Fluid migration pathways to groundwater in mature oil fields: Exploring the roles of water injection/production and oil-well integrity in California, USA.

Mature oil fields potentially contain multiple fluid migration pathways toward protected groundwater (total dissolved solids, TDS, in nonexempted aquifer <10,000 mg/L) because of their extensive development histories. Time-series data for water use, fluid pressures, oil-well construction, and geochemistry from the South Belridge and Lost Hills mature oil fields in California are used to explore the roles of injection/production of oil-field water and well-integrity issues in fluid migration. Injection/production of oil-field water modified hydraulic gradients in both oil fields, resulting in chemical transport from deeper groundwater and hydrocarbon-reservoir systems to aquifers in the oil fields. Those aquifers are used for water supply outside the oil-field boundaries. Oil wells drilled before 1976 can be fluid migration pathways because a relatively large percentage of them have >10 m of uncemented annulus that straddles oil-well casing damage and/or the base of groundwater with TDS <10,000 mg/L. The risk of groundwater-quality degradation is higher when wells with those risk factors occur in areas with upward hydraulic gradients created by positive net injection, groundwater withdrawals, or combinations of these variables. The complex changes in hydrologic conditions and groundwater chemistry likely would not have been discovered in the absence of years to decades of monitoring data for groundwater elevations and chemistry, and installation of monitoring wells in areas with overlapping risk factors. Important monitoring concepts based on results from this and other studies include monitoring hydrocarbon-reservoir and groundwater systems at multiple spatiotemporal scales and maintaining transparency and accessibility of data and analyses. This analysis focuses on two California oil fields, but the methods used and processes affecting fluid migration could be relevant in other oil fields where substantial injection/production of oil-field water occurs and oil-well integrity is of concern.

Effectiveness of COVID-19 mRNA Vaccines in Preventing COVID-19-Associated Outpatient Visits and Hospitalizations Among American Indian and Alaska Native Persons, January-November 2021: A Test-Negative Case-Control Analysis Using Surveillance Data.

Background: Despite the disproportionate morbidity and mortality experienced by American Indian and Alaska Native (AI/AN) persons during the coronavirus disease 2019 (COVID-19) pandemic, few studies have reported vaccine effectiveness (VE) estimates among these communities. Methods: We conducted a test-negative case-control analysis among AI/AN persons aged ≥12 years presenting for care from January 1, 2021, through November 30, 2021, to evaluate the effectiveness of mRNA COVID-19 vaccines against COVID-19-associated outpatient visits and hospitalizations. Cases and controls were patients with ≥1 symptom consistent with COVID-19-like illness; cases were defined as those test-positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and controls were defined as those test-negative for SARS-CoV-2. We used unconditional multivariable logistic regression to estimate VE, defined as 1 minus the adjusted odds ratio for vaccination among cases vs controls. Results: The analysis included 207 cases and 267 test-negative controls. Forty-four percent of cases and 78% of controls received 2 doses of either BNT162b2 or mRNA-1273 vaccine. VE point estimates for 2 doses of mRNA vaccine were higher for hospitalized participants (94.6%; 95% CI, 88.0-97.6) than outpatient participants (86.5%; 95% CI, 63.0-95.0), but confidence intervals overlapped. Conclusions: Among AI/AN persons, mRNA COVID-19 vaccines were highly effective in preventing COVID-associated outpatient visits and hospitalizations. Maintaining high vaccine coverage, including booster doses, will reduce the burden of disease in this population.

Development of Stable Pickering Emulsions with TEMPO-Oxidized Chitin Nanocrystals for Encapsulation of Quercetin.

