Characteristics and Practices of High-Performing Centers in Organ Donor Identification and Referral: A Qualitative Study.

Background: The identification and referral (ID&R) of potential organ donors to provincial organ donation organizations (ODOs) is a critical first step in the organ donation process. However, even in provinces with mandatory referral legislation, there remains variability in ID&R rates across critical care units, with some units demonstrating high performance despite experiencing similar constraints associated with existing structures, policies, and practices. Objective: We sought to identify the enablers and specific strategies that high-performing critical care units leveraged to achieve their exceptional performance. Design: We conducted a descriptive qualitative study to inform ID&R improvement efforts as part of a positive deviance initiative. Setting: We identified three high-performing critical care units as study sites. Participants: Clinicians working in identified critical care units. Methods: At each site, we interviewed clinical team members about their perceptions and experiences of ID&R. Data analysis followed a thematic analysis approach. Results: We outline three themes describing how the high-performing hospitals achieve strong ID&R practices. First, all units demonstrated a high degree of integration between the concepts of high-quality end-of-life care and organ donation. Team members were consistently notified of successful transplants stemming from their unit, and all missed ID&Rs were tracked and discussed. Second, participants described a team approach with strong medical leadership, where all team members embrace their role in ensuring that no potential donor is missed. Finally, the units adopted strategies to support and simplify ID&R such as collectively simplifying triggers for referral, developing strong working relationships with provincial donor coordinators, and creating informal avenues of communication between clinicians and donor coordinators. Limitations: The lack of comparable data for potential organ donor referral rates across Canada impacted our ability to identify high-performing hospitals based on data. Instead, we contacted the ODOs directly to identify high-performing units that met our criteria. Second, our study sample was limited to three hospital sites from three different provinces and the three hospitals perform organ recovery and transplant on-site. Conclusion: Critical care units can adopt strategies and implement interventions to support ID&R improvement efforts. We provide examples informed by this study. We also highlight considerations that require attention when engaging in this work such as ensuring that all team members are aware of changes in care plans and physicians consistently engage in discussions about organ donation. Local medical leadership is critical to supporting these changes.

Contexte: L'identification et l'aiguillage (ID+AIG) des donneurs d'organes potentiels vers les organismes provinciaux de don d'organes (OPDO) constituent une première étape essentielle du processus de don d'organes. Toutefois, même dans les provinces où la loi oblige l'aiguillage des donneurs potentiels, les taux d'ID+AIG varient entre les unités de soins intensifs, certaines affichant un rendement élevé malgré des contraintes similaires associées aux structures, aux politiques et aux pratiques existantes. Objectif: Nous cherchions à identifier les facilitateurs et les stratégies que les unités de soins intensifs hautement performantes ont exploités pour atteindre des taux exceptionnels d'ID+AIG. Conception: Nous avons mené une étude qualitative descriptive afin de guider les efforts d'amélioration des taux d'ID+AIG dans le cadre d'une initiative de déviation positive. Cadre: Trois unités de soins intensifs hautement performantes ont été désignées comme sites d'étude. Participants: Les cliniciens exerçant dans les unités de soins intensifs identifiées. Méthodologie: À chaque site, nous avons interrogé des membres de l'équipe clinique sur leurs perceptions et leurs expériences d'ID+AIG. L'analyze des données a suivi une approche d'analyze thématique. Résultats: Nous présentons trois thèmes décrivant la manière dont les hôpitaux les plus performants parviennent à mettre en place de solides pratiques d'ID+AIG. Premièrement, toutes ces unités démontrent un degré élevé d'intégration entre les concepts de soins de fin de vie de haute qualité et le don d'organes. Les membres de l'équipe sont informés sur une base régulière des greffes réussies provenant de leur unité et toutes les occasions d'ID+AIG manquées font l'objet d'un suivi et de discussion. Deuxièmement, les participants ont décrit une approche d'équipe, menée par un solide leadership médical, où tous les membres assument leur rôle en s'assurant qu'aucun donneur potentiel ne soit manqué. Enfin, nous avons constaté que les unités hautement performantes adoptent des stratégies visant à soutenir et à simplifier l'ID+AIG, comme la simplification collective des critères d'aiguillage, le développement de solides relations de travail avec les coordonnateurs de dons provinciaux et la création de voies de communication informelles entre les cliniciens et les coordonnateurs de dons. Limites: L'absence de données comparables sur les taux d'aiguillage des donneurs d'organes potentiels au Canada a limité notre capacité à identifier les hôpitaux les plus performants à partir des données. Nous avons plutôt communiqué directement avec les OPDO pour identifier les unités les plus performantes répondant à nos critères. Aussi, notre échantillon était limité à trois hôpitaux de trois provinces différentes, qui procèdent tous au prélèvement et à la transplantation d'organes sur place. Conclusion: Les unités de soins intensifs peuvent adopter des stratégies et mettre en œuvre des interventions pour soutenir les efforts d'amélioration des taux d'ID+AIG. Notre étude en fournit des exemples. Nous mettons également en évidence les aspects qui nécessitent une attention particulière lorsqu'on s'engage dans cette voie; notamment s'assurer que tous les membres de l'équipe sont au courant des changements apportés aux plans de soins et que les médecins participent systématiquement aux discussions sur le don d'organes. Du leadership médical local est essentiel pour soutenir ces changements.

Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review.

Normothermic regional perfusion (NRP) is a surgical technique that can improve the quality and number of organs recovered for donation after the determination of death by circulatory criteria. Despite its promise, adoption of NRP has been hindered because of unresolved ethical issues. To inform stakeholders, this scoping review provides an impartial overview of the major ethical controversies surrounding NRP. We undertook this review according to a modified 5-step methodology proposed by Arksey and O'Malley. Publications were retrieved through MEDLINE and Embase. Gray literature was sourced from Canadian organ donation organizations, English-language organ donation organization websites, and through our research networks. Three reviewers independently screened all documents for inclusion, extracted data, and participated in content analysis. Disagreements were resolved through consensus meetings. Seventy-one documents substantively engaging with ethical issues in NRP were included for full-text analysis. We identified 6 major themes encompassing a range of overlapping ethical debates: (1) the compatibility of NRP with the dead donor rule, the injunction that organ recovery cannot cause death, (2) the risk of donor harm posed by NRP, (3) uncertainties regarding consent requirements for NRP, (4) risks to stakeholder trust posed by NRP, (5) the implications of NRP for justice, and (6) NRP's potential to benefits of NRP for stakeholders. We found no agreement on the ethical permissibility of NRP. However, some debates may be resolved through additional empirical study. As decision-makers contemplate the adoption of NRP, it is critical to address the ethical issues facing the technique to ensure stakeholder trust in deceased donation and transplantation systems is preserved.

Development of an evidence-based swimming representative military task to assess swimming competency in the British Army.

BACKGROUND: There is a requirement for British Army personnel to operate in/around water. Assessing role-related swimming/water competence will support personnel to conduct their job-roles safely and effectively. OBJECTIVE: To undertake a Job-Task Analysis (JTA) of British Army personnel when working in/around water and use this information to develop a Swimming Representative Military Task (RMT) to assess swimming/water competence. METHODS: Workshops, surveys, and observations were used to conduct a JTA, which identified and described job-tasks conducted by British Army personnel in/around water. Ergonomic analysis of these job-tasks identified seven water-based physical actions, which were considered fundamental for all personnel to be competent in performing. These seven actions guided design of a Swimming RMT, which was subsequently conducted twice by 103 serving personnel (89 men, 11 women) and once by 65 recruits (49 men, 16 women). RESULTS: The RMT comprised of entering the water in combat fatigues and webbing, removing webbing, swimming 50 m, and staying afloat for up to 10 minutes. During RMT trials, in trial 1, 85% of serving personnel and 74% of recruits successfully completed the RMT, which increased to 93% in serving personnel for trial 2. Across trials 1 and 2, all three timed RMT elements showed moderate-high correlational reliability (ICC range: 0.462-0.791). On average, serving personnel were quicker to complete the 50 m swim phase compared to recruits (91±24 s vs. 100±26 s; U = 2575.0, rb = -0.192, p = 0.039). CONCLUSIONS: The JTA-informed Swimming RMT provides an assessment of the minimum role-related swimming/water competence standard for British Army personnel.

Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Diffuse Alveolar Hemorrhage With Avacopan.

