Adenomyoepithelioma of the Breast: Radiologic-Pathologic Correlation and Management.

Adenomyoepithelioma (AME) is a rare, usually benign breast neoplasm with low potential for malignant transformation. Imaging features are nonspecific and overlap with other benign and malignant breast lesions. On mammography, AME most often presents as a mass, usually oval in shape, with variable reported margins. Less commonly, AME can present mammographically as an asymmetry or can be mammographically occult. Associated calcifications are uncommon. On US, AME is usually seen as a hypoechoic oval mass, but it can also manifest as a complex cystic and solid mass. On US, the majority of AME have noncircumscribed margins (indistinct, angular, or microlobulated). Internal vascularity is usually present, and posterior enhancement can be seen. Although there is limited literature on MRI features, the most frequent finding is an irregular mass with washout kinetics; T2 hyperintensity can be observed. These nonspecific and often suspicious imaging features usually merit biopsy. On histologic analysis, AME is characterized by a biphasic proliferation of myoepithelial and epithelial cells. Pathologic diagnosis can be difficult due to the variety of histologic features of AME and heterogeneity in these tumors, especially when sampling is limited, such as in core needle biopsies. Wide local surgical excision of AME is recommended due to potential for recurrence and malignant transformation.

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review.

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Molecular Breast Imaging in the Screening Setting.

Early detection of breast cancer through screening mammography saves lives. However, the sensitivity of mammography for breast cancer detection is reduced in women with dense breast tissue. Imaging modalities for supplemental breast cancer screening include MRI, whole breast US, contrast-enhanced mammography, and molecular breast imaging (MBI). Molecular breast imaging with 99mTc-sestamibi is a functional imaging test to identify metabolically active areas in the breast with positioning analogous to mammography. Since 2011, there have been six large, published studies of screening MBI as a supplement to mammography involving over 6000 women from four different institutions. A multicenter, prospective clinical trial of 3000 women comparing breast cancer detection using screening digital breast tomosynthesis alone or in combination with MBI recently completed enrollment. This review focuses on the current evidence of MBI use for supplemental breast cancer screening, the strengths and limitations of MBI, and recent technological advances.

Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis.

PURPOSE: To evaluate the feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis (AWE). MATERIALS AND METHODS: A retrospective review of percutaneous cryoablation (CT or MR) of AWE was performed from January 2018 to December 2020. Eighteen patients were identified from an internal percutaneous ablation database. Technical success, complications, and outcomes were analyzed according to standard nomenclature. RESULTS: Patients comprised 18 females (mean age 36.9 years) who underwent 18 cryoablation procedures to treat 23 AWE deposits. Three of the 18 cases were performed under MR guidance, while the remaining 15 employed CT guidance. Technical success was achieved in all 18 cases (100%). Fifteen of 18 patients (83%) had biopsy proven AWE deposits prior to treatment. Hydrodisplacement was used to displace adjacent bowel, bladder, or neurovascular structures in 13/18 cases (72%). The mean number of probes used per case was 3. Sixteen of 23 (70%) of AWE deposits had imaging follow-up (median 85 days). Of the 16 lesions with imaging follow-up, 15 (94%) demonstrated no residual enhancement or T1 hyperintensity at the treatment site and 1 lesion (6%) demonstrated residual/progressive disease. At clinical follow-up, 13 of 14 (93%) patients reported improvement in AWE-related symptoms. Eleven patients had clinically documented pain scores before and after ablation and all demonstrated substantial symptomatic improvement. No society of interventional radiology (SIR) major complications were observed. CONCLUSIONS: Percutaneous cryoablation of AWE is feasible with a favorable safety profile. Further longitudinal studies are needed to document durable response over time.

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children.

OBJECTIVES: We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale. DESIGN: Mixed-methods, observational cohort. SETTING: Pediatric and neonatal ICUs. SUBJECTS: Critical care nurses and patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale. CONCLUSIONS: When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

A scoping review of parental roles in rehabilitation interventions for children with developmental delay, disability, or long-term health condition.

