Exploring Combat Tourniquet Application Errors and Duration Among Skilled and Novice Medical Trainees.

INTRODUCTION: The use of tourniquets in combat medicine continues to be a key focus as they have consistently been shown to combat one of the leading causes of preventable death on the battlefield, massive hemorrhage to extremities. The present study analyzed tourniquet application among combat medics (68W) and combat lifesavers (CLSs) in a training environment to determine whether trainees' performance is consistent among one another and whether performance can be associated with participant demographics such as experience or role. MATERIALS AND METHODS: Study participants treated male and female patient simulators within a tactical field care phase, both of which experienced an amputated leg and required the application of a Combat Application Tourniquet (CAT). To assess tourniquet application variability and performance, a series of application subtasks and potential errors were measured via video coding of the scenarios by a team of 5 coders. Time to tourniquet application and tourniquet application duration were also coded to assess correlations between application duration and variability or performance. RESULTS: Results from analyzing tourniquet application subtasks and errors through a series of one-way ANOVA tests showed that application of the CAT first, hasty CAT application, and high tourniquet application were not predictive of participant role, time within the role, and self-reported tourniquet skill, confidence, or experience. Such demographic variables were also not predictive of successful tourniquet application as defined by the number of windlass rod rotations. Results from binomial logistic regressions showed that participant role and self-reported tourniquet skill and experience were predictors of tourniquet application duration. CONCLUSION: The findings suggest that high variability in CAT application methodology and performance exists among CLS and combat medics, which is largely not predictable by various demographics such as role, experience within the designated role, and self-reported confidence, skill, or experience. The observed disconnect between training or experience and CAT application performance suggests substantial variability in the consistency of training for both CLS and 68W soldiers. These inconsistencies may stem from variability in instructor knowledge, teaching styles, or training materials or may be developed through informal methods such as experiences in the field or recommendations from colleagues and experts. These findings highlight a potential need to reassess CAT application training, particularly in regard to consistency and validation. Finally, it should be noted that the study's findings may be limited or fail to capture some study effects because of the sample size and wide range of reported experience among participants.

Assessing Photostability of mAb Formulations In Situ Using Light-Coupled NMR Spectroscopy.

Biopharmaceuticals, such as monoclonal antibodies (mAbs), need to maintain their chemical and physical stability in formulations throughout their lifecycle. It is known that exposure of mAbs to light, particularly UV, triggers chemical and physical degradation, which can be exacerbated by trace amounts of photosensitizers in the formulation. Although routine assessments of degradation following defined UV dosages are performed, there is a fundamental lack of understanding regarding the intermediates, transient reactive species, and radicals formed during illumination, as well as their lifetimes and immediate impact post-illumination. In this study, we used light-coupled NMR spectroscopy to monitor in situ live spectral changes in sealed samples during and after UV-A illumination of different formulations of four mAbs without added photosensitizers. We observed a complex evolution of spectra, reflecting the appearance within minutes of transient radicals during illumination and persisting for minutes to tens of minutes after the light was switched off. Both mAb and excipient signals were strongly affected by illumination, with some exhibiting fast irreversible photodegradation and others exhibiting partial recovery in the dark. These effects varied depending on the mAb and the presence of excipients, such as polysorbate 80 (PS80) and methionine. Complementary ex situ high-performance size-exclusion chromatography analysis of the same formulations post-UV exposure in the chamber revealed significant loss of purity, confirming formulation-dependent degradation. Both approaches suggested the presence of degradation processes initiated by light but continuing in the dark. Further studies on photoreaction intermediates and transient reactive species may help mitigate the impact of light on biopharmaceutical degradation.

