Development of an Automated Ultrasound Signal Indicator of Lung Interstitial Syndrome.

OBJECTIVES: The number and distribution of lung ultrasound (LUS) imaging artifacts termed B-lines correlate with the presence of acute lung disease such as infection, acute respiratory distress syndrome (ARDS), and pulmonary edema. Detection and interpretation of B-lines require dedicated training and is machine and operator-dependent. The goal of this study was to identify radio frequency (RF) signal features associated with B-lines in a cohort of patients with cardiogenic pulmonary edema. A quantitative signal indicator could then be used in a single-element, non-imaging, wearable, automated lung ultrasound sensor (LUSS) for continuous hands-free monitoring of lung fluid. METHODS: In this prospective study a 10-zone LUS exam was performed in 16 participants, including 12 patients admitted with acute cardiogenic pulmonary edema (mean age 60 ± 12 years) and 4 healthy controls (mean age 44 ± 21). Overall,160 individual LUS video clips were recorded. The LUS exams were performed with a phased array probe driven by an open-platform ultrasound system with simultaneous RF signal collection. RF data were analyzed offline for candidate B-line indicators based on signal amplitude, temporal variability, and frequency spectrum; blinded independent review of LUS images for the presence or absence of B-lines served as ground truth. Predictive performance of the signal indicators was determined with receiving operator characteristic (ROC) analysis with k-fold cross-validation. RESULTS: Two RF signal features-temporal variability of signal amplitude at large depths and at the pleural line-were strongly associated with B-line presence. The sensitivity and specificity of a combinatorial indicator were 93.2 and 58.5%, respectively, with cross-validated area under the ROC curve (AUC) of 0.91 (95% CI = 0.80-0.94). CONCLUSION: A combinatorial signal indicator for use with single-element non-imaging LUSS was developed to facilitate continuous monitoring of lung fluid in patients with respiratory illness.

"God was with me": A qualitative study of Christian meaning-making among refugees.

In this consensual qualitative research study, we investigated the role of refugees' Christian faith in meaning-making coping. High percentages of religiosity in refugee populations support the need to understand the role of religion in their coping processes. Interviews with 20 Christian refugees from 10 African and Asian countries revealed that participants drew heavily from their faith resources to cope with their experiences. Specifically, refugees reported coping practices that included trust in God, prayer, intimacy with God, spiritual surrender, lament, worship, and social support. Although many participants described spiritual struggles, including doubting God, feeling distant from God, and questioning God, most found meaning amid refugee-related suffering and reported perspective shifts, a deepening of faith, seeing suffering as part of God's plan, experiencing a deepened sense of purpose, and growing in the likeness of Christ. Refugees also reported growth through suffering in the form of gratitude, altruism, testimony, and humility. Clinical implications include encouraging the use of religious resources for meaning-making and supporting the resolution of spiritual struggles.

Perspectives of Healthcare Professionals on the Management and Treatment of Advanced Ovarian Cancer in the UK: Results From the KNOW-OC Survey.

AIMS: New treatment options for advanced ovarian cancer have the potential to significantly change the treatment pathway in the UK. Understanding the structures and responsibilities of multidisciplinary teams/tumour boards (MDT) and regional variations will enable services to adapt more effectively to these changes. MATERIALS AND METHODS: The KNOW-OC survey was conducted in 2020 to understand the views of a selected group of 66 healthcare professionals (HCPs) involved in advanced ovarian cancer care in UK hospitals. RESULTS: The results showed that MDT involvement in the management of advanced ovarian cancer varied depending on pathway stage and line of relapse, with 98.5% of HCPs responding that the MDT was involved in decisions at initial presentation, but only 40.9% for patients with multiple relapses. The MDT was mostly responsible for determining whether the patients would undergo primary or interval cytoreductive surgery according to 75.8% of respondents, and most HCPs (80.3%) stated that tumour dissemination patterns were the most important factor influencing this decision. The most commonly assessed biomarkers at the time of the survey were CA125, gBRCA and tBRCA. Homologous recombination deficiency was viewed as the second most important factor for determining prognosis, but few centres had access to testing at the time of survey completion. The use of active surveillance was expected to decrease in favour of first-line targeted therapies. Nearly all (98.5%) HCPs agreed there is a role for secondary cytoreductive surgery for the treatment of recurrence (for carefully selected patients). CONCLUSIONS: The results highlighted UK-specific geographical variation in the views of HCPs on MDT involvement and specific practices, such as molecular biomarker testing, and the overall treatment approach. Together, these findings improve the understanding of reported clinical practice across the UK for ovarian cancer and provide insight into decision-making associated with updates to recommendations for best practice (e.g. European Society for Medical Oncology/European Society of Gynaecological Oncology consensus statements) and the introduction of new treatment options.

