Fast-Food Optimal Defaults Reduce Calories Ordered, as Well as Dietary Autonomy: A Scenario-Based Experiment.

BACKGROUND: Low-calorie menu items as optimal defaults may encourage healthier choices when people eat out. Limited research has studied default effects from the restauranteurs' perspective, as well as the public health perspective. OBJECTIVE: To examine the effects of optimal defaults on calories ordered, dietary autonomy, and visit intention in the context of a fast-food drive-through. DESIGN: Between-subjects randomized scenario-based experiment. PARTICIPANTS/SETTING: In all, 377 adults who lived in the United States were recruited through a crowdsourcing platform in July 2020. INTERVENTION: Participants were asked to visualize ordering a combo meal in a fast-food drive-through. They were randomly assigned to order from 1 of 3 menu boards: (1) menu items available for combos by customer choice, (2) combos that included traditional high-calorie default items, or (3) combos that included low-calorie optimal defaults. MAIN OUTCOME MEASURES: Differences in calories ordered among groups, dietary autonomy, and restaurant visit intention. ANALYSIS: Statistical tests included multiple regression, Kruskal-Wallis, χ2, and 1-way analysis of variance. Covariates such as education and sex were tested in regression models as potential confounders. RESULTS: Compared with the choice combo meals, optimal combo meals reduced calories ordered by consumers (-337 kcal, standard error = 19, P < .001), while traditional combos increased them (+132 kcal, standard error = 20, P < .001). No significant difference was found in visit intention. Dietary autonomy was affected by the optimal defaults (P = .025), even in participants with high health concern. Conversely, the traditional combo's effect on dietary autonomy was moderated by health concern (B = -0.26, P = .023), with only individuals with very high levels of health concern perceiving less autonomy. CONCLUSIONS: Optimal defaults provided a robust reduction in calories ordered but had implications for dietary autonomy.

Visual Cues and Optimal Defaults in Fast-Food Combo Meals Benefit Health-Concerned Consumers-A Randomized Scenario-Based Experiment.

BACKGROUND: The use of low-calorie menu items as optimal defaults and visual cues may nudge consumers to healthier choices at restaurants. However, little is known regarding their effects on emotions and behavioral intentions, particularly among people with different levels of health concern. OBJECTIVE: Evaluate optimal defaults and visual cues' effect on anticipated pleasure and order intention depending upon consumers' health concern level. DESIGN: Between-subjects randomized scenario-based experiment. PARTICIPANTS/SETTING: In all, 636 US adults recruited through an online crowdsourcing platform in July 2020. INTERVENTION: Participants saw 1 of 6 menu boards in a fast-food drive-through simulation. Half the menu boards included meal photos with (1) menu items to be arranged as a combo by choice (ie, create-your-own combo); (2) traditional combos that included high-calorie default items; or (3) optimal combos that included low-calorie default items. The remaining 3 boards were identical without photos. MAIN OUTCOME MEASURES: Anticipated pleasure, order intention, and health concern were evaluated with 7-point Likert scales. ANALYSIS: Statistical tests included multiple regression, Kruskal-Wallis, χ2, and analysis of variance. Education and sex were tested as potential confounders. RESULTS: Optimal combos negatively affected anticipated pleasure (P = .003) and order intention (P < .001) compared with choice combos. Order intention reduction was the same for traditional and optimal combos (P = .128). The presence of photos changed order intention for optimal combos but varied by consumer's health concern level. When health concern was lower, photos decreased the likelihood of ordering the optimal combos (B = -3.06, P = .001), but when health concern was higher, photos enhanced ordering intention compared with the choice group (B = 0.60, P = .001). The photos did not affect anticipated pleasure for any level of health concern. CONCLUSIONS: The adverse effect of optimal defaults and how visual cues may reduce their negative effect should be considered in menu design.

Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study.

STUDY OBJECTIVE: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS: During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION: Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.

Native Bacterial Community Convergence in Augmented and Stimulated Ureolytic MICP Biocementation.

Microbially induced calcite precipitation is a biomineralization process with numerous civil engineering and ground improvement applications. In replicate soil columns, the efficacy and microbial composition of soil bioaugmented with the ureolytic bacterium Sporosarcina pasteurii were compared to a biostimulation method that enriches native ureolytic soil bacteria in situ under conditions analogous to field implementation. The selective enrichment resulting from sequential stimulation treatments strongly selected for Firmicutes (>97%), with Sporosarcina and Lysinibacillus comprising 60 to 94% of high-throughput 16S rDNA sequences in each suspended community sample. Seven species of the former and two of the latter were present in greater than 10% abundance at different times, demonstrating unexpected within-genus diversity and robustness in the suspended phase of this highly selective environment. Based on longer 16S sequences, it was inferred that augmented S. pasteurii competed poorly with natural bacteria, decreasing to below detection after nine treatments, while the native microbial community was enriched to approximately that present in the stimulated columns. These analyses were corroborated by the observed convergence in bulk ureolytic rates and calcite contents between techniques. However, a 10-fold discrepancy between the observed cell density and an activity-based estimate indicates the attached community, uncharacterized despite efforts, substantially contributes to bulk behavior.