Removals and Revisions of Cervical Total Disc Replacement Devices in a Consecutive Series of 1,626 Patients Beginning with the First Case Experience in 2003.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to investigate the rate of cervical total disc replacement (TDR) device removal or revision. SUMMARY OF BACKGROUND DATA: Cervical TDR has gained acceptance as an alternative to anterior cervical discectomy and fusion (ACDF) in appropriately selected patients. There have been concerns over device safety, one measure of which is subsequent surgery related to device problems. METHODS: A consecutive series of 1,626 cervical TDR patients from 2003 to June 2021 were included, consisting of TDRs up to 3 levels and hybrids (TDR and fusion). TDR removal or revision surgeries and reasons for these surgeries, procedures performed, and duration from index procedure were recorded. Data were analyzed to determine removal/revision rate and factors possibly related to these events. RESULTS: There were 24 removals/revisions (1.48%) in the 1,626 patients. Removal was performed in 23 cases (1.41%) and revision in 1 (0.06%). Among removal cases, ACDF was performed in 18 and TDR was replaced with another TDR in 5. Removals with fusion included 5 cases of osteolysis with/without C. acnes, 4 device displacement/migration, 4 posterior spinal pathology, and one for each of the following: metal allergy, approach-related complications, malpositioning, subsidence, and hypermobility. The revision involved TDR repositioning 3 days after index surgery. There were 66 patients for whom minimum of 10year follow-up was confirmed, and none had removal/revision surgery 10 or more years after index surgery. There was no relationship between occurrence of removal/revision and age, gender, body mass index, or physician experience (learning curve). The removal/revision rate was significantly higher in FDA trials vs. post-approval (4.1% vs. 1.3%, P<0.05). CONCLUSION: In this large consecutive series of patients, 1.48% of cervical TDRs were removed/revised. The low rate of removals/revisions over a long period of time provides support for the devices' safety.

No evidence for a signal in mammalian basal metabolic rate associated with a fossorial lifestyle.

A vast array of challenging environments are inhabited by mammals, such as living in confined spaces where oxygen levels are likely to be low. Species can exhibit adaptations in basal metabolic rate (BMR) to exploit such unique niches. In this study we use 801 species to determine the relationship between BMR and burrow use in mammals. We included pre-existing data for mammalian BMR and 16 life history traits. Overall, mammalian BMR is dictated primarily by environmental ambient temperature. There were no significant differences in BMR of terrestrial, semi-fossorial and fossorial mammals, suggesting that species occupying a subterranean niche do not exhibit baseline metabolic costs on account of their burrowing lifestyle. Fossorial mammals likely show instantaneous metabolic responses to low oxygen in tunnels, rather than exhibit adaptive long-term responses in their BMR.

Clinical Outcome of Lumbar Hybrid Surgery in a Consecutive Series of Patients with Long-term Follow-up.

STUDY DESIGN: This was a retrospective study combined with attempted prospective patient contact to collect current data. OBJECTIVE: The purpose of this study was to investigate long-term clinical outcome of patients undergoing lumbar hybrid surgery (total disc replacement (TDR) at one level and fusion at an adjacent level. SUMMARY OF BACKGROUND DATA: Many patients with symptomatic lumbar disc degeneration are affected at more than one level. Lumbar TDR was introduced as a fusion alternative; however, some disc levels are not amenable to TDR and fusion is preferable at such levels. Hybrid surgery was introduced as an option to fusing multiple levels. METHODS: A consecutive series of 305 patients undergoing lumbar hybrid surgery was identified beginning with the first case experience in 2005. Operative and clinical outcome data including visual analog scales (VAS) assessing back and leg pain, Oswestry Disability Index (ODI), and re-operations were collected. The mean follow-up duration was 67.1 months. RESULTS: There were statistically significant improvements (P<0.01) in the mean values of all three clinical outcome measures: VAS back pain scores improved from 6.7 to 3.3; leg pain improved from 4.3 to 2.0; and ODI scores improved from 45.5 to 24.6. There were no significant differences in pain and function scores for patients with minimum 10-year follow-up vs. those with shorter follow-up duration. Re-operation occurred in 16.1% of patients, many of which involved removal of posterior instrumentation at the fusion level (6.2% of study group, 38.8% of re-operations). Re-operation involving the TDR level occurred in 9 patients (2.9%), only 3 of which (1.0%) involved TDR removal/revision. CONCLUSION: This study supports that for many patients with multilevel symptomatic disc degeneration, hybrid surgery is a viable surgical option. Significant improvements were demonstrated in pain and function scores with no diminished improvement in scores among patients with more than 10-year follow-up.

Association of large core middle cerebral artery stroke and hemorrhagic transformation with hospitalization outcomes.

