Brain drain in pediatric anesthesiology: The geographic and demographic distribution of national origin among pediatric anesthesiologists in the United States.

BACKGROUND: American pediatric anesthesiologists have a long history of international volunteerism. However, the US healthcare system also benefits from the contributions of a large number of physicians who come from other nations to work within its borders. Despite this fact, little is known about the contribution of international medical graduates (IMG) to the pediatric anesthesiology subspecialty. AIMS: To characterize the contribution of IMG to the field of pediatric anesthesiology in the United States, and to elucidate the geographic and demographic distribution of their national origins so as to understand the movement of skilled personnel between countries. METHODS: Online physician directories of American children's hospitals were searched, and anesthesiologists were recorded for their national origin of medical education. International graduates were reported as a percentage of the pediatric anesthesiology workforce. Those attending medical colleges catering to American students ("offshore" medical schools) were analyzed separately from other IMGs. The cohort of non-offshore IMGs were analyzed for national and continental origins, and by national level of economic development. RESULTS: Of 1979 anesthesiologists analyzed, 397 attended medical school outside the United States, with 58 being from offshore schools. The remaining 338 represented 17.1% of the total pediatric anesthesiology workforce. They came from 58 countries on six continents. Of those, 65.1% attended medical school in low- and middle-income countries. CONCLUSIONS: International medical graduates, disproportionately from low- and middle-income countries, compose a large proportion of the US Pediatric Anesthesiology workforce. While these clinicians play a vital role in providing care for American children, the potential impacts of skilled physician loss on their nations of origin must also be considered.

Diffusion-Weighted Imaging of the Orbit: A Case Series and Systematic Review.

PURPOSE: To describe the findings of diffusion-weighted imaging (DWI) for a series of orbital lesions and provide a systematic review of relevant literature. METHODS: A retrospective review of 20 patients with orbital lesions who underwent MRI with DWI at two academic institutions between 2015 and 2020 was performed. Lesion diagnosis was histopathologically confirmed except a presumed cavernous hemangioma. Echoplanar diffusion-weighted images had been acquired using 2 or 3 b values (b=0 and 1000 or b=0, 500, and 1000) at 1.5T or 3T. Lesions with significant artifacts were excluded. DWI sequences were analyzed by neuro-radiologists blinded to the diagnosis. Mean ADC values of lesions were calculated from a single region of interest. An independent two-tailed t test was used to compare categories of lesions with p < 0.05 considered significant. A systematic review of the literature was performed. RESULTS: Our study included 21 lesions. ADC values were significantly lower for malignant lesions (0.628 ± 0.125 × 10 -3 mm 2 /s) than inflammatory lesions (1.167 ± 0.381 × 10 -3 mm 2 /s) ( p < 0.001). ADC values were significantly lower for orbital lymphoma (mean 0.621 ± 0.147 × 10 -3 mm 2 /s) than idiopathic orbital inflammation (mean 1.188 ± 0.269 × 10 -3 mm 2 /s) with no overlap ( p < 0.001). CONCLUSIONS: Orbital malignancies demonstrated lower ADC values, while inflammatory processes demonstrated higher ADC values, except IgG4-related disease. DWI and ADC values differentiated idiopathic orbital inflammation from orbital lymphoma. This study highlights the role of DWI in evaluating orbital pathology.

Epidemiology, evaluation, and management of conduction disturbances after transcatheter aortic valve replacement.

Aortic stenosis is the most common valvulopathy requiring replacement by means of the surgical or transcatheter approach. Transcatheter aortic valve replacement (TAVR) has quickly become a viable and often preferred treatment strategy compared to surgical aortic valve replacement. However, transcatheter heart valve system deployment not infrequently injures the specialized electrical system of the heart, leading to new conduction disorders including high-grade atrioventricular block and complete heart block (CHB) necessitating permanent pacemaker implantation (PPI), which may lead to deleterious effects on cardiac function and patient outcomes. Additional conduction disturbances (e.g., new-onset persistent left bundle branch block, PR/QRS prolongation, and transient CHB) currently lack clearly defined management algorithms leading to variable strategies among institutions. This article outlines the current understanding of the pathophysiology, patient and procedural risk factors, means for further risk stratification and monitoring of patients without a clear indication for PPI, our institutional approach, and future directions in the management and evaluation of post-TAVR conduction disturbances.

