The Peripheral Reduction With Keyhole Tongue Reduction Technique for Macroglossia in Beckwith-Wiedemann Syndrome.

OBJECTIVE: Patients with Beckwith-Wiedemann syndrome commonly have macroglossia, which can negatively affect dentoskeletal development, breathing, speaking, and eating. Tongue reduction surgery can improve symptoms, but there is no standardized surgical approach. METHODS: A video and observational commentary highlighting the effectiveness of a tongue reduction technique for BWS were presented. RESULTS: The peripheral resection with a keyhole approach safely reduced tongue volume, maintained the lateral neurovascular pedicles, optimized intraoperative visualization, and limited bleeding. CONCLUSIONS: The peripheral resection with a keyhole tongue reduction surgical technique is effective for treating symptomatic macroglossia in BWS.

Long-Term Surgical Outcomes of Primary Rhinoplasty.

OBJECTIVE: To examine the impact of primary rhinoplasty on subsequent rhinoplasties for patients with cleft lip nasal deformity. DESIGN: Retrospective cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Individuals who underwent definitive cleft lip repair at our institution from 2000 to 2006 with a current age of 18 or older. MAIN OUTCOME MEASURES: Number and timing of subsequent rhinoplasties. RESULTS: Among 199 individuals, 94 (47.2%) underwent primary rhinoplasty. Follow-up was 15.0 ± 4.8 years in the PR cohort and 15.0 ± 5.1 years in the NPR cohort (p = 0.993). In bilateral cleft lip, interdomal suture predicted fewer subsequent rhinoplasties (ß=-0.310, p = 0.033), while history of primary rhinoplasty predicted greater age at subsequent rhinoplasty (ß=1.800, p = 0.040). Among individuals with follow-up beyond age 18, intranasal stenting predicted fewer subsequent rhinoplasties (ß=-0.609, p = 0.015). Most underwent subsequent nasal correction aside from 7 (19.4%) and 9 (20.9%) in the PR and NPR cohorts, respectively (p = 0.536). There was no difference in mean subsequent rhinoplasties between cohorts (1.1 ± 0.8 versus 1.3 ± 1.1, p = 0.284). Individuals with complete cleft lip underwent more lifetime rhinoplasties (1.9 ± 1.0 versus 1.2 ± 1.2, p = 0.007). CONCLUSIONS: Primary rhinoplasty with interdomal tip sutures in bilateral cleft lip was associated with fewer subsequent rhinoplasties. Primary rhinoplasty may delay subsequent nasal correction, though most who underwent primary rhinoplasty ultimately required nasal correction later in childhood. Postoperative nasal stenting may provide longer-term nasal benefits and should be considered at time of definitive cleft lip repair.

Feasibility of predicting changes in gait biomechanics following muscle strength perturbations using optimal control in patients with transfemoral amputation.

Bone-anchored limbs (BALs) are socket prosthesis alternatives, directly fixing to residual bone via osseointegrated implant. There is a need to quantify multi-level effects of rehabilitation for transfemoral BAL users (i.e. changes in joint loading and movement patterns). Our primary objective was determining feasibility of using optimal control to predict gait biomechanics compared to ground-truth experimental data from transfemoral BAL users. A secondary objective was examining biomechanical effects from estimated changes in hip abductor muscle strength. We developed and validated a workflow for predicting gait biomechanics in four transfemoral BAL users and investigated the biomechanical effects of altered hip abductor strengths.

The doc versus the bot: A pilot study to assess the quality and accuracy of physician and chatbot responses to clinical questions in gynecologic oncology.