Historically, investigators have not differentiated between patients with and without hemorrhagic transformation (HT) in large core ischemic stroke at risk for life-threatening mass effect (LTME) from cerebral edema. Our objective was to determine whether LTME occurs faster in those with HT compared to those without. We conducted a two-center retrospective study of patients with ≥ 1/2 MCA territory infarct between 2006 and 2021. We tested the association of time-to-LTME and HT subtype (parenchymal, petechial) using Cox regression, controlling for age, mean arterial pressure, glucose, tissue plasminogen activator, mechanical thrombectomy, National Institute of Health Stroke Scale, antiplatelets, anticoagulation, temperature, and stroke side. Secondary and exploratory outcomes included mass effect-related death, all-cause death, disposition, and decompressive hemicraniectomy. Of 840 patients, 358 (42.6%) had no HT, 403 (48.0%) patients had petechial HT, and 79 (9.4%) patients had parenchymal HT. LTME occurred in 317 (37.7%) and 100 (11.9%) had mass effect-related deaths. Parenchymal (HR 8.24, 95% CI 5.46-12.42, p < 0.01) and petechial HT (HR 2.47, 95% CI 1.92-3.17, p < 0.01) were significantly associated with time-to-LTME and mass effect-related death. Understanding different risk factors and sequelae of mass effect with and without HT is critical for informed clinical decisions.

Later Midline Shift Is Associated with Better Outcomes after Large Middle Cerebral Artery Stroke.

Background/Objective: Space occupying cerebral edema is the most feared early complication after large ischemic stroke, occurring in up to 30% of patients with middle cerebral artery (MCA) occlusion, and is reported to peak 2-4 days after injury. Little is known about the factors and outcomes associated with peak edema timing, especially when it occurs after 96 hours. We aimed to characterize differences between patients who experienced maximum midline shift (MLS) or decompressive hemicraniectomy (DHC) in the acute (<48 hours), average (48-96 hours), and subacute (>96 hours) groups and determine whether patients with subacute peak edema timing have improved discharge dispositions. Methods: We performed a two-center, retrospective study of patients with ≥1/2 MCA territory infarct and MLS. We constructed a multivariable model to test the association of subacute peak edema and favorable discharge disposition, adjusting for age, admission Alberta Stroke Program Early CT Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS), acute thrombolytic intervention, cerebral atrophy, maximum MLS, parenchymal hemorrhagic transformation, DHC, and osmotic therapy receipt. Results: Of 321 eligible patients with MLS, 32%, 36%, and 32% experienced acute, average, and subacute peak edema. Subacute peak edema was significantly associated with higher odds of favorable discharge than non-subacute swelling, adjusting for confounders (aOR, 1.85; 95% CI, 1.05-3.31). Conclusions: Subacute peak edema after large MCA stroke is associated with better discharge disposition compared to earlier peak edema courses. Understanding how the timing of cerebral edema affects risk of unfavorable discharge has important implications for treatment decisions and prognostication.

Photochemistry of Ru(II) Triazole Complexes with 6-Membered Chelate Ligands: Detection and Reactivity of Ligand-Loss Intermediates.

Photochemical ligand release from metal complexes may be exploited in the development of novel photoactivated chemotherapy agents for the treatment of cancer and other diseases. Highly intriguing photochemical behavior is reported for two ruthenium(II) complexes bearing conformationally flexible 1,2,3-triazole-based ligands incorporating a methylene spacer to form 6-membered chelate rings. [Ru(bpy)2(pictz)]2+ (1) and [Ru(bpy)2(btzm)]2+ (2) (bpy = 2,2'-bipyridyl; pictz = 1-(picolyl)-4-phenyl-1,2,3-triazole; btzm = bis(4-phenyl-1,2,3-triazol-4-yl)methane) exhibit coordination by the triazole ring through the less basic N2 atom as a consequence of chelation and readily undergo photochemical release of the pictz and btzm ligands (ϕ = 0.079 and 0.091, respectively) in acetonitrile solution to form cis-[Ru(bpy)2(NCMe)2]2+ (3) in both cases. Ligand-loss intermediates of the form [Ru(bpy)2(κ1-pictz or κ1-btzm)(NCCD3)]2+ are detected by 1H NMR spectroscopy and mass spectrometry. Photolysis of 1 yields three ligand-loss intermediates with monodentate pictz ligands, two of which form through simple decoordination of either the pyridine or triazole donor with subsequent solvent coordination (4-tz(N2) and 4-py, respectively). The third intermediate, shown to be able to form photochemically directly from 1, arises through linkage isomerism in which the monodentate pictz ligand is coordinated by the triazole N3 atom (4-tz(N3)) with a comparable ligand-loss intermediate with an N3-bound κ1-btzm ligand also observed for 2.