The importance of parental roles in rehabilitation interventions (i.e. the tasks and responsibilities assigned to parents in intervention) is widely reported but there is a paucity of information regarding the tasks linked with specific parental roles. A rigorous scoping review was conducted to understand the various roles that parents of children with developmental delays, disabilities, and long-term health conditions perform in intervention and the tasks and responsibilities associated with each role. The results confirm that parents take on distinct intervention roles which can be placed on a continuum from passive to active responsibility. Some parental roles are clearly associated with tasks completed in-session, some are linked with out-of-session tasks while others entail a combination of in-and out-of-session tasks. The in-session tasks linked with the Learner role emerged as central to enabling parents to assume other in-and out-of-session roles. The results also highlight the influence of the parent-professional relationship on the type of roles parents take on in their child's intervention. The findings of the scoping review serve as the initial step in generating items for a tool to measure the type of roles that parents assume in intervention to empirically test the relationship between these roles and parental engagement.

Postoperative Urinary Retention Rates after Autofill versus Backfill Void Trial following Total Laparoscopic Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare the rate of postoperative urinary retention (POUR) after total laparoscopic hysterectomy (TLH) using the autofill vs the backfill void trial. Secondary objectives were to compare the time to discharge from the recovery room, rate of postoperative urinary tract infection (UTI), perceived bladder condition, the effect of bladder function on life, and patient satisfaction. DESIGN: Randomized controlled trial. SETTING: Single academic medical center. PATIENTS: Women who underwent TLH by conventional laparoscopy or robotic-assisted laparoscopy for benign non-urogynecologic indications. INTERVENTIONS: After TLH, participants were randomized to have an autofill void trial (group A) or a backfill void trial once they were able to ambulate (group B). Failure rate, time to discharge, and UTI rate were assessed. Participants completed the patient perception of bladder condition and the incontinence impact questionnaire-short form questionnaires. Patient satisfaction was assessed. Multiple regression analysis was performed to determine the predictors of POUR. MEASUREMENTS AND MAIN RESULTS: Eighty-two participants completed the study after randomization, 42 in group A and 40 in group B. There were no statistically significant differences in demographic or perioperative outcomes. Seven participants had POUR in group A (16.7%) and 11 in group B (27.5%) (p = .36), respectively. The median time to discharge was 176 minutes for group A (160.5, 255.5) and 218 minutes for group B (180, 265) (p = .01), respectively. There were no statistically significant differences in rate of postoperative UTI (p >.99), patient perception of bladder condition scores (p = .24), incontinence impact questionnaire-short form scores (p = .23), and patient satisfaction scores (p = .26). A stepwise logistic regression analysis did not demonstrate any predictors of POUR. CONCLUSION: Backfill void trial once the participant was able to ambulate was not superior to the autofill void trial with respect to the rate of POUR. The autofill void trial resulted in faster same-day discharge.

Alveolar macrophage-derived extracellular vesicles inhibit endosomal fusion of influenza virus.

Alveolar macrophages (AMs) and epithelial cells (ECs) are the lone resident lung cells positioned to respond to pathogens at early stages of infection. Extracellular vesicles (EVs) are important vectors of paracrine signaling implicated in a range of (patho)physiologic contexts. Here we demonstrate that AMs, but not ECs, constitutively secrete paracrine activity localized to EVs which inhibits influenza infection of ECs in vitro and in vivo. AMs exposed to cigarette smoke extract lost the inhibitory activity of their secreted EVs. Influenza strains varied in their susceptibility to inhibition by AM-EVs. Only those exhibiting early endosomal escape and high pH of fusion were inhibited via a reduction in endosomal pH. By contrast, strains exhibiting later endosomal escape and lower fusion pH proved resistant to inhibition. These results extend our understanding of how resident AMs participate in host defense and have broader implications in the defense and treatment of pathogens internalized within endosomes.

Integrating Optical and Electrochemical Approaches to Assess the Actions of Dynamin at the Fusion Pore.