Artificial intelligence (AI) applications to medical care are currently under investigation. We aimed to evaluate and compare the quality and accuracy of physician and chatbot responses to common clinical questions in gynecologic oncology. In this cross-sectional pilot study, ten questions about the knowledge and management of gynecologic cancers were selected. Each question was answered by a recruited gynecologic oncologist, ChatGPT (Generative Pretreated Transformer) AI platform, and Bard by Google AI platform. Five recruited gynecologic oncologists who were blinded to the study design were allowed 15 min to respond to each of two questions. Chatbot responses were generated by inserting the question into a fresh session in September 2023. Qualifiers and language identifying the response source were removed. Three gynecologic oncology providers who were blinded to the response source independently reviewed and rated response quality using a 5-point Likert scale, evaluated each response for accuracy, and selected the best response for each question. Overall, physician responses were judged to be best in 76.7 % of evaluations versus ChatGPT (10.0 %) and Bard (13.3 %; p < 0.001). The average quality of responses was 4.2/5.0 for physicians, 3.0/5.0 for ChatGPT and 2.8/5.0 for Bard (t-test for both and ANOVA p < 0.001). Physicians provided a higher proportion of accurate responses (86.7 %) compared to ChatGPT (60 %) and Bard (43 %; p < 0.001 for both). Physicians provided higher quality responses to gynecologic oncology clinical questions compared to chatbots. Patients should be cautioned against non-validated AI platforms for medical advice; larger studies on the use of AI for medical advice are needed.

Revealing the Local Structure and Dynamics of the Solid Li Ion Conductor Li3P5O14.

The development of fast Li ion-conducting materials for use as solid electrolytes that provide sufficient electrochemical stability against electrode materials is paramount for the future of all-solid-state batteries. Advances on these fast ionic materials are dependent on building structure-ionic mobility-function relationships. Here, we exploit a series of multinuclear and multidimensional nuclear magnetic resonance (NMR) approaches, including 6Li and 31P magic angle spinning (MAS), in conjunction with density functional theory (DFT) to provide a detailed understanding of the local structure of the ultraphosphate Li3P5O14, a promising candidate for an oxide-based Li ion conductor that has been shown to be a highly conductive, energetically favorable, and electrochemically stable potential solid electrolyte. We have reported a comprehensive assignment of the ultraphosphate layer and layered Li6O16 26- chains through 31P and 6Li MAS NMR, respectively, in conjunction with DFT. The chemical shift anisotropy of the eight resonances with the lowest 31P chemical shift is significantly lower than that of the 12 remaining resonances, suggesting the phosphate bonding nature of these P sites being one that bridges to three other phosphate groups. We employed a number of complementary 6,7Li NMR techniques, including MAS variable-temperature line narrowing spectra, spin-alignment echo (SAE) NMR, and relaxometry, to quantify the lithium ion dynamics in Li3P5O14. Detailed analysis of the diffusion-induced spin-lattice relaxation data allowed for experimental verification of the three-dimensional Li diffusion previously proposed computationally. The 6Li NMR relaxation rates suggest sites Li1 and Li5 (the only five-coordinate Li site) are the most mobile and are adjacent to one another, both in the a-b plane (intralayer) and on the c-axis (interlayer). As shown in the 6Li-6Li exchange spectroscopy NMR spectra, sites Li1 and Li5 likely exchange with one another both between adjacent layered Li6O16 26- chains and through the center of the P12O36 12- rings forming the three-dimensional pathway. The understanding of the Li ion mobility pathways in high-performing solid electrolytes outlines a route for further development of such materials to improve their performance.

Arthroscopic Management of Posterior Shoulder Instability.

Posterior shoulder instability is a distinct subcategory of shoulder instability with an incidence higher than previously reported. Pain is typically the primary complaint, with pathology due to repetitive microtrauma being more common that a specific traumatic event. If nonoperative treatment fails, arthroscopic posterior capsulolabral repair has been shown to result in excellent outcomes and return to sport, with American football players having the best outcomes and throwers being slightly less predictable. Risk factors for surgical failure include decreased glenoid bone width, rotator cuff injury, female gender, and the use of less than 3 anchors.

Adjuvant therapy and recurrence risk in non-myoinvasive high-grade (stage IC) endometrial cancer: A systematic review and meta-analysis.