Removal and Reoccurrence of LLZTO Surface Contaminants under Glovebox Conditions.

The reactivity of Li6.4La3Zr1.4Ta0.6O12 (LLZTO) solid electrolytes to form lithio-phobic species such as Li2CO3 on their surface when exposed to trace amounts of H2O and CO2 limits the progress of LLZTO-based solid-state batteries. Various treatments, such as annealing LLZTO within a glovebox or acid etching, aim at removing the surface contaminants, but a comprehensive understanding of the evolving LLZTO surface chemistry during and after these treatments is lacking. Here, glovebox-like H2O and CO2 conditions were recreated in a near ambient pressure X-ray photoelectron spectroscopy chamber to analyze the LLZTO surface under realistic conditions. We find that annealing LLZTO at 600 °C in this atmosphere effectively removes the surface contaminants, but a significant level of contamination reappears upon cooling down. In contrast, HCl(aq) acid etching demonstrates superior Li2CO3 removal and stable surface chemistry post treatment. To avoid air exposure during the acid treatment, an anhydrous HCl solution in diethyl ether was used directly within the glovebox. This novel acid etching strategy delivers the lowest lithium/LLZTO interfacial resistance and the highest critical current density.

To what extent do oral and maxillofacial surgery residents suffer from imposter syndrome?

OBJECTIVE: This study aims to evaluate the frequency and severity of imposter syndrome (IS) in oral and maxillofacial surgery (OMS) residents and identify factors associated with higher Clance Imposter Phenomenon Survey (CIPS) scores. STUDY DESIGN: A cross-sectional study was performed with a survey including CIPS, demographic, and training program structure questions distributed to all OMS training programs and residents in the United States. The primary predictor variable was gender, and the main outcome variable was the CIPS score. Statistical analyses were performed using linear regression in R v4.3.1; statistical significance was set to P value < .05. RESULTS: A total of 175 OMS residents responded. The average CIPS score was 59.8 (IQR 52, 70). Statistically significant differences were found between average male and female resident scores (56.5 vs 66.9; P < .001) and male and female single-degree residents (54.3 vs 73.1; P < .001), but not for dual-degree residents (58.8 vs 63.9; P = .35). CONCLUSIONS: The average male resident experiences moderate IS, whereas the average female resident experiences frequent IS. Loss of significance between male and female dual-degree resident scores may be due to the completion of a doctoral degree, an internship, and/or dental board exams upon entering medical school, leading to more favorable accomplishment comparisons among medical school peers.

RosetteArray Platform for Quantitative High-Throughput Screening of Human Neurodevelopmental Risk.

Neural organoids have revolutionized how human neurodevelopmental disorders (NDDs) are studied. Yet, their utility for screening complex NDD etiologies and in drug discovery is limited by a lack of scalable and quantifiable derivation formats. Here, we describe the RosetteArray ® platform's ability to be used as an off-the-shelf, 96-well plate assay that standardizes incipient forebrain and spinal cord organoid morphogenesis as micropatterned, 3-D, singularly polarized neural rosette tissues (>9000 per plate). RosetteArrays are seeded from cryopreserved human pluripotent stem cells, cultured over 6-8 days, and immunostained images can be quantified using artificial intelligence-based software. We demonstrate the platform's suitability for screening developmental neurotoxicity and genetic and environmental factors known to cause neural tube defect risk. Given the presence of rosette morphogenesis perturbation in neural organoid models of NDDs and neurodegenerative disorders, the RosetteArray platform could enable quantitative high-throughput screening (qHTS) of human neurodevelopmental risk across regulatory and precision medicine applications.

A retrospective study of orthognathic surgery reimbursement and volume changes at an American academic medical center over a 13-year period.