Pickering emulsions stabilized by TEMPO-oxidized chitin nanocrystals (T-ChNCs) were developed for quercetin delivery. T-ChNCs were synthesized by TEMPO oxidation chitin and systematically characterized in terms of their physicochemical properties. T-ChNCs were rod-like with a length of 279.7 ± 11.5 nm and zeta potential around -56.1 ± 1.6 mV. The Pickering emulsions were analyzed through an optical microscope and CLSM. The results showed that the emulsion had a small droplet size (972.9 ± 86.0 to 1322.3 ± 447.7 nm), a high absolute zeta potential value (-48.2 ± 0.8 to -52.9 ± 1.9 mV) and a high encapsulation efficiency (quercetin: 79.6%). The emulsion stability was measured at different levels of T-ChNCs and pH values. The droplet size and zeta potential decreased with longer storage periods. The emulsions formed by T-ChNCs retarded the release of quercetin at half rate of that of the quercetin ethanol solution. These findings indicated that T-ChNCs are a promising candidate for effectively stabilizing Pickering emulsions and controlling release of quercetin.

The Learning Curve of an Absorbable Subcuticular Stapling Device in Plastic and Reconstructive Surgery.

Background: Learning curves can reflect a surgical trainee's rate of progress and competence in acquiring new skills. The INSORB subdermal staple device has been well established to facilitate decreased closure time across various surgical procedures, with similar cosmesis, healing, and consistency as those of standard subdermal sutures. This study is unique, as it demonstrated an observable learning curve with this device when used by a junior surgeon. Methods: Sixty-six patients underwent a cosmetic procedure during the second half of 2019 under the care of a single plastic surgeon in Melbourne, Australia. This corresponded to 254 unique linear incisions. Subdermal closure was done either with interrupted 3-0 Monocryl sutures or with the INSORB device. The consultant closed the incisions on one side, with the contralateral incision closed by the assistant using the same closure method. Data were then compared retrospectively, and closure times were compared over the ensuing 6 months. Results: Overall, consultant closure speed is 25% faster than assistant speed. When using 3-0 Monocryl, the difference is 33%, whereas the difference is reduced to 21% when using the INSORB. Furthermore, a mild learning curve could be appreciated with the assistant's use of the INSORB over the comparatively short 6-month study period. Conclusions: In addition to improved speed, cost, outcome, and ergonomics, subdermal absorbable staples may also garner a faster learning curve than standard closure with 3-0 Monocryl. This study supported the learning curve of a surgical device as another innovative benefit and an important aspect of developing surgical technology.

Palliative care clinical rotations among undergraduate and postgraduate medical trainees in Canada: a descriptive study.

BACKGROUND: The number of medical undergraduate and postgraduate students completing palliative care clinical rotations in Canadian medical schools is currently unknown. The aim of this study was to assess the proportion of Canadian medical trainees completing clinical rotations in palliative care and to determine whether changes took place between 2008 and 2018. METHODS: In this descriptive study, all Canadian medical schools (n = 17) were invited to provide data at the undergraduate and postgraduate levels (2007/08-2015/16 and 2007/08-2017/18, respectively). Information collected included the number, type and length of palliative care clinical rotations offered and the total number of medical trainees or residents enrolled at each school. RESULTS: All 17 Canadian medical schools responded to the request for information. At the undergraduate level, palliative care clinical rotations were not offered in 2 schools, mandatory in 2 and optional in 13. Three schools that offered optional rotations were unable to provide complete data and were therefore excluded from further analyses. In 2015/16, only 29.7% of undergraduate medical students completed palliative care clinical rotations, yet this was a significant improvement compared to 2011/12 (13.6%, p = 0.02). At the postgraduate level, on average, 57.9% of family medicine trainees completed such rotations between 2007/08 and 2016/17. During the same period, palliative care clinical rotations were completed by trainees in specialty or subspecialty programs in anesthesiology (34.2%), geriatric medicine (64.4%), internal medicine (30.9%), neurology (28.2%) and psychiatry (64.5%). INTERPRETATION: Between 2008 and 2018, a large proportion of Canadian medical trainees graduated without the benefit of a clinical rotation in palliative care. Without dedicated clinical exposure to palliative care, many physicians will enter practice without vital palliative care competencies.

Implementing the access and waiting time standard for early intervention in psychosis in the United Kingdom: An evaluation of referrals and post-assessment outcomes over the first year of operation.

