Temperature-associated virulence, species susceptibility and interspecies transmission of a Lactococcus petauri strain from rainbow trout.

Lactococcus petauri is an important emergent aquaculture pathogen in the USA. To better understand environmental conditions conducive to piscine lactococcosis and the susceptibility of fish species, laboratory-controlled challenges were used as models of infection. Rainbow trout Oncorhynchus mykiss maintained at 13 or 18°C were challenged by intracoelomic (ICe) injection with 101, 103 or 105 colony-forming units per fish (CFU fish-1) and monitored for 21 d. At 13°C, trout experienced mortalities of 7, 7 and 0%, and bacterial persistence of 0, 20 and 0% in survivors, respectively. When exposed to the same bacterial doses, trout maintained at 18°C experienced mortalities of 59, 84 and 91%, and bacterial persistence of 60, 66 and 0% in survivors, confirming a significant role of temperature in the pathogenesis of lactococcosis. Additionally, the susceptibility of rainbow trout, Chinook salmon Oncorhynchus tshawytscha, white sturgeon Acipenser transmontanus, Nile tilapia Oreochromis niloticus, and koi Cyprinus carpio to infection by L. petauri was compared using ICe challenges at 18°C. Trout and salmon experienced 96 and 56% cumulative mortality, respectively, and 17% of surviving salmon remained persistently infected. There were no mortalities in the other fish species, and no culturable bacteria recovered at the end of the challenge. However, when surviving fish were used in further cohabitation trials, naïve trout housed with previously exposed tilapia exhibited 6% mortality, demonstrating that non-salmonids can become sub-clinical carriers of this pathogen. The data obtained provide useful information regarding temperature-associated virulence, fish species susceptibility, and potential carrier transmission of L. petauri that can be used in the development of better management practices to protect against piscine lactococcosis.

Long-term quality of life improvement for chronic intractable back and leg pain patients using spinal cord stimulation: 12-month results from the SENZA-RCT.

PURPOSE: Chronic axial low-back pain is a debilitating disorder that impacts all aspects of an afflicted individual's life. Effective, durable treatments have historically been elusive. Interventional therapies, such as spinal cord stimulation (SCS), have shown limited efficacy at best. Recently, a novel treatment, 10 kHz SCS, has demonstrated superior pain relief compared with traditional SCS in a randomized controlled trial (RCT). In this manuscript, we report on the long-term improvements in quality of life (QoL) outcomes for subjects enrolled in this study. METHODS: A prospective, multicenter, randomized controlled trial (SENZA-RCT) was conducted. Patients with both chronic back and leg pain were enrolled and randomized (1:1) into 10 kHz SCS or traditional SCS treatment groups. A total of 171 subjects received a permanent SCS device implant. QoL and functionality measures were collected up to 12 months. The device remote control utilization, which is an indication of patient interaction with the device for adjustments, was collected at 24-month post-implantation. RESULTS: At 12 months, a higher proportion of 10 kHz SCS subjects had marked improvement of their disability (Oswestry Disability Index) to a "moderate" or "minimal" impact on their daily function versus the control group. The subjects also reported better improvement in the Global Assessment of Functioning, Clinician Global Impression of Change, Pittsburgh Sleep Quality Index, and short-form McGill Pain Questionnaire, compared to traditional SCS subjects. The 10 kHz SCS subjects also reported far higher rates of both driving and sleeping with their device turned on, as well as reduced reliance on their programmers to adjust therapy settings. CONCLUSIONS: In addition to superior pain relief, 10 kHz SCS provides long-term improvements in quality of life and functionality for subjects with chronic low-back and leg pain. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01609972).

The Biologic Response to Polyetheretherketone (PEEK) Wear Particles in Total Joint Replacement: A Systematic Review.