OBJECTIVE: This study aimed to measure the association between orthognathic surgeon reimbursement and surgical volume over time. STUDY DESIGN: A retrospective cohort study of patients who underwent orthognathic surgery from January 1, 2010, to December 23, 2022, at an academic medical center was performed. Five patients per year were randomly selected and evaluated for insurance type and associated costs to create representative averages. Pearson correlation analysis was performed to test associations over 13 years with 2-tailed significance reported and statistical significance set at P < .05. RESULTS: A total of 618 patients who underwent 942 procedures were included. The average procedure charge was $6,153.76, and the average total surgeon collection was $1,535.75 per procedure. When monetary values were adjusted to reflect 2010 purchasing power, there was a negative correlation between the average charge per procedure and the year (r[11] = -0.59, P = .04). The year was not significantly correlated with the average amount collected (r[11] = -0.09, P = .78) or average insurance reimbursement (r[11] = -0.52, P = .07). CONCLUSIONS: Collections by surgeons did not change significantly over 13 years and were not correlated with the volume of procedures performed. Increased collections were correlated with increased patient costs. The stagnation of surgeon collection is concerning in the face of increased monetary inflation during this period. Increased volume of surgeries per year was correlated with decreases in patient cost and total collections.

Gasdermin D promotes influenza virus-induced mortality through neutrophil amplification of inflammation.

Influenza virus activates cellular inflammasome pathways, which can be both beneficial and detrimental to infection outcomes. Here, we investigate the function of the inflammasome-activated, pore-forming protein gasdermin D (GSDMD) during infection. Ablation of GSDMD in knockout (KO) mice (Gsdmd-/-) significantly attenuates influenza virus-induced weight loss, lung dysfunction, lung histopathology, and mortality compared with wild type (WT) mice, despite similar viral loads. Infected Gsdmd-/- mice exhibit decreased inflammatory gene signatures shown by lung transcriptomics. Among these, diminished neutrophil gene activation signatures are corroborated by decreased detection of neutrophil elastase and myeloperoxidase in KO mouse lungs. Indeed, directly infected neutrophils are observed in vivo and infection of neutrophils in vitro induces release of DNA and tissue-damaging enzymes that is largely dependent on GSDMD. Neutrophil depletion in infected WT mice recapitulates the reductions in mortality, lung inflammation, and lung dysfunction observed in Gsdmd-/- animals, while depletion does not have additive protective effects in Gsdmd-/- mice. These findings implicate a function for GSDMD in promoting lung neutrophil responses that amplify influenza virus-induced inflammation and pathogenesis. Targeting the GSDMD/neutrophil axis may provide a therapeutic avenue for treating severe influenza.

Scleral Fixated Secondary IOLs: An Outcomes Comparison Between the Yamane and Gore-Tex-Sutured Techniques.

BACKGROUND AND OBJECTIVE: Among secondary intraocular lens (IOL) techniques, scleral fixated IOLs (SFIOLs) offer advantages in cases without capsular support. In this article, we compare outcomes between two types of Gore-Tex scleral sutured IOLs with the Yamane technique. PATIENTS AND METHODS: This study was a retrospective chart review of patients who underwent SFIOL implantation. RESULTS: Analysis revealed a statistically significant improvement in final postoperative visual acuity (VA) for sutured SFIOLs (P < 0.001, Envista (n = 29) 95% CI 0.47-1.04, Akreos (n = 23) 95% CI 0.32-0.81) with no statistical improvement in the Yamane group (P = 0.44, n = 15, 95% CI -0.33-0.71). Outcomes analysis revealed greater incidences of cystoid macular edema (CME) in the Yamane cohort (P < 0.05) and a higher rate of reoperations in the Akreos cohort (P < 0.02). All complications related to suture material (n = 4) and IOL decentration (n = 2) occurred in the sutured SFIOL group. CONCLUSIONS: The sutureless Yamane technique offered fewer subsequent surgeries and suture-specific complications while revealing diminished VA improvement in long-term follow-up compared to the sutured SFIOLs. [Ophthalmic Surg Lasers Imaging Retina 2024;55:xx-xx.].

Overview of the Alaskan Layered Pollution and Chemical Analysis (ALPACA) Field Experiment.

