Best practice guidelines for evaluating patients in custody in the emergency department.

Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system.

The Cby3/ciBAR1 complex positions the annulus along the sperm flagellum during spermiogenesis.

Proper compartmentalization of the sperm flagellum is essential for fertility. The annulus is a septin-based ring that demarcates the midpiece (MP) and the principal piece (PP). It is assembled at the flagellar base, migrates caudally, and halts upon arriving at the PP. However, the mechanisms governing annulus positioning remain unknown. We report that a Chibby3 (Cby3)/Cby1-interacting BAR domain-containing 1 (ciBAR1) complex is required for this process. Ablation of either gene in mice results in male fertility defects, caused by kinked sperm flagella with the annulus mispositioned in the PP. Cby3 and ciBAR1 interact and colocalize to the annulus near the curved membrane invagination at the flagellar pocket. In the absence of Cby3, periannular membranes appear to be deformed, allowing the annulus to migrate over the fibrous sheath into the PP. Collectively, our results suggest that the Cby3/ciBAR1 complex regulates local membrane properties to position the annulus at the MP/PP junction.

Intracranial Intraosseous Catheter Placement to Temporize an Epidural Hematoma.

Acute epidural hematomas can lead to rapid neurologic decompensation and death. Epidural hematomas may require emergency surgical clot removal, but many patients live far away from a trauma center. This case report describes a pediatric patient with an acute epidural hematoma with significant neurologic compromise who initially presented to a nontrauma center. The emergency department (ED) had no neurosurgeon or equipment to perform burr hole craniostomy. The emergency physician at the nontrauma ED inserted an intraosseous catheter intracranially to temporarily decompress the hematoma due to long transport times. The patient survived with complete neurologic recovery. This is the youngest known patient in whom an intraosseous catheter was used to drain an intracranial hematoma.

Sexual selection drives the coevolution of male and female reproductive traits in Peromyscus mice.

When females mate with multiple partners within a single reproductive cycle, sperm from rival males may compete for fertilization of a limited number of ova, and females may bias the fertilization of their ova by particular sperm. Over evolutionary timescales, these two forms of selection shape both male and female reproductive physiology when females mate multiply, yet in monogamous systems, post-copulatory sexual selection is weak or absent. Here, we examine how divergent mating strategies within a genus of closely related mice, Peromyscus, have shaped the evolution of reproductive traits. We show that in promiscuous species, males exhibit traits associated with increased sperm production and sperm swimming performance, and females exhibit traits that are predicted to limit sperm access to their ova including increased oviduct length and a larger cumulus cell mass surrounding the ova, compared to monogamous species. Importantly, we found that across species, oviduct length and cumulus cell density are significantly correlated with sperm velocity, but not sperm count or relative testes size, suggesting that these female traits may have coevolved with increased sperm quality rather than quantity. Taken together, our results highlight how male and female traits evolve in concert and respond to changes in the level of post-copulatory sexual selection.

Principles of Screening for Disease and Health Risk Factors in the Emergency Department.

The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.

Approach considerations for the management of strangulation in the emergency department.

Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.

Anti-microRNA-21 Therapy on Top of ACE Inhibition Delays Renal Failure in Alport Syndrome Mouse Models.

Col4a3-/- Alport mice serve as an animal model for renal fibrosis. MicroRNA-21 (miR-21) expression has been shown to be increased in the kidneys of Alport syndrome patients. Here, we investigated the nephroprotective effects of Lademirsen anti-miR-21 therapy. We used a fast-progressing Col4a3-/- mouse model with a 129/SvJ background and an intermediate-progressing F1 hybrid mouse model with a mixed genetic background, with angiotensin-converting enzyme inhibitor (ACEi) monotherapy in combination with anti-miR-21 therapy. In the fast-progressing model, the anti miR-21 and ACEi therapies showed an additive effect in the reduction in fibrosis, the decline of proteinuria, the preservation of kidney function and increased survival. In the intermediate-progressing F1 model, the anti-miR-21 and ACEi therapies individually improved kidney pathology. Both also improved kidney function and survival; however, the combination showed a significant additive effect, particularly for survival. RNA sequencing (RNA-seq) gene expression profiling revealed that the anti-miR-21 and ACEi therapies modulate several common pathways. However, anti-miR-21 was particularly effective at normalizing the expression profiles of the genes involved in renal tubulointerstitial injury pathways. In conclusion, significant additive effects were detected for the combination of anti-miR-21 and ACEi therapies on kidney function, pathology and survival in Alport mouse models, as well as a strong differential effect of anti-miR-21 on the renal expression of fibrotic factors. These results support the addition of anti-miR-21 to the current standard of care (ACEi) in ongoing clinical trials in patients with Alport syndrome.

