Characteristics of coexisting attractors and ghost orbiting in an optomechanical microresonator.

We explore the nonlinear interactions of an optomechanical microresonator driven by two external optical signals. Optical whispering-gallery waves are coupled to acoustic surface waves of a fused silica medium in the equatorial plane of a generic microresonator. The system exhibits coexisting attractors whose behaviors include limit cycles, steady states, tori, quasi-chaos, and fully developed chaos with ghost orbits of a known attractor. Bifurcation diagrams demonstrate the existence of self-similarity, periodic windows, and coexisting attractors and show high-density lines within chaos that suggests a potential ghost orbit. In addition, the Lyapunov spectral components as a function of control parameter illuminate the dynamic nature of attractors and periodic windows with symmetric and asymmetric formations, their domains of existence, their bifurcations, and other nonlinear effects. We show that the power-shift method can access accurately and efficiently attractors in the optomechanical system as it does in other nonlinear systems. To test whether the ghost orbit is the link between two attractors interrupted by chaos, we examine the elements of the bifurcation diagrams as a function of control parameter. We also use detuning as a second control parameter to avoid the chaotic region and clarify that the two attractors are one.

Identifying research priorities for infection prevention and control. A mixed methods study with a convergent design.

Background: Meaningful research creates evidence for Infection Prevention and Control (IPC) practice. Aim: To establish Infection Prevention Society (IPS) members' research priorities to support future research projects. Methods: A mixed methods convergent parallel design incorporating a cross-sectional survey of IPS members (2022-2023), and focus group findings from the IPS Consultative Committee, (October 2022). Quantitative data were analysed using descriptive statistics. Qualitative data were transcribed verbatim, entered into NVivo 12, and analysed using a thematic analysis approach. Findings/Results: 132 IPS members responded to the survey, including 120 (90.9%) nurses. The three most prevalent priorities were: Quality Improvement and Patient Safety (n = 84, 16.1%); IPC Training and Education (n = 77, 14.8%); and IPC Evidence-based Guidelines (n = 76, 14.6%). Analysis of the focus group transcripts identified six emergent themes 'Patient Centred Care', 'Training and Education', 'IPC Role and Identity', 'IPC Leadership', 'IPC is Everyone's Responsibility', and 'Research Activity'. Triangulation of findings demonstrated concordance between quantitative and qualitative findings with Quality Improvement and Patient Safety (QIPS) and Training and Education identified as priority research areas. Discussion: This study highlights the necessity of developing support systems and incorporating research priorities in QIPS, as well as Training and Education. The findings of this study align with the recommended core competencies and components for effective infection prevention and control programs, making them relevant to QIPS initiatives. The outcomes of the study will serve as a valuable resource to guide the IPS Research and Development Committee in delivering practical support to IPS members.

Insurance Approval for Laparoscopic Sleeve Gastrectomy in Adolescents in the Midsouth.

Background: Metabolic and bariatric surgery (MBS) has been shown to be safe and effective for the treatment of adolescent obesity, yet many providers express hesitance to refer adolescents for surgery due to concerns for insufficient insurance coverage. Methods: The Healthy Lifestyle Clinic, a pediatric weight management clinic, was established in 2014, and an adolescent MBS program was added in 2017. Patients 15 years or older who meet the selection criteria are eligible for the surgery track. A retrospective chart review was conducted to describe our experience obtaining insurance approval for laparoscopic sleeve gastrectomy (LSG) for our adolescent patients. Results: Almost all patients who were interested in and eligible for LSG ultimately received insurance approval. Most patients had public insurance (70%). Sixty-four percent of patients were approved after the initial application, 23% were approved after a peer-to-peer review, and 11% required an appeal for approval. There was no difference in the time from insurance application to insurance approval based on age, race/ethnicity, or type of insurance. Conclusions: Age <18 years and having public health insurance have not been demonstrated as barriers to insurance approval for LSG in our cohort. Providers should not delay referral for MBS for eligible adolescents based on concern for insufficient insurance coverage. Adolescent MBS programs would benefit from a patient advocate to help families navigate the insurance approval process and reduce barriers to surgery.

