The impact of headache intensity on speech in participants with migraine and acute post-traumatic headache.

BACKGROUND: Slower speaking rates and higher pause rates are found in individuals with migraine or post-traumatic headache during headache compared to when headache-free. We aimed to determine whether headache intensity influences the speaking rate and pause rate of participants with migraine or acute post-traumatic headache (aPTH) following mild traumatic brain injury (mTBI). METHODS: Using a speech elicitation tool, participants with migraine, aPTH, and healthy controls (HC) submitted speech samples over a period of 3 months. Speaking and pause rates were calculated when participants were headache-free and when they had mild or moderate headache. In this observational study, speaking and pause rates in participants with migraine and aPTH were compared to HC, controlling for age, sex, and days since mTBI (participants with aPTH only). RESULTS: A total of 2902 longitudinal speech samples from 13 individuals with migraine (mean age = 33.5, SD = 6.6; 12 females/1 male), 43 individuals with aPTH (mean age = 44.4, SD = 13.5; 28 females/15 males), and 56 HC (mean age = 40.8, SD = 13.0; 36 females/20 males) were collected. There was no difference in speaking rate between HC and the combined headache cohort of participants (migraine and aPTH) when they had headache freedom or a mild headache. When participants had moderate intensity headache, their speaking rate was significantly slower compared to that of HC and compared to their speaking rate during mild headache intensity or headache freedom. For the combined headache cohort of participants, pause rates were significantly higher when they had headache freedom or had a headache of mild or moderate intensity relative to HC. Compared to participants' pause rate during headache freedom, their pause rate was significantly higher during mild and moderate headache intensity. Participants with aPTH had significantly slower speaking rates compared to participants with migraine during headache freedom, mild headache intensity, and moderate headache intensity. Participants with aPTH had significantly higher pause rates compared to participants with migraine when experiencing moderate headache intensity. DISCUSSION: For both aPTH and migraine, more severe headache pain was associated with higher pause rates and slower speaking rates, suggesting that speaking rate and pause rate could serve as objective biomarkers for headache-related pain. Slower speaking rate in participants with aPTH could reflect additional consequences of TBI-related effects on motor control and speech production.

The Outer Membrane Cytochrome OmcA Is Essential for Infection of Shewanella oneidensis by a Zebrafish-Associated Bacteriophage.

The microbiota-the mixture of microorganisms in the intestinal tract of animals-plays an important role in host biology. Bacteriophages are a prominent, though often overlooked, component of the microbiota. The mechanisms that phage use to infect susceptible cells associated with animal hosts, and the broader role they could play in determining the substituents of the microbiota, are poorly understood. In this study, we isolated a zebrafish-associated bacteriophage, which we named Shewanella phage FishSpeaker. This phage infects Shewanella oneidensis strain MR-1, which cannot colonize zebrafish, but it is unable to infect Shewanella xiamenensis strain FH-1, a strain isolated from the zebrafish gut. Our data suggest that FishSpeaker uses the outer membrane decaheme cytochrome OmcA, which is an accessory component of the extracellular electron transfer (EET) pathway in S. oneidensis, as well as the flagellum to recognize and infect susceptible cells. In a zebrafish colony that lacks detectable FishSpeaker, we found that most Shewanella spp. are sensitive to infection and that some strains are resistant to infection. Our results suggest that phage could act as a selectivity filter for zebrafish-associated Shewanella and show that the EET machinery can be targeted by phage in the environment. IMPORTANCE Phage exert selective pressure on bacteria that influences and shapes the composition of microbial populations. However, there is a lack of native, experimentally tractable systems for studying how phage influence microbial population dynamics in complex communities. Here, we show that a zebrafish-associated phage requires both the outer membrane-associated extracellular electron transfer protein OmcA and the flagellum to infect Shewanella oneidensis strain MR-1. Our results suggest that the newly discovered phage-FishSpeaker-could exert selective pressure that restricts which Shewanella spp. colonize zebrafish. Moreover, the requirement of OmcA for infection by FishSpeaker suggests that the phage preferentially infects cells that are oxygen limited, a condition required for OmcA expression and an ecological feature of the zebrafish gut.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations.

OBJECTIVE: The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. METHODS: Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. RESULTS: TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. CONCLUSIONS: TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Dorsal Fixation of Coronal Hamate and Fifth Metacarpal Base Fractures: An Anatomic Evaluation of the Ulnar Nerve.