Tunable Chemical Disorder in Concentrated Alloys: Defect Physics and Radiation Performance.

The development of advanced structural alloys with performance meeting the requirements of extreme environments in nuclear reactors has been long pursued. In the long history of alloy development, the search for metallic alloys with improved radiation tolerance or increased structural strength has relied on either incorporating alloying elements at low concentrations to synthesize so-called dilute alloys or incorporating nanoscale features to mitigate defects. In contrast to traditional approaches, recent success in synthesizing multicomponent concentrated solid-solution alloys (CSAs), including medium-entropy and high-entropy alloys, has vastly expanded the compositional space for new alloy discovery. Their wide variety of elemental diversity enables tunable chemical disorder and sets CSAs apart from traditional dilute alloys. The tunable electronic structure critically lowers the effectiveness of energy dissipation via the electronic subsystem. The tunable chemical complexity also modifies the scattering mechanisms in the atomic subsystem that control energy transport through phonons. The level of chemical disorder depends substantively on the specific alloying elements, rather than the number of alloying elements, as the disorder does not monotonically increase with a higher number of alloying elements. To go beyond our knowledge based on conventional alloys and take advantage of property enhancement by tuning chemical disorder, this review highlights synergistic effects involving valence electrons and atomic-level and nanoscale inhomogeneity in CSAs composed of multiple transition metals. Understanding of the energy dissipation pathways, deformation tolerance, and structural stability of CSAs can proceed by exploiting the equilibrium and non-equilibrium defect processes at the electronic and atomic levels, with or without microstructural inhomogeneities at multiple length scales. Knowledge of tunable chemical disorder in CSAs may advance the understanding of the substantial modifications in element-specific alloy properties that effectively mitigate radiation damage and control a material's response in extreme environments, as well as overcome strength-ductility trade-offs and provide overarching design strategies for structural alloys.

Educational interventions for physical activity among Brazilian adults: systematic review.

OBJECTIVE: To summarize the main evidence from educational interventions designed to increase levels of physical activity (PA) among Brazilian adults. METHODS: Systematic review of intervention studies carried out in Brazil that implemented educational components aimed at promoting increased levels of PA among adult populations (18 to 65 years old). In October 2020, systematic searches were conducted in six databases, and in the reference lists of the assessed studies. RESULTS: Of the initial 2,511 studies, nine were included in the synthesis. Samples with specific characteristics (such as social vulnerability, physical inactivity, and overweight or obesity) were observed, with a greater number of women. Five interventions (55.6%) occurred in primary healthcare settings (PHC) of the Brazilian Unified Health System (SUS). Only four studies (44.4%) described the pedagogical frameworks structuring the educational approaches, among which counseling was the most used strategy, such as those carried out through face-to-face meetings, home visits, lectures, and phone calls (n = 8; 88.9%). Positive results were observed in three different indicators: increase in weekly PA volume (n = 4); increase in leisure-time PA rate (n = 1); and increase in the proportion of women classified as "very active/active" (n = 1). Given the sampling specificities, the domain "participant selection" showed a high number of interventions with high risk of bias. CONCLUSIONS: Educational approaches engendered some positive effects on different PA indicators, notably counseling as the main strategy used and approaches involving other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, future interventions should be conducted in different locations of Brazil in order to evaluate, in a broader way, their implementation processes and articulation with the many professionals working in PHC.