OBJECTIVE: To summarize practice patterns and outcomes among patients with non-myoinvasive high-grade (formerly stage IA, now stage IC) endometrial cancer. METHODS: We conducted a systematic search using MEDLINE, Embase, Cochrane, Web of Science, and ClinicalTrials.gov databases from inception to May 8, 2024 to identify studies reporting on treatment and outcomes of non-myoinvasive high-grade endometrial cancer. We included full-text English reports of patients undergoing adjuvant therapy or surveillance for polyp- or endometrium-confined high-grade endometrial cancer without myometrial invasion containing data on recurrence or survival outcomes. Two reviewers independently screened studies; a third reviewer resolved disagreements. Data were extracted using a standardized form. The primary outcome was recurrence risk. Random-effects meta-analysis was used to summarize binomial proportions and to compare outcomes by adjuvant treatment strategy. RESULTS: A total of 29 studies were included, representing 2770 unique patients. Overall, 49.0 % of patients were managed with observation and 37.9 % with chemotherapy. Most patients (92.5 %) had serous histology. Of 23 studies with data on recurrence, 13.7 % of patients recurred, with a meta-analysis estimate recurrence risk of 11 % (95 % confidence interval [CI]: 8-15 %). Across 13 studies reporting on recurrence by receipt of chemotherapy versus no chemotherapy, comparative meta-analysis showed similar likelihood of recurrence (8.0 % versus 13.2 %; odds ratio 0.73, 95 % CI: 0.38-1.42). Comparative meta-analyses for (1) adjuvant therapy versus observation and (2) observation or vaginal brachytherapy versus chemotherapy and/or external beam radiation therapy demonstrated no statistically significant difference in recurrence risk. Sensitivity analyses results, including those limiting to studies of patients with serous histology (12 studies) or complete surgical staging (10 studies), were overall consistent with the primary analysis. Survival data was inconsistently reported and not amenable to meta-analysis. CONCLUSION: Among patients with non-myoinvasive high-grade endometrial cancer, recurrence risk was 11 % and use of adjuvant therapy was not associated with reduced recurrence risk. Prospective study of this population is warranted.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer.

BACKGROUND: While utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist. OBJECTIVE: To evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer. STUDY DESIGN: Patients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race. RESULTS: Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery. CONCLUSIONS: Patients, particularly those of Black race, who lack local access to gynecologic oncologist specialty care benefit from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Near fatal case of mirvetuximab soravtansine-gynx induced interstitial lung disease and a review of the primary literature.

•Mirvetuximab soravtansine-gynx should be recognized as a cause of drug-induced interstitial lung disease (ILD).•Radiographic manifestations of mirvetuximab soravtansine-gyn induced ILD include organizing pneumonia pattern.•Interstitial lung disease related to mirvetuximab soravtansine-gyn can cause high morbidity.•Corticosteroids are commonly used in drug-induced interstitial lung disease and should be considered when encountering ILD related to mirvetuximab.•Changes to manufacturer dosing guidelines for grade 1 pneumonitis related to mirvetuximab soravtansine-gyn need to be considered.

Long-term photogrammetric outcomes of midface advancement in Apert syndrome: are we nearing normal?

BACKGROUND: The aesthetic goals of midface surgery in Apert syndrome are to correct the multi-planar midface deficiency and normalize facial ratios. This study characterizes the long-term photogrammetric outcomes of midface advancement in Apert syndrome. METHODS: Patients with Apert syndrome who underwent midface distraction from 2000 to 2023 were retrospectively reviewed. Soft tissue measurements were applied to preoperative (T0), short-term postoperative (T1), and long-term postoperative (T2) photographs. Long-term changes were compared between subcranial and transcranial procedures, segmental and non-segmental osteotomies, and individual techniques. Frontal facial dimensions at time T2 were compared to age- and sex-matched normal controls from the NIMH-ChEFS face database. RESULTS: Twenty patients had postoperative follow-up of T1 = 0.6 ± 0.4 and T2 = 4.7 ± 1.1 years and were compared to 40 normal controls. From time T0 to T2, middle facial third height increased (26.1 ± 3.0% to 27.8 ± 2.6%, p = 0.026), canthal tilt improved (- 7.6° ± 3.7° to - 3.9° ± 4.4°, p < 0.001), and facial convexity increased (182.9° ± 6.2° to 167.9° ± 8.6°, p < 0.001). From time T1 to T2, facial convexity flattened (159.4° ± 10.1° to 167.9° ± 8.6°, p < 0.001). Compared to controls, patients at time T2 had shorter middle facial third height (27.8 ± 2.6% vs. 32.0 ± 1.9%, p < 0.001) and reverse canthal tilt (- 3.9° ± 4.4° vs. 5.4° ± 2.6°, p < 0.001). CONCLUSIONS: A tailored treatment approach to the Apert midface yields varying degrees of resolution of central midfacial shortening, canthal tilt, and facial concavity at 5 years postoperatively. A slight reduction in facial convexity over time, likely reflecting pseudorelapse in the setting of sagittal overcorrection, should be anticipated. Greater utilization of segmental osteotomies may bring facial third ratios and canthal tilt closer to normal morphometric values.