OBJECTIVE: Avacopan, an activated complement factor 5 receptor antagonist, has been approved as adjunct therapy for severe active antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Current evidence supports the management of AAV presenting with diffuse alveolar hemorrhage (DAH) by administering glucocorticoids combined with either rituximab or cyclophosphamide in addition to supportive care. The role of avacopan in patients with DAH as a primary severe disease manifestation of AAV has not been well established. Furthermore, concerns remain regarding timely access to avacopan, the best glucocorticoid tapering regimen, and long-term efficacy and safety of the drug. We sought to identify clinical features and outcomes of patients presenting with DAH secondary to AAV who received avacopan in addition to glucocorticoids and rituximab or cyclophosphamide. METHODS: We performed a retrospective cohort study of all consecutive patients presenting with DAH as part of active severe granulomatosis with polyangiitis or microscopic polyangiitis. Demographic and clinical characteristics were collected at presentation and follow-up. RESULTS: Fifteen patients met inclusion criteria and were observed for a median time of 17 weeks (interquartile range [IQR] 6-37 weeks) after initiation of avacopan. Patients were predominantly female and White, had never smoked, and were a median age of 66 years (IQR 52-72 years) at diagnosis. The majority had newly diagnosed severe AAV with renal involvement. Three patients progressed to respiratory failure. The timing of avacopan introduction and patterns of glucocorticoid tapers varied widely in this cohort. Two serious adverse events related to infection were observed, including one opportunistic infection leading to the patient's death, although neither was directly attributed to avacopan administration. CONCLUSION: We describe the clinical course of patients who presented with the severe AAV disease manifestation of DAH and received avacopan as adjunct therapy. Most patients achieved remission during follow-up, and adverse events, including infection, were observed.

Metabolic, cardiovascular, neuromuscular and perceptual responses to repeated military-specific load carriage treadmill simulations.

Bouts of military load carriage are rarely completed in isolation; however, limited research has investigated the physiological responses to repeated load carriage tasks. Twelve civilian men (age, 28 ± 8 years; stature, 185.6 ± 5.8 cm; body mass 84.3 ± 11.1 kg and maximal oxygen uptake, 51.5 ± 6.4 mL·kg-1 min-1) attended the laboratory on two occasions to undertake a familiarisation and an experimental session. Following their familiarisation session, participants completed three bouts of a fast load carriage protocol (FLCP; ∼65 min), carrying 25 kg, interspersed with a 65-min recovery period. Physiological strain (oxygen uptake [V̇O2] and heart rate [HR]) was assessed during the FLCP bouts, and physical performance assessments (weighted counter-movement jump [wCMJ], maximal isometric voluntary contraction of the quadriceps [MIVC] and seated medicine ball throw [SMBT]) was measured pre and post each FLCP bout. A main effect for bout and measurement time was evident for V̇O2 and HR (both p < 0.001 and Ñ 2 = 0.103-0.816). There was no likely change in SMBT distance (p = 0.201 and Ñ 2 = 0.004), but MIVC peak force reduced by approximately 25% across measurement points (p < 0.001 and Ñ 2 = 0.133). A mean percentage change of approximately -12% from initial values was also evident for peak wCMJ height (p = 0.001 and Ñ 2 = 0.028). Collectively, these data demonstrate that repeated FLCP bouts result in an elevated physiological strain for each successive bout, along with a substantial reduction in lower body power (wCMJ and MIVC). Therefore, future research should investigate possible mitigation strategies to maintain role-related capability.

Food for thought: dietary nootropics for the optimisation of military operators' cognitive performance.

Nootropics are compounds that enhance cognitive performance and have been highlighted as a medium-term human augmentation technology that could support soldier performance. Given the differing ethical, safety and legal considerations associated with the pharmaceutical subset of nootropics, this analysis focuses on dietary supplementation which may enhance cognition during training and operations. Numerous supplements have been investigated as possible nootropics; however, research is often not context specific or of high quality, leading to questions regarding efficacy. There are many other complex cofactors that may affect the efficacy of any dietary nootropic supplement which is designed to improve cognition, such as external stressors (eg, sleep deprivation, high physical workloads), task specifics (eg, cognitive processes required) and other psychological constructs (eg, placebo/nocebo effect). Moreover, military population considerations, such as prior nutritional knowledge and current supplement consumption (eg, caffeine), along with other issues such as supplement contamination, should be evaluated when considering dietary nootropic use within military populations. However, given the increasing requirement for cognitive capabilities by military personnel to complete role-related tasks, dietary nootropics could be highly beneficial in specific contexts. While current evidence is broadly weak, nutritional nootropic supplements may be of most use to the military end user during periods of high military specific stress. Currently, caffeine and L-tyrosine are the leading nootropic supplement candidates within the military context. Future military-specific research on nootropics should be of high quality and use externally valid methodologies to maximise the translation of research to practice.