Local delivery of mRNA-encoded cytokines promotes antitumor immunity and tumor eradication across multiple preclinical tumor models.

Local immunotherapy ideally stimulates immune responses against tumors while avoiding toxicities associated with systemic administration. Current strategies for tumor-targeted, gene-based delivery, however, are limited by adverse effects such as off-targeting or antivector immunity. We investigated the intratumoral administration of saline-formulated messenger (m)RNA encoding four cytokines that were identified as mediators of tumor regression across different tumor models: interleukin-12 (IL-12) single chain, interferon-α (IFN-α), granulocyte-macrophage colony-stimulating factor, and IL-15 sushi. Effective antitumor activity of these cytokines relied on multiple immune cell populations and was accompanied by intratumoral IFN-γ induction, systemic antigen-specific T cell expansion, increased granzyme B+ T cell infiltration, and formation of immune memory. Antitumor activity extended beyond the treated lesions and inhibited growth of distant tumors and disseminated tumors. Combining the mRNAs with immunomodulatory antibodies enhanced antitumor responses in both injected and uninjected tumors, thus improving survival and tumor regression. Consequently, clinical testing of this cytokine-encoding mRNA mixture is now underway.

Size but not relatedness drives the spatial distribution of males within an urban population of Anolis carolinensis lizards.

The way that individuals are spatially organized in their environment is a fundamental population characteristic affecting social structure, mating system, and reproductive ecology. However, for many small or cryptic species, the factors driving the spatial distribution of individuals within a population are poorly understood and difficult to quantify. We combined microsatellite data, remote sensing, and mark-recapture techniques to test the relative importance of body size and relatedness in determining the spatial distribution of male Anolis carolinensis individuals within a focal population over a five-year period. We found that males maintain smaller home ranges than females. We found no relationship between male body size and home range size, nor any substantial impact of relatedness on the geographic proximity. Instead, the main driver of male spatial distribution in this population was differences in body size. We also found no evidence for offspring inheritance of their parent's territories. Males were never sampled within their father's territory providing strong support for male-biased dispersal. This study introduces a novel approach by combining standard mark release capture data with measures of pairwise relatedness, body size, and GPS locations to better understand the factors that drive the spatial distribution of individuals within a population.

Educational interventions for physical activity among Brazilian adults: systematic review / Intervenções educativas para atividade física em adultos brasileiros: revisão sistemática

ABSTRACT OBJECTIVE To summarize the main evidence from educational interventions designed to increase levels of physical activity (PA) among Brazilian adults. METHODS Systematic review of intervention studies carried out in Brazil that implemented educational components aimed at promoting increased levels of PA among adult populations (18 to 65 years old). In October 2020, systematic searches were conducted in six databases, and in the reference lists of the assessed studies. RESULTS Of the initial 2,511 studies, nine were included in the synthesis. Samples with specific characteristics (such as social vulnerability, physical inactivity, and overweight or obesity) were observed, with a greater number of women. Five interventions (55.6%) occurred in primary healthcare settings (PHC) of the Brazilian Unified Health System (SUS). Only four studies (44.4%) described the pedagogical frameworks structuring the educational approaches, among which counseling was the most used strategy, such as those carried out through face-to-face meetings, home visits, lectures, and phone calls (n = 8; 88.9%). Positive results were observed in three different indicators: increase in weekly PA volume (n = 4); increase in leisure-time PA rate (n = 1); and increase in the proportion of women classified as "very active/active" (n = 1). Given the sampling specificities, the domain "participant selection" showed a high number of interventions with high risk of bias. CONCLUSIONS Educational approaches engendered some positive effects on different PA indicators, notably counseling as the main strategy used and approaches involving other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, future interventions should be conducted in different locations of Brazil in order to evaluate, in a broader way, their implementation processes and articulation with the many professionals working in PHC.