Of the techniques currently available to monitor dense core granule exocytosis in adrenal chromaffin cells, two have proven particularly useful: carbon-fiber amperometry and total internal reflection fluorescence (TIRF) microscopy. Amperometry enables the detection of oxidizable catecholamines escaping a fusion pore with millisecond time resolution. TIRF microscopy, and its variant polarized-TIRF (pTIRF) microscopy, provides information on the characteristics of fusion pores at temporally later stages. Used in conjunction, amperometry and TIRF microscopy allow an investigator to follow the fate of a fusion pore from its formation to expansion or reclosure. The properties of fusion pores, including their structure and dynamics, have been shown by multiple groups to be modified by the dynamin GTPase (Dyn1). In this chapter, we describe how amperometry and TIRF microscopy enable insights into dynamin-dependent effects on exocytosis in primary cultures of bovine adrenal chromaffin cells.

Feasibility and preliminary validity evidence for remote video-based assessment of clinicians in a global health setting.

BACKGROUND: Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries. OBJECTIVE: To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana. METHODS: This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss' Kappa. A structured log was utilized for feasibility of remote video capture. RESULTS: Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695-0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596-0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034-0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025-0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability. CONCLUSIONS: Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible.

The effects of dietary nitrate on plasma glucose and insulin sensitivity in sheep.

Nitrate (NO3 ¯ ) is an effective non-protein nitrogen source for gut microbes and reduces enteric methane (CH4 ) production in ruminants. Nitrate is reduced to ammonia by rumen bacteria with nitrite (NO2 ¯ ) produced as an intermediate. The absorption of NO2 ¯ can cause methaemoglobinaemia in ruminants. Metabolism of NO3 ¯ and NO2 ¯ in blood and animal tissues forms nitric oxide (NO) which has profound physiological effects in ruminants and has been shown to increase glucose uptake and insulin secretion in rodents and humans. We hypothesized that absorption of small quantities of NO2 ¯ resulting from a low-risk dose of dietary NO3 ¯ will increase insulin sensitivity (SI ) and glucose uptake in sheep. We evaluated the effect of feeding sheep with a diet supplemented with 18 g NO3 ¯ /kg DM or urea (Ur) isonitrogenously to NO3 ¯ , on insulin and glucose dynamics. A glucose tolerance test using an intravenous bolus of 1 ml/kg LW of 24% (w/v) glucose was conducted in twenty sheep, with 10 sheep receiving 1.8% supplementary NO3 ¯ and 10 receiving supplementary urea isonitrogenously to NO3 ¯ . The MINMOD model used plasma glucose and insulin concentrations to estimate basal plasma insulin (Ib ) and basal glucose concentration (Gb ), insulin sensitivity (SI ), glucose effectiveness (SG ), acute insulin response (AIRg) and disposition index (DI). Nitrate supplementation had no effect on Ib (p > .05). The decrease in blood glucose occurred at the same rate in both dietary treatments (SG ; p = .60), and there was no effect of NO3 ¯ on either Gb , SI , AIRg or DI. This experiment found that the insulin dynamics assessed using the MINMOD model were not affected by NO3 ¯ administered to fasted sheep at a low dose of 1.8% NO3 ¯ in the diet.

Innate Lymphoid Cells in Helminth Infections-Obligatory or Accessory?

ILCs burst onto the immunological scene with their involvement in bacterial and helminth infections. As their influence has emerged, it has become clear that they play a fundamental role in regulating barrier tissue homeostasis and the immune response during inflammation. A subset of ILCs, ILC2s, has become the focus of attention for many helminth biologists-stepping into the limelight as both the elusive initiator and amplifier of the type-2 response. In many of the early reports, conclusions as to their function were based on experiments using unadapted parasites or immune-compromised hosts. In this review we re-examine the generation and function of type-2 ILCs in helminth infection and the extent to which their roles may be essential or redundant, in both primary and challenge infections. ILC2s will be discussed in terms of a broader innate network, which when in dialogue with adaptive immunity, allows the generation of the anti-parasite response. Finally, we will review how helminths manipulate ILC2 populations to benefit their survival, as well as dampen systemic inflammation in the host, and how this understanding may be used to improve strategies to control disease.

Fallopian tube perfusion in ex-vivo and in-vivo laparoscopic hysterectomy specimens: potential application for uterine transplantation.