PURPOSE: Traumatic drill overshoot during dorsal fixation of coronal hamate and fifth metacarpal base fractures risks iatrogenic ulnar nerve injury. This study describes the anatomic relationships between exiting volar drill tips and ulnar nerve branches. METHODS: Dorsal drilling of hamate bones and fifth metacarpal bases was performed on cadavers. Dorsal hamate bodies were subdivided into 4 quadrants: (1) distal-ulnar, (2) distal-radial, (3) proximal-ulnar, and (4) proximal-radial. Screws measuring 5 mm more than the dorsal-to-volar bone depths were placed in each quadrant to represent drill exit trajectories with consistent overshoot. A single screw was similarly placed 5 mm distal to the midline articular surface of the dorsal fifth metacarpal base. Distances between estimated drill tips and ulnar nerve branches were measured. RESULTS: Ten cadaver hands were examined. The fifth metacarpal base screw tips directly abutted the ulnar motor branch in 6 hands, and were within 1 mm in 4 hands (mean, 0.4 ± 0.5 mm). Distances from the tips to the ulnar motor and sensory branches were largest in the distal-radial quadrant (11.8 ± 0.8 mm and 9.2 ± 1.9 mm, respectively) and smallest in the proximal-ulnar quadrant (7.3 ± 1.5 mm and 4.3 ± 1.1 mm, respectively). Distances to the ulnar motor and sensory branches were similar between the proximal-ulnar and distal-ulnar quadrants, and between the proximal-radial and distal-radial quadrants. CONCLUSIONS: Dorsal drilling of coronal hamate fractures appears to be safe, as volar drill tips are well away from ulnar nerve motor and sensory branches. Distances to ulnar nerve branches are largest, and theoretically safest, with dorsal drilling in the distal-radial hamate. Dorsal drilling of fifth metacarpal base fractures appears to carry a high risk for potential ulnar motor nerve injury. CLINICAL RELEVANCE: These findings may help minimize potential risks for iatrogenic ulnar nerve injury with dorsal drilling of hamate and fifth metacarpal base fractures.

Using ultrasound to examine muscle mass in preterm infants at term-equivalent age.

The aim of this study was to compare the skeletal muscle thickness of three different muscles and muscle groups in 44 preterm infants studied at term-equivalent age and 44 full-term controls: the biceps brachii, quadriceps femoris, and anterior tibial. The study was carried out at the Careggi University Hospital, Florence, Italy, from January 2018 to December 2019. We assumed that impaired muscle thickness in premature infants would be correlated with exposure to risk factors in the postnatal period. When the premature babies reached term-equivalent age, they were statistically significantly thinner and shorter and had a lower head circumference and lower body mass index than the full-term controls. The muscle thicknesses in the proximal and distal districts were statistically significantly smaller in prematurely born than term-born infants. The skeletal muscle thickness was related to the revised Clinical Risk Index for Babies score and days of invasive mechanical ventilation.Conclusion: Our data show that at term-equivalent age the premature babies had lower skeletal muscle mass acquisition than the full-term controls. This was particularly due to critical conditions at birth and the subsequent duration of invasive mechanical ventilation. What is Known: • The deleterious effects of prolonged mechanical ventilation on skeletal muscle function have been reported by adult intensive care studies. • Ultrasound imagines of fat and muscle thickness have been used in neonatology, as the method is safe, portable, and noninvasive. What is New: • Premature babies studied at term-equivalent age had lower muscle acquisition, but similar subcutaneous fat thickness, to full-term controls. • A high revised Clinical Risk Index for Babies score at birth, and prolonged invasive mechanical ventilation, was associated with skeletal muscle impairment.

Trends in Peripheral Nerve Epidemiology and Reconstruction: A State Database Study of Direct Repairs, Grafts, and Conduits.