Impact of upper airway obstruction management in Robin Sequence on need for myringotomy tubes.

OBJECTIVE: Investigate an association between upper airway obstruction (UAO) management in Robin Sequence (RS) and need for bilateral myringotomy and tubes (BMT). METHODS: Retrospective chart review of RS patients treated at a tertiary free-standing pediatric hospital from 1995 to 2020 was performed. Patients were grouped based on airway management: conservative, tracheostomy, tongue-lip adhesion (TLA), and mandibular distraction osteogenesis (MDO). Demographic data, cleft palate (CP) association, numbers of BMT and ear infections, and audiogram data including tympanograms were collected. One-way ANOVA and Chi-square/Fisher's exact tests were used to compare continuous and categorical data, respectively. Multivariable regression analysis was used to compare BMT rates between treatment groups. RESULTS: One hundred forty-eight patients were included, 70.3 % of which had CP. Most patients (67.6 %) had at least one BMT; 29.1 % required two or more BMT. The rate of BMT was higher in patients with CP compared to those with intact palates (p = 0.003; 95 % CI 1.30-3.57) and those treated with tracheostomy (p = 0.043; 95 % CI 1.01, 2.27). Surgically managed patients were more likely to have hearing loss (67.5 % vs. 35.3 %, p = 0.017) and ear infections (42.1 % vs. 20.0 %, p = 0.014) pre-compared to post-procedure for airway management. CONCLUSION: Most RS patients require at least 1 set of BMT. Those with CP and/or treated with tracheostomy had a higher likelihood of needing BMT. Rate of hearing loss and ear infection was higher in surgically managed RS patients. Patients with RS and overt CP require a statistically higher number of BMTs compared to those with either submucous cleft palate or intact palate.

Overexpression of the plastidial pseudo-protease AtFtsHi3 enhances drought tolerance while sustaining plant growth.

With climate change, droughts are expected to be more frequent and severe, severely impacting plant biomass and quality. Here, we show that overexpressing the Arabidopsis gene AtFtsHi3 (FtsHi3OE) enhances drought-tolerant phenotypes without compromising plant growth. AtFtsHi3 encodes a chloroplast envelope pseudo-protease; knock-down mutants (ftshi3-1) are found to be drought tolerant but exhibit stunted growth. Altered AtFtsHi3 expression therefore leads to drought tolerance, while only diminished expression of this gene leads to growth retardation. To understand the underlying mechanisms of the enhanced drought tolerance, we compared the proteomes of ftshi3-1 and pFtsHi3-FtsHi3OE (pFtsHi3-OE) to wild-type plants under well-watered and drought conditions. Drought-related processes like osmotic stress, water transport, and abscisic acid response were enriched in pFtsHi3-OE and ftshi3-1 mutants following their enhanced drought response compared to wild-type. The knock-down mutant ftshi3-1 showed an increased abundance of HSP90, HSP93, and TIC110 proteins, hinting at a potential downstream role of AtFtsHi3 in chloroplast pre-protein import. Mathematical modeling was performed to understand how variation in the transcript abundance of AtFtsHi3 can, on the one hand, lead to drought tolerance in both overexpression and knock-down lines, yet, on the other hand, affect plant growth so differently. The results led us to hypothesize that AtFtsHi3 may form complexes with at least two other protease subunits, either as homo- or heteromeric structures. Enriched amounts of AtFtsH7/9, AtFtsH11, AtFtsH12, and AtFtsHi4 in ftshi3-1 suggest a possible compensation mechanism for these proteases in the hexamer.

Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey.

PURPOSE: Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. METHODS: We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. RESULTS: Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n = 78), but 63% of these (n = 62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n = 48) and believed that an ICU stay is required to improve confidence (99%, n = 97). Most (96%, n = 94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. CONCLUSION: In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.