Engaging multisector stakeholders to identify priorities for global health innovation, change and research: an engagement methodology and application to prosthetics service delivery in Cambodia.

PURPOSE: While innovation is known to catalyse solutions to global sustainable development challenges, lack of engagement from stakeholders during conceptualisation and development may influence the degree of success of implementation. METHODS AND MATERIALS: This paper presents a complete and novel engagement methodology, developed from value led business modelling approaches, for working with multi-sector stakeholders. The methodology can be used to determine barriers and facilitators to clinical practice innovations or translational research, within a country-specific context. The approach has then been applied in the Cambodian prosthetics and orthotics sector to provide a practice-based exemplar application of the framework. RESULTS: This approach seeks to ensure the suitability and sustainability of clinical practice and research programmes being implemented within a complex ecosystem. A theoretical basis, drawn from academic and business innovation sectors, has been consolidated and adapted for practical application to design, direct, and inform initiatives in low resource settings. CONCLUSIONS: The methods presented provide a way to both develop and articulate the mission, vision, and goals of any proposed change, and to effectively communicate these with stakeholders in a way that engages the personal and professional values that exist in their ecosystem. It provides a structured process through which meaningful conversations can happen, and a basis for relationship management with key stakeholders; intrinsic to enable a sustained legacy from research and development.

The engagement from stakeholders during conceptualisation and throughout development can determine the success, or not, of any implementation and scale of innovation.This paper presents a conceptual stakeholder-led engagement methodology, developed from value led business modelling approaches, for determining barriers and facilitators to translational global healthcare research in a country-specific context, in this case the Cambodian prosthetics and orthotics sector.Subsequent research and development work in this area needs to carefully manage and negotiate influencing factors identified through the application of the described methodology, to ensure initiatives (whether research or wider national development work) are sustainable and successful.

Reduction in N-Acetylglucosaminyltransferase-I Activity Decreases Survivability and Delays Development of Zebrafish.

A lack of complex and hybrid types of N-glycans in mice is embryonically lethal due to neural tube maldevelopment. N-acetylglucosaminyltransferase-I (GnT-I; Mgat1) catalyzes a required step for converting oligomannose N-glycans into hybrid and complex N-glycans. Unlike mice, zebrafish have two Mgat1a/b genes. Herein, CRISPR/Cas9 technology was used to knockdown GnT-Ib activity in zebrafish, referred to as Mgat1b-/-, to examine the impact of a decrease in complex types of N-glycans on survival and development, and sensory and motor functions. Genotyping verified the occurrence of edited Mgat1b, and LC-ESI-MS and lectin blotting identified higher levels of oligomannose and lower levels of complex N-glycans in Mgat1b-/- relative to Wt AB. The microscopic visualization of developmental stages and locomotor studies using an automated tracking unit and manual touch assays revealed reduced survivability, and delayed motor and sensory functions in Mgat1b-/-. Moreover, embryonic staging linked reduced survivability of Mgat1b-/- to disruption in brain anlagen formation. Birefringence measurements supported delayed skeletal muscle development, which corresponded with motor and sensory function impediments in Mgat1b-/-. Furthermore, GnT-Ib knockdown hindered cardiac activity onset. Collectively, Mgat1b-/- displayed incomplete penetrance and variable expressivity, such that some died in early embryonic development, while others survived to adulthood, albeit, with developmental delays. Thus, the results reveal that reducing the amount of complex-type N-glycans is unfavorable for zebrafish survival and development. Moreover, our results support a better understanding of human congenital disorders of glycosylation.

Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism.

BACKGROUND: Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. METHODS: We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. RESULTS: Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. CONCLUSION: Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

Fit for Purpose? The Suitability of Oral Health Outcome Measures to Inform Policy.

KNOWLEDGE TRANSFER STATEMENT: Oral health research and program evaluation should consider alternative outcome measures for population oral health other than the DMFT index.

A content review of state tobacco pre-emption laws in the US.

OBJECTIVES: State ceiling pre-emption laws effectively limit the authority of local governments to regulate numerous public health issues, including tobacco. While general trends in the number of state tobacco pre-emption laws have been well-documented, less is known about the specific content of these laws. This study provides a comprehensive analysis of the content of current state tobacco pre-emption laws and captures the salient features of these laws. STUDY DESIGN: This was a comparative analysis of tobacco pre-emption laws in the United States. METHODS: The study team collected data about tobacco pre-emption laws from the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Trained legal researchers further verified and reviewed each law's content using the Westlaw database. A coding scheme was developed to capture and analyse these laws' most salient features. RESULTS: State tobacco pre-emption laws use various terms to indicate the pre-emption of a local authority, including supersede, pre-empt, uniform, exclusive, and consistent. State laws cover numerous general topics and vary widely in explicit terminology of authorities and fields pre-empted. Several state laws included grandfathering exceptions and a few allowed exceptions for particular local jurisdictions. CONCLUSIONS: State laws that undermine local tobacco control efforts from implementing more stringent laws pose a threat to public health. These laws vary widely in their scope across the U.S., and local jurisdictions should be empowered to enact and maintain tobacco control measures that protect their communities from the harms of tobacco use and exposure.

"God wastes nothing": A consensual qualitative study of coping among Catholic individuals with cancer diagnoses.

While religious meaning-making has been extensively studied, emic religious coping remains largely unexplored. This consensual qualitative research study explored Catholic cancer survivors' (N = 22) descriptions of drawing on their religious framework throughout their cancer journeys. Findings revealed distinctive Catholic resources such as the power of blessings, drawing comfort from the saints and sacraments, and "offering up" suffering as a form of spiritual surrender, suggesting the existence of underlying theodicies of divine purpose as well as potential clinical resources. While many participants described spiritual struggles and questions, most found meaning through deepening their faith, helping others, and re-examining their priorities. Exploratory mixed-method analyses suggest that questioning God may promote turning toward faith, while being angry at God is associated with difficulty in doing so. The findings have implications for research, pointing to emic practices that merit further study.

When suffering contradicts belief: measuring theodical struggling.

Global meaning systems help people make sense of their experiences, but suffering can violate global meaning and create distress. One type of potential violation is conflict between one's experience of suffering and one's deeply-held beliefs about God as loving, powerful, and just. The problem of theodicy-why an all-powerful and all-loving God would allow suffering-has long been an important theological and philosophical concern, but little is known about how theodicy plays out psychologically for religious individuals facing serious life difficulties. To address this issue within a specific religious tradition, Christianity, we drew upon philosophy, Christian theology, and psychology to develop the construct of theodical struggling. Through theological and philosophical input, we generated a 28-item pool and conducted 10 cognitive interviews with a diverse sample of Christian adults. In three consecutive online studies of Christian adult samples, we reduced the scale to 11 items through PCA, found a strong one-factor solution using EFA, and found support for the one-factor solution along with preliminary reliability and validity. This newly-developed Theodical Struggling Scale represents an important advance in understanding individuals' experiences of ruptures in their beliefs regarding God's goodness and paves the way for future research on this topic. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-023-04642-w.