Y and Mitochondrial Chromosomes in the Heterogeneous Stock Rat Population.

Genome-wide association studies typically evaluate the autosomes and sometimes the X Chromosome, but seldom consider the Y or mitochondrial Chromosomes. We genotyped the Y and mitochondrial Chromosomes in heterogeneous stock rats (Rattus norvegicus), an outbred population created from eight inbred strains. We identified 8 distinct Y and 4 distinct mitochondrial Chromosomes among the 8 founders. However, only two types of each nonrecombinant chromosome were observed in our modern heterogeneous stock rat population (generations 81-97). Despite the relatively large sample size, there were virtually no significant associations for behavioral, physiological, metabolome, or microbiome traits after correcting for multiple comparisons. However, both Y and mitochondrial Chromosomes were strongly associated with expression of a few genes located on those chromosomes, which provided a positive control. Our results suggest that within modern heterogeneous stock rats there are no Y and mitochondrial Chromosomes differences that strongly influence behavioral or physiological traits. These results do not address other ancestral Y and mitochondrial Chromosomes that do not appear in modern heterogeneous stock rats, nor do they address effects that may exist in other rat populations, or in other species.

Short-term outcomes in infants following general anesthesia with low-dose sevoflurane/dexmedetomidine/remifentanil versus standard dose sevoflurane (The TREX trial).

BACKGROUND: The TREX (Trial Remifentanil DEXmedetomidine) trial aimed to determine if, in children < 2 years old, low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia (LD-SEVO) is superior to standard dose sevoflurane (STD-SEVO) anesthesia in terms of global cognitive function at 3 years of age. The aim of the present secondary analyses was to compare incidence of intraoperative hypotension and bradycardia, postoperative pain, time to recovery, need for treatment of intraoperative hypotension and bradycardia, incidence of light anesthesia and need for treatment, need for postoperative pain medications, and morbidity and mortality outcomes at 5 days between the two arms. METHODS: This Phase III randomized active controlled, parallel group, assessor blinded, multicenter, superiority trial was performed in 20 centers in Australia, Italy, and the United States. Four hundred and fifty-five infants <2 years of age expected to undergo general anesthesia for at least 2 hours were enrolled. They were randomized between LD-SEVO and STD-SEVO. The short-term perioperative outcomes noted above were compared between these two groups. RESULTS: There was less hypotension (risk difference -11.6%, 95% confidence interval (CI) -18.9% to -4.3%) and more bradycardia (risk difference 18.2%, 95% CI 8.8% to 27.7%) in the LD-SEVO compared to the STD-SEVO arm. There were more patients with episodes of light anesthesia (89 vs. 4), and protocol abandonments (1 vs. 0) in the LD-SEVO arm. Time from eye-opening to Post Anesthesia Care Unit (PACU) discharge was similar in both arms, as were morbidity and mortality. One patient in each arm suffered a life-threatening event but neither suffered long-term sequelae. CONCLUSIONS: These early postoperative results suggest that in children less than 2 years of age receiving greater than 2 hours of general anesthesia, the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia technique and the standard sevoflurane anesthesia technique are broadly clinically similar, with no clear evidence to support choosing one technique over the other.

