A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists.

This project sought to explore the experiences, self-perceived preparation, professional development needs, and preferred learning methods of certified registered nurse anesthetists (CRNAs) in a management role. A sample of 10 current chief CRNAs responded to a demographics survey and participated in one-on-one interviews using a 14-question, semi-structured interview framework modified from a previous study. Interview responses were deidentified and qualitatively analyzed for common themes by two content experts and one qualitative analysis expert. Results suggest that CRNAs entering the management field feel somewhat unprepared to perform the administrative tasks associated with their role. Qualitative analysis of interview responses elicited multiple key themes including interpersonal communication and handling crucial conversations, time and organizational management skills, team building and motivation, and financial management skills. Themes related to preferred learning methods of chief CRNAs included mentorship, peer networking, and experiential learning to obtain the required knowledge and skills for the role. The authors recommend incorporating each of the identified themes to guide development of CRNA management-specific educational programs. Establishing such a program will serve to better prepare aspiring CRNA managers and further develop the knowledge and skillset of current chief CRNAs.

Heterogeneous deposition of regular and mentholated little cigar smoke in the lungs of Sprague-Dawley rats.

BACKGROUND: Quantifying the dose and distribution of tobacco smoke in the respiratory system is critical for understanding its toxicity, addiction potential, and health impacts. Epidemiologic studies indicate that the incidence of lung tumors varies across different lung regions, suggesting there may be a heterogeneous deposition of smoke particles leading to greater health risks in specific regions. Despite this, few studies have examined the lobar spatial distribution of inhaled particles from tobacco smoke. This gap in knowledge, coupled with the growing popularity of little cigars among youth, underscores the need for additional research with little cigars. RESULTS: In our study, we analyzed the lobar deposition in rat lungs of smoke particles from combusted regular and mentholated Swisher Sweets little cigars. Twelve-week-old male and female Sprague-Dawley rats were exposed to smoke particles at a concentration of 84 ± 5 mg/m3 for 2 h, after which individual lung lobes were examined. We utilized Inductively Coupled Plasma Mass Spectrometry to quantify lobar chromium concentrations, serving as a smoke particle tracer. Our findings demonstrated an overall higher particle deposition from regular little cigars than from the mentholated ones. Higher particle deposition fraction was observed in the left and caudal lobes than other lobes. We also observed sex-based differences in the normalized deposition fractions among lobes. Animal study results were compared with the multi-path particle dosimetry (MPPD) model predictions, which showed that the model overestimated particle deposition in certain lung regions. CONCLUSIONS: Our findings revealed that the particle deposition varied between different little cigar products. The results demonstrated a heterogenous deposition pattern, with higher particle deposition observed in the left and caudal lobes, especially with the mentholated little cigars. Additionally, we identified disparities between our measurements and the MPPD model. This discrepancy highlights the need to enhance the accuracy of models before extrapolating animal study results to human lung deposition. Overall, our study provides valuable insights for estimating the dose of little cigars during smoking for toxicity research.

Subpectoral Biceps Tenodesis Using an All-Suture Knotless Anchor.

The long head of the biceps tendon is a common pain generator in the anterior shoulder and is concomitantly seen with other shoulder pathology including subacromial impingement, as well as rotator cuff and labral tears. This Technical Note describes a mini-open onlay biceps tenodesis technique using all-suture knotless anchor fixation. This technique is easily reproducible, is efficient, and offers the unique benefits of providing a consistent length-tension relation and mitigating the risk of peri-implant reaction and fracture without sacrificing strength of fixation.

Evaluating safe time to discharge after closed reduction and percutaneous pinning of uncomplicated type III supracondylar humerus fractures: a single-center retrospective review.