STUDY QUESTION: Is there perfusion to the fallopian tubes in ex-vivo and in-vivo uteri at the time of total laparoscopic hysterectomy (TLH), as observed using laser angiography with indocyanine green (ICG)? SUMMARY ANSWER: The fallopian tubes may have perfusion from the utero-ovarian vasculature alone. WHAT IS KNOWN ALREADY: The fallopian tubes are perfused by the uterine and utero-ovarian vessels. Perfusion can be measured using laser angiography with ICG. STUDY DESIGN, SIZE, DURATION: This prospective pilot cohort study included 15 women, ages 32-59 years old, who underwent TLH with bilateral salpingectomy for benign indications. PARTICIPANTS/MATERIALS, SETTING, METHODS: In five participants, TLH was performed and the utero-ovarian artery was cannulated ex vivo and injected with ICG. The other 10 participants underwent the in-vivo protocol. The mesosalpinx and uterine vessels were transected in the partial protocol. Colpotomy was also performed in the complete protocol. All fallopian tubes were imaged using laser angiography with ICG. The relative fluorescence and the fluorescence intensity ratio (length of fluorescent fallopian tube/total length of fallopian tube) of the fallopian tubes were measured in the ex-vivo and in-vivo protocols, respectively. MAIN RESULTS AND THE ROLE OF CHANCE: Ex vivo, the fimbria of the ipsilateral fallopian tube had 47% median relative fluorescence as compared to the contralateral fallopian tube, which had 2.4% median relative fluorescence. In vivo, the post-ICG fluorescence intensity ratios were 0.61 ± 0.40 for the partial protocol, and 0.78 ± 0.30 for the complete protocol, with mean differences of 0.37 (95% CI: 0.23-0.50, P < .0001) and 0.22 (95% CI: 0.12-0.31, P < 0.0001), respectively, between the pre-procedure and the post-ICG fluorescence intensity ratios. Greater than 0.75 fluorescence intensity ratios (i.e. >75% tubal length fluorescence) was seen in 60% of fallopian tubes. LIMITATIONS, REASONS FOR CAUTION: This is a pilot study with a small sample size and pathologic uteri, which would not be appropriate for uterine transplantation. No conclusions can be made regarding the functionality of the fallopian tubes. WIDER IMPLICATIONS OF THE FINDINGS: The fallopian tubes may have perfusion with the utero-ovarian vasculature alone, potentially allowing for future animal studies regarding tubal viability in recipients of uterine-tubal transplants. If successful, human uterine-tubal transplantation may allow for spontaneous conception rather than IVF. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used. S.F., P.F.P., K.A.S. and R.F. have no conflicts of interest to report. M.L.S. is an educational consultant for Medtronic (Dublin, Republic of Ireland) and Applied Medical (Rancho Santa Margarita, CA, USA), as well as a stockholder for SynDaver Labs (Tampa, FL, USA). S.E.Z. is an educational consultant for Applied Medical (Rancho Santa Margarita, CA, USA) and is on the advisory board for AbbVie Inc. (Chicago, IL, USA). TRIAL REGISTRATION NUMBER: Not applicable.

Concerted IL-25R and IL-4Rα signaling drive innate type 2 effector immunity for optimal helminth expulsion.

Interleukin 25 (IL-25) is a major 'alarmin' cytokine, capable of initiating and amplifying the type immune response to helminth parasites. However, its role in the later effector phase of clearing chronic infection remains unclear. The helminth Heligmosomoides polygyrus establishes long-term infections in susceptible C57BL/6 mice, but is slowly expelled in BALB/c mice from day 14 onwards. We noted that IL-25R (Il17rb)-deficient BALB/c mice were unable to expel parasites despite type 2 immune activation comparable to the wild-type. We then established that in C57BL/6 mice, IL-25 adminstered late in infection (days 14-17) drove immunity. Moreover, when IL-25 and IL-4 were delivered to Rag1-deficient mice, the combination resulted in near complete expulsion of the parasite, even following administration of an anti-CD90 antibody to deplete innate lymphoid cells (ILCs). Hence, effective anti-helminth immunity during chronic infection requires an innate effector cell population that is synergistically activated by the combination of IL-4Rα and IL-25R signaling.

Development and Validation of a Simulation Model for Laparoscopic Colpotomy.