BACKGROUND: Polyetheretherketone (PEEK) and its composites are polymers resistant to fatigue strain, radiologically transparent, and have mechanical properties suitable for a range of orthopaedic applications. In bulk form, PEEK composites are generally accepted as biocompatible. In particulate form, however, the biologic response relevant to joint replacement devices remains unclear. The biologic response to wear particles affects the longevity of total joint arthroplasties. Particles in the phagocytozable size range of 0.1 µm to 10 µm are considered the most biologically reactive, particularly particles with a mean size of < 1 µm. This systematic review aimed to identify the current evidence for the biologic response to PEEK-based wear debris from total joint arthroplasties. QUESTIONS/PURPOSES: (1) What are the quantitative characteristics of PEEK-based wear particles produced by total joint arthroplasties? (2) Do PEEK wear particles cause an adverse biologic response when compared with UHMWPE or a similar negative control biomaterial? (3) Is the biologic response affected by particle characteristics? METHODS: Embase and Ovid Medline databases were searched for studies that quantified PEEK-based particle characteristics and/or investigated the biologic response to PEEK-based particles relevant to total joint arthroplasties. The keyword search included brands of PEEK (eg, MITCH, MOTIS) or variations of PEEK types and nomenclature (eg, PAEK, CFR-PEEK) in combination with types of joint (eg, hip, knee) and synonyms for wear debris or immunologic response (eg, particles, cytotoxicity). Peer-reviewed studies, published in English, investigating total joint arthroplasty devices and cytotoxic effects of PEEK particulates were included. Studies investigating devices without articulating bearings (eg, spinal instrumentation devices) and bulk material or contact cytotoxicity were excluded. Of 129 studies, 15 were selected for analysis and interpretation. No studies were found that isolated and characterized PEEK wear particles from retrieved periprosthetic human tissue samples. RESULTS: In the four studies that quantified PEEK-based particles produced using hip, knee, and spinal joint replacement simulators, the mean particle size was 0.23 µm to 2.0 µm. The absolute range reported was approximately 0.01 µm to 50 µm. Rod-like carbon particulates and granular-shaped PEEK particles were identified in human tissue by histologic analysis. Ten studies, including six animal models (rat, mouse, and rabbit), three cell line experiments, and two human tissue retreival studies, investigated the biologic response to PEEK-based particles. Qualitative histologic assessments showed immunologic cell infiltration to be similar for PEEK particles when compared with UHMWPE particles in all six of the animal studies identified. However, increased inflammatory cytokine release (such as tumor necrosis factor-α) was identified in only one in vitro study, but without substantial suppression in macrophage viability. Only one study tested the effects of particle size on cytotoxicity and found the largest unfilled PEEK particles (approximately 13 µm) to have a toxic effect; UHMWPE particles in the same size range showed a similar cytotoxic effect. CONCLUSIONS: Wear particles produced by PEEK-based bearings were, in almost all cases, in the phagocytozable size range (0.1-10 µm). The studies that evaluated the biologic response to PEEK-based particles generally found cytotoxicity to be within acceptable limits relative to the UHMWPE control, but inconsistent when inflammatory cytokine release was considered. CLINICAL RELEVANCE: To translate new and advanced materials into clinical use more quickly, the clinical relevance and validity of preclinical tests need to be improved. To achieve this for PEEK-based devices, human tissue retrieval studies including subsequent particle isolation and characterization analyses are required. In vitro cell studies using isolated wear particles from tissue or validated joint replacement simulators, instead of manufactured particles, are also required.

Extent of medicolegal burden in neurosurgery - An analysis of the National Health Service Litigation Authority Database.

INTRODUCTION: Neurosurgery remains amongst the highest malpractice risk specialties. We aimed to better understand the medicolegal burden in neurosurgery by analysing a large volume of claims recorded by the National Health Service Litigation Authority (NHSLA). METHODS: The NHSLA database was retrospectively interrogated for all closed (i.e. with legal outcomes) claims in neurosurgery recorded between 1997 and 2011. Collected data included clinical event; subspecialty; patient injury sustained; reason for claim; legal outcome and litigation costs. RESULTS: The total neurosurgical litigation cost associated with 617 closed claims over the time period investigated was £67.4 million. 282 claims (46%) were successful with damages awarded. The annual claim volume and damages paid increased between 2002 and 2011 by 50% and 140%, respectively, and two-thirds of these increases were attributable to spinal claims. 30% of the total litigation cost was legal fees. The leading causes of damages paid in cranial surgery were delayed diagnosis (29%) and delayed treatment (24%). In contrast, the leading causes of damages paid in spinal surgery were delayed diagnosis (32%) and surgical negligence (22%). The greatest mean damages awarded per claim were for brain damage (£617,000), compared to only £51,000 for fatality. CONCLUSION: Neurosurgical litigation in NHS hospitals has significantly increased over the last decade, predominantly due to spinal claims. A neurosurgical claim has a very high likelihood of success, and even for unsuccessful claims, associated legal fees are considerable. Causes of claims are differently distributed between cranial and spinal neurosurgery, although overall, delay to diagnosis accounted for the predominant share of claims volume and damages. There was a significant medicolegal burden associated with serious long-term injury and need for life-long care as in the case of brain damage as compared with death as an outcome. This analysis represents the largest U.K. study on litigation in surgery to date.