A blended genome and exome sequencing method captures genetic variation in an unbiased, high-quality, and cost-effective manner.

We deployed the Blended Genome Exome (BGE), a DNA library blending approach that generates low pass whole genome (1-4× mean depth) and deep whole exome (30-40× mean depth) data in a single sequencing run. This technology is cost-effective, empowers most genomic discoveries possible with deep whole genome sequencing, and provides an unbiased method to capture the diversity of common SNP variation across the globe. To evaluate this new technology at scale, we applied BGE to sequence >53,000 samples from the Populations Underrepresented in Mental Illness Associations Studies (PUMAS) Project, which included participants across African, African American, and Latin American populations. We evaluated the accuracy of BGE imputed genotypes against raw genotype calls from the Illumina Global Screening Array. All PUMAS cohorts had R 2 concordance ≥95% among SNPs with MAF≥1%, and never fell below ≥90% R 2 for SNPs with MAF<1%. Furthermore, concordance rates among local ancestries within two recently admixed cohorts were consistent among SNPs with MAF≥1%, with only minor deviations in SNPs with MAF<1%. We also benchmarked the discovery capacity of BGE to access protein-coding copy number variants (CNVs) against deep whole genome data, finding that deletions and duplications spanning at least 3 exons had a positive predicted value of ~90%. Our results demonstrate BGE scalability and efficacy in capturing SNPs, indels, and CNVs in the human genome at 28% of the cost of deep whole-genome sequencing. BGE is poised to enhance access to genomic testing and empower genomic discoveries, particularly in underrepresented populations.

Novel application of latent class analysis to outcome assessment in traumatic brain injury with multiple injury subtypes or poly-TBI.

OBJECTIVE: The aim of this study was to stratify poly-traumatic brain injury (poly-TBI) patterns into discrete classes and to determine the association of these classes with mortality and withdrawal of life-sustaining treatment (WLST). METHODS: The authors performed a single-center retrospective review of their institutional trauma registry from 2018 to 2020 to identify patients with traumatic brain injury (TBI). Patients were included if they had moderate to severe TBI, defined as Glasgow Coma Scale score ≤ 12 and Abbreviated Injury Scale (AIS) head score ≥ 3, and the presence of more than one TBI subtype. TBI subtypes were defined as subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and epidural hemorrhage (EDH). Latent class analysis was used to identify patient classes based on TBI subtypes and Rotterdam CT (RCT) scores. The authors then evaluated class membership in relation to categorical outcomes of in-hospital mortality and WLST by using Lanza et al.'s method. RESULTS: A total of 125 patients met inclusion criteria for poly-TBI. Latent class analysis yielded 3 poly-TBI classes: class 1-mixed; class 2-SDH/SAH; and class 3-EDH/SAH. Class 1-mixed had a higher likelihood of SDH, SAH, and ICH, and a lower likelihood of EDH. Class 2-SDH/SAH had a higher likelihood of only SDH and SAH. Class 3-EDH/SAH had a higher likelihood of EDH and SAH, and a lower likelihood of SDH and ICH. Class 1-mixed was relatively more likely to have an RCT score of 2. Class 2-SDH/SAH was relatively more likely to have an RCT score of 2, 3, and 4. Class 3-EDH/SAH had a higher likelihood of an RCT score of 3, 4, and 5. Class 1-mixed had significantly lower mortality (χ2 = 7.968; p = 0.005) and less WLST (χ2 = 4.618; p = 0.032) than Class 2-SDH/SAH. Class 2-SDH/SAH had the highest probability of death (0.612), followed by class 3-EDH/SAH (0.385) and class 1-mixed (0.277). Similarly, class 2-SDH/SAH had the highest WLST probability (0.498), followed by class 3-EDH/SAH (0.615) and class 1-mixed (0.238). CONCLUSIONS: Distinct poly-TBI classes were associated with increased in-hospital mortality and WLST. Further research with larger datasets will allow for more comprehensive poly-TBI class definitions and outcomes analysis.

