Oral Hypoxia-Inducible Factor 2α Inhibitor Belzutifan in Ocular von Hippel-Lindau Disease: Subgroup Analysis of the Single-Arm Phase 2 LITESPARK-004 Study.

PURPOSE: To report the efficacy of the oral hypoxia-inducible factor 2α inhibitor belzutifan in participants with von Hippel-Lindau disease-associated retinal hemangioblastomas in the LITESPARK-004 study. DESIGN: Subgroup analysis of the phase 2, single-arm, open-label LITESPARK-004 study. PARTICIPANTS: Adults with 1 or more von Hippel-Lindau disease-associated measurable renal cell carcinoma tumors not requiring immediate surgical intervention were eligible. METHODS: Participants received oral belzutifan 120 mg once daily until disease progression or unacceptable treatment-related toxicity. MAIN OUTCOME MEASURES: Efficacy of belzutifan in retinal hemangioblastomas was a secondary end point, measured as response (improved, stable, or progressed) by independent reading center-certified graders based on color fundus imaging performed every 12 weeks using the investigator's preferred imaging standards. Additional assessments, where available, included OCT and ultra-widefield fluorescein angiography. RESULTS: Among 61 participants in LITESPARK-004, 12 had 1 or more evaluable active retinal hemangioblastomas in 16 eyes at baseline per independent reading center. As of April 1, 2022, the median follow-up for participants with ocular von Hippel-Lindau disease at baseline was 37.3 months. All 16 eyes were graded as improved, with a response rate of 100.0% (95% confidence interval, 79.4%-100%). No new retinal hemangioblastomas or ocular disease progression were reported as of data cutoff date. Eight participants underwent additional multimodal eye assessments performed at the National Institutes of Health study site. Among this subgroup, 10 of 24 hemangioblastomas in 8 eyes of 6 participants measured 500 µm or more in greatest linear dimension at baseline and were analyzed further. All 10 hemangioblastomas had a mean area reduction of 15% or more by month 12 and of 30% or more by month 24. CONCLUSIONS: Belzutifan showed promising activity against ocular von Hippel-Lindau disease, including capacity to control retinal hemangioblastomas, with effects sustained for more than 2 years while treatment is ongoing. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Effect of floating treatment wetland coverage ratio and operating parameters on nitrogen removal: toward design optimization.

Floating treatment wetlands (FTWs) have the potential to improve the quality of wastewater discharges, yet design basics are unavailable to size these systems. This study investigates the effect of FTWs' coverage ratio and hydraulic retention time on agri-food wastewater treatment. This was studied in a pilot-scale experiment comprising four lagoons (6.5 m3 each) fed with real effluent from an existing tertiary treatment lagoon. An evaluation of FTW of different sizes (L24, L48, and L72 representing 24, 48, and 72% of pilot lagoons surface areas) and a control, L0 (without FTW), was performed over 16 months. Overall, L72 and L48 moderately improved total nitrogen (TN) mass removal compared to L0 (p < 0.05), while L24 exhibited similar TN mass removal (p = 0.196). The highest improvement was observed for L72, exhibiting up to 55% (mean of 13%) greater N mass removal than the control. The net increase in TN removal by FTWs was mainly related to denitrification, promoted by decreasing dissolved oxygen for increasing FTW coverage ratio. Residence time, temperature, and dissolved oxygen were the main parameters driving TN removal by FTWs. Retrofitting existing lagoons with FTW can facilitate N retrieval through plant harvesting, thereby reducing N remobilization from sediment (common in conventional lagoons).

Safety and Efficacy of Immune Checkpoint Inhibitors in Patients with Cancer and Viral Hepatitis: The MD Anderson Cancer Center Experience.