First Direct Measurement Constraining the

The rate of the final step in the astrophysical αp process, the ^{34}Ar(α,p)^{37}K reaction, suffers from large uncertainties due to a lack of experimental data, despite having a considerable impact on the observable light curves of x-ray bursts and the composition of the ashes of hydrogen and helium burning on accreting neutron stars. We present the first direct measurement constraining the ^{34}Ar(α,p)^{37}K reaction cross section, using the Jet Experiments in Nuclear Structure and Astrophysics gas jet target. The combined cross section for the ^{34}Ar,Cl(α,p)^{37}K,Ar reaction is found to agree well with Hauser-Feshbach predictions. The ^{34}Ar(α,2p)^{36}Ar cross section, which can be exclusively attributed to the ^{34}Ar beam component, also agrees to within the typical uncertainties quoted for statistical models. This indicates the applicability of the statistical model for predicting astrophysical (α,p) reaction rates in this part of the αp process, in contrast to earlier findings from indirect reaction studies indicating orders-of-magnitude discrepancies. This removes a significant uncertainty in models of hydrogen and helium burning on accreting neutron stars.

Methane emission, nutrient digestibility, and rumen microbiota in Holstein heifers fed 14 different grass or clover silages as the sole feed.

This experiment investigated the variation in enteric methane production and associated gas exchange parameters, nutrient digestibility, rumen fermentation, and rumen microbiome when a range of silages based on different forage types (grass or clover), and different species within the 2 types, were fed as the sole feed to heifers. Three grass species (perennial ryegrass, festulolium, and tall fescue) and 2 clover species (red clover and white clover) were included. Perennial ryegrass was harvested at 2 maturity stages in the primary growth, white clover was harvested once in the primary growth, and 4 cuts of festulolium and tall fescue and 3 cuts of red clover were harvested during the growing season, giving 14 different silage batches in total. Sixteen Holstein heifers 16 to 21 mo old and 2 to 5 mo in pregnancy were fed the silages ad libitum as the sole feed in an incomplete crossover design. Each silage was fed to 4 heifers, except for the 2 perennial ryegrass silages, which were fed to 8 heifers; in total 64 observations. The CH4 production was measured for 3 d in respiration chambers. Heifers fed clover silages had higher dry matter intake (DMI) compared with heifers fed grass silages, and heifers fed tall fescue silages had the numerically the lowest DMI. Compared with grass silages, feeding clover silages led to higher crude protein digestibility but lower neutral detergent fiber (NDF) digestibility. Rumen pH was higher in heifers fed clover silages compared with those fed grass silages. Based on composition analysis, the rumen microbiota of the heifers clustered clearly according to forage type and species. More specifically, 7 of the 34 dominating rumen bacterial genus-level groups showed higher relative abundances for the clover silages, whereas 7 genus-level groups showed higher abundances for the grass silages. Methane yield was higher for heifers fed grass silages than for those fed clover silages when methane production was related to dry matter and digestible organic matter intake, whereas the opposite was seen when related to NDF digestion. The gross energy lost as methane (CH4 conversion factor, %) reduced from 7.5% to 6.7%, equivalent to an 11% reduction. The present study gives the outlines for choosing the optimal forage type and forage species with respect to nutrient digestibility and enteric methane emission in ruminants.

Osteoarthritis year in review 2022: Epidemiology & therapy.

This 'Year in Review' provides a synopsis of key research themes and individual studies from the clinical osteoarthritis (OA) field, focused on epidemiology and therapy. The electronic database search for the review was adapted from the 2021 year in review search, to increase search specificity for relevant study designs, and was conducted in Medline, Embase and medRxiv (31st March 2021 to 4th March 2022). Following screening for eligibility, studies were grouped according to their key research design, including reviews, cohorts and randomised trials. 11 key themes emerged, including the importance of several comorbidities in predicting OA incidence and prevalence, surgical approaches that can reduce the risk of post-traumatic OA, the heterogenous but nevertheless relatively stable nature of OA subgroup trajectories, the paucity of robust studies particularly of surgery for OA and the very modest benefit of many therapies under evaluation in trials. A particular interest of the authors was to consider whether new studies are helping determine how to better ensure the right patient with OA is matched to the right treatment at the right time. There are several new studies developing improved predictive models through big data analytics and machine learning which show promise, need validation, and may support new approaches to stratified care.

Advanced crystallisation methods for small organic molecules.

