Waddell (Nonorganic) Signs and Their Association With Interventional Treatment Outcomes for Low Back Pain.

BACKGROUND: The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions. METHODS: We prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported "average" numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. We conducted secondary and sensitivity analyses to account for potential confounders. RESULTS: We enrolled 318 patients: 152 in the ESI cohort, 102 in the facet cohort, and 64 in the SIJ cohort, having sufficient data for primary analysis on 308 patients. Among these, 62% (n = 192) had no Waddell signs, 18% (n = 54) had 1 sign, 11% (n = 33) had 2, 5% (n = 16) had 3, 2% (n = 7) had 4, and about 2% (n = 6) had all 5 signs. The mean change in average NRS-PI in each of these 6 groups was -1.6 ± 2.6, -1.1 ± 2.7, -1.5 ± 2.5, -1.6 ± 2.6, -1 ± 1.5, and 0.7 ± 2.1, respectively, and their corresponding treatment failure rates were 54% (102 of 192), 67% (36 of 54), 70% (23 of 33), 75% (12 of 16), 71% (5 of 7), and 83% (5 of 6). In the primary analysis, an increasing number of Waddell signs were not associated with a significant decrease in average NRS-PI (coefficient [Coef] = 0.19; 95% confidence interval [CI], -0.43 to 0.05; P = .12). A higher number of Waddell signs were associated with treatment failure, with a 1.35 increased odds of treatment failure per cumulative number of signs (P = .008). CONCLUSIONS: Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.

The IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact (IMPROVE) trial: Study design and rationale.

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been shown in clinical trials, registries, and meta-analyses to reduce recurrent major adverse cardiovascular events after PCI. However, IVUS utilization remains low. An increasing number of high-risk or complex coronary artery lesions are treated with PCI, and we hypothesize that the impact of IVUS in guiding treatment of these complex lesions will be of increased importance in reducing major adverse cardiovascular events while remaining cost-effective. The "IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact" trial (registered on clinicaltrials.gov: NCT04221815) is a multicenter, international, clinical trial randomizing subjects to IVUS-guided versus angiography-guided PCI in a 1:1 ratio. Patients undergoing PCI involving a complex lesion are eligible for enrollment. Complex lesion is defined as involving at least 1 of the following characteristics: chronic total occlusion, in-stent restenosis, severe coronary artery calcification, long lesion (≥28 mm), or bifurcation lesion. The clinical investigation will be conducted at approximately 120 centers in North America and Europe, enrolling approximately 2,500 to 3,100 randomized subjects with an adaptive design. The primary clinical end point is the rate of target vessel failure at 12 months, defined as the composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization. The co-primary imaging end point is the final post-PCI minimum stent area assessed by IVUS. The primary objective of this study is to assess the impact of IVUS guidance on the PCI treatment of complex lesions.

Seed size, number and strategies in annual plants: a comparative functional analysis and synthesis.

BACKGROUND AND AIMS: Plants depend fundamentally on establishment from seed. However, protocols in trait-based ecology currently estimate seed size but not seed number. This can be rectified. For annuals, seed number should simply be a positive function of vegetative biomass and a negative function of seed size. METHODS: Using published values of comparative seed number as the 'gold standard' and a large functional database, comparative seed yield and number per plant and per m2 were predicted by multiple regression. Subsequently, ecological variation in each was explored for English and Spanish habitats, newly calculated C-S-R strategies and changed abundance in the British flora. KEY RESULTS: As predicted, comparative seed mass yield per plant was consistently a positive function of plant size and competitive ability, and largely independent of seed size. Regressions estimating comparative seed number included, additionally, seed size as a negative function. Relationships differed numerically between regions, habitats and C-S-R strategies. Moreover, some species differed in life history over their geographical range. Comparative seed yield per m2 was positively correlated with FAO crop yield, and increasing British annuals produced numerous seeds. Nevertheless, predicted values must be viewed as comparative rather than absolute: they varied according to the 'gold standard' predictor used. Moreover, regressions estimating comparative seed yield per m2 achieved low precision. CONCLUSIONS: For the first time, estimates of comparative seed yield and number for >800 annuals and their predictor equations have been produced and the ecological importance of these regenerative traits has been illustrated. 'Regenerative trait-based ecology' remains in its infancy, with work needed on determinate vs. indeterminate flowering ('bet-hedging'), C-S-R methodologies, phylogeny, comparative seed yield per m2 and changing life history. Nevertheless, this has been a positive start and readers are invited to use estimates for >800 annuals, in the Supplementary data, to help advance 'regenerative trait-based ecology' to the next level.