BACKGROUND: Despite the clinical benefit of immune checkpoint inhibitors (ICIs), patients with a viral hepatitis have been excluded from clinical trials because of safety concerns. The purpose of this study was to determine the incidence rate of adverse events (AEs) in patients with viral hepatitis who received ICIs for cancer treatment. MATERIALS AND METHODS: We conducted a retrospective study in patients with cancer and concurrent hepatitis B or C, who had undergone treatment with ICI at MD Anderson Cancer Center from January 1, 2010 to December 31, 2019. RESULTS: Of the 1076 patients screened, we identified 33 with concurrent hepatitis. All 10 patients with HBV underwent concomitant antiviral therapy during ICI treatment. Sixteen of the 23 patients with HCV received it before the initiation of ICI. The median follow-up time was 33 months (95% CI, 23-45) and the median duration of ICI therapy was 3 months (IQR, 1.9-6.6). Of the 33 patients, 12 (39%) experienced irAEs (immune-related adverse events) of any grade, with 2 (6%) having grade 3 or higher. None of the patients developed hepatitis toxicities. CONCLUSION: ICIs may be a therapeutic option with an acceptable safety profile in patients with cancer and advanced liver disease.

An old foe on peculiar paths: severe falciparum malaria in a Syrian refugee, possibly infected during migrant smuggling from Türkiye to Germany.

Infectious diseases and their imperative awareness gain major relevance through global warming and multi-continent refugee crises. Here, we demonstrate the challenges of malaria diagnosis, disease course, and treatment, including post-artesunate hemolysis in a Syrian refugee with severe falciparum malaria, most probably infected during migrant smuggling from Türkiye to Germany.

Imaging Update for Hereditary Abdominopelvic Neuroendocrine Neoplasms.

ABSTRACT: Neuroendocrine neoplasms have shown a linear increase in incidence and prevalence in recent decades, primarily due to improved cross-sectional imaging, expanded use of endoscopic procedures, and advanced genetic analysis. However, diagnosis of hereditary neuroendocrine tumors is still challenging because of heterogeneity in their presentation, the variety of tumor locations, and multiple associated syndromes. Radiologists should be familiar with the spectrum of these tumors and associated hereditary syndromes. Furthermore, as the assessment of multiple tumor elements such as morphology, biochemical markers, and presence of metastatic disease are essential for the treatment plan, conventional anatomic and functional imaging methods are fundamental in managing and surveilling these cases. Our article illustrates the role of different cross-sectional imaging modalities in diagnosing and managing various hereditary abdominopelvic neuroendocrine tumors.

Correlation of Ocular Plane-Wave Doppler With Optical Coherence Tomography Angiography in Preeclampsia.

OBJECTIVES: Preeclampsia (PE) is a severe complication of pregnancy characterized by hypertension, proteinuria and compromised fetal blood supply. The eye, like other end organs, is affected by this systemic condition, but unlike in other organs, ocular media transparency allows high-resolution optical visualization of the vascular structure of the retina. Our aim was to assess how ultrasound-determined ocular blood-flow correlates with vascular structure of the retina and choriocapillaris determined by optical coherence tomography angiography (OCTA). METHODS: Plane-wave ultrasound and OCTA were performed on both eyes of 40 consecutive subjects consisting of normal controls (n = 11), mild PE (n = 5), severe PE (n = 17) and chronic or gestational hypertension (n = 7) within 72 hours following delivery. From ultrasound, we measured pulsatile flow velocity and resistance indices in the central retinal artery (CRA) and vein, the short posterior ciliary arteries (SPCAs) and choroid. From OCTA, we measured vascular density (VD) in the superficial, deep retina and choriocapillaris. We determined differences in Doppler and OCTA parameters among groups and correlations between ultrasound and OCTA. RESULTS: In severe PE, flow resistance was reduced with respect to controls. Flow velocity and resistance in the and SPCA were moderately correlated with VD in the choriocapillaris and peripapillary retina, but VD in PE did not differ significantly from controls. CONCLUSIONS: Although OCTA parameters were moderately correlated with Doppler ultrasound, OCTA did not demonstrate significant differences between PE and controls postpartum.

Insulin signaling represents a gating mechanism between different memory phases in Drosophila larvae.