The role of atrial fibrillation catheter ablation in patients with heart failure.

Atrial Fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF) frequently coexist, resulting in significant morbidity and mortality. Therapeutic options for patients with AF and HFrEF are limited due to few antiarrhythmic drug (AAD) choices and historically equivocal effects of procedural interventions on mortality. However, recent randomized trials examining catheter ablation (CA) in AF patients with HFrEF have shown a beneficial effect on arrhythmic burden and HF symptoms, as well as an improvement in mortality. This review focuses on the role of CA for AF patients with HFrEF.

Evaluation of multi-level barriers and facilitators in a large diabetic retinopathy screening program in federally qualified health centers: a qualitative study.

BACKGROUND: Recommended annual diabetic retinopathy (DR) screening for people with diabetes has low rates in the USA, especially in underserved populations. Telemedicine DR screening (TDRS) in primary care clinics could expand access and increase adherence. Despite this potential, studies have observed high variability in TDRS rates among clinics and over time, highlighting the need for implementation supports. Previous studies of determinants of TDRS focus on patients' perspectives, with few studies targeting upstream multi-level barriers and facilitators. Addressing this gap, this qualitative study aimed to identify and evaluate multi-level perceived determinants of TDRS in Federally Qualified Health Centers (FQHCs), to inform the development of targeted implementation strategies. METHODS: We developed a theory-based semi-structured interview tool based on the Consolidated Framework for Implementation Research (CFIR). We conducted 22 key informant interviews with professionals involved in TDRS (administrators, clinicians, staff). The interviews were audio-recorded and transcribed verbatim. Reported barriers and facilitators were organized into emergent themes and classified according to CFIR constructs. Constructs influencing TDRS implementation were rated for each study site and compared across sites by the investigators. RESULTS: Professionals identified 21 main barriers and facilitators under twelve constructs of the five CFIR domains. Several identified themes were novel, whereas others corroborated previous findings in the literature (e.g., lack of time and human resources, presence of a champion). Of the 21 identified themes, 13 were classified under the CFIR's Inner Setting domain, specifically under the constructs Compatibility and Available Resources. Themes under the Outer Setting domain (constructs External Incentives and Cost) were primarily perceived by administrators, whereas themes in other domains were perceived across all professional categories. Two Inner Setting (Leadership Engagement, Goals and Feedback) and two Process (Champion, Engaging) constructs were found to strongly distinguish sites with high versus low TDRS performance. CONCLUSIONS: This study classified barriers and facilitators to TDRS as perceived by administrators, clinicians, and staff in FQHCs, then identified CFIR constructs that distinguished high- and low-performance clinics. Implementation strategies such as academic detailing and collection and communication of program data and successes to leadership; engaging of stakeholders through involvement in implementation planning; and appointment of intervention champions may therefore improve TDRS implementation and sustainment in resource-constrained settings.

Comparison of an Offline SPE-GC-MS and Online HS-SPME-GC-MS Method for the Analysis of Volatile Terpenoids in Wine.

The aroma profile is an important marker for wine quality. Various classes of compounds are responsible for the aroma of wine, and one such class is terpenoids. In the context of this work, a validated gas chromatography-mass spectrometry (GC-MS) method for the quantitation of terpenoids in red and white wine using headspace solid-phase microextraction (HS-SPME) and solid-phase extraction (SPE) was established. Calibrations were performed in the respective base wine using both sample preparation methods. The linearity, precision and accuracy evaluated for the respective matrices were excellent for both sample preparations. However, the HS-SPME approach was more sensitive and more accurate. For both sample preparations, the quantification limits were lower than the odor thresholds in wine. The terpenoid concentrations (µg/L) were evaluated for 13 white wines using both sample preparation methods. Importantly, the online HS-SPME approach was more sensitive than the offline SPE method. The major terpenoids identified in the white wines evaluated were linalool (0.2-63 µg/L), geraniol (nd-66 µg/L) and α-terpineol (nd-85 µg/L).