AIM: Improving timely access to evidence-based treatment for people aged 14-65 years experiencing a first episode psychosis (FEP) or an at-risk mental state (ARMS) for psychosis is a national priority within the United Kingdom. An early intervention in psychosis (EIP) access and waiting time standard has been set which has extended the age range and acceptance criteria for services. METHODS: This descriptive evaluation reports upon the referrals and access to treatment times within an EIP service over the first year of operating in line with the access and waiting time standard. Patient pathways and post-assessment status are also described. RESULTS: The service received 406 referrals, of which 88% (n = 357) were assessed. The mean length of time to treatment was 1.5 weeks, with 88% being seen within 2 weeks. Of those who engaged in an assessment, 34% (n = 138) were identified as ARMS cases and 30% (n = 123) were identified as FEP. Over 35 year olds accounted for 22% (n = 80) of the total accepted cases. CONCLUSIONS: The findings indicate clinical and operational issues, which will need careful consideration in the future planning of services. The high number of ARMS cases highlights the importance of clear treatment pathways and targeted interventions and may suggest a need to commission distinct ARMS services. The number of people who met the extended age and service acceptance criteria may suggest a need to adapt or redesign clinical services to meet the age-specific needs of over 35 year olds and those with an ARMS. It is unclear how changes to the remit of EIP services will impact upon future clinical outcomes.

Closed Partial Flexor Digitorum Profundus Rupture: An Unusual Cause of Pediatric Trigger Finger.

BACKGROUND: Trigger finger is a common condition, causing impaired gliding of the digital flexor tendons. Chronic inflammation is the usual cause, but acute trigger finger following partial tendon laceration has also been described. METHODS: We describe the case of a four year old girl who presented with inability to flex her index finger. Operative exploration revealed a closed partial rupture of the flexor digitorum profundus tendon, catching on the A2 pulley and preventing normal tendon gliding. RESULTS: Excision of the damaged section of tendon allowed normal gliding motion, and once the wound had healed the patient regained full painless motion. CONCLUSION: Acute trigger finger caused by partial flexor tendon injury is an uncommon but well-documented presentation. Surgical exploration not only confirms the diagnosis, but allows for excision of the damaged segment to return normal movement without compromising strength.

EZOGABINE (POTIGA) MACULOPATHY.

PURPOSE: To present a case of partially reversible retinal toxicity related to a newer epilepsy medication, ezogabine (Potiga). METHODS: Case report with multimodal imaging. PATIENT: A patient presented 9 months after starting ezogabine for a screening eye examination with new retinal pigment abnormalities in the maculas of both eyes. RESULTS: These macular abnormalities are characterized for the first time with multimodal imaging. They were partially reversible after cessation of the drug. CONCLUSION: Ezogabine toxicity presents as pigmentary changes in the macula on fundus examination and has newly described characteristics on imaging that can guide ophthalmologists when they perform the FDA-recommended 6-month screening visits for ocular toxicity.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Differentiation of follicular helper T cells by salivary gland epithelial cells in primary Sjögren's syndrome.

Follicular helper T cells (Tfh), which play a pivotal role in B cell activation and differentiation in lymphoid structures, secrete IL-21 whose augmented secretion is a hallmark of several autoimmune diseases. To decipher the cellular and molecular interactions occurring in salivary glands of patients suffering from primary Sjögren's syndrome (pSS), we investigated whether salivary gland epithelial cells (SGECs) were capable to induce Tfh differentiation. Co-cultures of naïve CD4(+) T cells and SGECs from both patients with pSS and controls were performed. Here, we report that IL-6 and ICOSL expression by SGECs contributes to naïve CD4(+) T differentiation into Tfh cells, as evidenced by their acquisition of a specific phenotype, characterized by Bcl-6, ICOS and CXCR5 expression and IL-21 secretion, but also but by their main functional feature: the capacity to enhance B lymphocytes survival. We demonstrated an increase of serum IL-21 with systemic activity. Finally, we analyzed the potential occurrence of a genetic association between IL-21 or IL-21R gene polymorphisms and pSS or elevated IL-21 secretion. This study, which demonstrates a direct induction of Tfh differentiation by SGECs, emphasizes a yet unknown pathogenic role of SGECs and suggests that Tfh and IL-21 might be relevant biomarkers and/or therapeutic targets in primary Sjögren's syndrome.