RéSUMé: OBJECTIF: L'insuffisance des recommandations fondées sur des données probantes pour guider les soins aux individus atteints de lésions cérébrales dévastatrices rend ces personnes vulnérables à des pratiques incohérentes à la jonction entre le service des urgences et de l'unité de soins intensifs (USI). Nous avons cherché à caractériser les croyances des directeurs médicaux canadiens en médecine d'urgence et médecine de soins intensifs concernant les pratiques de prise en charge actuelles des personnes ayant subi une lésion cérébrale dévastatrice. MéTHODE: Nous avons réalisé un sondage transversal auprès des directeurs médicaux des urgences et des unités de soins intensifs pour adultes du Canada (décembre 2022 à mars 2023). Notre critère d'évaluation principal était la proportion de répondant·es qui prennent en charge (ou jouent un rôle de consultation auprès) des personnes atteintes de lésions cérébrales dévastatrices à l'urgence. Nous avons effectué des analyses en sous-groupes pour comparer les croyances des médecins des urgences et des soins intensifs. RéSULTATS: Sur les 303 personnes répondantes admissibles, 98 (32 %) ont répondu aux sondages (directions médicales des urgences, 46; directions médicales d'USI, 52). La plupart des directeurs médicaux ont déclaré avoir participé à la décision de retirer des traitements de maintien des fonctions vitales (TFMV) pour des patient·es atteint·es de lésions cérébrales dévastatrices à l'urgence (80 %, n = 78), mais 63 % (n = 62) ont déclaré que c'était peu fréquent. Les directions médicales ont indiqué que les méthodes de neuropronostic existantes sont rarement suffisantes pour appuyer le retrait des TMFV à l'urgence (49 %, n = 48) et croyaient qu'un séjour aux soins intensifs était nécessaire pour améliorer leur confiance en ces méthodes (99 %, n = 97). La plupart (96 %, n = 94) estimaient que le fait d'offrir du temps de visite aux personnes soignantes avant le retrait des TMFV était un motif valable d'admission aux soins intensifs. CONCLUSION: Dans le cadre de notre sondage mené auprès des directions médicales des services d'urgence et des USI au Canada, 80 % d'entre elles ont participé au retrait de TMFV à l'urgence pour des patient·es souffrant de lésions cérébrales dévastatrices. Malgré cela, la plupart d'entre elles étaient en faveur d'une admission aux soins intensifs afin d'optimiser le neuropronostic et les soins de fin de vie axés sur les patient·es, y compris le don d'organes.

Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death.

In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.

Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute.

In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.

Beyond change scores: Employing an improved statistical approach to analyze the impact of entry fitness on physical performance during British Army basic training in men and women.

The aim was to use a robust statistical approach to examine whether physical fitness at entry influences performance changes between men and women undertaking British Army basic training (BT). Performance of 2 km run, seated medicine ball throw (MBT) and isometric mid-thigh pull (MTP) were assessed at entry and completion of Standard Entry (SE), Junior Entry-Short (JE-Short), and Junior Entry-Long (JE-Long) training for 2350 (272 women) recruits. Performance change was analyzed with entry performance as a covariate (ANCOVA), with an additional interaction term allowing different slopes for courses and genders (p < 0.05). Overall, BT courses saw average improvements in 2 km run performance (SE: -6.8% [-0.62 min], JE-Short: -4.6% [-0.43 min], JE-Long: -7.7% [-0.70 min]; all p < 0.001) and MBT (1.0-8.8% [0.04-0.34 m]; all p < 0.05) and MTP (4.5-26.9% [6.5-28.8 kg]; all p < 0.001). Regression models indicate an expected form of "regression to the mean" whereby test performance change was negatively associated with entry fitness in each course (those with low baseline fitness exhibit larger training improvements; all interaction effects: p < 0.001, η p 2 $$ {\eta}_{\mathrm{p}}^2 $$ > 0.006), particularly for women. However, when matched for entry fitness, men displayed considerable improvements in all tests, relative to women. Training courses were effective in developing recruit physical fitness, whereby the level of improvement is, in large part, dependent on entry fitness. Factors including age, physical maturity, course length, and physical training, could also contribute to the variability in training response between genders and should be considered when analyzing and/or developing physical fitness in these cohorts for future success of military job-task performance.

Associations between body mass index and episodic memory for recent eating, mindful eating, and cognitive distraction: A cross-sectional study.