Use of wheat dilution to improve digestive function in broilers: application in low protein diets.

1. This study evaluated the effect of wheat dilution increasing in particle size in low crude protein diets on growth performance, digestive tract, nitrogen efficiency and litter quality in broiler chickens.2. Ross 308 male broiler chicks (n = 336) were allocated to one of four dietary treatments (each with 7 pens, 12 chicks per pen); Control (CON; commercial pellet diet with standard crude protein, CP: 22.50%), W578 (CON +20% wheat of geometric mean diameter (GMD) of 578 µm; CP: 20.25%), W1326 (CON +20% wheat of GMD 1326 µm; CP: 20.25%) and WW (CON +20% whole wheat, CP: 20.25%), from d 0 to 21 of age.3. Body weight gain was increased (P < 0.05) for birds fed CON compared to the low crude protein diets. However, WW increased (P < 0.05) body weight gain compared to W578 and W1326, while feed intake and feed conversion ratio on CON and WW were similar (P > 0.05). Birds fed W1326 showed the poorest (P < 0.05) FCR compared to CON, W578 and WW.4. Gizzard relative weight (g/kg body weight) was increased (P < 0.05) on WW compared to CON on d 14 and 21, whereas gastric isthmus diameter was significantly reduced on W1326 and WW compared with CON and W578.5. There were no differences (P > 0.05) in the depth of gizzard mucosa of lamina propria between CON and WW at d 14 and 21. Birds fed WW increased (P < 0.05) gizzard tensile strength compared to W578 and W1326, whereas no difference was observed between WW and CON on d 14.6. No significant differences were seen for ileum villus height and mucosal layer between CON and WW on d 21, however, feeding CON increased the extent of the mucosal layer compared to W578 and W1326.7. Nitrogen excretion (g/kg BWG) was significantly lower (P > 0.05) on W1326 and WW compared with CON and W578. Litter nitrogen, moisture, and footpad scores significantly decreased (P < 0.05) for birds fed WW compared with CON.8. Diluting dietary protein content from 22.50 to 20.25% resulted in lower body weight gain in broilers. However, dilution with whole wheat resulted in comparable FCR, reduced nitrogen excretion, litter moisture and footpad dermatitis compared with a standard protein diet.

Assessment of Adverse Childhood Experiences and Social Determinants of Health: A Survey of Practices in Pediatric Weight Management Programs.

Introduction: Adverse childhood experiences (ACEs) and social determinants of health (SDoH) are associated with increased incidence of pediatric obesity. Recent literature highlights an imperative need to assess ACEs and SDoH among youth and families with obesity to identify those individuals requiring targeted interventions. The primary objective of the present study was to examine the frequency, methodology, and barriers in evaluation of ACEs and SDoH within pediatric weight management programs (PWMPs). Methods: Invitations were e-mailed to a comprehensive directory of 92 PWMPs in the United States with a link to complete an electronic survey. Results: Forty-one PWMPs from 26 states completed the survey. Assessment of one or more ACEs and SDoH was common and typically took place during the initial patient visit by the psychologist or medical practitioner through unstructured conversations. Reported barriers to assessment included lack of time to assess and to follow-up, lack of clinic protocols, and inadequate referral resources. Programs offering bariatric surgery and those with embedded mental health clinicians reported fewer barriers to ACEs/SDoH referral resources, while family-based and healthy lifestyle-focused programs perceived more barriers related to insufficient support staff and time to follow-up with families. Conclusions: Most PWMPs assess a subset of ACEs and SDoH; however, approaches to assessment vary, are often unstructured, and several barriers remain to optimizing assessment and follow-up. Future research should evaluate standardized ACEs/SDoH assessment protocols, ideal workflow, and their impact on obesity treatment and related health outcomes.

Xylo-oligosaccharide-based prebiotics upregulate the proteins of the Sus-like system in caecal Bacteroidetes of the chicken: evidence of stimbiotic mechanism.