A coddling of the sagittal suture: inequality in spring-assisted expansion.

PURPOSE: We examined differences in long-term morphometric outcomes of spring-mediated cranioplasty (SMC) for various forms of isolated nonsyndromic sagittal craniosynostosis. METHODS: A retrospective review was performed of children who underwent SMC from 2011 to 2020 at the Children's Hospital of Philadelphia. Cephalic indices (CI), Whitaker grades, parietal bone thickness, and degree of suture fusion were assessed. Frontal bossing and vertex-nasion-opisthocranion (VNO) angles were compared to a normal control group. RESULTS: Fifty-four subjects underwent surgery at age 3.6 ± 1.0 months with follow-up of 6.3 ± 1.8 years. Mean CI was 75.2 ± 4.1 at 5.9 ± 2.0 years postoperatively. Mean CI were 75.8 ± 4.1 (n = 32), 76.4 ± 4.0 (n = 22), and 77.1 ± 4.8 (n = 11) at 5, 7, and 9+ years postoperatively, respectively. Three (5.6%) required reoperation for persistent scaphocephalic cranial deformity. Fifty-one (94.4%) were Whitaker Grade I. On physical examination, 12 (22.2%) demonstrated craniofacial abnormalities. At long-term follow-up, there were no differences in frontal bossing angle (102.7 ± 5.2 degrees versus 100.7 ± 5.6 degrees, p = .052) and VNO angle (44.9 ± 3.3 degrees versus 43.9 ± 2.2 degrees, p = .063) between study and control groups. Younger age at surgery predicted a lower Whitaker grade, more normalized VNO angle, and greater change in CI during active expansion. Increased percentage fused of the posterior sagittal suture predicted a higher Whitaker grade, while decreased anterior fusion was associated with frontal bossing and temporal hollowing. CONCLUSIONS: Overall, children undergoing spring-mediated cranioplasty for sagittal craniosynostosis demonstrated maintenance of CI, favorable cosmetic outcomes, and a low reoperation rate at mid-term follow-up. Early intervention is associated with improved aesthetic outcomes, and regional fusion patterns may influence long-term craniofacial dysmorphology.

Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit.

BACKGROUND: ICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied. OBJECTIVE: We explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency. METHODS: This retrospective study at MedStar Washington Hospital Center included 209 adult patients admitted to the CICU between December 2021 and June 2022 receiving PCC. We compared outcomes between those receiving early (<72 h) and late (>72 h) PCC, including mortality, length of stay, and family meeting frequency. Statistical analysis included Wilcoxon rank sum tests, Chi-squared tests, Fisher's exact test, and Poisson regression models. RESULTS: The study included 209 patients admitted to the (M age = 68 years, SD = 14; 45 % female; 62 % Black, 30 % White) who received PCC, most (79 %) within 72 h. Early PCC was associated with shorter CICU stays (median, 3 vs. 5.5 days; p = 0.005). Early PCC patients had higher odds of family meetings (IRR=3.59; p < 0.001) and experienced a change in code status sooner (median 1 day vs. 3 days, p < 0.001). Late PCC patients were more likely to undergo tracheostomy (13.6% vs. 2.4 %; p = 0.007), cardioversion (9.1% vs. 1.8 %; p = 0.037), and have PEG tubes placed (13.6% vs. 2.4 %; p = 0.007). CONCLUSIONS: Early PCC in the CICU is associated with shorter CICU stays, fewer procedures, and more frequent family meetings.

First Report of Rhizoctonia solani AG 4 HG-III Causing Stem Lesion of Watermelon in Idaho.