The Alaskan Layered Pollution And Chemical Analysis (ALPACA) field experiment was a collaborative study designed to improve understanding of pollution sources and chemical processes during winter (cold climate and low-photochemical activity), to investigate indoor pollution, and to study dispersion of pollution as affected by frequent temperature inversions. A number of the research goals were motivated by questions raised by residents of Fairbanks, Alaska, where the study was held. This paper describes the measurement strategies and the conditions encountered during the January and February 2022 field experiment, and reports early examples of how the measurements addressed research goals, particularly those of interest to the residents. Outdoor air measurements showed high concentrations of particulate matter and pollutant gases including volatile organic carbon species. During pollution events, low winds and extremely stable atmospheric conditions trapped pollution below 73 m, an extremely shallow vertical scale. Tethered-balloon-based measurements intercepted plumes aloft, which were associated with power plant point sources through transport modeling. Because cold climate residents spend much of their time indoors, the study included an indoor air quality component, where measurements were made inside and outside a house to study infiltration and indoor sources. In the absence of indoor activities such as cooking and/or heating with a pellet stove, indoor particulate matter concentrations were lower than outdoors; however, cooking and pellet stove burns often caused higher indoor particulate matter concentrations than outdoors. The mass-normalized particulate matter oxidative potential, a health-relevant property measured here by the reactivity with dithiothreiol, of indoor particles varied by source, with cooking particles having less oxidative potential per mass than pellet stove particles.

Functional knee brace use for 21 h leads to a longer duration to achieve peak vertical ground reaction forces and the removal of the brace after 17.5 h results in faster loading of the knee joint.

PURPOSE: To investigate the landing strategies used after discontinuing and continuing the use of a functional knee brace (FKB) while performing a drop jump. METHODS: Following published methodology and power analysis, 23 uninjured male athletes, mean age of 19.4 ± 3.0 years, performed seven tests, during three test conditions (nonbraced, braced and removed brace or continued brace use), over 6 days of 12 testing sessions (S) for a total of 38.5 h. Each subject was provided with a custom-fitted FKB. This study focuses on the single leg drop jump kinetics during S12 when subjects were randomly selected to remove the FKB after 17.5 h or continued use of FKB. The time to peak vertical ground reaction forces (PVGRF) and PVGRF were recorded on landing in eight trials. RESULTS: After brace removal, a significantly shorter mean time to PVGRF was recorded (9.4 ± 22.9 msec (3.9%), p = 0.005, 95% confidence interval (95% CI): -168.1, 36.1), while continued brace use required a nonsignificant (n.s.) longer mean duration to achieve PVGRF (19.4 ± 53.6 msec (8.9%), n.s., 95% CI: -49.7, 73.4). No significant mean PVGRF difference was found in brace removal (25.3 ± 65.8 N) and continued brace use (25.1 ± 23.0 N). CONCLUSION: Removal of FKB after 17.5 h of use led to a significantly shorter time to achieve PVGRF, while continued brace use for 21 h required a longer duration to achieve PVGRF, suggesting faster and slower knee joint loading, respectively. Understanding the concerns associated with the use of FKB and the kinetics of the knee joint will assist clinicians in counselling athletes about the risks and benefits of using an FKB. LEVEL OF EVIDENCE: Level II.

Mycobacterium avium ssp. paratuberculosis and Crohn's Disease-Diagnostic Microbiological Investigations Can Inform New Therapeutic Approaches.

Mycobacterium avium ssp. paratuberculosis (MAP) is the cause of Johne's disease (JD), which is a chronic infectious gastrointestinal disease of ruminants and is often fatal. In humans, MAP has been associated with Crohn's disease (CD) for over a century, without conclusive evidence of pathogenicity. Numerous researchers have contributed to the subject, but there is still a need for evidence of the causation of CD by MAP. An infectious aetiology in CD that is attributable to MAP can only be proven by bacteriological investigations. There is an urgency in resolving this question due to the rising global incidence rates of CD. Recent papers have indicated the "therapeutic ceiling" may be close in the development of new biologics. Clinical trial outcomes have demonstrated mild or inconsistent improvements in therapeutic interventions over the last decades when compared with placebo. The necessity to revisit therapeutic options for CD is becoming more urgent and a renewed focus on causation is essential for progress in identifying new treatment options. This manuscript discusses newer interventions, such as vaccination, FMT, dietary remediation and gut microbiome regulation, that will become more relevant as existing therapeutic options expire. Revisiting the MAP theory as a potential infectious cause of CD, rather than the prevailing concept of an "aberrant immune response" will require expanding the current therapeutic programme to include potential new alternatives, and combinations of existing treatments. To advance research on MAP in humans, it is essential for microbiologists and medical scientists to microscopically detect CWDM and to biologically amplify the growth by directed culture.

