina) and Antarctic fur seals (Arctocephalus gazella), in the South Orkney Islands, Antarctica, and three isolates from post-mortem samples from grey seals (Halichoerus grypus) in Scotland, UK. This is the first report of S. schleiferi ssp. coagulans isolation from Antarctic fur seal and grey seal. The Antarctic fur seal represents the first isolation of S. schleiferi ssp. coagulans from the family Otariidae, while the grey seal represents the first isolation from a pinniped in the Northern Hemisphere. We compare seal, dog and human isolates from both S. schleiferi subspecies in the first genome-based phylogenetic analysis of the species.

A virtual experimenter does not increase placebo hypoalgesia when delivering an interactive expectancy manipulation.

Lack of standardization and unblinding threaten the research of mechanisms involved in expectancy effects on pain. We evaluated a computer-controlled virtual experimenter (VEx) to avoid these issues. Fifty-four subjects underwent a baseline-retest heat pain protocol. Between sessions, they received an expectancy manipulation (placebo or no-treatment) delivered by VEx or text-only control condition. The VEx provided standardized "social" interaction with the subjects. Pain ratings and psychological state/trait measures were recorded. We found an interaction of expectancy and delivery on pain improvement following the intervention. In the text conditions, placebo was followed by lower pain, whereas in the VEx conditions, placebo and no-treatment were followed by a comparable pain decrease. Secondary analyses indicated that this interaction was mirrored by decreases of negative mood and anxiety. Furthermore, changes in continuous pain were moderated by expectation of pain relief. However, retrospective pain ratings show an effect of expectancy but not of delivery. We conclude that we successfully applied an automated protocol for inducing expectancy effects on pain. The effect of the VEx regardless of treatment may be due to interactions of attention allocation and locus of control. This points to the diversity of expectancy mechanisms, and has implications for research and computer-based treatment applications.

A descriptive analysis of shoulder muscle activities during individual stages of the Turkish Get-Up exercise.

The Turkish Get-Up (TGU) is a complex and multi-planar exercise; the performer begins in a supine lying position, progresses toward upright standing through a series of 7 stages while holding a mass overhead in one hand, and returns to the original supine lying position through a reversal of the same 7 stages. A descriptive analysis of shoulder muscle activity during the TGU may provide insight toward its use in training and rehabilitation contexts. Our objectives were to: (1) describe the activity patterns from a subset of muscles that span the glenohumeral joint during individual stages of the TGU, and (2) interpret these patterns through comparisons between left- and right-side muscles, and between the up and down phases of the TGU. Twelve individuals with at least one-year experience performing the TGU were included in this study. Surface electromyographic (EMG) recordings were bilaterally obtained from 8 glenohumeral muscle groups while participants performed ten trials of the TGU with a kettlebell in their right hand. Instants representing the start and end of each TGU stage were identified from a synchronized video for each trial, and EMG activities for each muscle were integrated over the duration of each stage. Average integrated EMG and within-participant coefficients of variation were calculated. Overall, the greatest muscular demand occurred during the second (press to elbow support) and fifth (leg sweep) stages. Activities from muscles on the ipsilateral side to the kettlebell (right-side) were greater during stages when the contralateral upper limb did not contribute to supporting the body; however, contralateral (left-side) muscles were invoked during stages when the non-kettlebell-bearing forearm or hand contributed to supporting the body. The results suggest the importance of training both phases of the TGU to gain the most benefit from the exercise and highlights the asymmetric nature of the exercise, which may be particularly relevant for athletes engaged in activities with rotational demands.

Examining the effects of altered avatars on perception-action in virtual reality.

In virtual reality (VR), avatars are graphical representations of people. Previous research highlights benefits of having a self-avatar when perceiving-acting while embedded in a virtual environment. We studied the effect that an altered avatar had on the perception of one's action capabilities. In Experiment 1, some participants acted with a normal, or faithful, avatar whereas another group of participants used an avatar with an extended arm, all in virtual reality. Experiment 2 utilized the same methodology and procedure as Experiment 1, except that only a calibration phase occurred in VR, whereas other phases were completed in the real world. All participants performed reaches to various distances presented visually. Results showed that calibration to altered dimensions of avatars is possible after receiving feedback while acting with the altered avatar. Calibration occurred more quickly when feedback was used to transition from a normal avatar to an altered avatar than when transitioning from the altered avatar back to the normal avatar without feedback. The implications of these findings for training in virtual reality simulations and for transfer to the real world are discussed, along with the implications for the concept of an embodied action schema. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prediction of need for intervention in posterior urethral valves: Use of urine osmolality.

AIM: Renal tubular dysfunction (RTD) causing obligate production of hypoosmolar urine in boys with posterior urethral valves (PUVs) has been described. It is not known how clinically significant this is. We hypothesize that a feedback loop is present in many PUV boys who suffer deterioration of their lower urinary tract (LUT). RTD results in hypoosmolar urine, obligate polyuria, and bladder stretch-injury. The increasing back-pressure worsens RTD, thus exacerbating the injury. Coexisting renal dysplasia and acquired renal scarring exacerbate this. We compared the concentrating ability (random clinic urine osmolality) of PUV boys who had no LUT deterioration to those who required intervention, examining the confounding effect of renal impairment with a subgroup analysis comparing those with plasma creatinine ≤80µmol/l. METHODS: A retrospective review of our PUV database was performed. Age, intervention, and highest recorded random clinic urine osmolality (>1year) with concurrent plasma creatinine were recorded (normal urine osmolality 500-850 mOsm/kg). Data are given as median values, analyzed by Mann-Whitney u-test, with P<0.05 deemed significant. MAIN RESULTS: Urine osmolality was available in 77 boys with PUV out of 125 in our series. Of these, 34 required subsequent intervention (e.g., Mitrofanoff procedure, bladder augmentation). Age at testing trended towards being higher in the intervention group [7.9 (4.3-10.9) years vs. nonintervention 6.3 (4-8.4); P=0.06]. Urine osmolality was significantly reduced in the intervention group [411(293-547) vs. 631 (441-805) mOsm/kg; P<0.001]. Subgroup analysis comparing only those with creatinine ≤80µmol/l was respectively 451 (322-567) mOsm/kg (n=22) vs. 645 (469-810) mOsm/kg (n=40), P<0.01. CONCLUSION: This study confirms that hypoosmolar urine is highly associated with progression of LUT dysfunction, requiring intervention. Even boys with normal creatinine values have a greater risk of LUT deterioration if they have a RTD and produce hypoosmolar urine. LEVEL OF EVIDENCE: IV (retrospective service development project).