Objectives: Eating while distracted has been associated with a higher body mass index (BMI), whereas mindful eating and episodic memory for recent eating have shown the opposite pattern. This pre-registered, global study (https://osf.io/rdjzk) compared the relative association between these variables (and four "positive controls": restraint, disinhibition, emotional eating, plate clearing) and self-reported BMI. The timing of data collection (April-May 2020) during the SARS-CoV-2 pandemic enabled an investigation of the impact of stay-at-home restrictions imposed on the UK population on the measures of eating behavior. Methods: An online survey was completed, including: (i) demographic data (e.g., self-reported BMI), (ii) Likert ratings assessing episodic memory for recent eating, mindful eating, cognitive distraction, restrained eating, emotional eating, disinhibition and plate clearing over the last 12 months and the last 7 days (during the first UK COVID-19 lockdown), and (iii) the Mindful Eating Questionnaire (MEQ). Results: A large adult sample participated (N = 846; mean (SD) age = 33.0 (14.3) years; mean (SD) BMI = 24.6 (5.6) kg/m2). Mindful eating (MEQ-total score) was associated with a lower self-reported BMI (ß = -0.12; 95% CI = -0.20, -0.04; p = 0.004), whereas disinhibited eating was associated with a higher self-reported BMI (ß = 0.30; 95% CI = 0.21, 0.38; p < 0.001). In UK participants (n = 520), consistent changes in eating behavior during lockdown were not found. For those that did experience change, decreases were reported in; emotional eating, disinhibited eating, focusing on taste during a meal (a measure of mindful eating), and using a smart phone while eating. Conclusions: These findings provide evidence in a large global sample for associations between BMI and (i) mindful eating, and (ii) disinhibited eating. Future research should evaluate whether mindful eating demonstrates a prospective association with body weight and should consider mechanisms of action.

Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review.

OBJECTIVE: Robin sequence (RS) consists of micrognathia and glossoptosis that result in upper airway obstruction (UAO). In RS patients who undergo tracheostomy, long-term goals include natural decannulation (ND) without further surgical airway intervention. The objective of this study was to identify long-term trends in the rate and length of time to ND. METHODS: Retrospective chart review on 144 patients with RS treated from 1995 to 2020 at a pediatric tertiary care center. Patients were grouped by year of tracheostomy. Demographic data, UAO management, postoperative care, complications, and time to decannulation were recorded. RESULTS: Thirty-six patients met the inclusion criteria. Tracheostomy was performed at a median age of 45.5 days. 19 (53%) patients experienced ND at a median time of 66.1 months. ND rate was higher in non-syndromic patients (93% non-syndromic vs 27% syndromic; P < .0001) and during the first study period (1995-2006: 78%, 2007-2020: 28%; P = .003). Cox proportional-hazard regression demonstrated that white race [aHR 0.15 (0.03-0.8); P = .023] and higher birthweight [aHR 0.9 (0.8-0.98); P = .018] were associated with a higher likelihood of ND while a syndromic diagnosis had a negative association with ND [aHR 12.5 (3.3-50.0); P < .001]. CONCLUSIONS: Our study documented that ND in patients with RS who underwent tracheostomy was significantly associated with ethnicity, birthweight, and syndromic status. The negative impact on successful ND was most observed in patients with syndromic associations. Additionally, ND rates are lower in the 2007 to 2020 subgroup. We suspect this is because alternative management techniques such as tongue lip adhesion and mandibular distraction osteogenesis became primary surgical treatment in severe RS upper airway obstruction at our institution starting in 2007.

Donor audits in deceased organ donation: a scoping review.

PURPOSE: We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance. SOURCE: We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement. PRINCIPAL FINDINGS: The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD. CONCLUSION: Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

RéSUMé: OBJECTIF: Nous avons cherché à colliger et résumer la documentation existante sur les vérifications des donneuses et donneurs (VD) et la façon dont elles ont été utilisées pour guider la performance et l'assurance de la qualité des systèmes de don et de transplantation d'organes de personnes décédées. SOURCES: Le 6 mai 2022, nous avons effectué des recherches dans MEDLINE, CINAHL et Web of Science, complétées par des recherches sur Google afin d'identifier la littérature grise et de localiser les études en anglais, en français et en espagnol. Les données ont été examinées, extraites et analysées de manière indépendants par deux personnes. Nous avons regroupé les résultats en cinq catégories : 1) motivation pour la VD, 2) méthodologie de la VD, 3) donneurs et donneuses potentiel·les et réel·les, 4) occasions de dons manquées, et 5) amélioration de la qualité. CONSTATATIONS PRINCIPALES: Notre recherche nous a permis de découvrir 2416 publications uniques et 52 ont été incluses dans cette revue. La plupart des études provenaient du Royaume-Uni (n = 13) et avaient été publiées entre 2001 et 2006 (n = 15). Les méthodologies décrites pour la vérification des donneuses et donneurs étaient diverses. Nos résultats ont montré que la principale motivation pour mener une VD était d'identifier des donneurs et donneuses potentiel·les et que le nombre potentiel de donneuses et donneurs d'organes après le décès était significativement plus élevé que le nombre réel. Parmi les études retenues, la proportion d'occasions de dons après un diagnostic de décès neurologique était de 95/222 (43 %), comparativement à 25/181 (14 %) pour le don après un décès cardiocirculatoire (DDC), ce qui suggère que le taux de dons manqués est plus élevé pour le DDC. CONCLUSION: Les vérifications des donneuses et donneurs aident à identifier les occasions de dons manquées le long du parcours de don après un décès et peuvent aider à soutenir l'évaluation des initiatives d'amélioration de la qualité.