Synthesis and hydroformylation evaluation of Fréchet-type organometallic dendrons with N,O-salicylaldimine Rh(i) complexes at the focal point.

A series of organometallic dendrons containing N,O-salicylaldimine entities at the focal point were synthesised by reacting the N,O-salicylaldimine-functionalised Fréchet dendrons (G0, G1 and G2) with a [Rh(µ-Cl)(η2:η2-COD)]2 dimer to yield the corresponding Rh(COD) [COD = cyclooctadiene] complexes. These Rh(COD) complexes were exposed to an atmosphere of CO to yield a new class of rhodium carbonyl organometallic dendrons with Rh(CO)2 units at the focal point. All the compounds were characterised using standard spectroscopic and analytical techniques, these include nuclear magnetic resonance, infrared spectroscopy, mass spectrometry and single-crystal X-ray diffraction for compounds 1, 4 and 7. All of the complexes were evaluated in the hydroformylation of 1-octene, with excellent conversion and chemoselectivity towards aldehydes. The G0-(CO)2 catalyst precursor (7) was active in the hydroformylation of 1-octene, styrene, 7-tetradecene, methyl oleate, triolein, d-limonene and R-citronellal. The conversion and chemoselectivity towards aldehydes for 7-tetradecene, methyl oleate, triolein and d-limonene were promising. Across a particular dendron series, an increase in chemoselectivity was observed due to the dendritic effect. Mercury drop tests were performed for the G0-analogues and these confirm that the hydroformylation can be attributed to a combination of homogeneous and heterogeneous catalysis.

Database-Centric Method for Automated High-Throughput Deconvolution and Analysis of Kinetic Antibody Screening Data.

The state-of-the-art industrial drug discovery approach is the empirical interrogation of a library of drug candidates against a target molecule. The advantage of high-throughput kinetic measurements over equilibrium assessments is the ability to measure each of the kinetic components of binding affinity. Although high-throughput capabilities have improved with advances in instrument hardware, three bottlenecks in data processing remain: (1) intrinsic molecular properties that lead to poor biophysical quality in vitro are not accounted for in commercially available analysis models, (2) processing data through a user interface is time-consuming and not amenable to parallelized data collection, and (3) a commercial solution that includes historical kinetic data in the analysis of kinetic competition data does not exist. Herein, we describe a generally applicable method for the automated analysis, storage, and retrieval of kinetic binding data. This analysis can deconvolve poor quality data on-the-fly and store and organize historical data in a queryable format for use in future analyses. Such database-centric strategies afford greater insight into the molecular mechanisms of kinetic competition, allowing for the rapid identification of allosteric effectors and the presentation of kinetic competition data in absolute terms of percent bound to antigen on the biosensor.

Introducing the Postsecondary Instructional Practices Survey (PIPS): A Concise, Interdisciplinary, and Easy-to-Score Survey.

Researchers, administrators, and policy makers need valid and reliable information about teaching practices. The Postsecondary Instructional Practices Survey (PIPS) is designed to measure the instructional practices of postsecondary instructors from any discipline. The PIPS has 24 instructional practice statements and nine demographic questions. Users calculate PIPS scores by an intuitive proportion-based scoring convention. Factor analyses from 72 departments at four institutions (N = 891) support a 2- or 5-factor solution for the PIPS; both models include all 24 instructional practice items and have good model fit statistics. Factors in the 2-factor model include (a) instructor-centered practices, nine items; and (b) student-centered practices, 13 items. Factors in the 5-factor model include (a) student-student interactions, six items; (b) content delivery, four items; (c) formative assessment, five items; (d) student-content engagement, five items; and (e) summative assessment, four items. In this article, we describe our development and validation processes, provide scoring conventions and outputs for results, and describe wider applications of the instrument.