The present study was conducted to investigate the stimbiotic mechanism of xylo-oligosaccharide (XOS) in degrading the complex polysaccharides by the caecal bacteria of the chicken, by applying a proteomic approach. A total of 800 as-hatched Ross 308 broiler chicks were equally divided into 4 experimental pens (200 chicks per pen) at a commercial poultry barn, allocating 2 pens per treatment. Birds were fed ad libitum with 2 dietary treatments; CON (without XOS) and XOS (with 0.1g XOS/kg diet) from d 0 to 35. From each pen, 60 Individual birds were weighed weekly whereas caecal content was obtained from 5 birds cervically dislocated on d 35. The caecal bacteria were lysed and their proteins were quantified using label-free quantitative proteomic mass spectrometry. The results showed that XOS significantly increased (P < 0.05) bird weight on d 7, 14, 21, and 28, and body weight gain on d 7, 14, 21, and 35 compared to CON. However, no difference (P > 0.05) in body weight gain was observed from d 0 to 35 between CON and XOS. The proteomic analysis of caecal bacteria revealed that 29 proteins were expressed differently between the CON and the XOS group. Out of 29, 20 proteins were significantly increased in the XOS group compared to CON and 9 of those proteins belonged to the starch-utilizing system (Sus)-like system of the gram-negative Bacteroidetes. Bacteroides thetaiotaomicron (Bt) is a significant constituent of the human gut microbiota, known for its remarkable ability to hydrolyze most glycosidic bonds of polysaccharides. This microorganism possesses a 5-protein complex in its outer membrane, named the starch utilization system (Sus), responsible for adhering to, breaking down, and transporting starch into the cell. Sus serves as an exemplar system for numerous polysaccharide utilization loci that target glycans found in Bt and other members of the Bacteroidetes phylum. The proteins of the Sus-like system are involved in the degradation of complex polysaccharides and transportation of the oligosaccharides into the periplasm of the caecal bacteria where they are further broken down into smaller units. These smaller units are then transported into the cytoplasm of the cell where they are utilized in metabolic pathways leading to potential generation of short-chain fatty acids, thus improving the nutritive value of residual feed. In conclusion, XOS supplementation upregulates the expression of the proteins of the Sus-like system indicating its role as a stimbiotic.

Addressing Obesity Care in Children With Chronic Health Conditions.

Obesity care in pediatric populations has entered a new era. The recent discovery of molecular genetic causes for abnormal weight gain, development of antiobesity medications, mounting data on the robust efficacy and favorable safety profile of bariatric surgery, and implementation of clinical guidelines fill a long-standing gap in the care of children affected by obesity, one of the most challenging pediatric diseases. However, these novel clinical approaches do not appear to have reached every individual who is in need, particularly children with chronic health conditions (CHCs), raising important questions for equitable medical care. In this study, we discuss specific etiologies, challenges, and ideas for future directions in diagnosing and managing obesity in children with CHCs. Although this article is not intended to be utilized as clinical guidelines, it underscores potential practical solutions for the current issues.

IL-6 and IL-27 play both distinct and redundant roles in regulating CD4 T-cell responses during chronic viral infection.

The IL-6 cytokine family signals through the common signal transduction molecule gp130 combined with a cytokine-specific receptor. Gp130 signaling on CD4 T cells is vital in controlling chronic infection of mice with lymphocytic choriomeningitis virus clone 13 (LCMV Cl13), but the precise role of individual members of the IL-6 cytokine family is not fully understood. Transcriptional analysis highlighted the importance of gp130 signaling in promoting key processes in CD4 T cells after LCMV Cl13 infection, particularly genes associated with T follicular helper (Tfh) cell differentiation and IL-21 production. Further, Il27r-/-Il6ra-/- mice failed to generate antibody or CD8 T-cell immunity and to control LCMV Cl13. Transcriptomics and phenotypic analyses of Il27r-/-Il6ra-/- Tfh cells revealed that IL-6R and IL-27R signaling was required to activate key pathways within CD4 T cells. IL-6 and IL-27 signaling has distinct and overlapping roles, with IL-6 regulating Tfh differentiation, IL-27 regulating CD4 T cell survival, and both redundantly promoting IL-21.