In July 2022, stem lesions, approximately 4 to 5 cm in length as well as leaf wilt and dark brown necrosis on stems and roots were observed in two fields in Southwest Idaho on 20 to 30% of watermelons (Citrullus lanatus). To determine the causal agent, isolations were attempted from symptomatic tissue. The surface of the affected material was disinfected with 0.6% sodium hypochlorite for 1 min and rinsed three times with sterile water. Approximately 2 mm3 sections of tissue were plated on water agar amended with 0.02% penicillin and 0.08% streptomycin and incubated at room temperature for 7 days. Fungal colonies were tentatively identified as Rhizoctonia from right-angle branching and septate hyphal structures, slight constriction and septum near the branch base, and the production of 1 to 2 mm white to light brown irregularly shaped sclerotia. Single hyphal tips were transferred to potato dextrose agar (PDA) and grown at room temperature. Approximately ten isolates from each field with a consistent macromorphology were observed. These isolates had light brown mycelia, produced sclerotia at ambient temperature with no exposure to continuous light, and a representative isolate, designated D22-110 was selected for sequencing and pathogenicity testing. For isolate D22-110, mycelia were removed with a scalpel after 7 days of growth, for DNA extraction and sequencing of the rDNA internal transcribed spacer (ITS) region as previously described (White et al., 1990). A 726 bp product was generated and the sequence was submitted to GenBank (Accession No. OQ794049). NCBI-BLAST indicated this sequence was 99% identical (631 of 634 bp and 632 of 634 bp identical) with known reference isolates previously identified as R. solani AG 4 HG-III (Accession No. AF354075 and AF354076, respectively) from a phylogenetic study (Gonzalez et al., 2001). Pathogenicity testing was performed twice on two-week-old seedlings of watermelon cultivars Endless Summer and Wingman in greenhouse conditions (29oC, 12 h daylight). Two disks (3 mm diam) from 7-day-old plates of PDA were placed around each seedling at the root and stem convergence point. Ten seedlings were mock-inoculated with sterile PDA plugs as a control. Approximately 35% damping-off incidence was observed on inoculated seedlings six days post-inoculation, while control seedlings remained healthy. At 20 days post-inoculation, 20 (first trial) and 34 seedlings (second trial) were assessed for visible stem and root lesions. Incidence of stem lesions occurred on 90% of seedlings, with 80% of seedlings possessing lesions greater than 10 mm in diameter. Seedlings without R. solani inoculation were free of stem and root lesions. R. solani was re-isolated from symptomatic tissue, with 40% frequency of isolation, identified by right-angle branching of the hyphae thus confirming Koch's postulates. R. solani AG 4 has been reported in watermelon in the US since 1994 (Hall and Summer, 1994) but the AG 4 subgroup was not reported. AG 4 HG-III was reported in melon seedlings causing damping-off in Kyrgyzstan (Erper et al. 2016). In other hosts, AG 4 HG-III was found in potatoes in South Africa (Muzhinji et al., 2014), buckwheat and foxtail millet in China (Zhou et al., 2015; Hao et al., 2023), broccoli and spinach (Kuramae et al., 2003) and turnip green (Sekiguchi et al., 2015). To the best of our knowledge, this is the first report of R. solani AG 4 HG-III causing disease in watermelon in Idaho. Given the the rate of disease incidence observed in the field, growers should consider avoiding planting alternative host crops to minimize inoculum buildup.

Effect of older adult health and age on psychology doctoral trainees' expectations of clinical work with older adult clients.

This experimental, repeated-measures study investigated the effects of client health and client age on doctoral psychology students' clinical expectations for their work with older adult clients. Doctoral clinical and counseling psychology trainees (N = 223) completed measures assessing clinical expectations for three older adult clients of varying health status (healthy, recent Alzheimer's Disease (AD) diagnosis, heart disease) who all presented with depressive symptoms. Trainees were randomly assigned to the 71-year-old or 81-year-old condition. Trainees perceived a depressed client with a recent AD diagnosis as a less appropriate candidate for therapy, less motivated and less responsible for therapy, and less able to develop a therapeutic relationship. Additional health-based differences in prognosis, comfort, and competence were moderated by client age. Although age did have a small effect, the health of the older adult client had a stronger influence on trainees' clinical expectations for work with older adults. Cognitive health concerns were perceived as a greater barrier to clinical work with older adults than were physical health concerns. Health biases for clinical work with older adults could impact the quality of mental healthcare provided.