RESUMO OBJETIVO Sumarizar as principais evidências de intervenções educativas delineadas para o aumento dos níveis de atividade física (AF) em adultos brasileiros. MÉTODOS Revisão sistemática de estudos de intervenção conduzidos no Brasil, que implementaram componentes educativos com a finalidade de promover o aumento dos níveis de AF em populações de adultos (18 a 65 anos). Em outubro de 2020, buscas sistemáticas foram conduzidas em seis bases de dados e nas listas de referências dos artigos avaliados. RESULTADOS Dos 2.511 artigos iniciais, nove compuseram a síntese. Foram observadas amostras com características específicas (como vulnerabilidade social, inatividade física e sobrepeso ou obesidade), com maior número de mulheres. Cinco intervenções (55,6%) ocorreram nos cenários da atenção primária à saúde (APS) do Sistema Único de Saúde (SUS). Apenas em quatro estudos (44,4%) houve descrição dos referenciais pedagógicos estruturantes das abordagens educativas, dentro os quais o aconselhamento se configurou como a estratégia mais utilizada, como aquelas realizadas por meio de encontros presenciais, visitas domiciliares, palestras e chamadas telefônicas (n = 8; 88,9%). Resultados positivos foram observados em três distintos indicadores: aumento do volume semanal de AF (n = 4); aumento do índice de AF no lazer (n = 1); e aumento da proporção de mulheres classificadas como "muito ativas/ativas" (n = 1). Visto as especificidades amostrais, o domínio "seleção dos participantes" apresentou elevado número de intervenções com alto risco de viés. CONCLUSÕES As abordagens educativas produziram alguns efeitos positivos em distintos indicadores de AF, destacando-se o aconselhamento como principal estratégia utilizada e as abordagens que envolveram outras temáticas de saúde, como nutrição e estresse. Contudo, frente aos diversos determinantes da AF no Brasil, é importante que futuras intervenções sejam conduzidas em variadas localizações do país, de forma que avaliem, de maneira mais ampla, seus processos de implementação e articulação com os distintos profissionais que atuam na APS.

Reconstructing Nonparametric Productivity Networks.

Network models provide a general representation of inter-connected system dynamics. This ability to connect systems has led to a proliferation of network models for economic productivity analysis, primarily estimated non-parametrically using Data Envelopment Analysis (DEA). While network DEA models can be used to measure system performance, they lack a statistical framework for inference, due in part to the complex structure of network processes. We fill this gap by developing a general framework to infer the network structure in a Bayesian sense, in order to better understand the underlying relationships driving system performance. Our approach draws on recent advances in information science, machine learning and statistical inference from the physics of complex systems to estimate unobserved network linkages. To illustrate, we apply our framework to analyze the production of knowledge, via own and cross-disciplinary research, for a world-country panel of bibliometric data. We find significant interactions between related disciplinary research output, both in terms of quantity and quality. In the context of research productivity, our results on cross-disciplinary linkages could be used to better target research funding across disciplines and institutions. More generally, our framework for inferring the underlying network production technology could be applied to both public and private settings which entail spillovers, including intra- and inter-firm managerial decisions and public agency coordination. This framework also provides a systematic approach to model selection when the underlying network structure is unknown.

A proposal for selective resuscitation of adult cardiac arrest patients in a pandemic.

Allocation of limited resources in pandemics begs for ethical guidance. The issue of ventilator allocation in pandemics has been reviewed by many medical ethicists, but as localities activate crisis standards of care, and health care workers are infected from patient exposure, the decision to pursue cardiopulmonary resuscitation (CPR) must also be examined to better balance the increased risks to healthcare personnel with the very low resuscitation rates of patients infected with coronavirus disease 2019 (COVID-19). A crisis standard of care that is equitable, transparent, and mindful of both human and physical resources will lessen the impact on society in this era of COVID-19. This paper builds on previous work of ventilator allocation in pandemic crises to propose a literature-based, justice-informed ethical framework for selecting treatment options for CPR. The pandemic affects regions differently over time, so these suggested guidelines may require adaptation to local practice variations.

Irradiation-Induced Extremes Create Hierarchical Face-/Body-Centered-Cubic Phases in Nanostructured High Entropy Alloys.