Dose-modified gemcitabine plus nab-paclitaxel front-line in advanced pancreatic ductal adenocarcinoma with baseline hyperbilirubinemia.

BACKGROUND: Von Hoff et al. demonstrated survival improvement with gemcitabine (GEM) + nab-paclitaxel (NabP) for metastatic pancreatic ductal adenocarcinoma (PDAC) compared to GEM alone. GEM + NabP resulted in a median overall survival (OS) and progression-free survival (PFS) of 8.5 and 5.5 months, respectively. Patients with baseline hyperbilirubinemia were excluded. Primary objective was OS. Secondary objectives included time on treatment (TOT), disease control rate, dosing practices, delays/admissions, and adverse effects. METHODS: Patients with borderline resectable, locally advanced, or metastatic PDAC who initiated front-line GEM-NabP during July 01, 2013-July 01, 2017 were reviewed. Patients with a baseline total bilirubin ≥2 mg/dL were included. RESULTS: Twelve patients total were included. Median age was 71 years old. Median baseline total bilirubin was 2.4 mg/dL (range, 2.1-5.2 mg/dL). 58% had metastatic disease. Median doses were NabP 100 mg/m2 + GEM 600 mg/m2 IV with a fixed-dose rate infusion (10 mg/m2/min). GEM-NabP was given biweekly or 3 weeks on 1 week off. Median OS, TOT, and disease control rate were 13.9, 5.2 months, and 58%, respectively. Fifty percent of patients required a dose delay. Metastatic patients only (n=7) had median OS and TOT of 6.9 and 2.1 months, respectively. No admissions related to toxicity were found. CONCLUSIONS: Our analysis revealed safety with NabP (median dose =100 mg/m2) + GEM (median dose =600 mg/m2 at fixed-dose rate) given predominately biweekly in patients with a baseline elevated total bilirubin (≥2 mg/dL).

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

OBJECTIVE: To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN: This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS: Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS: In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.

Investigating Ammonium By-product Removal for Ureolytic Bio-cementation Using Meter-scale Experiments.

Microbially Induced Calcite Precipitation (MICP), or bio-cementation, is a promising bio-mediated technology that can improve the engineering properties of soils through the precipitation of calcium carbonate. Despite significant advances in the technology, concerns regarding the fate of produced NH4+ by-products have remained largely unaddressed. In this study, five 3.7-meter long soil columns each containing one of three different soils were improved using ureolytic bio-cementation, and post-treatment NH4+ by-product removal was investigated during the application of 525 L of a high pH and high ionic strength rinse solution. During rinsing, reductions in aqueous NH4+ were observed in all columns from initial concentrations between ≈100 mM to 500 mM to final values between ≈0.3 mM and 20 mM with higher NH4+ concentrations observed at distances furthest from the injection well. In addition, soil Vs measurements completed during rinse injections suggested that no significant changes in cementation integrity occurred during NH4+ removal. After rinsing and a 12 hour stop flow period, all column solutions achieved cumulative NH4+ removals exceeding 97.9%. Soil samples collected following rinsing, however, contained significant sorbed NH4+ masses that appeared to have a near linear relationship with surrounding aqueous NH4+ concentrations. While these results suggest that NH4+ can be successfully removed from bio-cemented soils, acceptable limits for NH4+ aqueous concentrations and sorbed NH4+ masses will likely be governed by site-specific requirements and may require further investigation and refinement of the developed techniques.

Biogeochemical Changes During Bio-cementation Mediated by Stimulated and Augmented Ureolytic Microorganisms.

Microbially Induced Calcite Precipitation (MICP) is a bio-mediated cementation process that can improve the engineering properties of granular soils through the precipitation of calcite. The process is made possible by soil microorganisms containing urease enzymes, which hydrolyze urea and enable carbonate ions to become available for precipitation. While most researchers have injected non-native ureolytic bacteria to complete bio-cementation, enrichment of native ureolytic microorganisms may enable reductions in process treatment costs and environmental impacts. In this study, a large-scale bio-cementation experiment involving two 1.7-meter diameter tanks and a complementary soil column experiment were performed to investigate biogeochemical differences between bio-cementation mediated by either native or augmented (Sporosarcina pasteurii) ureolytic microorganisms. Although post-treatment distributions of calcite and engineering properties were similar between approaches, the results of this study suggest that significant differences in ureolysis rates and related precipitation rates between native and augmented microbial communities may influence the temporal progression and spatial distribution of bio-cementation, solution biogeochemical changes, and precipitate microstructure. The role of urea hydrolysis in enabling calcite precipitation through sustained super-saturation following treatment injections is explored.

Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review.

OBJECTIVE: To review the presentation and treatment of children diagnosed with bacterial tracheitis at our institution and to review the available literature focusing on key presenting symptoms and clinical outcomes of children diagnosed with bacterial tracheitis. STUDY DESIGN: Case series with literature review. SETTING: Tertiary children's hospital and available literature. SUBJECTS AND METHODS: Case series of children with bacterial tracheitis retrospectively reviewed at a tertiary children's hospital. Those with a tracheostomy or those who developed bacterial tracheitis as a complication of prolonged intubation were excluded. RESULTS: Thirty-six children were identified (mean ± SD age, 6.7 ± 4.5 years). The most common presenting symptom was cough (85%), followed by stridor (77%) and voice changes/hoarseness (67%). A concurrent viral illness was found for 55%, and the most common bacteria cultured was methicillin-sensitive Staphylococcus aureus. Pediatric intensive care admission occurred for 69%, and 43% required intubation. No patient required tracheostomy. One patient (2.7%) died secondary to airway obstruction and subsequent respiratory arrest. Four patients had recurrence of bacterial tracheitis 4 to 12 months following their initial presentation. CONCLUSION: Bacterial tracheitis is an uncommon condition with an atypical presentation and variable clinical course but serious consequences if left unrecognized. Staphylococcus is the most common bacteria identified, and many patients will have a prodromal viral illness. Changes in patient epidemiology and presentation may have occurred over time.

Prospective study of serum and ionized magnesium pharmacokinetics in the treatment of children with severe acute asthma.

PURPOSE: Intravenous (IV) magnesium sulfate (MgSO4) is clinically useful as adjunct therapy in treating acute asthma exacerbations. Despite its clinical utility, the disposition of magnesium in children is poorly described. The purpose of this study is to describe the pharmacokinetics (PK) of ionized and total serum magnesium following IV MgSO4 administration in children with severe acute asthma. METHODS: Thirty-two children receiving 50 mg/kg IV MgSO4 for acute asthma exacerbations at Primary Children's Hospital in Salt Lake City, UT, were prospectively enrolled in the study. Blood samples were collected before, as well as 30 min and 2 h after each child's IV MgSO4 dose, and used to determine total serum and ionized magnesium concentrations. The collected data were analyzed using population PK techniques using NONMEM® software. RESULTS: Total serum magnesium concentrations were used to externally validate our previously published model constructed with retrospective data (median prediction error 10.3%, median absolute prediction error 18.1%). The mean (%CV) observed endogenous ionized magnesium concentration was calculated to be 6.0 mg/L (12%), approximately one third of the same value for endogenous total serum magnesium (17.6 mg/L (22%)) in this dataset. Weight was a significant predictor of both clearance and volume in a population PK model describing ionized magnesium concentrations. No adverse events were observed in this pediatric cohort. CONCLUSIONS: This prospective study supports and extends our previous PK analysis of total serum magnesium concentrations. Ionized and total serum magnesium followed similar PK profiles following IV MgSO4 administration in children. A single bolus infusion of IV MgSO4 was safe in this small sample of children receiving it for acute asthma.

Methicillin-resistant Staphylococcal aureus patellar tendon abscess and septic prepatellar bursitis in an injection drug user.

We report a case of intratendinous patellar abscess and prepatellar septic bursitis following direct inoculation in a 26-year-old male injection drug user. The patient presented with 2 days of progressive knee pain, swelling, and erythema. Computed tomography demonstrated an enlarged patellar tendon with central low attenuation. Ultrasonography revealed a complex intratendinous fluid collection concerning for abscess. Aspiration of this fluid collection yielded grossly purulent fluid which grew methicillin-resistant staphylococcal aureus. The patient subsequently underwent operative debridement which revealed an intratendinous patellar abscess with extension to involve the prepatellar bursa. This case report demonstrates typical, though nonspecific, radiographic findings of abscess in an atypical location and highlights the importance of clinical history in diagnosing musculoskeletal disorders, particularly in the absence of traditional types of traumatic injury.

Noise-robust speech triage.