The purpose of this retrospective study was to review complications following closed reduction, percutaneous pinning of isolated, type III supracondylar fractures without associated injuries to evaluate if patients may be discharged safely on the day of surgery. We performed a retrospective chart and radiographic review of patients with isolated Gartland type III supracondylar humerus fractures who underwent closed reduction and percutaneous pinning over a 4-year period. We reviewed admission time to the emergency department, time and length of surgery, time to discharge, postoperative complications, readmission rate and office visits. Of the 110 patients included, 19 patients were discharged in less than 6 h, 45 patients between 6 and 12 h and 46 patients greater than 12 h. A total of 61 patients were discharged on the same day as surgery and 49 were discharged the next day. There were 11 postoperative complications. No postoperative complications were found in patients discharged less than 6 hours from surgery. For patients discharged between 6 and 12 hours postoperatively, one patient returned to the office earlier than scheduled. The result of our review suggests that patients can be safely discharged within the 12-h postoperative period with no increased risk of complications. This is contingent upon the patient having a stable neurovascular examination, pain control and caregiver's comfort level. This can decrease medical cost, family stress and burden to the hospital system. Time to discharge should still be evaluated on a case-by-case basis after evaluating medical and social barriers.

MRI/PET multimodal imaging of the innate immune response in skeletal muscle and draining lymph node post vaccination in rats.

The goal of this study was to utilize a multimodal magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging approach to assess the local innate immune response in skeletal muscle and draining lymph node following vaccination in rats using two different vaccine platforms (AS01 adjuvanted protein and lipid nanoparticle (LNP) encapsulated Self-Amplifying mRNA (SAM)). MRI and 18FDG PET imaging were performed temporally at baseline, 4, 24, 48, and 72 hr post Prime and Prime-Boost vaccination in hindlimb with Cytomegalovirus (CMV) gB and pentamer proteins formulated with AS01, LNP encapsulated CMV gB protein-encoding SAM (CMV SAM), AS01 or with LNP carrier controls. Both CMV AS01 and CMV SAM resulted in a rapid MRI and PET signal enhancement in hindlimb muscles and draining popliteal lymph node reflecting innate and possibly adaptive immune response. MRI signal enhancement and total 18FDG uptake observed in the hindlimb was greater in the CMV SAM vs CMV AS01 group (↑2.3 - 4.3-fold in AUC) and the MRI signal enhancement peak and duration were temporally shifted right in the CMV SAM group following both Prime and Prime-Boost administration. While cytokine profiles were similar among groups, there was good temporal correlation only between IL-6, IL-13, and MRI/PET endpoints. Imaging mass cytometry was performed on lymph node sections at 72 hr post Prime and Prime-Boost vaccination to characterize the innate and adaptive immune cell signatures. Cell proximity analysis indicated that each follicular dendritic cell interacted with more follicular B cells in the CMV AS01 than in the CMV SAM group, supporting the stronger humoral immune response observed in the CMV AS01 group. A strong correlation between lymph node MRI T2 value and nearest-neighbor analysis of follicular dendritic cell and follicular B cells was observed (r=0.808, P<0.01). These data suggest that spatiotemporal imaging data together with AI/ML approaches may help establish whether in vivo imaging biomarkers can predict local and systemic immune responses following vaccination.

Do Acetabular Buttress Augment Pose Risk to the Superior Gluteal Nerve? A Cadaveric Study.

BACKGROUND: Management of acetabular defects in total joint reconstruction can be challenging. Various algorithmic approaches have been developed, with some recommending using posterosuperior acetabular buttress augments for severe defects. The superior gluteal nerve lies in close proximity to their application, and damage to it results in deterioration of hip stability and gait mechanics. There has been investigation into the relationship of the superior gluteal nerve to various anatomic points. To our knowledge, no study exists examining the relationship between the acetabular rim and the superior gluteal nerve for the application of these particular devices. METHODS: Ten adult cadaver specimens were examined. A reproducible technique in relation to the typical placement of a buttress augment was used. From a distance of 20 millimeters (mm) lateral to the greater sciatic notch, the distance from the superior gluteal nerve to the posterosuperior acetabular rim was measured. RESULTS: The average distance between the posterosuperior acetabular rim and the superior gluteal nerve was found to be 52 mm, ranging from 48 mm to 60 mm. CONCLUSION: With proprietary acetabular augments measuring up to 68 mm in length, the superior gluteal nerve could be at substantial risk with placement of these devices. Surgeons should take great care with dissection for and intraoperative placement of these devices, and particularly strive for optimized prosthetic hip stability to mitigate the risk of dislocation from nerve injury. To our knowledge, this study is the first of its kind and provides valuable anatomic and operative knowledge during these highly complex cases.

Heat adaptation of phage T7 under an extended genetic code.