OBJECTIVE: To develop a realistic simulation model for performance of laparoscopic colpotomy and evaluate its construct and face validity. METHODS: A simulation model was developed and constructed using polyvinyl chloride piping, a uterine manipulator, and synthetic vaginal tissue paired with a commercially available laparoscopic trainer. An observational study was conducted to validate the simulation model for use as a teaching tool. Construct validity was measured through performance evaluation of novice and expert surgeons using a standard and modified Global Operative Assessment of Laparoscopic Skills scale with possible score ranges of 5-25 and 5-40, respectively. Expert surgeons included attending surgeons across various gynecologic subspecialties who teach total laparoscopic hysterectomy to trainees and perform more than 50 total laparoscopic hysterectomies annually. Novice surgeons included residents who perform total laparoscopic hysterectomy as part of their training. Standards were set using a modified contrasting groups approach. Interrater reliability was calculated using Kendall's τ correlation coefficient. Participants were surveyed regarding the realism of the model and its utility as a teaching tool to assess face validity. RESULTS: Five expert and 15 novice surgeons volunteered to participate. Expert surgeons scored higher than novice surgeons on the Global Operative Assessment of Laparoscopic Skills scale (22.8±1.52 vs 13.53±2.69, respectively) with a mean difference of 9.27 (95% CI 7.12-11.4, P<.01) and on a modified Global Operative Assessment of Laparoscopic Skills scale (36.9±2.19 vs 22.6±3.95, respectively) with a mean difference of 14.30 (95% CI 11.2-17.4, P<.01). Suggested passing range was set at 30.5-32.5 out of 40 total points. Kendall's τ interrater reliability was 0.86 (95% CI 0.798-0.923) and 0.87 (95% CI 0.818-0.922), respectively. All participants agreed that the training model was useful for teaching and learning laparoscopic colpotomy and for assessing the learner's ability to perform colpotomy before live surgery. CONCLUSION: This validated simulation system offers novice surgeons an opportunity to practice the skill set necessary to perform laparoscopic colpotomy efficiently and may be used as an educational tool.

Management, Prevention, and Sequelae of Adhesions in Women Undergoing Laparoscopic Gynecologic Surgery: A Systematic Review.

Surgical adhesions can lead to significant consequences including abdominopelvic pain, bowel obstruction, subfertility, and subsequent surgery. Although laparoscopic surgery is associated with a decreased risk of adhesion formation, methods to further decrease adhesions are warranted. We systematically reviewed literature addressing the management, prevention, and sequelae of adhesions in women undergoing laparoscopic gynecologic surgery. We searched PubMed, EMBASE, EBSCOhost, and Cochrane Central Register of Controlled Trials and found 6566 records. The primary outcome was adhesion formation. The secondary outcomes were abdominopelvic pain, quality of life, subfertility, pregnancy, bowel obstruction, urinary symptoms, and subsequent surgery. After applying inclusion and exclusion criteria, 52 studies remained for qualitative synthesis. Risk of bias assessments were applied independently by 2 authors. There was evidence that Hyalobarrier Gel (Anika Therapeutics, Bedford, MA), HyaRegen NCH Gel (Bilar Medikal, Istanbul, Turkey), Oxiplex/AP Gel (Fziomed, Inc., San Luis Obispo, CA), SprayGel (Confluent Surgical Inc., Waltham, MA), and Beriplast (CSL Behring, LLCm King of Prussia, PA) all decrease the incidence of adhesions. Adept (Baxter, Deerfield, IL) significantly decreased de novo adhesion scores of the posterior uterus. Using an integrated treatment approach to pelvic pain significantly improved pain and quality of life compared with standard laparoscopic treatment. Lastly, Hyalobarrier Gel Endo (Anika Therapeutics, Bedford, MA) placement led to a higher pregnancy rate than no barrier usage. Our findings underscore the need for high-quality trials to evaluate the efficacy of surgical techniques, adhesion barriers, and other treatment modalities on the management and prevention of adhesions and their clinical sequelae. This review was registered on PROSPERO (ID = CRD42017068053).

User Authentication in Smartphones for Telehealth.