Trade-offs between seed and leaf size (seed-phytomer-leaf theory): functional glue linking regenerative with life history strategies and taxonomy with ecology?

Background and Aims: While the 'worldwide leaf economics spectrum' (Wright IJ, Reich PB, Westoby M, et al. 2004. The worldwide leaf economics spectrum. Nature : 821-827) defines mineral nutrient relationships in plants, no unifying functional consensus links size attributes. Here, the focus is upon leaf size, a much-studied plant trait that scales positively with habitat quality and components of plant size. The objective is to show that this wide range of relationships is explicable in terms of a seed-phytomer-leaf (SPL) theoretical model defining leaf size in terms of trade-offs involving the size, growth rate and number of the building blocks (phytomers) of which the young shoot is constructed. Methods: Functional data for 2400+ species and English and Spanish vegetation surveys were used to explore interrelationships between leaf area, leaf width, canopy height, seed mass and leaf dry matter content (LDMC). Key Results: Leaf area was a consistent function of canopy height, LDMC and seed mass. Additionally, size traits are partially uncoupled. First, broad laminas help confer competitive exclusion while morphologically large leaves can, through dissection, be functionally small. Secondly, leaf size scales positively with plant size but many of the largest-leaved species are of medium height with basally supported leaves. Thirdly, photosynthetic stems may represent a functionally viable alternative to 'small seeds + large leaves' in disturbed, fertile habitats and 'large seeds + small leaves' in infertile ones. Conclusions: Although key elements defining the juvenile growth phase remain unmeasured, our results broadly support SPL theory in that phytometer and leaf size are a product of the size of the initial shoot meristem (≅ seed mass) and the duration and quality of juvenile growth. These allometrically constrained traits combine to confer ecological specialization on individual species. Equally, they appear conservatively expressed within major taxa. Thus, 'evolutionary canalization' sensu Stebbins (Stebbins GL. 1974. Flowering plants: evolution above the species level . Cambridge, MA: Belknap Press) is perhaps associated with both seed and leaf development, and major taxa appear routinely specialized with respect to ecologically important size-related traits.

Pleural mesothelioma and lung cancer risks in relation to occupational history and asbestos lung burden.

BACKGROUND: We have conducted a population-based study of pleural mesothelioma patients with occupational histories and measured asbestos lung burdens in occupationally exposed workers and in the general population. The relationship between lung burden and risk, particularly at environmental exposure levels, will enable future mesothelioma rates in people born after 1965 who never installed asbestos to be predicted from their asbestos lung burdens. METHODS: Following personal interview asbestos fibres longer than 5 µm were counted by transmission electron microscopy in lung samples obtained from 133 patients with mesothelioma and 262 patients with lung cancer. ORs for mesothelioma were converted to lifetime risks. RESULTS: Lifetime mesothelioma risk is approximately 0.02% per 1000 amphibole fibres per gram of dry lung tissue over a more than 100-fold range, from 1 to 4 in the most heavily exposed building workers to less than 1 in 500 in most of the population. The asbestos fibres counted were amosite (75%), crocidolite (18%), other amphiboles (5%) and chrysotile (2%). CONCLUSIONS: The approximate linearity of the dose-response together with lung burden measurements in younger people will provide reasonably reliable predictions of future mesothelioma rates in those born since 1965 whose risks cannot yet be seen in national rates. Burdens in those born more recently will indicate the continuing occupational and environmental hazards under current asbestos control regulations. Our results confirm the major contribution of amosite to UK mesothelioma incidence and the substantial contribution of non-occupational exposure, particularly in women.

Interventional Management of Unprotected Left Main Coronary Artery Disease: Patient Selection and Technique Optimization.

For many years, coronary artery bypass graft surgery has been the gold standard for revascularization of patients with left main disease; however, increasing evidence suggests that percutaneous coronary intervention with drug-eluting stents may be an acceptable alternative or even preferred in select cases. This review will present clinical evidence examining the outcomes of drug-eluting stents compared to coronary artery bypass graft surgery for unprotected left main coronary artery disease and discuss the anatomic factors, patient variables, and clinical strategies that may dictate choice of revascularization modality for patients with left main disease. If percutaneous coronary intervention is selected to treat unprotected left main disease, meticulous technique is essential to optimize outcomes, including use of procedural physiology and imaging guidance, optimal stent and adjunct pharmacology use, and expert management of the distal bifurcation. Finally, issues of equipoise and uncertainty are identified, representing areas for future investigation.

Gene expression patterns unveil a new level of molecular heterogeneity in colorectal cancer.