The ability to learn new skills and to store them as memory entities is one of the most impressive features of higher evolved organisms. However, not all memories are created equal; some are short-lived forms, and some are longer lasting. Formation of the latter is energetically costly and by the reason of restricted availability of food or fluctuations in energy expanses, efficient metabolic homeostasis modulating different needs like survival, growth, reproduction, or investment in longer lasting memories is crucial. Whilst equipped with cellular and molecular pre-requisites for formation of a protein synthesis dependent long-term memory (LTM), its existence in the larval stage of Drosophila remains elusive. Considering it from the viewpoint that larval brain structures are completely rebuilt during metamorphosis, and that this process depends completely on accumulated energy stores formed during the larval stage, investing in LTM represents an unnecessary expenditure. However, as an alternative, Drosophila larvae are equipped with the capacity to form a protein synthesis independent so-called larval anaesthesia resistant memory (lARM), which is consolidated in terms of being insensitive to cold-shock treatments. Motivated by the fact that LTM formation causes an increase in energy uptake in Drosophila adults, we tested the idea of whether an energy surplus can induce the formation of LTM in the larval stage. Suprisingly, increasing the metabolic state by feeding Drosophila larvae the disaccharide sucrose directly before aversive olfactory conditioning led to the formation of a protein synthesis dependent longer lasting memory. Moreover, formation of this memory component is accompanied by the suppression of lARM. We ascertained that insulin receptors (InRs) expressed in the mushroom body Kenyon cells suppresses the formation of lARM and induces the formation of a protein synthesis dependent longer lasting memory in Drosophila larvae. Given the numerical simplicity of the larval nervous system this work offers a unique prospect to study the impact of insulin signaling on the formation of protein synthesis dependent memories on a molecular level.

Below-ground plant-soil interactions affecting adaptations of rice to iron toxicity.

Iron toxicity is a major constraint to rice production, particularly in highly weathered soils of inland valleys in sub-Saharan Africa where the rice growing area is rapidly expanding. There is a wide variation in tolerance of iron toxicity in the rice germplasm. However, the introgression of tolerance traits into high-yielding germplasm has been slow owing to the complexity of the tolerance mechanisms and large genotype-by-environment effects. We review current understanding of tolerance mechanisms, particularly those involving below-ground plant-soil interactions. Until now these have been less studied than above-ground mechanisms. We cover processes in the rhizosphere linked to exclusion of toxic ferrous iron by oxidation, and resulting effects on the mobility of nutrient ions. We also cover the molecular physiology of below-ground processes controlling iron retention in roots and root-shoot transport, and also plant iron sensing. We conclude that future breeding programmes should be based on well-characterized molecular markers for iron toxicity tolerance traits. To successfully identify such markers, the complex tolerance response should be broken down into its components based on understanding of tolerance mechanisms, and tailored screening methods should be developed for individual mechanisms.

An experimental approach to training interoceptive sensitivity: study protocol for a pilot randomized controlled trial.

BACKGROUND: Eating in absence of hunger is quite common and often associated with an increased energy intake co-existent with a poorer food choice. Intuitive eating (IE), i.e., eating in accordance with internal hunger and satiety cues, may protect from overeating. IE, however, requires accurate perception and processing of one's own bodily signals, also referred to as interoceptive sensitivity. Training interoceptive sensitivity might therefore be an effective method to promote IE and prevent overeating. As most studies on eating behavior are conducted in younger adults and close social relationships influence health-related behavior, this study focuses on middle-aged and older couples. METHODS: The present pilot randomized intervention study aims at investigating the feasibility and effectiveness of a 21-day mindfulness-based training program designed to increase interoceptive sensitivity. A total of N = 60 couples participating in the NutriAct Family Study, aged 50-80 years, will be recruited. This randomized-controlled intervention study comprises three measurement points (pre-intervention, post-intervention, 4-week follow-up) and a 21-day training that consists of daily mindfulness-based guided audio exercises (e.g., body scan). A three-arm intervention study design is applied to compare two intervention groups (training together as a couple vs. training alone) with a control group (no training). Each measurement point includes the assessment of self-reported and objective indicators of interoceptive sensitivity (primary outcome), self-reported indicators of intuitive and maladaptive eating (secondary outcomes), and additional variables. A training evaluation applying focus group discussions will be conducted to assess participants' overall acceptance of the training and its feasibility. DISCUSSION: By investigating the feasibility and effectiveness of a mindfulness-based training program to increase interoceptive sensitivity, the present study will contribute to a deeper understanding of how to promote healthy eating in older age. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), no. DRKS00024903. Retrospectively registered on April 21, 2021.

Intimate partner violence: analysis of current screening practices in the primary care setting.