While bacteriophages have previously been used as a model system to understand thermal adaptation, most adapted genomes observed to date contain very few modifications and cover a limited temperature range. Here, we set out to investigate genome adaptation to thermal stress by adapting six populations of T7 bacteriophage virions to increasingly stringent heat challenges. Further, we provided three of the phage populations' access to a new genetic code in which Amber codons could be read as selenocysteine, potentially allowing the formation of more stable selenide-containing bonds. Phage virions responded to the thermal challenges with a greater than 10°C increase in heat tolerance and fixed highly reproducible patterns of non-synonymous substitutions and genome deletions. Most fixed mutations mapped to either the tail complex or to the three internal virion proteins that form a pore across the E. coli cell membrane during DNA injection. However, few global changes in Amber codon usage were observed, with only one natural Amber codon being lost. These results reinforce a model in which adaptation to thermal stress proceeds via the cumulative fixation of a small set of highly adaptive substitutions and that adaptation to new genetic codes proceeds only slowly, even with the possibility of potential phenotypic advantages.

Discovery of Novel Gain-of-Function Mutations Guided by Structure-Based Deep Learning.

Despite the promise of deep learning accelerated protein engineering, examples of such improved proteins are scarce. Here we report that a 3D convolutional neural network trained to associate amino acids with neighboring chemical microenvironments can guide identification of novel gain-of-function mutations that are not predicted by energetics-based approaches. Amalgamation of these mutations improved protein function in vivo across three diverse proteins by at least 5-fold. Furthermore, this model provides a means to interrogate the chemical space within protein microenvironments and identify specific chemical interactions that contribute to the gain-of-function phenotypes resulting from individual mutations.

Prevalence of Ulnar Artery Thrombosis in Orthopedic Surgeons.

Ulnar artery thrombosis (UAT) occurs most commonly in athletes and manual laborers who repeatedly use their palm in high-impact activities. Anecdotal evidence has shown an increased prevalence of UAT in orthopedic surgeons, especially in joint arthroplasty surgeons, compared with the general population. This study sought to determine the prevalence of UAT among orthopedic surgeons and to identify risk factors for developing UAT. Eighty orthopedic surgeons and residents were included in the study. Participants completed a demographic questionnaire, and a timed Allen test was performed on each hand with the radial artery occluded. A reperfusion result greater than 6 seconds was considered abnormal. Participants with a positive Allen test and UAT-associated symptoms were deemed to have UAT. Statistical analysis was performed using the Fisher exact and Wilcox-on rank-sum tests. The prevalence of UAT was 11% (9 of 80) in the study population compared with 1.6% (21 of 1300) in the general population (P<.0001). For surgeons with 15 years or more of practice, the UAT rate was 24% (8 of 33) compared with 2% (1 of 47) for surgeons with less than 15 years of practice (P=.0030). The prevalence of UAT in adult reconstruction surgeons trended toward significance at 40% (2 of 5) compared with 9% (7 of 75) in the other subspecialties (P=.095). Orthopedic surgeons have an increased risk for developing UAT compared with the general population. The risk of UAT is significantly correlated with advancing years in clinical practice and may be associated with the number of arthroplasty cases performed. [Orthopedics. 2019; 42(5):e415-e422.].

Developmental exposure to silver nanoparticles at environmentally relevant concentrations alters swimming behavior in zebrafish (Danio rerio).

Silver nanoparticles (Ag-NPs) are ubiquitous in household and medical products because of their antimicrobial activity. A consequence of the high volume of Ag-NP production and usage is increased amounts of Ag-NPs released into the environment. Their small size (1-100 nm) results in unique physiochemical properties that may increase toxicity relative to their bulk counterpart. Therefore, the goal of the present study was to assess the potential toxicity of environmentally relevant concentrations of Ag-NPs in zebrafish (Danio rerio). Wild-type tropical 5D zebrafish embryos were exposed to Ag-NPs from 4 to 120 h postfertilization at 0.03, 0.1, 0.3, 1, and 3 ppm (mg/L). Inductively coupled plasma-mass spectrometry confirmed concentration-dependent uptake of Ag into zebrafish as well as bioaccumulation over time. A morphological assessment revealed no significant hatching impairment, morphological abnormalities, or mortality at any concentration or time point examined. However, assessment of photomotor behavior at 3 d postfertilization (dpf) revealed significant hyperactivity in the 0.3, 1, and 3 ppm Ag-NP treatment groups. At 4 dpf, significant hyperactivity was observed only in the 3 ppm treatment group, whereas 5 dpf larvae exposed to Ag-NPs displayed no significant abnormalities in photomotor behavior. These findings suggest that nonteratogenic concentrations of Ag-NPs are capable of causing transient behavioral changes during development. Environ Toxicol Chem 2018;37:3018-3024. © 2018 SETAC.