BACKGROUND: Peripheral nerve injuries (PNIs) are most commonly treated with direct nerve repair procedures or nerve autografts. However, recent advancements in synthetic and vein conduits have led to their increased utilization. The present study quantifies the incidence of these procedures over time and geography and identifies differences in complication rates, illustrating the current epidemiologic climate regarding conduit use for PNI repair. METHODS: A query was conducted using the State Ambulatory Surgery and Services Databases data from 2006 to 2011 in both Florida and California for patients undergoing nerve repair, nerve grafting, synthetic conduits, and vein conduits. Patient zip code data were analyzed to determine the geographic distribution of various types of repair. In addition, text-mining algorithms were used to identify trends in PNI-related publications. RESULTS: In the 6-year period investigated, direct nerve repair was the most frequently used procedure for PNIs. However, the utilization of direct repairs declined significantly from 2006 to 2011. Synthetic and vein conduits demonstrated a significant increase over the same period. There were significantly higher rates of complications for autologous grafts (3.3%), vein conduits (3.5%), and synthetic conduits (2.4%), as compared with direct nerve repairs (1.4%). There was a nonsignificant difference in infection rates between these types of nerve repair. CONCLUSIONS: From an epidemiologic perspective, both graft and synthetic conduit-based PNI repairs are increasing in prevalence both in clinical practice and in the academic literature. This will likely continue in the future with the development of advancements in biologic and synthetic nerve conduit PNI repair options.

Evaluation of National Resident Matching Program and Electronic Residency Application Service Data in the Integrated Plastic Surgery Match.

INTRODUCTION: The National Resident Matching Program and Electronic Residency Application Service provide data for tracking trends among applicants in each specialty over the past 5 years. The purpose of this study was to examine this information and determine sex and race/ethnicity distribution over the past 5 years. METHODS: The National Resident Matching Program and Electronic Residency Application Service databases were surveyed for trends in the following categories: number of positions, number of applicants, percent of applicants per position, and number of applicants by sex and self-identified race/ethnicity. This information was analyzed graphically for visual representation of the changes in the field. RESULTS: While there has been a steady increase in number of positions offered, there has also been a significant decrease in number of applicants, resulting in an increase in number of positions offered per applicant. While female and Asian applicants have increased in number, rates of applications from other diverse groups have remained stagnant. CONCLUSIONS: The number of plastic surgery positions offered has increased, whereas the number of applicants has decreased, resulting in a reduction in the number of applicants per position. Lack of racial diversity remains a significant issue in the applicant pool.

Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon.

Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.

Impact of COVID-19 on Away Rotations in Surgical Fields.

The COVID-19 pandemic has presented a variety of challenges in the medical education curriculum, one of which is the possible loss of summer and fall away rotations for fourth year students applying into surgical subspecialties. Subsequently, a lack of in-person evaluations may have a major impact on an applicant's perception of the residency and the program's ability to assess the individual applicant. This is especially crucial for applicants without a home program in their specialty of interest, as away rotations are an important opportunity to confirm interest in pursuit of a subspecialty, obtain letters of recommendation, and make positive impressions at programs of interest. The objective of this article is to assess the current COVID-19 pandemic situation in light of away rotations and to provide recommendations for surgical subspecialty programs and applicants to have the best outcome during this upcoming application cycle. In particular, we emphasize the importance of implementing universal processes within each individual subspecialty. This will provide equitable opportunities for all applicants, minimizing potential biases or disadvantages based on geographic location or availability of a program at an applicant's home institution.

From bench to bedside: in vitro and in vivo evaluation of a neonate-focused nebulized surfactant delivery strategy.

BACKGROUND: Non-invasive delivery of nebulized surfactant has been a neonatology long-pursued goal. Nevertheless, the clinical efficacy of nebulized surfactant remains inconclusive, in part, due to the great technical challenges of depositing nebulized drugs in the lungs of preterm infants. The aim of this study was to investigate the feasibility of delivering nebulized surfactant (poractant alfa) in vitro and in vivo with an adapted, neonate-tailored aerosol delivery strategy. METHODS: Particle size distribution of undiluted poractant alfa aerosols generated by a customized eFlow-Neos nebulizer system was determined by laser diffraction. The theoretical nebulized surfactant lung dose was estimated in vitro in a clinical setting replica including a neonatal continuous positive airway pressure (CPAP) circuit, a cast of the upper airways of a preterm neonate, and a breath simulator programmed with the tidal breathing pattern of an infant with mild respiratory distress syndrome (RDS). A dose-response study with nebulized surfactant covering the 100-600 mg/kg nominal dose-range was conducted in RDS-modelling, lung-lavaged spontaneously-breathing rabbits managed with nasal CPAP. The effects of nebulized poractant alfa on arterial gas exchange and lung mechanics were assessed. Exogenous alveolar disaturated-phosphatidylcholine (DSPC) in the lungs was measured as a proxy of surfactant deposition efficacy. RESULTS: Laser diffraction studies demonstrated suitable aerosol characteristics for inhalation (mass median diameter, MMD = 3 µm). The mean surfactant lung dose determined in vitro was 13.7% ± 4.0 of the 200 mg/kg nominal dose. Nebulized surfactant delivered to spontaneously-breathing rabbits during nasal CPAP significantly improved arterial oxygenation compared to animals receiving CPAP only. Particularly, the groups of animals treated with 200 mg/kg and 400 mg/kg of nebulized poractant alfa achieved an equivalent pulmonary response in terms of oxygenation and lung mechanics as the group of animals treated with instilled surfactant (200 mg/kg). CONCLUSIONS: The customized eFlow-Neos vibrating-membrane nebulizer system efficiently generated respirable aerosols of undiluted poractant alfa. Nebulized surfactant delivered at doses of 200 mg/kg and 400 mg/kg elicited a pulmonary response equivalent to that observed after treatment with an intratracheal surfactant bolus of 200 mg/kg. This bench-characterized nebulized surfactant delivery strategy is now under evaluation in Phase II clinical trial (EUDRACT No.:2016-004547-36).