BACKGROUND: Intimate partner violence (IPV) is a largely undetected occurrence in the United States reported by 36-50% of women in their lifetime and associated with extensive physical and psychological implications. Currently, conflicting recommendations exist regarding screening practices with the United States Preventative Services Task Force (USPSTF) and the World Health Organization (WHO) advocating for and against universal screening, respectively. With research suggesting that women are seldom asked about IPV during clinic visits, further information is needed regarding current screening practices. OBJECTIVES: To identify current IPV screening approaches in the primary care setting and factors that may impact screening completion. METHODS: We retrospectively examined patients presenting for annual examinations at four university-associated primary care clinics in southeast Florida (n = 400). Patient demographics, screener demographics, screening completion, and screening results were collected from the medical record. Results were compared to depression and anxiety screenings due to comparable prevalence and screening recommendations. Pearson chi square and Fisher exact tests were utilized to compare screening rates by demographic characteristics. RESULTS: IPV screening occurred at a much lower frequency (8.5%) compared to screenings for anxiety (37.3%) and depression (71.3%). Among documented IPV screenings, 64.7% of encounters resulted in patient refusal to be screened. Screening rates were found to be marginally impacted by patient ethnicity (P = 0.052). CONCLUSIONS: Findings of both low screening rates and low screening success raise significant concerns for the shortcomings of advocating for universal IPV screening. Therefore, additional studies are necessary to identify covert barriers to screening completion before universal inquiry is advised.

Intimate partner violence (IPV) is a largely undetected occurrence reported by 36­50% of women in their lifetime. Currently, IPV screening recommendations vary across organizations like the USPSTF and WHO. Given its widespread impact, we aimed to identify current IPV screening practices and gaps using patients who presented for annual examinations at four primary care clinics (n = 400). Patient demographics, screener demographics, screening completion, and screening results were collected from the medical record. IPV screening frequency was compared to frequency of depression and anxiety screenings given comparable screening recommendations and prevalence. IPV screening occurred less frequently (8.5%) compared to anxiety (37.3%) and depression (71.3%) screenings. Out of attempted IPV screens, 64.7% resulted in patient refusal to answer related questions. IPV screening rates were marginally impacted by patient ethnicity (P = 0.052). Our findings suggest shortcomings of universal screening and highlight the necessity to further elucidate barriers and improve screening efficacy.

An unusual etiology of obstructive shock in the emergency department.

Obstructive shock describes any disease process that causes physical obstruction to blood flow into or out of the heart which results in impaired systemic oxygen or nutrient delivery. Common etiologies include cardiac tamponade, tension pneumothorax, and pulmonary embolus. However, several other causes exist and should prompt consideration in the correct clinical circumstances. In this report, we describe a 72-year-old female patient with history of hepatic cysts presenting with respiratory distress, mottled extremities, and abnormal vital signs. Contrast enhanced computed tomography scans showed a massive hepatic cyst which was compressing her vena cava and heart, causing hemodynamic instability. The patient was admitted to the ICU and the hepatic cyst was drained percutaneously, but ultimately, she succumbed to her illness post-operatively. This report highlights the importance of keeping a broad differential when considering etiologies of undifferentiated shock as well as the need for additional research regarding management of rare causes of obstructive shock.

Secular trends in functional abilities, health and psychological well-being among community-dwelling 75- to 95-year-old cohorts over three decades in Helsinki, Finland.

Background: Life expectancy has increased markedly in the past decades. Thus, it is of great importance to understand how people are ageing and if the trajectories of health and disability are changing over time. This study aimed to examine trends in functional abilities and health in independent cohorts of people aged 75-95 over three decades. Methods: This Helsinki Ageing Study consists of repeated cross-sectional postal surveys examining independent cohorts of old people (75, 80, 85 and 90+ years old). This study combined data from four waves (1989, 1999, 2009 and 2019). Results: In the most recent wave, there was an increase in the portion of participants who were able to walk outdoors easily (75-year-olds p=0.03, 80-year-olds p=0.002, 85-year-olds p<0.001; p for linearity for the study year effect, all adjusted for sex). Fewer people in the youngest age group (75-year-olds) needed daily help from another person in 2019 compared to the earlier waves (p=0.02 for linearity for the study year). Over the past three decades, the proportions of self-reported good mobility have risen 8.7% (95% confidence interval (CI) 2.3-15.1) in 75-year-olds, 11.7% (95% CI 3.9-19.6) in 80-year-olds and 20.1% (95% CI 10.7-29.4) in 85-year-olds, after adjusting for sex. Furthermore, in 2019, more people rated their health as good and scored better in psychological well-being than in the previous waves among 75-, 80- and 85-year-olds. However, no improvements were found among 90+-year-olds in any of these variables. Conclusions: People between 75 and 85 years old are presently feeling and functioning better than their predecessors. This may be an important objective for both economics and health policy.