The recognition that colorectal cancer (CRC) is a heterogeneous disease in terms of clinical behaviour and response to therapy translates into an urgent need for robust molecular disease subclassifiers that can explain this heterogeneity beyond current parameters (MSI, KRAS, BRAF). Attempts to fill this gap are emerging. The Cancer Genome Atlas (TGCA) reported two main CRC groups, based on the incidence and spectrum of mutated genes, and another paper reported an EMT expression signature defined subgroup. We performed a prior free analysis of CRC heterogeneity on 1113 CRC gene expression profiles and confronted our findings to established molecular determinants and clinical, histopathological and survival data. Unsupervised clustering based on gene modules allowed us to distinguish at least five different gene expression CRC subtypes, which we call surface crypt-like, lower crypt-like, CIMP-H-like, mesenchymal and mixed. A gene set enrichment analysis combined with literature search of gene module members identified distinct biological motifs in different subtypes. The subtypes, which were not derived based on outcome, nonetheless showed differences in prognosis. Known gene copy number variations and mutations in key cancer-associated genes differed between subtypes, but the subtypes provided molecular information beyond that contained in these variables. Morphological features significantly differed between subtypes. The objective existence of the subtypes and their clinical and molecular characteristics were validated in an independent set of 720 CRC expression profiles. Our subtypes provide a novel perspective on the heterogeneity of CRC. The proposed subtypes should be further explored retrospectively on existing clinical trial datasets and, when sufficiently robust, be prospectively assessed for clinical relevance in terms of prognosis and treatment response predictive capacity. Original microarray data were uploaded to the ArrayExpress database (http://www.ebi.ac.uk/arrayexpress/) under Accession Nos E-MTAB-990 and E-MTAB-1026.

Point-of-Care Ultrasound Aids in the Management of Patient Taking Semaglutide Before Surgery: A Case Report.

Semaglutide, a glucagon-like peptide-1 (GLP-1) analog, has various effects on the gastrointestinal tract. In patients undergoing anesthesia delayed gastric emptying time can have sequelae if not identified preoperatively. Modalities include thorough history regarding the last dose administration of a GLP-1 analog and ultrasound of gastric contents before induction of anesthesia. We present a case in which gastric ultrasound identified a patient at increased risk for aspiration on induction and allowed for appropriate alterations in the anesthetic plan.

Seeing the fields through the weeds: introducing the WeedEco R package for comparing past and present arable farming systems using functional weed ecology.

The functional ecology of arable weeds provides a way of comparing present-day and past farming regimes. This paper presents the R package WeedEco, an open-source resource which allows users to compare their archaeobotanical dataset against three previously published arable weed models to understand fertility, disturbance or a combination of both. The package provides functions for data organisation, classification and visualisation, allowing users to enter raw archaeobotanical data, obtain trait values from the functional trait dataset, conduct discriminant analysis and plot the results against the relevant present-day model. Using data from the early medieval site of Stafford in the UK, the paper provides a detailed example of the use of the package, demonstrating its different functions, as well as how the results can be interpreted. Supplementary Information: The online version contains supplementary material available at 10.1007/s00334-023-00964-8.

Fine-Tuning Large Language Models to Enhance Programmatic Assessment in Graduate Medical Education.

Background: Natural language processing is a collection of techniques designed to empower computer systems to comprehend and/or produce human language. The purpose of this investigation was to train several large language models (LLMs) to explore the tradeoff between model complexity and performance while classifying narrative feedback on trainees into the Accreditation Council for Graduate Medical Education subcompetencies. We hypothesized that classification accuracy would increase with model complexity. Methods: The authors fine-tuned several transformer-based LLMs (Bidirectional Encoder Representations from Transformers [BERT]-base, BERT-medium, BERT-small, BERT-mini, BERT-tiny, and SciBERT) to predict Accreditation Council for Graduate Medical Education subcompetencies on a curated dataset of 10 218 feedback comments. Performance was compared with the authors' previous work, which trained a FastText model on the same dataset. Performance metrics included F1 score for global model performance and area under the receiver operating characteristic curve for each competency. Results: No models were superior to FastText. Only BERT-tiny performed worse than FastText. The smallest model with comparable performance to FastText, BERT-mini, was 94% smaller. Area under the receiver operating characteristic curve for each competency was similar on BERT-mini and FastText with the exceptions of Patient Care 7 (Situational Awareness and Crisis Management) and Systems-Based Practice. Discussion: Transformer-based LLMs were fine-tuned to understand anesthesiology graduate medical education language. Complex LLMs did not outperform FastText. However, equivalent performance was achieved with a model that was 94% smaller, which may allow model deployment on personal devices to enhance speed and data privacy. This work advances our understanding of best practices when integrating LLMs into graduate medical education.