A method is presented in which conventional speech algorithms are applied, with no modifications, to improve their performance in extremely noisy environments. It has been demonstrated that, for eigen-channel algorithms, pre-training multiple speaker identification (SID) models at a lattice of signal-to-noise-ratio (SNR) levels and then performing SID using the appropriate SNR dependent model was successful in mitigating noise at all SNR levels. In those tests, it was found that SID performance was optimized when the SNR of the testing and training data were close or identical. In this current effort multiple i-vector algorithms were used, greatly improving both processing throughput and equal error rate classification accuracy. Using identical approaches in the same noisy environment, performance of SID, language identification, gender identification, and diarization were significantly improved. A critical factor in this improvement is speech activity detection (SAD) that performs reliably in extremely noisy environments, where the speech itself is barely audible. To optimize SAD operation at all SNR levels, two algorithms were employed. The first maximized detection probability at low levels (-10 dB ≤ SNR < +10 dB) using just the voiced speech envelope, and the second exploited features extracted from the original speech to improve overall accuracy at higher quality levels (SNR ≥ +10 dB).

Diversity of Sporosarcina-like Bacterial Strains Obtained from Meter-Scale Augmented and Stimulated Biocementation Experiments.

Microbially Induced Calcite Precipitation (MICP) is a biomediated soil cementation process that offers an environmentally conscious alternative to conventional geotechnical soil improvement technologies. This study provides the first comparison of ureolytic bacteria isolated from sand cemented in parallel, meter-scale, MICP experiments using either biostimulation or bioaugmentation approaches, wherein colonies resembling the augmented strain ( Sporosarcina pasteurii ATCC 11859) were interrogated. Over the 13 day experiment, 47 of the 57 isolates collected were strains of Sporosarcina and the diversity of these strains was high, with 20 distinct strains belonging to 5 species identified. Although the S. pasteurii inoculant used for augmentation was recovered immediately after introduction in the augmented specimen, the strain was not recovered after 8 days in either augmented or stimulated soils, suggesting that it competes poorly with indigenous bacteria. Past studies on the physiological properties of S. pasteurii ATCC 11859 suggest that close relatives may have selective advantages under the biogeochemical conditions employed during MICP; however, the extent to which these properties apply to isolates of the current study is unknown. Whole cell urease kinetic properties were investigated for representative isolates and suggest up to 100-fold higher rates of carbonate production when compared to other biomediated processes proposed for MICP.

Virtually Nursing: Emerging Technologies in Nursing Education.

Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

A strategic cleaning assessment program: menu cleanliness at restaurants.

The importance of clean food contact surfaces has been recognized; however, the importance of cleanliness on nonfood contact surfaces such as menus may be underestimated. The aim of the study described in this article was to determine the cleanliness of restaurant menus, evaluate typical cleaning methods used in a restaurant, and provide recommendations for improving menu cleanliness. The authors' study used an adenosine triphosphate meter to assess the cleanliness of the menus. A pretest identified the most commonly touched areas of the menu by consumers. Based on the results of the pretest, menus were collected from casual-family dining restaurants and analyzed for cleanliness. Results suggested that menus should be cleaned after each shift and that menus distributed by the staff when guests are seated are cleaner than those kept on the table.

A case of infraorbital lichen sclerosus.

We present a 57-year-old man with erosive lichen sclerosus isolated to the infraorbital area.

How activation, entanglement, and searching a semantic network contribute to event memory.

Free-association norms indicate that words are organized into semantic/associative neighborhoods within a larger network of words and links that bind the net together. We present evidence indicating that memory for a recent word event can depend on implicitly and simultaneously activating related words in its neighborhood. Processing a word during encoding primes its network representation as a function of the density of the links in its neighborhood. Such priming increases recall and recognition and can have long-lasting effects when the word is processed in working memory. Evidence for this phenomenon is reviewed in extralist-cuing, primed free-association, intralist-cuing, and single-item recognition tasks. The findings also show that when a related word is presented in order to cue the recall of a studied word, the cue activates the target in an array of related words that distract and reduce the probability of the target's selection. The activation of the semantic network produces priming benefits during encoding, and search costs during retrieval. In extralist cuing, recall is a negative function of cue-to-distractor strength, and a positive function of neighborhood density, cue-to-target strength, and target-to-cue strength. We show how these four measures derived from the network can be combined and used to predict memory performance. These measures play different roles in different tasks, indicating that the contribution of the semantic network varies with the context provided by the task. Finally, we evaluate spreading-activation and quantum-like entanglement explanations for the priming effects produced by neighborhood density.

Enhancing medical device training with hybrid physical-virtual simulators: smart peripherals for virtual devices.

We introduce a novel platform for medical device training: hybrid physical-virtual simulators of medical devices, combining touchscreen-enabled virtual emulations of real devices with sensorized physical peripherals to enable tactile, hands-on interaction between the trainee, simulated device and standardized patients or mannequins. The system enables objective measurement and recording of trainee performance, including interactions with both the virtual device elements and the physical components, and can include metrics and feedback not available in the real device. The system also includes an integrated wireless signaling device for use with standardized patients. We present the implementation of an example system, a virtual defibrillator with sensorized paddles and wireless signaling of successful defibrillator operation.