Anaplastic large cell lymphoma and breast implants: five Australian cases.

BACKGROUND: There has never been a convincing association between breast implants and breast malignancy. A total of 42 cases of non-Hodgkin's lymphoma of the breast associated with implant capsules have been reported. The majority of the patients have anaplastic large cell lymphoma of T-cell origin. These lymphoma types have less frequently been observed in women without implants. METHODS: The senior author (H.R.W.) diagnosed and treated two women with anaplastic large cell lymphoma in a short period of time. After this, the authors were contacted by other surgeons in Australia who had treated similar cases. RESULTS: The authors report five new cases of anaplastic large cell lymphoma associated with breast implants. There is an apparent spectrum of disease, with some cases pursuing an aggressive clinical course, although most have experienced a good prognosis. Both saline and silicone implants are implicated. All implant shells were textured. CONCLUSIONS: Textured surface implants only became widely used in the 1990s and therefore were not significantly represented in the large cohort studies of breast implant safety undertaken in the early 1990s. The diagnosis of anaplastic large cell lymphoma in the breast needs to be considered in patients, particularly those presenting with a periprosthetic seroma 6 months or more after breast implant insertion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

Carpal tunnel syndrome secondary to ganglion cyst in a child.

Carpal tunnel syndrome is uncommon in children and is associated with an underlying etiology in the majority of cases. The diagnosis of the condition in childhood is dependent on a high degree of clinical suspicion, careful clinical examination, and judicious use of confirmatory investigations. The authors report a novel cause of carpal tunnel syndrome in a child, and discuss the investigation and management strategies in childhood carpal tunnel syndrome.

Consumption of diets high in prebiotic fiber or protein during growth influences the response to a high fat and sucrose diet in adulthood in rats.

BACKGROUND: Early dietary exposure can influence susceptibility to obesity and type 2 diabetes later in life. We examined the lasting effects of a high protein or high prebiotic fiber weaning diet when followed by a high energy diet in adulthood. METHODS: At birth, litters of Wistar rats were culled to 10 pups. At 21 d pups were weaned onto control (C), high prebiotic fiber (HF) or high protein (HP) diet. Rats consumed the experimental diets until 14 wk when they were switched to a high fat/sucrose (HFHS) diet for 6 wk. Body composition and energy intake were measured and an oral glucose tolerance test (OGTT) performed. Blood was analyzed for satiety hormones and tissues collected for real-time PCR. RESULTS: Weight gain was attenuated in male rats fed HF from 12 wk until study completion. In females there were early reductions in body weight that moderated until the final two wk of HFHS diet wherein HF females weighed less than HP. Final body weight was significantly higher following the high fat challenge in male and female rats that consumed HP diet from weaning compared to HF. Lean mass was higher and fat mass lower with HF compared to HP and compared to C in males. Energy intake was highest in HP rats, particularly at the start of HFHS feeding. Plasma glucose was higher in HP rats compared to HF during an OGTT. Plasma amylin was higher in HF females compared to C and glucagon-like peptide-1 (GLP-1) was higher in HF rats during the OGTT. Leptin was higher in HP rats during the OGTT. HF upregulated GLUT 5 mRNA expression in the intestine and downregulated hepatic hydroxymethylglutaryl coenzyme A reductase. Male rats fed HP had higher hepatic triglyceride content than C or HF. CONCLUSION: These data suggest that while a long-term diet high in protein predisposes to an obese phenotype when rats are given a high energy diet in adulthood, consumption of a high fiber diet during growth may provide some protection.

Comparison of measured versus predicted energy requirements in critically ill cancer patients.