Time trends in the incidence of work-related mental ill-health and musculoskeletal disorders in the UK.

OBJECTIVES: To determine UK trends (from 1996 to 2009) in incidence of work-related mental ill-health and musculoskeletal disorders, for all industry as well as for health and social care employees. Second, to investigate whether there may have been a recent shift from a physical to psychological perspective in how patients present their illness by comparing reporting trends for back pain and 'other work stress'. METHODS: Multilevel models were used to investigate changes in incidence of work-related illness, as diagnosed by specialist physicians. The dependent variable comprised case reports to The Health and Occupation Research network. Comparisons were made between medical specialties, industry (health and social care vs all other employees), gender and diagnosis. RESULTS: Trends for Occupational Physicians' (OP) reporting mental ill-health (average annual increase +3.7% (95% CI +2.2% to +5.2%)) differed significantly (p<0.001) from psychiatrists' reporting over the same time period (-5.9% (95% CI -7.6% to -4.2%)). For OPs' reporting, the rate of increase was greater for females and for health and social care employees. A fall in incidence of musculoskeletal disorders for OPs of -5.8% (95% CI -7.3% to -4.3%) and rheumatologists' reporting -6.6% (95% CI -8.3% to -4.8%) was found, with little variation by gender or industry. Within health and social care, an increase in incidence of 'other work stress' was accompanied by a similar decrease in 'spine/back pain'. CONCLUSIONS: The evidence presented is consistent with a shift in the presentation of ill-health from a physical to psychological perspective, although changes in hazards, prevention measures and physician awareness should also be considered as explanations.

Patient selection in ambulatory surgery.

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Investigating the Correlation between Force Output, Strains, and Pressure for Active Skeletal Muscle Contractions.

Experimental observations suggest that the force output of the skeletal muscle tissue can be correlated to the intra-muscular pressure generated by the muscle belly. However, pressure often proves difficult to measure through in-vivo tests. Simulations on the other hand, offer a tool to model muscle contractions and analyze the relationship between muscle force generation and deformations as well as pressure outputs, enabling us to gain insight into correlations among experimentally measurable quantities such as principal and volumetric strains, and the force output. In this work, a correlation study is performed using Pearson's and Spearman's correlation coefficients on the force output of the skeletal muscle, the principal and volumetric strains experienced by the muscle and the pressure developed within the muscle belly as the muscle tissue undergoes isometric contractions due to varying activation profiles. The study reveals strong correlations between force output and the strains at all locations of the belly, irrespective of the type of activation profile used. This observation enables estimation on the contribution of various muscle groups to the total force by the experimentally measurable principal and volumetric strains in the muscle belly. It is also observed that pressure does not correlate well with force output due to stress relaxation near the boundary of muscle belly.

Endovascular Plug for Endobronchial Management of an Expectorated Pulmonary Artery Embolization Coil: A Case Report.

Pulmonary artery aneurysms are frequently managed with endovascular embolization. Rare but serious complications of coil embolization are erosion and migration of the coils into the adjacent airways, posing a risk for massive hemoptysis. We report the case of a medically complex patient with a left main pulmonary artery aneurysm treated with coil embolization who ultimately experienced transbronchial migration and expectoration of the coil. We discuss the challenging anesthetic and surgical management of these serious complications, including the use of an endovascular plug to occlude the erosion site and distal airways.

Competency-Based Assessments: Leveraging Artificial Intelligence to Predict Subcompetency Content.

PURPOSE: Faculty feedback on trainees is critical to guiding trainee progress in a competency-based medical education framework. The authors aimed to develop and evaluate a Natural Language Processing (NLP) algorithm that automatically categorizes narrative feedback into corresponding Accreditation Council for Graduate Medical Education Milestone 2.0 subcompetencies. METHOD: Ten academic anesthesiologists analyzed 5,935 narrative evaluations on anesthesiology trainees at 4 graduate medical education (GME) programs between July 1, 2019, and June 30, 2021. Each sentence (n = 25,714) was labeled with the Milestone 2.0 subcompetency that best captured its content or was labeled as demographic or not useful. Inter-rater agreement was assessed by Fleiss' Kappa. The authors trained an NLP model to predict feedback subcompetencies using data from 3 sites and evaluated its performance at a fourth site. Performance metrics included area under the receiver operating characteristic curve (AUC), positive predictive value, sensitivity, F1, and calibration curves. The model was implemented at 1 site in a self-assessment exercise. RESULTS: Fleiss' Kappa for subcompetency agreement was moderate (0.44). Model performance was good for professionalism, interpersonal and communication skills, and practice-based learning and improvement (AUC 0.79, 0.79, and 0.75, respectively). Subcompetencies within medical knowledge and patient care ranged from fair to excellent (AUC 0.66-0.84 and 0.63-0.88, respectively). Performance for systems-based practice was poor (AUC 0.59). Performances for demographic and not useful categories were excellent (AUC 0.87 for both). In approximately 1 minute, the model interpreted several hundred evaluations and produced individual trainee reports with organized feedback to guide a self-assessment exercise. The model was built into a web-based application. CONCLUSIONS: The authors developed an NLP model that recognized the feedback language of anesthesiologists across multiple GME programs. The model was operationalized in a self-assessment exercise. It is a powerful tool which rapidly organizes large amounts of narrative feedback.