Single cell mutational analysis of PIK3CA in circulating tumor cells and metastases in breast cancer reveals heterogeneity, discordance, and mutation persistence in cultured disseminated tumor cells from bone marrow.

BACKGROUND: Therapeutic decisions in cancer are generally guided by molecular biomarkers or, for some newer therapeutics, primary tumor genotype. However, because biomarkers or genotypes may change as new metastases emerge, circulating tumor cells (CTCs) from blood are being investigated for a role in guiding real-time drug selection during disease progression, expecting that CTCs will comprehensively represent the full spectrum of genomic changes in metastases. However, information is limited regarding mutational heterogeneity among CTCs and metastases in breast cancer as discerned by single cell analysis. The presence of disseminated tumor cells (DTCs) in bone marrow also carry prognostic significance in breast cancer, but with variability between CTC and DTC detection. Here we analyze a series of single tumor cells, CTCs, and DTCs for PIK3CA mutations and report CTC and corresponding metastatic genotypes. METHODS: We used the MagSweeper, an immunomagnetic separation device, to capture live single tumor cells from breast cancer patients' primary and metastatic tissues, blood, and bone marrow. Single cells were screened for mutations in exons 9 and 20 of the PIK3CA gene. Captured DTCs grown in cell culture were also sequenced for PIK3CA mutations. RESULTS: Among 242 individual tumor cells isolated from 17 patients and tested for mutations, 48 mutated tumor cells were identified in three patients. Single cell analyses revealed mutational heterogeneity among CTCs and tumor cells in tissues. In a patient followed serially, there was mutational discordance between CTCs, DTCs, and metastases, and among CTCs isolated at different time points. DTCs from this patient propagated in vitro contained a PIK3CA mutation, which was maintained despite morphological changes during 21 days of cell culture. CONCLUSIONS: Single cell analysis of CTCs can demonstrate genotypic heterogeneity, changes over time, and discordance from DTCs and distant metastases. We present a cautionary case showing that CTCs from any single blood draw do not always reflect metastatic genotype, and that CTC and DTC analyses may provide independent clinical information. Isolated DTCs remain viable and can be propagated in culture while maintaining their original mutational status, potentially serving as a future resource for investigating new drug therapies.

Circular RNA expression in turkey skeletal muscle satellite cells is significantly altered by thermal challenge.

Introduction: Understanding the genetic mechanisms behind muscle growth and development is crucial for improving the efficiency of animal protein production. Recent poultry studies have identified genes related to muscle development and explored how environmental stressors, such as temperature extremes, affect protein production and meat quality. Non-coding RNAs, including circular RNAs (circRNAs), play crucial roles in modulating gene expression and regulating the translation of mRNAs into proteins. This study examined circRNA expression in turkey skeletal muscle stem cells under thermal stress. The objectives were to identify and quantify circRNAs, assess circRNA abundance following RNAse R depletion, identify differentially expressed circRNAs (DECs), and predict potential microRNA (miRNA) targets for DECs and their associated genes. Materials and methods: Cultured cells from two genetic lines (Nicholas commercial turkey and The Ohio State Random Bred Control 2) under three thermal treatments: cold (33°C), control (38°C), and hot (43°C) were compared at both the proliferation and differentiation stages. CircRNA prediction and differential expression and splicing analyses were conducted using the CIRIquant pipeline for both the untreated and RNase R depletion treated libraries. Predicted interactions between DECs and miRNAs, as well as the potential impact of circRNA secondary structure on these interactions, were investigated. Results: A total of 11,125 circRNAs were predicted within the treatment groups, between both untreated and RNase R treated libraries. Differential expression analyses indicated that circRNA expression was significantly altered by thermal treatments and the genetic background of the stem cells. A total of 140 DECs were identified across the treatment comparisons. In general, more DECs within temperature treatment comparisons were identified in the proliferation stage and more DECs within genetic line comparisons were identified in the differentiation stage. Discussion: This study highlights the significant impact of environmental stressors on non-coding RNAs and their role in gene regulation. Elucidating the role of non-coding RNAs in gene regulation can help further our understanding of muscle development and poultry production, underscoring the broader implications of this research for enhancing animal protein production efficiency.