Risk Factors for Pediatric Facial Trauma in an Appalachian Region: An Epidemiological Review at a Single Institution.

BACKGROUND: Rural and low-income pediatric populations are at higher risk for trauma. Craniomaxillofacial (CMF) trauma in this population has not been studied. PURPOSE: This study's purpose was to determine if rural populations or low-income populations are at higher risk for pediatric CMF trauma than urban or high-income populations, respectively, and to determine differences in mechanism of injury (MOI). STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of CMF trauma patients younger than 17 years-old, living in the region served by one institution in Tennessee, and requiring oral and maxillofacial surgery consultation between January 2011 and December 2022 was performed. Exclusion criteria were incomplete medical records. PREDICTOR VARIABLE: The primary predictor variable was geographic residence of the patient grouped into two categories: rural or urban defined by the state of Tennessee. Secondary variables were postal code (PC) average median household income (MHI) and PC population density. MAIN OUTCOME VARIABLE(S): The main outcome variable was pediatric CMF injury rate per 100,000 people. MOI is a secondary outcome variable. COVARIATE(S): Covariates included sex, age, and race. ANALYSES: Frequencies and percentages, Fisher's exact test, and Poisson regression models were utilized. Statistical significance was assumed at P-value <.05. RESULTS: Rural or urban county designation was not associated with differing trauma rates (incident risk ratio (IRR) = 0.91; 95% confidence interval (CI) 0.78 to 1.05; P = .18) by itself. One standard deviation increase in MHI decreased CMF trauma rates in rural designation counties by 24% (IRR: 0.76, 95% CI: 0.66, 0.88) and 6% in urban designation counties (IRR: 0.94, 95% CI: 0.87, 1.02). Lower rates of CMF trauma were associated with residence in higher income PCs (IRR = 0.91; 95% (CI) 0.86 to 0.97; P = .004), and higher population density (IRR = 0.87; 95% CI 0.79 to 0.94; P < .001). Dog bites and falls were more common in infancy and early childhood. Interpersonal violence was more common in older patients. CONCLUSIONS AND RELEVANCE: Patients in PCs with lower population density or incomes were at highest risk for CMF injuries. MOI differences by age were similar to findings in other studies. Tennessee's urban/rural county designation has complex interactions with MHI and pediatric CMF trauma rates.

Lumbar Total Disk Replacement Device Removals and Revisions Performed During a 20-Year Experience with 2141 Patients.

STUDY DESIGN: This was a retrospective study with prospective patient contact attempted to collect current data. OBJECTIVE: The purpose was to investigate the incidence and reasons for lumbar total disk replacement (TDR) removal or revision. SUMMARY OF BACKGROUND DATA: A concern regarding lumbar TDR was safety, particularly the need for device removal or revision. This may be particularly important considering removal/revision requires repeat anterior exposure with an increased risk of vascular injury. METHODS: Data were collected for a series of 2141 lumbar TDR patients, beginning with the first case experience in 2000. The mean follow-up was 78.6 months. For each case of device removal/revision, the reason, duration from index surgery, and procedure performed were recorded. RESULTS: Of 2141 patients, 27 (1.26%) underwent TDR removal or revision. Device removal was performed in 24 patients (1.12%), while three patients underwent revision (0.14%). Of the 24 removals, 12 were due to migration and/or loosening, three developed problems post-trauma, two developed lymphocytic reaction to device materials, two had ongoing pain, and there was one case of each: TDR was too large, vertebral body fracture (osteoporosis), lytic lesion, device subsidence and facet arthrosis, and infection seeded from a chest infection 146 months post-TDR. The three revisions were for Core repositioning (technique error), device repositioning after displacement, and core replacement due to wear/failure. With respect to timing, 37.0% of removals/revisions occurred within one-month postimplantation. Of note, 40.7% of removals/revisions occurred in the first 25 TDR cases performed by individual surgeons. There was one significant vascular complication occurring in a patient whose TDR was removed due to trauma. This was also the only patient among 258 with ≥15-year follow-up who underwent removal/revision. CONCLUSION: In this large consecutive series, 1.26% of TDRs were removed/revised. The low rate over a 20 year period supports the safety of these devices.