Efficacy of oat hulls varying in particle size in mitigating performance deterioration in broilers fed low-density crude protein diets.

Dietary fibres with increased particle size may develop foregut more efficiently in meat poultry fed diets moderately low in crude protein. The study investigated the performance of broilers fed low-density crude protein diets with the inclusion of oat hulls increasing in particle size. Ross 308 male broiler chicks (n = 336) were divided into 48 pens, 12 pens per treatment (7 chicks per pen). Pens were allocated to 4 dietary treatments in mash form; positive control (PC), a standard crude protein diet, negative control (NC), around 5% lower in protein with 5% celite as an inert material, OH400: 5% lower protein diet with 5% oat hulls of geometric mean diameter (GMD) 400 µm, OH850: 5% lower protein diet with 5% oat hulls of GMD 850µm. Birds were fed ad libitum from d 1 to 35 in 3 phases; starter: d 0 to 10, grower: d 10 to 24 and finisher: d 24 to 35. Growth performance was calculated at the end of the trial. Two birds per pen were sampled on d 24 and 35 to collect data on proventriculus and gizzard weights and pooled ileal digesta. Apparent ileal digestibility of amino acids on d 24, and metabolizable energy on d 24 and 35 were recorded for each pen. Litter was sampled from each pen on d 34 to analyze litter N and moisture content. Footpad dermatitis scores of all birds per pen were recorded on d 35. Overall, no difference (P > 0.05) in body weight gain and feed intake was found between the treatments. However, NC and OH400 showed poorer FCR than PC, whereas FCR on PC and OH850 was similar (P > 0.05). Gizzard absolute weight and relative to body weight, and gizzard to proventriculus ratio were higher (P < 0.05) on OH850 compared to PC and NC on d 24 and 35. Gizzard digesta particle size was reduced (P < 0.05) on OH850 compared to all other diets on d 24 and 35. Amino acids digestibility coefficients for aspartic acid and valine increased (P < 0.05) in birds fed OH850 compared to PC, whereas coefficients for several other amino acids were improved compared to NC and OH400. The apparent ileal digestibility of metabolizable energy was similar (P > 0.05) between PC and OH850. Litter moisture and nitrogen, and footpad dermatitis scores were reduced (P < 0.05) on OH850 compared to PC. In conclusion, the inclusion of coarse oat hulls of GMD 850 µm in low-density crude protein diets can be beneficial for the broilers in developing the foregut, utilizing the nutrients efficiently and reducing litter nitrogen and moisture, and footpad scores.

Efficacy of immune checkpoint inhibitors for the treatment of advanced melanoma in patients with concomitant chronic lymphocytic leukemia.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the management of advanced melanoma (AM). However, data on ICI effectiveness have largely been restricted to clinical trials, thereby excluding patients with co-existing malignancies. Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia and is associated with increased risk of melanoma. CLL alters systemic immunity and can induce T-cell exhaustion, which may limit the efficacy of ICIs in patients with CLL. We, therefore, sought to examine the efficacy of ICI in patients with these co-occurring diagnoses. PATIENTS AND METHODS: In this international multicenter study, a retrospective review of clinical databases identified patients with concomitant diagnoses of CLL and AM treated with ICI (US-MD Anderson Cancer Center, N = 24; US-Mayo Clinic, N = 15; AUS, N = 19). Objective response rates (ORRs), assessed by RECIST v1.1, and survival outcomes [overall survival (OS) and progression-free survival (PFS)] among patients with CLL and AM were assessed. Clinical factors associated with improved ORR and survival were explored. Additionally, ORR and survival outcomes were compared between the Australian CLL/AM cohort and a control cohort of 148 Australian patients with AM alone. RESULTS: Between 1997 and 2020, 58 patients with concomitant CLL and AM were treated with ICI. ORRs were comparable between AUS-CLL/AM and AM control cohorts (53% versus 48%, P = 0.81). PFS and OS from ICI initiation were also comparable between cohorts. Among CLL/AM patients, a majority were untreated for their CLL (64%) at the time of ICI. Patients with prior history of chemoimmunotherapy treatment for CLL (19%) had significantly reduced ORRs, PFS, and OS. CONCLUSIONS: Our case series of patients with concomitant CLL and melanoma demonstrate frequent, durable clinical responses to ICI. However, those with prior chemoimmunotherapy treatment for CLL had significantly worse outcomes. We found that CLL disease course is largely unchanged by treatment with ICI.