Many functions previously conducted on desktop computers are now performed on smartphones. Smartphones provide convenience, portability, and connectivity. When smartphones are used in the conduct of telehealth, sensitive data is invariably accessed, rendering the devices in need of user authentication to ensure data protection. User authentication of smartphones can help mitigate potential Health Insurance Portability and Accountability Act (HIPAA) breaches and keep sensitive patient information protected, while also facilitating the convenience of smartphones within everyday life and healthcare. This paper presents and examines several types of authentication methods available to smartphone users to help ensure security of sensitive data from attackers. The applications of these authentication methods in telehealth are discussed.

A case of fatal internal jugular vein perforation during nasogastric tube insertion.

Nasogastric tube (NGT) insertion is a routine procedure in the management of surgical patients. We report the second case of internal jugular vein perforation during NGT insertion. A 79-year-old man presented with diffuse abdominal pain secondary to a perforated viscus. Abdominal CT revealed pneumoperitoneum, necessitating emergent exploratory laparotomy. On post-operative Day 7, the patient developed mild abdominal distension and subjective nausea for which NGT placement was ordered for decompression. Tube placement was confirmed by insufflation of air without aspiration of gastric contents. Output from the NGT upon placement revealed frank blood. The patient then developed respiratory distress requiring intubation, followed by a fatal arrhythmia. Post-mortem exam revealed the trajectory of the NGT through the pharyngeal wall into the right internal jugular vein. This case illustrates the importance of systematic evaluation of all procedures, as the outcome resulted from failure to recognize the initial error in tube placement.

Physician Engagement in Improving Operative Supply Chain Efficiency Through Review of Surgeon Preference Cards.

STUDY OBJECTIVE: To reduce operative costs involved in the purchase, packing, and transport of unnecessary supplies by improving the accuracy of surgeon preference cards. STUDY DESIGN: Quality improvement study (Canadian Task Force classification II-3). SETTING: Gynecologic surgery suite of an academic medical center. PARTICIPANTS: Twenty-one specialized and generalist gynecologic surgeons. INTERVENTIONS: The preference cards of up to the 5 most frequently performed procedures per surgeon were selected. A total of 81 cards were distributed to 21 surgeons for review. Changes to the cards were communicated to the operating room charge nurse and finalized. MEASUREMENTS AND MAIN RESULTS: Fourteen surgeons returned a total of 48 reviewed cards, 39 of which had changes. A total of 109 disposable supplies were removed from these cards, at a total cost savings of $767.67. The cost per card was reduced by $16 on average for disposables alone. Three reusable instrument trays were also eliminated from the cards, resulting in savings of approximately $925 in processing costs over a 3-month period. Twenty-two items were requested by surgeons to be available on request but were not routinely placed in the room at the start of each case, at a total cost of $6,293.54. The rate of return of unused instruments to storage decreased after our intervention, from 10.1 to 9.6 instruments per case. CONCLUSIONS: Surgeon preference cards serve as the basis for economic decision making regarding the purchase, storing, packing, and transport of operative instruments and supplies. A one-time surgeon review of cards resulted in a decrease in the number of disposable and reusable instruments that must be stocked, transported, counted in the operating room, or returned, potentially translating into cost savings. Surgeon involvement in preference card management may reduce waste and provide ongoing cost savings.

Chronic infections with viruses or parasites: breaking bad to make good.

Eukaryotic forms of life have been continually invaded by microbes and larger multicellular parasites, such as helminths. Over a billion years ago bacterial endosymbionts permanently colonized eukaryotic cells leading to recognized organelles with a distinct genetic lineage, such as mitochondria and chloroplasts. Colonization of our skin and mucosal surfaces with bacterial commensals is now known to be important for host health. However, the contribution of chronic virus and parasitic infections to immune homeostasis is being increasingly questioned. Persistent infection does not necessarily equate to exhibiting a chronic illness: healthy hosts (e.g. humans) have chronic viral and parasitic infections with no evidence of disease. Indeed, there are now examples of complex interactions between these microbes and hosts that seem to confer an advantage to the host at a particular time, suggesting that the relationship has progressed along an axis from parasitic to commensal to one of a mutualistic symbiosis. This concept is explored using examples from viruses and parasites, considering how the relationships may be not only detrimental but also beneficial to the human host.