The regulatory status of health apps that employ gamification.

Smartphone applications are one of the main delivery modalities in digital health. Many of these mHealth apps use gamification to engage users, improve user experience, and achieve better health outcomes. Yet, it remains unclear whether gamified approaches help to deliver effective, safe, and clinically beneficial products to users. This study examines the compliance of 69 gamified mHealth apps with the EU Medical Device Regulation and assesses the specific risks arising from the gamified nature of these apps. Of the identified apps, 32 (46.4%) were considered non-medical devices; seven (10.1%) were already cleared/approved by the regulatory authorities, and 31 (44.9%) apps were assessed as likely non-compliant or potentially non-compliant with regulatory requirements. These applications and one approved application were assessed as on the market without the required regulatory approvals. According to our analysis, a higher proportion of these apps would be classified as medical devices in the US. The level of risk posed by gamification remains ambiguous. While most apps showed only a weak link between the degree of gamification and potential risks, this link was stronger for those apps with a high degree of gamification or an immersive game experience.

Prospective assessment of novice learners in a simulation-based extracorporeal membrane oxygenation (ECMO) education program.

This study aimed to assess the impact of integrating a simulation-based education module into an extracorporeal membrane oxygenation (ECMO) curriculum on novice learners and to test the duration of time that skills obtained during this training exercise were retained. The authors hypothesized that multidisciplinary, simulation-based ECMO training would improve comfort and confidence levels among participants. An ECMO training curriculum was developed that incorporated in situ simulation modules to train multidisciplinary health care professionals involved in the management of patients receiving ECMO in the pediatric cardiac intensive care unit (PCICU). During the simulation, a team was assembled similar to the one that would staff the PCICU during a routine workday. Pre- and postparticipation questionnaires were used to determine the effects on the knowledge, ability, and confidence level of the participants. The participants were required to repeat the simulation test within 6-8 months. The study enrolled 26 providers (10 fellow physicians, 12 nurses and nurse practitioners, 4 respiratory therapists). All except one had no previous training in the management of ECMO. Of the 26 participants, 24 passed the initial written and practical tests. One participant failed the written test, whereas another failed the practical test. All the responding participants scored the didactic and scenarios education as useful, at 4 or higher (5 = very useful), in improving their perception of their overall knowledge and their ability to perform the required critical performance criteria on simulated ECMO. The 20 participants who appeared for the 6 month follow-up visit to assess maintenance of competency skills demonstrated success with simulated ECMO emergencies. All four questionnaires were completed by 18 participants. Simulation-based training is an effective method of improving knowledge, ability, and confidence levels among novice ECMO specialists and physician trainees. Further research is needed to assess real-time demonstration of skills retention during ECMO emergencies.

Expression of miRNAs in turkey muscle satellite cells and differential response to thermal challenge.