Fertility and Pregnancy Outcomes After Robotic-assisted Laparoscopic Myomectomy in a Canadian Cohort.

STUDY OBJECTIVE: Myomectomy is the gold standard treatment for patients with symptomatic fibroids who desire fertility preservation. Given the relatively recent application of robotic surgery in the field of gynecology, there is only a small amount of data describing fertility outcomes after robotic-assisted laparoscopic myomectomy (RALM). The objective of this study was to determine the pregnancy rate in patients trying to conceive after RALM. DESIGN: A single-center, retrospective case series. SETTING: Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada. PATIENTS: All patients who underwent RALM between October 2008 and September 2015 and who consented to a telephone interview were included. INTERVENTION: None. The primary outcome was pregnancy rate after RALM. Secondary outcomes included whether patients underwent fertility treatment, rate of live births after RALM, rate of spontaneous abortion mode of delivery in pregnancies following RALM, obstetric complications, and symptoms experienced postoperatively. MEASUREMENTS AND MAIN RESULTS: A total of 123 patients underwent RALM between 2008 and 2015. Of them, 101 consented to be interviewed. Average age ± standard deviation was 34.4 ± 4.4 years. Average myoma size was 8.9 ± 2.2 cm. Of all myomas, 64 (63.4%) were intramural, 35 (34.7%) were subserosal, and 2 (2%) were submucosal according to preoperative imaging. The pregnancy rate after RALM was 42/60 (70.0%). Three additional patients became pregnant who were not trying to conceive. Of the 45 patients who became pregnant, 38 (84.4%) successfully delivered or were pregnant at the time of data collection. CONCLUSION: The pregnancy rate after RALM was 70.0%, which is similar to that reported in previous studies. Future research should aim to conduct larger, prospective studies investigating fertility outcomes after RALM and should aim to identify variables that predict pregnancy.

The virtual infertility community: a qualitative analysis of patient experiences shared on Instagram.

PURPOSE: To characterize the experiences of patients undergoing in vitro fertilization (IVF) through a qualitative analysis of content shared on Instagram. METHODS: We analyzed Instagram posts from five randomly selected days in February 2020. The hashtag, #ivfcommunity, was selected to identify public posts authored by Instagram's IVF community members from multiple treatment centers. Text, photos, hashtags, and emojis were collected from 452 included posts and entered into a study-specific database. Using thematic coding, a four-member team initially coded the first day in February. Common themes were agreed upon by all team members, and a preliminary codebook was created for further analysis. The remaining posts were coded by two-member teams who reached a consensus on the multiple themes assigned to each individual post. RESULTS: Analysis of posts led to the identification of five major themes: documentation of the medical and physical experience of IVF (76.1%), the emotional spectrum (43.1%), social support (49.2%), coping mechanisms (29.9%), and education (receipt, provision) (11.1%). CONCLUSION: Our findings suggest that women undergoing IVF often utilize social media to document daily experiences, offer and recognize sources of community support, and provide and receive education regarding their treatments. Given the increased prevalence of mental health conditions, medical providers should explore challenges discussed on online platforms and consider harnessing the supportive nature of online communities to supplement care for IVF patients.

Temperature-dependent phenology of the parasitoid Fopius arisanus on the host Bactrocera dorsalis.