Abnormal neurological soft signs in babies born to smoking mothers were associated with lower breastfeeding for first three months.

AIM: We examined associations between neurological alterations in infants born to smoking mothers and breastfeeding success at discharge and three months of age. METHODS: This 2016 study compared 35 normal weight infants born to smoking mothers at 37-41 weeks and 35 matched controls born to non-smoking mothers at the Maternity Hospital of Careggi University, Florence, Italy. Neonatal behaviour was evaluated using the neurological soft signs (NSS) component of the Graham-Rosenblith Scale. Breastfeeding variables were measured using the LATCH score that covers: breast latching, audible swallowing, type of nipple, mother's comfort and help they needed to hold their baby to their breast. A questionnaire on excessive crying and feeding was distributed at discharge, and further data were collected during a three-month telephone interview. RESULTS: At discharge, the infants born to smoking mothers had a significantly lower LATCH score and significantly poorer performance on several items of the NSS component than the controls. The LATCH score and number of NSS were inversely proportional. At the three-month follow-up only 57.1% of the smoking group infants were breastfeeding compared with 87.5% of the control infants (p < 0.01). CONCLUSION: Infants with smoking mothers displayed altered neurobehavioural profiles and had a difficult start to breastfeeding.

Peripheral nervous system maturation in preterm infants: longitudinal motor and sensory nerve conduction studies.

OBJECTIVE: To study the evolution of sensory-motor nerves in the upper and lower limbs in neurologically healthy preterm infants and to use sensory-motor studies to compare the rate of maturation in preterm infants at term age and full-term healthy neonates. METHODS: The study comprised 26 neurologically normal preterm infants born at 23-33 weeks of gestational age, who underwent sensory nerve conduction and motor nerve conduction studies from plantar medial and median nerves and from tibial and ulnar nerves, respectively. We repeated the same neurophysiological studies in 19 of the preterm infants every 2 weeks until postnatal term age. The data from the preterm infants at term was matched with a group of ten full-term babies a few days after birth. RESULTS: The motor nerve conduction velocity of the tibial and ulnar nerves showed progressive increases in values in relation to gestational age, but there was a decrease of values in distal latencies and F wave latencies. Similarly, there was a gradual increase of sensory nerve conduction velocity values of the medial plantar and median nerves and decreases in latencies in relation to gestational age. At term age, the preterm infants showed significantly lower values of conduction velocities and distal latencies than the full-term neonates. These results were probably because the preterm infants had significantly lower weights, total length and, in particular, distal segments of the limbs at term age. CONCLUSION: The sensory-motor conduction parameters were clearly related to gestational age, but extrauterine life did not affect the maturation of the peripheral nervous system in the very preterm babies who were neurologically healthy.

Maternal obesity and perinatal oxidative stress: the strength of the association.