Plant Development in the Garden Pea as Revealed by Mutations in the Crd/PsYUC1 Gene.

In common with other plant species, the garden pea (Pisum sativum) produces the auxin indole-3-acetic acid (IAA) from tryptophan via a single intermediate, indole-3-pyruvic acid (IPyA). IPyA is converted to IAA by PsYUC1, also known as Crispoid (Crd). Here, we extend our understanding of the developmental processes affected by the Crd gene by examining the phenotypic effects of crd gene mutations on leaves, flowers, and roots. We show that in pea, Crd/PsYUC1 is important for the initiation and identity of leaflets and tendrils, stamens, and lateral roots. We also report on aspects of auxin deactivation in pea.

Cognitive, Psychophysiological, and Perceptual Responses to a Repeated Military-Specific Load Carriage Treadmill Simulation.

BACKGROUND: Dismounted military operations require soldiers to complete cognitive tasks whilst undertaking demanding and repeated physical taskings. OBJECTIVE: To assess the effects of repeated fast load carriage bouts on cognitive performance, perceptual responses, and psychophysiological markers. METHODS: Twelve civilian males (age, 28 ± 8 y; stature, 186 ± 6 cm; body mass 84.3 ± 11.1 kg; V̇O2max, 51.5 ± 6.4 mL·kg-1·min-1) completed three ∼65-min bouts of a Fast Load Carriage Protocol (FLCP), each interspersed with a 65-min recovery period, carrying a representative combat load of 25 kg. During each FLCP, cognitive function was assessed using a Shoot/Don't-Shoot Task (SDST) and a Military-Specific Auditory N-Back Task (MSANT), along with subjective ratings. Additional psychophysiological markers (heart rate variability, salivary cortisol, and dehydroepiandrosterone-sulfate concentrations) were also measured. RESULTS: A main effect of bout on MSANT combined score metric (p < .001, Kendall's W = 69.084) and for time on the accuracy-speed trade-off parameter of the SDST (p = .025, Ñ 2 = .024) was evident. These likely changes in cognitive performance were coupled with subjective data indicating that participants perceived that they increased their mental effort to maintain cognitive performance (bout: p < .001, Ñ 2 = .045; time: p < .001, Ñ 2 = .232). Changes in HRV and salivary markers were also evident, likely tracking increased stress. CONCLUSION: Despite the increase in physiological and psychological stress, cognitive performance was largely maintained; purportedly a result of increased mental effort. APPLICATION: Given the likely increase in dual-task interference in the field environment compared with the laboratory, military commanders should seek approaches to manage cognitive load where possible, to maintain soldier performance.

Persistent perineal sinus following proctocolectomy in the inflammatory bowel disease patient.

Prolonged perineal wound healing following proctocolectomy in patients with inflammatory bowel disease (IBD) is a frustrating result for the medical team and patients who were hoping for improved quality of life. Prolonged healing, which lasts more than 6 months following proctocolectomy, is termed persistent perineal sinus (PPS) and typically necessitates further surgical management. Healing of the PPS is difficult due to the resulting "dead space" following proctocolectomy, necessitating the need to fill the void with viable tissue in an area with anatomic constraints. Here we provide a narrative review and comprehensively address the incidence, pathogenesis, and clinical and operative management of a PPS in patients with IBD following proctocolectomy. Operative methods discussed include surgical debridement, flap closure of the perineum, omental flap closure, and gracilis muscle transposition. It is necessary to further investigate and establish a gold standard of care for these patients.