Thermal stress alters the transcriptome and subsequent tissue physiology of poultry; thus, it can negatively impact poultry production through reduced meat quality, egg production, and health and wellbeing. The modulation of gene expression is critical to embryonic development and cell proliferation, and growing evidence suggests the role of non-coding RNAs (RNA:RNA interaction) in response to thermal stress in animals. MicroRNAs (miRNAs) comprise a class of small regulatory RNAs that modulate gene expression through posttranscriptional interactions and regulate mRNAs, potentially altering numerous cellular processes. This study was designed to identify and characterize the differential expression of miRNAs in satellite cells (SCs) from the turkey pectoralis major muscle and predict important miRNA:mRNA interactions in these developing SCs under a thermal challenge. Small RNA sequencing was performed on RNA libraries prepared from SCs cultured from 1-week-old male Nicholas commercial turkeys (NCTs) and non-selected Randombred Control Line 2 turkeys during proliferation and differentiation at the control temperature (38°C) or under a thermal challenge (33°C or 43°C). A total of 353 miRNAs (161 known and 192 novel) were detected across the sequenced libraries. Expression analysis found fewer differentially expressed miRNAs in the SCs of NCT birds, suggesting that the miRNA response to heat stress has been altered in birds selected for their modern commercial growth traits. Differentially expressed miRNAs, including those with described roles in muscle development, were detected both among temperature treatments and between genetic lines. A prominent differential expression of miR-206 was found in proliferating turkey SCs with a significant response to thermal challenges in both lines. In differentiating SCs, isoforms of miR-1 had significant differential responses, with the expression of miR-206 being mainly affected only by cold treatment. Target gene predictions and Gene Ontology analysis suggest that the differential expression of miRNAs during thermal stress could significantly affect cellular proliferation and differentiation.

Occurrence and antimicrobial resistance of Salmonella species and potentially pathogenic Escherichia coli in free-living seals of Canadian Atlantic and eastern Arctic waters.

Seal populations in Canadian waters provide sustenance to coastal communities. There is potential for pathogenic and/or antimicrobial-resistant bacteria to transfer to humans through inadvertent faecal contamination of seal products. The objective of this study was to investigate the occurrence and potential antimicrobial resistance of Salmonella spp., Escherichia coli and Listeria monocytogenes in faecal samples collected from grey seals (Halichoerus grypus) in the Gulf of St. Lawrence and from ringed seals (Pusa hispida) in Frobisher Bay and Eclipse Sound, Nunavut, Canada. Grey seals were harvested during commercial hunts or during scientific sampling; ringed seals were collected by Inuit hunters during subsistence harvests. Virulence genes defining pathogenic E. coli were identified by PCR, and antimicrobial susceptibility testing was performed on recovered isolates. In grey seals, E. coli was detected in 34/44 (77%) samples, and pathogenic E. coli (extraintestinal E. coli [ExPEC], enteropathogenic E. coli [EPEC] or ExPEC/EPEC) was detected in 13/44 (29%) samples. Non-susceptibility to beta-lactams and quinolones was observed in isolates from 18 grey seals. In ringed seals from Frobisher Bay, E. coli was detected in 4/45 (9%) samples; neither virulence genes nor antimicrobial resistance was detected in these isolates. In ringed seals from Eclipse Sound, E. coli was detected in 8/50 (16%) samples and pathogenic E. coli (ExPEC and ExPEC/EPEC) in 5/50 (10%) samples. One seal from Eclipse Sound had an E. coli isolate resistant to beta-lactams. A monophasic Salmonella Typhimurium was recovered from 8/50 (16%) seals from Eclipse Sound. All Salmonella isolates were resistant to ampicillin, streptomycin, sulfisoxazole and tetracycline. L. monocytogenes was not detected in any sample. These findings suggest that seals may act as important sentinel species and as reservoirs or vectors for antimicrobial-resistant and virulent E. coli and Salmonella species. Further characterization of these isolates would provide additional insights into the source and spread of antimicrobial resistance and virulence genes in these populations of free-living seals.

Isolation and characterisation of wear debris surrounding failed total ankle replacements.