Maternal obesity is a chronic inflammatory state, which has been shown to induce increased levels of free fatty acids, reactive oxygen species and inflammatory cells. Recent evidence reveals increased levels of lipid peroxidation products in the plasma of obese women during pregnancy. The aim of this study was to test the hypothesis that maternal overweight or obesity is associated with increased oxidative stress (OS) in offspring. Two hundred and forty-five pregnant women and their newborns were prospectively enrolled. Mothers were divided in two groups: lean control - LC (n=175, Group I); overweight or obese (n=70, Group II) according to BMI ≥ 25 before pregnancy. Cord blood F2-isoprostanes (F2-IsoPs), as reliable markers of OS, were measured in all newborns. Lower 1 minute APGAR score and higher weight at discharge were found in Group II neonates, compared to those of Group I (p less than 0.05). Small for gestational age (SGA) newborns of both groups showed increased levels of F2-IsoPs than appropriate (AGA) or large (LGA) for gestational age (GA) (p less than 0.01). SGA newborns of Group II had higher F2-IsoPs levels compared to SGA of Group I (p less than 0.01), which were significantly correlated to maternal BMI at the end of pregnancy (r=0.451, p less than 0.01). Multivariate regression analysis corrected for confounding factors, showed that maternal overweight or obesity was significantly associated with high F2-IsoPs levels in SGA offspring (p less than 0.01). Maternal overweight or obesity is associated with increased OS in their SGA newborns. Data suggest the need of antioxidant protection for both mothers during pregnancy and infants soon after birth.

It's not just what you know: junior trainees' approach to follow-up and documentation.

CONTEXT: In teaching hospitals, junior trainees (first-year residents and third-year medical students) are responsible for patient follow-up and documentation under the supervision of senior team members. In order to support trainees in their role, supervisors need to understand how trainees approach these tasks and how they can be coached to develop best practices. OBJECTIVES: The purpose of our study was to explore the range of practices used by junior trainees in clinical settings. METHODS: Constructivist grounded theory was used to guide the collection and analysis of data on follow-up and documentation during 34 observation periods with 17 junior trainees. Data sources included field notes, field interviews and de-identified copies of patient charts. We also held two focus groups with four attending physicians in each. RESULTS: We were able to describe three interrelated characteristics that influenced a trainee's approach to and ability to perform the tasks of patient follow-up and documentation: (i) diligence; (ii) relationship to the team (dependent, independent, collaborative), and (iii) level of performance (Data Gatherer, Sensemaker, Manager). Diligence and relationship to the team appeared to influence the quality and focus of a trainee's approach at all levels of performance. Level of performance was felt, by focus group attending physicians, to reflect a developmental progression of knowledge and skills. CONCLUSIONS: Our findings contribute to the existing literature in three ways. Firstly, they extend our understanding of how junior trainees approach the task of in-patient follow-up and clinical documentation and the value of those activities. Secondly, they provide new insights to support formative and summative assessment. Finally, they contribute to a growing body of literature exploring the factors that impact trainees' roles and interactions with the team. Future research should focus on validating our findings and exploring their utility in the development of novel assessment strategies.

Challenges in Translation: Lessons from Using Business Pedagogy to Teach Leadership in Undergraduate Medicine.

PROBLEM: Leadership is increasingly recognized as a core physician competency required for quality patient care, continual system improvement, and optimal healthcare team performance. Consequently, integration of leadership into medical school curriculum is becoming a priority. This raises the question of the appropriate context, timing, and pedagogy for conveying this competency to medical students. INTERVENTION: Our program introduced a 1-week leadership course grounded in business pedagogy to Year 1 medical students. The curriculum centred on four themes: (a) Understanding Change, (b) Effective Teamwork, (c) Leading in Patient Safety, and (d) Leadership in Action. Post-curriculum qualitative student feedback was analyzed for insight into student satisfaction and attitude towards the leadership course content. CONTEXT: The Undergraduate Medical Education program of the Schulich School of Medicine & Dentistry, Western University, is delivered over 4 years across 2 campuses in London and Windsor, Ontario, Canada. Course structure moved from traditional passive lectures to established business pedagogy, which involves active engagement in modules, case-based discussions, insights from guest speakers, and personal reflection. OUTCOME: A student-led survey evaluated student opinion regarding the leadership course content. Students valued career development reading materials and insights from guest speakers working in healthcare teams. Students did not relate to messages from speakers in senior healthcare leadership positions. Course scheduling late in the second semester was viewed negatively. Overall student opinion suggested that the 1-week course was suboptimal for establishing leadership principles and translated business pedagogy was ineffective in this context. LESSONS LEARNED: Leadership curriculum in Undergraduate Medical Education should be grounded in a healthcare context relevant to the student's stage of training. Student engagement may be better supported if leadership is framed as a competency throughout their career. Schools considering such innovations could draw lessons from other professional schools and utilize material and faculty that resonate with students.