Rituximab-Induced Acute ST Elevation Myocardial Infarction.

BACKGROUND: Rituximab has rarely been associated with acute coronary syndrome (ACS). We report the case of a patient in whom rituximab, a monoclonal antibody used to treat lymphomas of B-cell origin, induced ST elevation myocardial infarction. CASE REPORT: A 46-year-old male patient diagnosed with stage II non-Hodgkin lymphoma presented to the emergency department with acute crushing, substernal chest pain that radiated to his back 1 day after a chemotherapy infusion with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. An electrocardiogram revealed normal sinus rhythm with ST elevations in the inferior leads. The patient underwent primary percutaneous coronary intervention (PCI) of his right coronary artery and first diagonal artery with placement of drug-eluting stents. He did well postprocedure and resumed therapy with rituximab under close monitoring by the cardiology and oncology departments without any further cardiac events. CONCLUSION: In patients with ACS because of chemotherapy, complete revascularization during PCI should be considered.

Metabolic accommodation to running on a body weight-supported treadmill.

PURPOSE: Body weight-supported treadmill training using positive air pressure has become increasingly popular, but little is known about the metabolic adaptations to these treadmills. This study aimed to evaluate the existence and length of a metabolic accommodation period to running on a lower body positive pressure (LBPP) treadmill. METHODS: A total of eight recreational runners (5 males and 3 females) ran 15 min trials (5 min at 50, 70, and 90 % body weight) on the AlterG Anti-gravity(®) P200 treadmill. No verbal instruction was given on how to run on the device. Their trial pace corresponded to 70-80 % of their velocity measured at [Formula: see text]O2max on a standard treadmill. Trials were continued until no significant metabolic change was observed. Two-way repeated measures analysis of variance was used to analyze changes in [Formula: see text]O2 across trials and levels of unloading. RESULTS: Participants completed 7 trials. Comparing trial 1 to the average of trials 5, 6, and 7, [Formula: see text]O2 decreased from 29.6 ± 3.8 to 23.6 ± 4.4 ml/kg/min at 50 % body weight (~20 % reduction), from 33.7 ± 4.5 to 29.2 ± 5.1 ml/kg/min at 70 % body weight (~13 % reduction), and from 41.0 ± 7.7 to 36.6 ± 5.6 ml/kg/min at 90 % body weight (~11 % reduction). No significant reduction occurred after trial 4 at any level of support. CONCLUSIONS: An accommodation effect of running on a treadmill with LBPP was observed and reached after 60 min of running (4 trials of 15 min). The accommodation effect was the largest at the greatest level of body weight support. These data suggest the importance of an accommodation period for reliable measures of metabolic cost to be made.

Evolution of secondary heads in Nassauviinae (Asteraceae, Mutisieae).

The evolution of the inflorescence head in Asteraceae is important in the diversification of this largest angiosperm family. The aggregation of heads into higher-order capitulescences (secondary heads or syncephalia) is considered evolutionarily advanced. The genera Moscharia, Nassauvia, Polyachyrus, and Triptilion of the subtribe Nassauviinae (Mutisieae) have syncephalia with differing degrees of capitula condensation. ITS and plastid trnL-trnF regions were analyzed separately and together using maximum parsimony and maximum likelihood to examine the evolution of syncephalia in the Nassauviinae. The four genera displaying syncephalia do not form a clade minus taxa without syncephalia, indicating that secondary heads in Nassauviinae have either convergently evolved twice in the subtribe (or, very unlikely) once with multiple reversions. Strong support was obtained for a sister relationship between Leucheria (without syncephalium) and Polyachyrus, and both sister to Moscharia. Nassauvia and Triptilion form a distinct clade but are sister to other genera, Perezia and Panphalea, without syncephalium. Previous hypotheses postulated the evolution from simple to more complex secondary heads. We show that the ancestor of Moscharia, Polyachyrus, and Leucheria, in a more arid habitat, had a complex type of secondary head, and loss of complexity occurred in response to a shift from arid to mesic conditions.