Uptake and incorporation of Al, Cr, V, Zn and Mo in hematite: Competition, synergies and influence on structural properties.

This study investigated multiple (di-, tri- and tetra-)incorporation of selected minor and trace elements (Al3+, Cr3+, V3-5+, Zn2+, Mo6+ and As5+) into hematite. The purpose was to improve understanding of how hematite may control trace element mobility in the environment, and how physical and chemical properties of hematite are impacted by multi-element incorporation at x/Fe molar ratios of up to 10%. Simultaneous structural incorporation of Al±Cr±V±Zn into hematite was achieved, with both synergistic and antagonistic effects occurring between certain element combinations. Cr+Al had synergistic effects on their co-incorporation, while V negatively affected Al incorporation, and both V and Zn negatively affected Cr incorporation. In contrast, Mo was minimally associated with hematite, and As prevented hematite formation completely. X-ray diffraction indicated contraction and expansion of the hematite unit-cell upon substitution was related to the ionic radius of the substituting element in single-element samples, while V predominantly controlled the direction of deviation in multi-element samples. X-ray absorption near-edge structure spectroscopy indicated V was present as a mixture of V3+-V5+, with a higher average V oxidation state associated with multi-element samples. Results provide new insights into trace element geochemistry within hematite, and highlight the importance of multi-element studies to better understand natural and anthropogenic systems.

Adverse childhood experiences, health behaviors, and associations with obesity among youth in the United States.

Adverse Childhood Experiences (ACEs) affect almost half of youth in the U.S. and are linked to a host of deleterious medical and psychosocial outcomes. The current study examines the relationships among ACEs, childhood obesity, and modifiable lifestyle behaviors to inform clinical care, future research, and policy. Using data from the 2016-2018 National Survey of Children's Health (NSCH), associations between children's ACEs, weight status, and health behaviors that may influence the link between ACEs and obesity were examined. In the NSCH data, 25.3% of youth aged 10-17 years experienced one ACE with another 25.9% experiencing two or more ACEs. Having ACEs was related to excess screen time and inadequate sleep, and independently associated with obesity. Findings highlight the importance of providers screening and finding ways to intervene on behalf of youth with obesity. The present provides guidelines for providers on intervening with youth experiencing ACEs.

Nonsuicidal Self-injury and Barriers to Accessibility of Dialectical Behavior Therapy Among Black Youth.

Youth in communities of color are disproportionately affected by the current mental health crisis, as highlighted in the recent Declaration of National Emergency by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and the Children's Hospital Association (CHA).1 The structural racism that Black youth encounter is a social determinant of health that contributes to inequitable access to evidence-based mental health services. Black youth in the United States experience inequities in financial hardships, access to educational resources, and the undue burden of the coronavirus disease 2019 (COVID-19) pandemic, further exacerbating an already outsized mental health burden.2.

Sex Education and Sexual Risk Behavior among Adolescents and Youth in the Deep South: Implications for Youth HIV Prevention.

OBJECTIVES: Adolescents and young adults represent the largest group of new human immunodeficiency virus (HIV) infections in the United States, especially in the South. We wanted to determine whether abstinence only until marriage (AOUM) sex education programs were effective in reducing HIV vulnerability among youth in Mississippi. METHODS: Using the 2015 Mississippi Youth Risk Behavior Surveillance System, we examined the effect of AOUM sex education among a sample of youth ages 12 to 18 years on 4 HIV-related sexual risk behaviors. RESULTS: Compared with youth not enrolled in AOUM sex education, we found no statistically significant differences on sexual risk behaviors. Race, age, and gender were significant risk factors in predicting sexual risk behavior. CONCLUSIONS: AOUM sex education programs are ineffective in reducing HIV vulnerability among youth in Mississippi. There is an urgent need to implement comprehensive sex education if we are to reduce the numbers of new HIV infections among youth and achieve our goals of ending the HIV epidemic by 2030.