Fopius arisanus (Sonan), an egg-pupal parasitoid of numerous fruit fly species, was recently introduced into Africa for the control of the Oriental fruit fly, Bactrocera dorsalis (Hendel). In this study, life-table data of F. arisanus were generated under laboratory conditions at six constant temperatures (15, 20, 25, 30, 28 and 35 °C; 75% RH, L12:D12 photoperiod) and under variable conditions in a screenhouse on B. dorsalis. Several non-linear functions were fitted to model species development, mortality, longevity and oviposition using the Insect Life Cycle Modeling (ILCYM) software. The established phenology models were stochastically simulated at variable temperatures to estimate the life table parameters. Fopius arisanus completed development from egg to adult at all the temperatures tested except at 35 °C. Mean developmental time from egg to adult was inversely proportional to the temperature. The minimum temperature threshold (Tmin) from egg to adult was 8.15 °C, while the maximum temperature threshold (Tmax) was estimated at 34.2 °C. The optimal temperature for immature stages survival was predicted for 20-30 °C. The optimum fecundity estimated was 251 eggs/female at 22 °C. Following the stochastic simulations under natural conditions of the selected agro-ecological zones, it appears that the Humid Forest with Bimodal Rainfall provides a suitable thermal condition for potential population growth of F. arisanus. The present study shows the importance of temperature on the demographic parameters of F. arisanus. Implications of present findings on the biological control of B. dorsalis under climate change scenarios is discussed.

Antagonistic species interaction drives selection for sex in a predator-prey system.

The evolutionary maintenance of sexual reproduction has long challenged biologists as the majority of species reproduce sexually despite inherent costs. Providing a general explanation for the evolutionary success of sex has thus proven difficult and resulted in numerous hypotheses. A leading hypothesis suggests that antagonistic species interaction can generate conditions selecting for increased sex due to the production of rare or novel genotypes that are beneficial for rapid adaptation to recurrent environmental change brought on by antagonism. To test this ecology-based hypothesis, we conducted experimental evolution in a predator (rotifer)-prey (algal) system by using continuous cultures to track predator-prey dynamics and in situ rates of sex in the prey over time and within replicated experimental populations. Overall, we found that predator-mediated fluctuating selection for competitive versus defended prey resulted in higher rates of genetic mixing in the prey. More specifically, our results showed that fluctuating population sizes of predator and prey, coupled with a trade-off in the prey, drove the sort of recurrent environmental change that could provide a benefit to sex in the prey, despite inherent costs. We end with a discussion of potential population genetic mechanisms underlying increased selection for sex in this system, based on our application of a general theoretical framework for measuring the effects of sex over time, and interpreting how these effects can lead to inferences about the conditions selecting for or against sexual reproduction in a system with antagonistic species interaction.

Association Between Web-Based Physician Ratings and Physician Disciplinary Convictions: Retrospective Observational Study.

BACKGROUND: Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood. OBJECTIVE: The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls. METHODS: This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country's leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment. RESULTS: There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment-except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003). CONCLUSIONS: Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.

Routine postprocedure ultrasound increases rate of detection of femoral arterial thrombosis in infants after cardiac catheterization.

OBJECTIVES: To examine the effect of implementing postcatheterization ultrasound (US) on femoral arterial thrombosis detection rates and factors associated with thrombosis in infants. BACKGROUND: Although femoral arterial thrombosis is an uncommon complication of cardiac catheterization, it can cause limb threatening complications. Previous studies assessing the utility of postprocedure US to detect thrombosis in infants have utilized US as an adjunct to standard clinical detection methods, are small scale, or include small cohorts of infants within older populations. METHODS: We reviewed institutional records of patients 0-12 months undergoing catheterization from 2007 to 2016. Demographics and procedural data were compared between the thrombosis and non-thrombosis group. Pre- and post-US groups were compared for detected thrombosis rate. Using univariate and multivariable analyses, we identified factors associated with thrombosis. RESULTS: In total, 270 patients underwent 509 catheterizations, with 40 (7.9%) documented thromboses. The rate of thrombus detection in patients younger than 6 months increased from 8.3% to 23.4% (P = 0.006) after implementing routine US. On multivariable analysis, lower weight (P < 0.001), larger arterial sheath size (P < 0.001), and longer procedure duration (P = 0.003) were independently associated with higher odds of thrombosis. CONCLUSIONS: Higher rates of femoral arterial thrombosis detection were observed since implementing an US screening program. Further studies are needed to evaluate age-related changes in hemostasis in this population and how advanced screening methods and anticoagulation protocols may help improve short-term and long-term sequelae of femoral arterial thrombosis.