Vitis labrusca leaf extract prevents pentylenetetrazol-induced oxidative damage but not seizures in rats.

Epilepsy is a disorder of the central nervous system characterized by recurrent seizures. It is a very common disease in which approximately 30% of patients do not respond favorably to treatment with anticonvulsants. Oxidative stress is associated with neuronal damage arising from epileptic seizures. The present study investigated the possible anticonvulsant and antioxidant effects of a leaf extract of Vitis labrusca in an animal model of seizures induced by pentylenetetrazole (PTZ). The animals received injections of V. labrusca extract (10, 30 and 100 mg/kg) or vehicle and, 30 minutes later, they received an injection of PTZ, and were then observed for 30 minutes. The latency time and tonic—clonic seizure time were registered. Oxidative damage in lipids and proteins was quantified in the cerebellum, cerebral cortex and hippocampus. It was observed that the leaf extract were capable of reducing lipid peroxidation and protein oxidation caused by PTZ at all doses tested.

P63 Positive Mucoepidermoid Tumor of the Lacrimal Sac with Associated Papilloma.

We report a case of a 44-year-old man who presented with a left medial canthal mass and epiphora. Imaging was suggestive of a mass continuous with the nasolacrimal sac. Subsequent surgical exploration revealed a mass adherent to bone with invasion of the lacrimal system. Histological examination revealed a squamous/transitional cell papilloma overlying a low-grade mucoepidermoid carcinoma (MEC). Complete surgical resection was completed and pathology confirmed the diagnosis. This is the first case in which a MEC has been reported concurrently with an overlying papilloma, providing support for the hypothesis that MECs arise from papillomas in the lacrimal sac. Additionally, the tissue stained positive for p63, which is congruent with MEC immunoreactivity in the salivary gland. The description of these unique histopathological findings may assist in definitive diagnosis and improve our understanding of the pathophysiology underlying lacrimal sac MEC tumors.

Clinical management of the neonatal pneumomediastinum.

pneumomediastinum (PM) occurs in approximately 0.1% of newborns but its incidence is underestimatedbecause it is often asymptomatic. PM generally has a benign course. Our knowledge of PM is insufficient,and its management is mainly based on the best practice and experience of each hospital rather thanon evidence-based data.

Seized drug reporting of NPS helps to guide regional toxicological practice: A 17 month review between 2022 and 2023.

Novel psychoactive substances (NPS) are everchanging and plague forensic laboratories who must identify an unending variety of emerging substances and evolve current methodologies to detect these substances. Identifying potential regional NPS targets and timely examining trends in seized drug data could help mitigate the burden laboratories face. Over 17 months, NPS seized drug data were processed and categorized from three laboratories located across the United States to determine any NPS regional similarities and prevalent NPS drug categories: the South Carolina Law Enforcement Division (SLED), the Sedgwick County Regional Forensic Science Center (SCRFSC), and the Orange County Crime Laboratory (OCCL). Seized drug materials, including pills, powders, and plant material, were primarily analyzed for NPS via gas chromatography-mass spectrometry and Fourier transform infrared spectroscopy. From June 2022 to October 2023, 1940 NPS seized drug identifications were reported by these laboratories with 63 different NPS reported. Novel synthetic opioids (NSO) were the most prevalent NPS class across all three laboratories (55%), with fluorofentanyl accounting for 74% of NSO identifications. This is unsurprising given the fentanyl epidemic in the United States. Furthermore, these data highlighted varying regional NPS seized drug trends: eutylone, a synthetic cathinone, was one of the most frequently identified NPS in SLED, SCRFSC observed the most diverse set of synthetic cannabinoids, and OCCL observed an increased prevalence in the designer benzodiazepine, bromazolam. NPS scope recommendations are a valuable resource for forensic laboratories; however, most focus on a national perspective. Timely analysis and reporting of NPS seized drug data may help to develop regional NPS scope recommendations laboratories may employ.

Comparison of "IN-REC-SUR-E" and LISA in preterm neonates with respiratory distress syndrome: a randomized controlled trial (IN-REC-LISA trial).

BACKGROUND: Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. METHODS: In this study, 382 infants born at 24+0-27+6 weeks' gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks' postmenstrual age. The secondary outcomes are BPD at 36 weeks' postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24+0 to 25+6 weeks or 26+0 to 27+6 weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). DISCUSSION: This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24+0-27+6 weeks' gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks' postmenstrual age of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT05711966. Registered on February 3, 2023.