The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals.

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals' knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September-October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: 'Knowledge'; 'Social/professional role and identity'; 'Social influences'; 'Memory, attention and decision processes'; 'Beliefs about consequences'; 'Environmental contexts and resources'. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

Prevalence of Upper Gastrointestinal Inflammation in Teens With Obesity Prior to Sleeve Gastrectomy.

INTRODUCTION: Upper gastrointestinal (UGI) pathologies are common in adolescents with obesity. This study aims to determine the prevalence of UGI inflammation on preoperative esophagogastroduodenoscopy (EGD) in adolescents undergoing sleeve gastrectomy (SG) and to assess weight loss outcomes. METHODS: This is a retrospective analysis of pathology reports from EGD biopsies performed prior to SG from September 2017 to August 2020. Percentage weight loss was measured at 3, 6, and 12 mo after surgery. Percent total body weight loss (TBWL) was compared between patients with and without UGI inflammation. RESULTS: Thirty adolescents underwent laparoscopic SG. Mean TBWL was 22% of total body weight 12 mo after surgery. Preoperative EGD identified 9 (30%) patients with esophagitis, 10 (33%) with gastritis, and 9 (30%) with duodenitis. Twenty-one patients (70%) had inflammation of at least one area, 5 (17%) were Helicobacter pylori positive, and 1 (3%) had a gastric ulcer that delayed surgery. Five (17%) patients were taking antacids prior to EGD. Patients with preoperative gastric or duodenal inflammation had significantly less TBWL 12 mo after SG compared to patients without gastric (24.6% versus 16.7%, P = 0.04) or duodenal inflammation (25.7% versus 14.1%, P = 0.02). CONCLUSIONS: There is a high prevalence of UGI inflammation in adolescents undergoing SG. Gastric and duodenal inflammation is associated with less TBWL after SG.

Prevention of Exposure Keratopathy in the Intensive Care Unit: Evaluation of an EMR-Based Lubrication Order Protocol for Ventilated Patients.

Purpose In this pilot study, we aimed to investigate the efficacy of an electronic medical record (EMR) order set for lubricating ointment (four times daily) in the prevention of exposure keratopathy in ventilated patients in the intensive care unit (ICU) at the University of Utah. We attempted to capture the magnitude of morbidity, cost, and care burden in ventilated patients, as well as the utility of a systematic EMR-based preventative lubrication protocol in the ICU setting. Methods After implementation of the order set, a retrospective chart review was performed to capture all ventilated ICU patients pre- and postintervention. Three separate study periods were used: (1) Six months prior to coronavirus disease 2019 (COVID-19) and prior to the ocular lubrication intervention; (2) the subsequent 6-month period including COVID-19 patients but prior to any intervention; and (3) the subsequent 6-month period postintervention, including COVID-19 patients. The primary endpoint of ointment use per day was analyzed with a Poisson regression model. Secondary endpoints including rates of ophthalmologic consultation and exposure keratopathy were compared with Fisher's exact test. A poststudy survey of ICU nurses was included. Results A total of 974 ventilated patients were included in the analysis. Ointment use per day increased by 155% (95% confidence interval [CI] 132-183%, p < 0.001) following the intervention. Rates also increased 80% (95% CI 63-99%, p < 0.001) during the COVID-19 study period but prior to intervention. The percentage of ventilated patients requiring a dilated eye exam for any indication was 3.2, 4, and 3.7% in each of the study periods, respectively. There was an overall down trend in the rate of exposure keratopathy which was diagnosed in 33.3, 20, and 8.3% of those receiving ophthalmologic consultation, though these rates were not statistically significant. Conclusion These preliminary data show a statistically significant increase in the rates of lubrication in mechanically ventilated patients using an EMR-based order set in the ICU setting. There was no statistically significant decrease in the rates of exposure keratopathy. Our preventative protocol with lubrication ointment was of minimal cost burden to the ICU. Further longitudinal and multicenter studies are needed to better assess the efficacy of such a protocol.