Cellular reagents for diagnostics and synthetic biology.

We have found that the overproduction of enzymes in bacteria followed by their lyophilization leads to 'cellular reagents' that can be directly used to carry out numerous molecular biology reactions. We demonstrate the use of cellular reagents in a variety of molecular diagnostics, such as TaqMan qPCR with no diminution in sensitivity, and in synthetic biology cornerstones such as the Gibson assembly of DNA fragments, where new plasmids can be constructed solely based on adding cellular reagents. Cellular reagents have significantly reduced complexity and cost of production, storage and implementation, features that should facilitate accessibility and use in resource-poor conditions.

Evolving Bacterial Fitness with an Expanded Genetic Code.

Since the fixation of the genetic code, evolution has largely been confined to 20 proteinogenic amino acids. The development of orthogonal translation systems that allow for the codon-specific incorporation of noncanonical amino acids may provide a means to expand the code, but these translation systems cannot be simply superimposed on cells that have spent billions of years optimizing their genomes with the canonical code. We have therefore carried out directed evolution experiments with an orthogonal translation system that inserts 3-nitro-L-tyrosine across from amber codons, creating a 21 amino acid genetic code in which the amber stop codon ambiguously encodes either 3-nitro-L-tyrosine or stop. The 21 amino acid code is enforced through the inclusion of an addicted, essential gene, a beta-lactamase dependent upon 3-nitro-L-tyrosine incorporation. After 2000 generations of directed evolution, the fitness deficit of the original strain was largely repaired through mutations that limited the toxicity of the noncanonical. While the evolved lineages had not resolved the ambiguous coding of the amber codon, the improvements in fitness allowed new amber codons to populate protein coding sequences.

Chronic Exertional Compartment Syndrome in the Forearm of a Collegiate Softball Pitcher.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is a recognized condition in the lower limb, with many reports in the literature. However, very few instances include CECS of the upper limb. This article presents the case of a collegiate softball pitcher presenting with CECS in her right forearm. To our knowledge, this is the first case report of a softball player with CECS, with only one similar incident in a major league baseball player. PURPOSE: The rarity of this condition normally places it low on the differential diagnosis. However, we hope that the presentation of this case and the review of the literature will aid in making swift and accurate diagnoses of CECS in future patients. We discuss the importance of three specific modalities in the diagnosis of this patient, what diagnostic criteria proved less conclusive, and the paradoxical course the syndrome presented with. STUDY DESIGN: Case Review RESULTS: Over a six-month period, the patient presented with peculiar presentations and exam results. A broad list of differential diagnoses had to be narrowed down through the presence or absence of relevant findings. These included cessation of exercise for 1 month, physical therapy, anti-inflammatory medicines, an electromyography/electromyogram (EMG), nerve conduction study (NCS), non-exercise magnetic resonance imaging (MRI) of the forearm, cervical MRI, and cervical computed tomography (CT) angiogram. After the above interventions were attempted and the relative findings of three important modalities were summarized, a fasciotomy and release of the dorsal, volar, and mobile wad compartments was performed. The patient's symptoms were relieved, and she eventually returned to full play in softball at the university. CONCLUSIONS: The three diagnostic criteria we believed to be most helpful in this case, and for future cases of CECS in the forearm, include the clinical presentation, pre- and post-exercise MRI, and pre- and post-exercise compartment pressure measurements. CLINICAL RELEVANCE: Chronic exertional compartment syndrome of the forearm is extremely rare, especially in the female athlete. This case report and review of the literature may be helpful to the clinician facing similar cases. It describes which clinical tests are most helpful for diagnosis and which findings may be distracting.