Are prediction models for vaginal birth after cesarean accurate?

BACKGROUND: The use of trial of labor after cesarean delivery calculators in the prediction of successful vaginal birth after cesarean delivery gives physicians an evidence-based tool to assist with patient counseling and risk stratification. Before deployment of prediction models for routine care at an institutional level, it is recommended to test their performance initially in the institution's target population. This allows the institution to understand not only the overall accuracy of the model for the intended population but also to comprehend where the accuracy of the model is most limited when predicting across the range of predictions (calibration). OBJECTIVE: The purpose of this study was to compare 3 models that predict successful vaginal birth after cesarean delivery with the use of a single tertiary referral cohort before continuous model deployment in the electronic medical record. STUDY DESIGN: All cesarean births for failed trial of labor after cesarean delivery and successful vaginal birth after cesarean delivery at an academic health system between May 2013 and March 2016 were reviewed. Women with a history of 1 previous cesarean birth who underwent a trial of labor with a term (≥37 weeks gestation), cephalic, and singleton gestation were included. Women with antepartum intrauterine fetal death or fetal anomalies were excluded. The probability of successful vaginal birth after cesarean delivery was calculated with the use of 3 prediction models: Grobman 2007, Grobman 2009, and Metz 2013 and compared with actual vaginal birth after cesarean delivery success. Each model's performance was measured with the use of concordance indices, Brier scores, and calibration plots. Decision curve analysis identified the range of threshold probabilities for which the best prediction model would be of clinical value. RESULTS: Four hundred four women met the eligibility criteria. The observed rate of successful vaginal birth after cesarean delivery was 75% (305/404). Concordance indices were 0.717 (95% confidence interval, 0.659-0.778), 0.703 (95% confidence interval, 0.647-0.758), and 0.727 (95% confidence interval, 0.669-0.779), respectively. Brier scores were 0.172, 0.205, and 0.179, respectively. Calibration demonstrated that Grobman 2007 and Metz vaginal birth after cesarean delivery models were most accurate when predicted probabilities were >60% and were beneficial for counseling women who did not desire to have vaginal birth after cesarean delivery but had a predicted success rates of 60-90%. The models underpredicted actual probabilities when predicting success at <60%. The Grobman 2007 and Metz vaginal birth after cesarean delivery models provided greatest net benefit between threshold probabilities of 60-90% but did not provide a net benefit with lower predicted probabilities of success compared with a strategy of recommending vaginal birth after cesarean delivery for all women . CONCLUSION: When 3 commonly used vaginal birth after cesarean delivery prediction models are compared in the same population, there are differences in performance that may affect an institution's choice of which model to use.

Assessing the feasibility of using a closed landfill for agricultural graze land.

Once landfills are closed and maintained according to the US Environmental Protection Agency's standards and regulations, they are potential sites for revitalization efforts, particularly via agricultural activities. This project was commissioned by the City of Tucson Environmental Services Department as part of an effort to explore ways to reuse one or more of the 16 landfills the department manages in the Tucson metropolitan area. The objective of this project was to assess the feasibility of using a closed landfill to support safe goat browsing. A site history and investigation was conducted at the Harrison Landfill in Tucson, Arizona, to characterize the soil quality and uptake of deleterious metals by the following plants observed at the landfill: Pennisetum ciliare (buffel grass), Baccharis sarothroides (desert broom), Salsola tragus L. (Russian thistle), Larrea tridentata (creosote), Tamarix ramosissima (salt cedar), and Atriplex canescens (fourwing saltbush). Site characterization data were combined with known goat browsing and plant consumption patterns to determine exposure risks. It was observed that soil concentrations of metals (Al, Ag, As, Be, Ba, Fe, Co, Cu, Cr, Cd, Fe, Mn, Ni, V, Se, Mo, Sn, Sb, Pb) did not exceed Arizona Department of Environmental Quality's soil remediation levels. Tamarix ramosissima, Baccharis salicifolia (willow baccharis), Pennisetum ciliare, Salsola tragus L., Baccharis sarothroides, Larrea tridentata, and Atriplex canescens contained metal concentrations that fell well within maximum tolerable levels. In general, this project determined that after soil and plant assessment, urban, arid landfills may be used effectively for economic development through agricultural grazing ventures.