Aseptic loosening and osteolysis continue to be a short- to mid-term problem for total ankle replacement (TAR) devices. The production of wear particles may contribute to poor performance, but their characteristics are not well understood. This study aimed to determine the chemical composition, size and morphology of wear particles surrounding failed TARs. A recently developed wear particle isolation method capable of isolating both high- and low-density materials was applied to 20 retrieved periprosthetic tissue samples from 15 failed TARs of three different brands. Isolated particles were imaged using ultra-high-resolution imaging and characterised manually to determine their chemical composition, size, and morphology. Six different materials were identified, which included: UHMWPE, calcium phosphate (CaP), cobalt chromium alloy (CoCr), commercially pure titanium, titanium alloy and stainless steel. Eighteen of the 20 samples contained three or more different wear particle material types. In addition to sub-micron UHMWPE particles, which were present in all samples, elongated micron-sized shards of CaP and flakes of CoCr were commonly isolated from tissues surrounding AES TARs. The mixed particles identified in this study demonstrate the existence of a complex periprosthetic environment surrounding TAR devices. The presence of such particles suggests that early failure of devices may be due in part to the multifaceted biological cascade that ensues after particle release. This study could be used to support the validation of clinically-relevant wear simulator testing, pre-clinical assessment of fixation wear and biological response studies to improve the performance of next generation ankle replacement devices. STATEMENT OF SIGNIFICANCE: Total ankle replacement devices do not perform as well as total hip and knee replacements, which is in part due to the relatively poor scientific understanding of how they fail. The excessive production of certain types of wear debris is known to contribute to joint replacement failure. This is the first study to successfully isolate and characterise high- and low-density wear particles from tissues collected from patients with a failed total ankle replacement. This article includes the chemical composition and characteristics of the wear debris generated by ankle devices, all of which may affect their performance. This research provides clinically relevant reference values and images to support the development of pre-clinical testing for future total ankle replacement designs.

Isolating highly enriched populations of circulating epithelial cells and other rare cells from blood using a magnetic sweeper device.

The enumeration of rare circulating epithelial cells (CEpCs) in the peripheral blood of metastatic cancer patients has shown promise for improved cancer prognosis. Moving beyond enumeration, molecular analysis of CEpCs may provide candidate surrogate endpoints to diagnose, treat, and monitor malignancy directly from the blood samples. Thorough molecular analysis of CEpCs requires the development of new sample preparation methods that yield easily accessible and purified CEpCs for downstream biochemical assays. Here, we describe a new immunomagnetic cell separator, the MagSweeper, which gently enriches target cells and eliminates cells that are not bound to magnetic particles. The isolated cells are easily accessible and can be extracted individually based on their physical characteristics to deplete any cells nonspecifically bound to beads. We have shown that our device can process 9 mL of blood per hour and captures >50% of CEpCs as measured in spiking experiments. We have shown that the separation process does not perturb the gene expression of rare cells. To determine the efficiency of our platform in isolating CEpCs from patients, we have isolated CEpCs from all 47 tubes of 9-mL blood samples collected from 17 women with metastatic breast cancer. In contrast, we could not find any circulating epithelial cells in samples from 5 healthy donors. The isolated CEpCs are all stored individually for further molecular analysis.

Advancing equity and justice through community science programming in design, construction, and research of a nature-based solution: the Duwamish Floating Wetlands Project.

Dxwdəw refers to the Black-Green Rivers confluences that made the Duwamish River in Seattle, Washington, USA, prior to the 1910s. Significant industrial activity and human-made diversions to these rivers caused heavy pollution and eliminated 97% of historic wetlands, forever altering the historic river systems, salmon runs and human and aquatic health. Today the Green-Duwamish River and Duwamish Estuary are an industrial and commercial corridor, albeit also a site of cultural significance and fishing rights for urban Indigenous and Coast Salish tribes, and home and workplace to diverse urban populations of sustenance fishers, immigrants and refugees, communities of color, and low-income neighborhoods. Using a socio-ecological and environmental justice perspective within a nature-based solution, the Duwamish Floating Wetlands Project designed and piloted four constructed floating wetland structures for two years on the Duwamish River and researched their feasibility to provide habitat for out-migrating juvenile salmon. A multi-pronged community team (community leaders, liaisons, stewards and scientists) worked alongside academics and professionals. This paper showcases the formulation and adaptation of a two-year citizen/community science program integrated into the project. We outline the frameworks, approach, outcomes, and lessons-learned of the community science and outreach program, and compiled these in a list of guidelines to provide practitioner, researcher and community insight into the value and necessity of prioritizing environmental justice, racial equity, and ecosystem needs in nature-based solutions.