A nanoscale hierarchical dual-phase structure is reported to form in a nanocrystalline NiFeCoCrCu high-entropy-alloy (HEA) film via ion irradiation. Under the extreme energy deposition and consequent thermal energy dissipation induced by energetic particles, a fundamentally new phenomenon is revealed, in which the original single-phase face-centered-cubic (FCC) structure partially transforms into alternating nanometer layers of a body-centered-cubic (BCC) structure. The orientation relationship follows the Nishiyama-Wasser-man relationship, that is, (011)BCC || ( 1¯1¯1)FCC and [100]BCC || [ 11¯0]FCC . Simulation results indicate that Cr, as a BCC stabilizing element, exhibits a tendency to segregate to the stacking faults (SFs). Furthermore, the high densities of SFs and twin boundaries in each nanocrystalline grain serve to accelerate the nucleation and growth of the BCC phase during irradiation. By adjusting the irradiation parameters, desired thicknesses of the FCC and BCC phases in the laminates can be achieved. This work demonstrates the controlled formation of an attractive dual-phase nanolaminate structure under ion irradiation and provides a strategy for designing new derivate structures of HEAs.

Interpreting nanovoids in atom probe tomography data for accurate local compositional measurements.

Quantifying chemical compositions around nanovoids is a fundamental task for research and development of various materials. Atom probe tomography (APT) and scanning transmission electron microscopy (STEM) are currently the most suitable tools because of their ability to probe materials at the nanoscale. Both techniques have limitations, particularly APT, because of insufficient understanding of void imaging. Here, we employ a correlative APT and STEM approach to investigate the APT imaging process and reveal that voids can lead to either an increase or a decrease in local atomic densities in the APT reconstruction. Simulated APT experiments demonstrate the local density variations near voids are controlled by the unique ring structures as voids open and the different evaporation fields of the surrounding atoms. We provide a general approach for quantifying chemical segregations near voids within an APT dataset, in which the composition can be directly determined with a higher accuracy than STEM-based techniques.

COVID-19 Conferences: Resident Perceptions of Online Synchronous Learning Environments.

INTRODUCTION: The coronavirus disease 2019 pandemic forced a rapid transition of in-class residency conferences to online residency conferences; little is known about learners' perceptions of this new didactic environment. Understanding learners' perceptions of virtual classrooms can help inform current and future best practices for online, synchronous, graduate medical education. METHODS: We surveyed emergency medicine and internal medicine residency programs at a large urban academic medical center about their perceptions of synchronous online residency conferences. RESULTS: Residents reported a preference for in-class interactions with peers (85%) and lecturers (80%), with 62% reporting decreased levels of engagement with lecturers during online conferences. Residents reported performing nearly twice as many non-conference-related activities (eg, email, exercise) during online conferences vs in-class conferences. Residents felt that the following methods improved engagement during online conferences: lecturers answering chat questions; small group sessions; and gamification of lectures. CONCLUSION: Synchronous online residency conferences were associated with decreased engagement and attention by learners. Simple methods to increase interactivity may help improve the online classroom experience and cultivate novel teaching environments that better support current learning styles.

Sprint speed is unaffected by dietary manipulation in trained male Anolis carolinensis lizards.

Performance traits are energetically costly, and their expression and use can drive trade-offs with other energetically costly life-history traits. However, different performance traits incur distinct costs and may be sensitive to both resource limitation and to the types of resources that are accrued. Protein is likely to be especially important for supporting burst performance traits such as sprint speed, but the effect of varying diet composition on sprint training in lizards, an emerging model system for exercise training, is unknown. We tested the hypothesis that the response to sprint training is sensitive to both the type and amount of resources in Anolis carolinensis. We also measured bite force across all treatments as a control whole-organism performance trait that should be unaffected by locomotor training. Both mass and bite force are reduced by dietary restriction over the course of 9 weeks of sprint training, but sprint speed is unaffected by either training or dietary restriction relative to controls. Furthermore, protein supplementation does not rescue a decline in either mass or bite force in trained, diet-restricted males. These results contrast with those for endurance training, and suggest that sprint speed is more canalized than either endurance or bite force in green anoles.