Addressing Structural Racism Is Critical for Ameliorating the Childhood Obesity Epidemic in Black Youth.

Racism and childhood obesity are both pervasive factors adversely affecting the health and wellbeing of children and adolescents in the United States. The association between racism and obesity has been touched upon in the literature; yet most work has focused on a few dimensions of intersectionality of these two domains at one time. The renewed focus on structural racism as the primary contributor to distress of Black individuals in the United States has highlighted the urgency of identifying the contributions of racism to the childhood obesity epidemic. The current article is not a complete review of the literature, rather, it is meant to take a broad narrative review of the myriad ways in which racism contributes to the obesity epidemic in Black youth to serve as a call to action for more research, prevention, and intervention. The current article illustrates how a number of mechanisms for the etiology and maintenance of obesity are heavily influenced by racism and how addressing racism is critical for ameliorating the childhood obesity epidemic.

Survival by age in paediatric and adolescent patients with Hodgkin lymphoma: a retrospective pooled analysis of children's oncology group trials.

BACKGROUND: Adolescents with Hodgkin lymphoma have worse disease outcomes than children. Whether these differences persist within clinical trials is unknown. We examined survival, by age, in patients receiving response-adapted therapy for Hodgkin lymphoma on Children's Oncology Group (COG) trials. METHODS: Patients (aged 1-21 years) diagnosed with classical Hodgkin lymphoma and enrolled between Sept 23, 2002, and Jan 19, 2012, on one of three phase 3 COG trials in the USA and Canada were eligible for inclusion. The three COG trials were defined by risk group according to Ann Arbor stage, B-symptoms, and bulk (AHOD0431 [low risk; NCT00302003], AHOD0031 [intermediate risk; NCT00025259], or AHOD0831 [high risk; NCT01026220]). The outcomes of this study were event-free survival (death, relapse, or subsequent neoplasm) and overall survival. Cox proportional hazards models estimated survival, adjusting for disease and treatment factors both overall and in patients with mixed cellularity or non-mixed cellularity (nodular sclerosing and not-otherwise-specified) disease. FINDINGS: Of 2155 patients enrolled on the three trials, 1907 (88·4%; 968 [50·8%] male and 939 [49·2%] female; 1227 [64·3%] non-Hispanic White) were included in this analysis. After a median follow-up of 7·4 years (IQR 4·3-10·2), older patients (aged ≥15 years) had worse unadjusted 5-year event-free survival (80% [95% CI 78-83]) than did younger patients (aged <15 years; 86% [83-88]; HR 1·38 [1·11-1·71]; p=0·0038). Older patients also had worse unadjusted 5-year overall survival than did younger patients (96% [95% CI 95-97] vs 99% [98-99]; HR 2·50 [1·41-4·45]; p=0·0012). In patients with non-mixed cellularity histology, older patients had a significantly increased risk of having an event than did younger patients with the same histology (HR 1·32 [1·03-1·68]; p=0·027). Older patients with mixed cellularity had significantly worse 5-year event-free survival than did younger patients in unadjusted (77% [95% CI 65-86] for older patients vs 94% [88-97] for younger patients; HR 2·93 [1·37-6·29]; p=0·0039) and multivariable models (HR 3·72 [1·56-8·91]; p=0·0032). Overall, older patients were more likely to die than younger patients (HR 3·08 [1·49-6·39]; p=0·0025). INTERPRETATION: Adolescents (≥15 years) treated on COG Hodgkin lymphoma trials had worse event-free survival and increased risk of death compared with children (<15 years). Our findings highlight the need for prospective studies to examine tumour and host biology, and to test novel therapies across the age spectrum. FUNDING: National Institutes of Health, St Baldrick's Foundation, and Lymphoma Research Foundation.