Mixed material wear particle isolation from periprosthetic tissue surrounding total joint replacements.

Submicron-sized wear particles are generally accepted as a potential cause of aseptic loosening when produced in sufficient volumes. With the accelerating use of increasingly wear-resistant biomaterials, identifying such particles and evaluating their biological response is becoming more challenging. Highly sensitive wear particle isolation methods have been developed but these methods cannot isolate the complete spectrum of particle types present in individual tissue samples. Two established techniques were modified to create one novel method to isolate both high- and low-density materials from periprosthetic tissue samples. Ten total hip replacement and eight total knee replacement tissue samples were processed. All particle types were characterized using high resolution scanning electron microscopy. UHMWPE and a range of high-density materials were isolated from all tissue samples, including: polymethylmethacrylate, zirconium dioxide, titanium alloy, cobalt chromium alloy and stainless steel. This feasibility study demonstrates the coexistence of mixed particle types in periprosthetic tissues and provides researchers with high-resolution images of clinically relevant wear particles that could be used as a reference for future in vitro biological response studies.

Alternative cannulation strategy for pediatric ECMO.

Vascular access in children who require extracorporeal membrane oxygenation (ECMO) support can be a challenging endeavor particularly in those who have undergone prior median sternotomies or interventional procedures. We present an alternative cannulation strategy that can be utilized in pediatric patients requiring ECMO that involves utilization of the iliac vein via a retroperitoneal approach.

Adult emergency department naloxone education and prescription program: Video and pamphlet education comparison.

OBJECTIVES: This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format. METHODS: This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods. RESULTS: Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53. CONCLUSIONS: There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.

Osteomyelitis in cold-stunned Kemp's ridley sea turtles (Lepidochelys kempii) hospitalized for rehabilitation: 25 cases (2008-2018).

OBJECTIVE: To characterize osteolytic lesions in cold-stunned Kemp's ridley sea turtles (Lepidochelys kempii) hospitalized for rehabilitation and describe methods used for the management of such lesions. ANIMALS: 25 stranded, cold-stunned Kemp's ridley sea turtles hospitalized between 2008 and 2018. PROCEDURES: Medical records of sea turtles with a diagnosis of osteolytic lesions were reviewed retrospectively to obtain the date of diagnosis, clinical signs, radiographic findings, microbial culture results, hematologic and plasma biochemical data, cytologic and histologic findings, antimicrobial history, time to first negative culture result, treatment duration, and outcome. RESULTS: Lesions were identified radiographically a median of 50 days after admission and were located within epiphyses or metaphyses of various appendicular joints. Lesions were associated with periarticular swelling (n = 24), lameness (16), lethargy (2), and hyporexia (2). Bacterial culture yielded growth of single organisms (n = 16), multiple organisms (2), or no growth (6). Significant differences in hematologic and biochemical data were detected between the times of diagnosis and convalescence. Cytologic and histologic findings characterized the lesions as osteomyelitis leading to septic arthritis. Sixteen sea turtles were managed medically, and 8 were managed medically and surgically. Surgery resulted in rapid improvement in joint mobility and overall clinical status. Most (22/25 [88%]) sea turtles survived and were released after long-term management. CONCLUSIONS AND CLINICAL RELEVANCE: During rehabilitation, cold-stunned Kemp's ridley sea turtles may be affected by osteomyelitis. Medical management based on antimicrobial susceptibility testing was effective for most turtles. Long term management efforts in turtles are justified by high survival rate.

Convulsion and Atrial Fibrillation after Transforaminal Cervical Epidural Lidocaine Injection.

Lidocaine has been widely used as a local anesthetic as well as an antiarrhythmic. Its use in epidural anesthesia is increasing, which has introduced new risk and potential for harm not associated with older indications. We present a case of convulsion and atrial fibrillation seen after transforaminal cervical epidural injection with two milliliters of 2% lidocaine (40 milligrams) that resolved with no long-term sequelae. Patient had a negative serum lidocaine level. With cervical epidural injections being a common treatment for radicular pain, it is important for medical providers to be aware of the various complications associated with this procedure.