Computer-controlled, MR-compatible foot-pedal device to study dynamics of the muscle tendon complex under isometric, concentric, and eccentric contractions.

PURPOSE: To design a computer-controlled, magnetic resonance (MR)-compatible foot pedal device that allows in vivo mapping of changes in morphology and in strain of different musculoskeletal components of the lower leg under passive, isometric, concentric, and eccentric contractions. MATERIALS AND METHODS: A programmable servomotor in the control room pumped hydraulic fluid to rotate a foot-pedal inside the magnet. To validate the performance of the device, six subjects were imaged with gated velocity-encoded phase-contrast (VE-PC) imaging to investigate the dynamics of muscle and aponeurotic structures. RESULTS: Artifact-free VE-PC imaging clearly delineated different muscle compartments by differences in distribution of mechanical strains. High repeatability of contraction cycles allowed establishing that fascicles lengthened 6.1% more during passive compared with eccentric contractions. Aponeurosis separation during passive (range between three locations: -2.6≈1.3 mm) and active (range: -2.4≈1.6 mm) contractions were similar but significantly different from concentric (range: -0.9≈3.3 mm), with proximal and distal regions showing mostly negative values for the first two modes, but positive for the last. CONCLUSION: The device was sufficiently robust and artifact-free to accurately assess, using VE-PC imaging, physiologically important structure and dynamics of the musculotendon complex.

Intraoperative Management of Tracheal Cautery Injury in a Post-Bypass Cardiac Surgery Patient.

We present the case of a tracheal injury that occurred during a Maze procedure performed via sternotomy that was not initially detected by ventilator air leak, but rather by the visual presence of gas bubbles escaping the trachea during chest irrigation. Careful investigation and machine check did reveal a subsequent air leak that would have otherwise been overlooked. Furthermore, the use of intraoperative bronchoscopy was essential in guiding and confirming surgical repair. This case underscores the need for ongoing vigilance and suggests the utility of chest irrigation with Valsalva maneuvers after procedures performed in the vicinity of the trachea to exclude injury.

A new functional ecological model reveals the nature of early plant management in southwest Asia.

The protracted domestication model posits that wild cereals in southwest Asia were cultivated over millennia before the appearance of domesticated cereals in the archaeological record. These 'pre-domestication cultivation' activities are widely understood as entailing annual cycles of soil tillage and sowing and are expected to select for domestic traits such as non-shattering ears. However, the reconstruction of these practices is mostly based on indirect evidence and speculation, raising the question of whether pre-domestication cultivation created arable environments that would select for domestic traits. We developed a novel functional ecological model that distinguishes arable fields from wild cereal habitats in the Levant using plant functional traits related to mechanical soil disturbance. Our results show that exploitation practices at key pre-domestication cultivation sites maintained soil disturbance conditions similar to untilled wild cereal habitats. This implies that pre-domestication cultivation did not create arable environments through regular tillage but entailed low-input exploitation practices oriented on the ecological strategies of the competitive large-seeded grasses themselves.

Maintaining One-Lung Ventilation With an Endobronchial Blocker Through a Damaged Left-Sided Double-Lumen Tube: A Case Report.

One-lung ventilation (OLV) can be accomplished utilizing a double-lumen tube (DLT) and an endobronchial blocker (EBB) or intentionally placing a standard endotracheal tube (ETT) into a mainstem bronchus. However, secondary options must be available should the primary method fail. We present a case where an EBB and a fiberoptic bronchoscope (FOB) were successfully passed through a left-sided DLT to reestablish right-lung isolation after the DLT bronchial cuff was surgically damaged. We advocate competency in placing both DLTs and EBBs, as well as having EBBs readily accessible as a secondary isolation method during OLV.