Molecular materials based on small organic molecules often require advanced structural analysis, beyond the capability of spectroscopic techniques, to fully characterise them. In such cases, diffraction methods such as single crystal X-ray diffraction (SCXRD), are one of the most powerful tools available to researchers, providing molecular and structural elucidation at atomic level resolution, including absolute stereochemistry. However SCXRD, and related diffraction methods, are heavily dependent on the availability of suitable, high-quality crystals, thus crystallisation often becomes the major bottleneck in preparing samples. Following a summary of classical methods for the crystallisation of small organic molecules, this review will focus on a number of recently developed advanced methods for crystalline material sample preparation for SCXRD. This review will cover two main areas of modern small organic molecule crystallisation, namely the inclusion of molecules within host complexes (e.g., "crystalline sponge" and tetraaryladamantane based inclusion chaperones) and the use of high-throughput crystallisation, employing "under-oil" approaches (e.g., microbatch under-oil and ENaCt). Representative examples have been included for each technique, together with a discussion of their relative advantages and limitations to aid the reader in selecting the most appropriate technique to overcome a specific analytical challenge.

Limited N-Glycan Processing Impacts Chaperone Expression Patterns, Cell Growth and Cell Invasiveness in Neuroblastoma.

Enhanced N-glycan branching is associated with cancer, but recent investigations supported the involvement of less processed N-glycans. Herein, we investigated how changes in N-glycosylation influence cellular properties in neuroblastoma (NB) using rat N-glycan mutant cell lines, NB_1(-Mgat1), NB_1(-Mgat2) and NB_1(-Mgat3), as well as the parental cell line NB_1. The two earlier mutant cells have compromised N-acetylglucosaminyltransferase-I (GnT-I) and GnT-II activities. Lectin blotting showed that NB_1(-Mgat3) cells had decreased activity of GnT-III compared to NB_1. ESI-MS profiles identified N-glycan structures in NB cells, supporting genetic edits. NB_1(-Mgat1) had the most oligomannose N-glycans and the greatest cell invasiveness, while NB_1(-Mgat2) had the fewest and least cell invasiveness. The proliferation rate of NB_1 was slightly slower than NB_1(-Mgat3), but faster than NB_1(-Mgat1) and NB_1(-Mgat2). Faster proliferation rates were due to the faster progression of those cells through the G1 phase of the cell cycle. Further higher levels of oligomannose with 6-9 Man residues indicated faster proliferating cells. Human NB cells with higher oligomannose N-glycans were more invasive and had slower proliferation rates. Both rat and human NB cells revealed modified levels of ER chaperones. Thus, our results support a role of oligomannose N-glycans in NB progression; furthermore, perturbations in the N-glycosylation pathway can impact chaperone systems.

The time is now: making the case for a UK registry of deployment of radiology artificial intelligence applications.

Artificial intelligence (AI)-based healthcare applications (apps) are rapidly evolving, and radiology is a target specialty for their implementation. In this paper, we put the case for a national deployment registry to track the spread of AI apps into clinical use in radiology in the UK. By gathering data on the specific locations, purposes, and people associated with AI app deployment, such a registry would provide greater transparency on their spread in the radiology field. In combination with other regulatory and audit mechanisms, it would provide radiologists and patients with greater confidence and trust in AI apps. At the same time, coordination of this information would reduce costs for the National Health Service (NHS) by preventing duplication of piloting activities. This commentary discusses the need for a UK-wide registry for such apps, its benefits and risks, and critical success factors for its establishment. We conclude by noting that a critical window of opportunity has opened up for the development of a deployment registry, before the current pattern of localised clusters of activity turns into the widespread proliferation of AI apps across clinical practice.

Invited review: Corrected milk: Reconsideration of common equations and milk energy estimates.