BACKGROUND: Accurate determination of caloric requirements is essential to avoid feeding-associated complications in critically ill patients. METHODS: In critically ill cancer patients we compared the measured and estimated resting energy expenditures. All patients admitted to the oncology intensive care unit between March 2004 and July 2005 were considered for inclusion. For those patients enrolled (n = 34) we measured resting energy expenditure via indirect calorimetry, and estimated resting energy expenditure in 2 ways: clinically estimated resting energy expenditure; and the Harris-Benedict basal energy expenditure equation. RESULTS: Clinically estimated resting energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 15%, 15%, and 71% of the patients, respectively. The Harris-Benedict basal energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 29%, 41%, and 29% of the patients, respectively. The mean measured resting energy expenditure (1,623 +/- 384 kcal/d) was similar to the mean Harris-Benedict basal energy expenditure without the addition of stress or activity factors (1,613 +/- 382 kcal/d, P = .87), and both were significantly lower than the mean clinically estimated resting energy expenditure (1,862 +/- 330 kcal/d, P < or = .003 for both). There was a significant correlation only between mean measured resting energy expenditure and mean Harris-Benedict basal energy expenditure (P < .001), but the correlation coefficient between those values was low (r = 0.587). CONCLUSIONS: Underfeeding and overfeeding were common in our critically ill cancer patients when resting energy expenditure was estimated rather than measured. Indirect calorimetry is the method of choice for determining caloric need in critically ill cancer patients, but if indirect calorimetry is not available or feasible, the Harris-Benedict equation without added stress and activity factors is more accurate than the clinically estimated resting energy expenditure.

Linkage analyses of rheumatoid arthritis and related quantitative phenotypes: the GAW15 experience.

The group that formed on the theme of linkage analyses of rheumatoid arthritis RA and related phenotypes (Group 10) in the Genetic Analysis Workshop 15 comprised 18 sets of investigators. Two data sets were available: one was a real set provided by the North American Rheumatoid Arthritis Consortium and collaborators in Canada, France (European Consortium Of Rheumatoid Arthritis Families) and the UK; the other was a simulated data set modelled after the real data set. Whereas a majority of the investigators analyzed the RA affection status as a binary phenotype, a few contributions considered data on correlated quantitative traits such as anti-cyclic citrullinated peptide and rheumatoid factor-immunoglobulin M. The different investigators applied a wide spectrum of linkage methods. As expected, most methods could identify the human leukocyfeantigen region on chromosome 6 as a major genetic factor for RA. In addition, some novel chromosomal regions provided significant evidence of linkage in multiple contributions in the group. In this report, we discuss the different strategies explored by the different investigators with the common goal of improving the power to detect linkage.

Clinical and genetic risk factors for pneumonia in systemic lupus erythematosus.

OBJECTIVE: To define the contribution of polymorphisms in genes encoding tumor necrosis factor (TNF), mannose-binding lectin (MBL), and Fcgamma receptor IIa (FCGR2A) as well as clinical factors, to the development of pneumonia in patients with systemic lupus erythematosus (SLE). METHODS: We studied 282 SLE patients from a multiethnic cohort. Pneumonia events and clinical risk factors for pneumonia were identified through medical record review. Genotyping was performed for MBL (+223, +230, and +239), TNF (-308, -238, and +488), and FCGR2A (-131H/R) polymorphisms. Univariate analyses were performed to identify clinical and genetic risk factors for pneumonia. Covariates for multivariate analysis included sex, ethnicity, treatment with immunomodulators, and leukopenia. RESULTS: Forty-two patients (15%) had at least 1 episode of pneumonia. Polymorphism of the TNF gene, particularly the -238A allele and a related haplotype, revealed the most striking and consistent association with pneumonia in univariate analyses. Results of multivariate analyses indicated an odds ratio (OR) for the TNF -238A allele of 3.5 (P = 0.007) and an OR for the related haplotype of 5.4 (P = 0.001). Male sex, treatment with immunomodulators, and leukopenia also influenced the risk of pneumonia. CONCLUSION: These findings suggest that specific TNF variants may identify SLE patients who are at particularly high risk of developing pneumonia. Given the prevalence and excessive morbidity associated with pneumonia in SLE, these findings have clinical relevance and provide insight into the pathogenesis.