Corrected milk equations were developed in attempts to bring milk weights to a standardized basis for comparison by expressing the weight and composition of milk as corrected to the energy content of milk of a specific composition. Expressed as milk weights familiar on farm and in commerce, this approach integrates energy contributions of the dissimilar components to make the mass units more comparable. Such values are applied in evaluating feed efficiency, lactation performance, and global milk production, as functional units for lifecycle assessments, and in translation of research results. Corrected milk equations are derived from equations relating milk gross energy to milk composition. First, a milk energy equation is used to calculate the energy value of the milk composition to correct to (e.g., 0.695 Mcal/kg for milk with 3.5% fat, 3.05% true protein, and 4.85% lactose). That energy value is divided into the energy equation to give the corrected milk equation. Confusion has arisen, as different equations purport to correct to the same milk composition; their differences are based on uses of different energy equations or divisors. Accuracy of corrected milk equations depends on the accuracy of the energy equations used to create them. Energy equations have evolved over time as different milk component analyses have become more available. Inclusion of multiple milk components more accurately predicts milk energy content than does fat content alone. Omission of components from an equation requires the assumption that their content in milk is constant or highly correlated with an included component. Neither of these assumptions is true. Milk energy equations evaluated on a small data set of measured milk values have demonstrated that equations that incorporate protein, fat, and lactose contents multiplied by the gross energy of each component more closely predict milk energy than equations containing fewer components or regression-derived equations. This provides a tentative recommendation for using energy equations that include the 3 main milk components and their gross energy multipliers for predicting milk energy and deriving corrected milk equations. Accuracy of energy equations is affected by the accuracy of gross energy values of individual components and variability of milk composition. Lactose has consistent reported gross energy values. In contrast, gross energy of milk fat and protein vary as their compositional profiles change. Future refinements could assess accuracy of milk fat and protein gross energy and whether that appreciably improves milk energy predictions. Fat gross energy has potential to be calculated using the milk fatty acid profile, although the influence on gross energy may be small. For research, direct reporting of milk energy values, rather than corrected milk, provides the most explicit, least manipulated form of the data. However, provision of corrected milk values in addition to information on components can serve to translate the energy information to a form familiar to and widely used in the field. When reporting corrected milk data, the corrected milk equation, citation for the energy equation used, and composition and energy contents of the corrected milk must be described to make clear what the values represent.

Quenching of Single-Particle Strength in A=15 Nuclei.

Absolute cross sections for the addition of s- and d-wave neutrons to ^{14}C and ^{14}N have been determined simultaneously via the (d,p) reaction at 10 MeV/u. The difference between the neutron and proton separation energies, ΔS, is around -20 MeV for the ^{14}C+n system and +8 MeV for ^{14}N+n. The population of the 1s_{1/2} and 0d_{5/2} orbitals for both systems is reduced by a factor of approximately 0.5 compared with the independent single-particle model, or about 0.6 when compared with the shell model. This finding strongly contrasts with results deduced from intermediate-energy knockout reactions between similar nuclei on targets of ^{9}Be and ^{12}C. The simultaneous technique used removes many systematic uncertainties.

First Series Using Ultrasonic Propulsion and Burst Wave Lithotripsy to Treat Ureteral Stones.

PURPOSE: Our goal was to test transcutaneous focused ultrasound in the form of ultrasonic propulsion and burst wave lithotripsy to reposition ureteral stones and facilitate passage in awake subjects. MATERIALS AND METHODS: Adult subjects with a diagnosed proximal or distal ureteral stone were prospectively recruited. Ultrasonic propulsion alone or with burst wave lithotripsy was administered by a handheld transducer to awake, unanesthetized subjects. Efficacy outcomes included stone motion, stone passage, and pain relief. Safety outcome was the reporting of associated anticipated or adverse events. RESULTS: Twenty-nine subjects received either ultrasonic propulsion alone (n = 16) or with burst wave lithotripsy bursts (n = 13), and stone motion was observed in 19 (66%). The stone passed in 18 (86%) of the 21 distal ureteral stone cases with at least 2 weeks follow-up in an average of 3.9±4.9 days post-procedure. Fragmentation was observed in 7 of the burst wave lithotripsy cases. All subjects tolerated the procedure with average pain scores (0-10) dropping from 2.1±2.3 to 1.6±2.0 (P = .03). Anticipated events were limited to hematuria on initial urination post-procedure and mild pain. In total, 7 subjects had associated discomfort with only 2.2% (18 of 820) propulsion bursts. CONCLUSIONS: This study supports the efficacy and safety of using ultrasonic propulsion and burst wave lithotripsy in awake subjects to reposition and break ureteral stones to relieve pain and facilitate passage.