Nipple-Sparing Gigantomastia Breast Reduction: A Systematic Review.

INTRODUCTION: There remains an unclear definition of the term "gigantomastia," with many studies using different parameters and measurements. Currently, the operative management and patient education for gigantomastia are outdated. The historical teaching that a free nipple graft is necessary in elongated pedicles to avoid nipple necrosis may not be factual. The principal goal of our review aims to determine the safety of nipple-sparing breast reductions on large ptotic breasts via complication rate analysis. METHODS: The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of conduct for systematic review and meta-analysis. In October 2021, PubMed was used to search the US National Library of Medicine database. Rayyan Intelligent Systematic Review aided in screening studies by title then abstract. If inclusion criteria were met, the entire article was reviewed. RESULTS: Twenty-two articles satisfied the inclusion and exclusion criteria. The study was composed of 1689 total patients with a mean body mass index of 32.9 (±3.4). Mean midclavicle-to-nipple distance and resection weight per breast was 39 cm (±3.8) and 1423.8 g (±268.9), respectively. A Wise pattern was preferred in 77.3% of the studies, with an inferior (45.5%) and superomedial (45.5%) pedicle used most commonly. Complete nipple areolar complex necrosis (1.7%) was found in 4 studies, whereas partial (5.9%) was observed in 11. More common complications included delayed wound healing (17.4%), surgical site infection (14.3%), seroma (10.5%), scar hypertrophy (9.9%), and wound dehiscence (9.2%). CONCLUSION: Nipple-sparing breast reduction surgery can be safely performed on hypertrophic and severely ptotic breasts with nipple areolar complications, such as partial or complete nipple areolar complex loss, at a rate less than previously believed.

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction. METHODS: This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE. RESULTS: This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001). CONCLUSION: In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Combined single-stage enterolysis with pedicle seromuscular bowel flaps, myocutaneous and fasciocutaneous flaps to repair recurrent enterocutaneous fistulas in complex abdominal Wall defects.

INTRODUCTION: Reconstruction of abdominal wall defects with enterocutaneous fistulas (ECF) remains challenging. The purpose of this report is to describe a single-stage approach using combined microscopic enterolysis, pedicle seromuscular bowel flaps, mesh, fasciocutaneous, and myocutaneous flaps. METHODS: Between 1990 and 2016 a retrospective review identified a total of 18 patients with an average age of 39 years (ranging 26-59 years). Thirteen cases were associated with trauma, four were complication of previous mesh repair, and one was after an aortic dissection. Average diameter of defect size was 22 cm (ranging 20-24 cm). Surgical technique involved enterolysis using microscope magnification, a pedicle seromuscular bowel flap to reinforce the bowel anastomosis, mesh, musculocutaneous, and fasciocutaneous flaps to reconstruct the abdominal wall. RESULTS: Fifteen patients required rotational flaps with an average skin paddle area of 442.7 cm2 (ranging 440 cm2 -260 cm2 ) and 10 patients required a serosal patch with an average length of 5 cm (ranging 4-6 cm). Complications included three wound dehiscence and one abdominal wall bulging. Flap survival was 100%. The majority of patients (12 out of 18) were able to resume normal activities, and the remaining (n = 6) were able to resume most activities. Functional outcome as assessed by 36-Item Short Form Survey (SF-36) physical function component questionnaire at 18-24 months follow up was 67.8% (ranging from 59 to 72%). Mean length of hospital stay was 2.2 weeks (ranging 1.4-2.7 weeks). Mean follow-up was 24 months (ranging 22-26 months) with clinical examination. CONCLUSION: Microscopically assisted intra-abdominal dissection with resection of diseased bowel, replacement with well-vascularized tissue at the anastomosis site in, and reinforcement with mesh combined with pedicle musculocutaneous and fasciocutaneous flaps may be an alternative when other local reconstructive options have failed.

Hemotin, a Regulator of Phagocytosis Encoded by a Small ORF and Conserved across Metazoans.

Translation of hundreds of small ORFs (smORFs) of less than 100 amino acids has recently been revealed in vertebrates and Drosophila. Some of these peptides have essential and conserved cellular functions. In Drosophila, we have predicted a particular smORF class encoding ~80 aa hydrophobic peptides, which may function in membranes and cell organelles. Here, we characterise hemotin, a gene encoding an 88aa transmembrane smORF peptide localised to early endosomes in Drosophila macrophages. hemotin regulates endosomal maturation during phagocytosis by repressing the cooperation of 14-3-3ζ with specific phosphatidylinositol (PI) enzymes. hemotin mutants accumulate undigested phagocytic material inside enlarged endo-lysosomes and as a result, hemotin mutants have reduced ability to fight bacteria, and hence, have severely reduced life span and resistance to infections. We identify Stannin, a peptide involved in organometallic toxicity, as the Hemotin functional homologue in vertebrates, showing that this novel regulator of phagocytic processing is widely conserved, emphasizing the significance of smORF peptides in cell biology and disease.

Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap.

BACKGROUND: Lower extremity salvage following significant soft tissue loss can be complicated by lack of recipient vessel for free tissue transfer. We describe our experience in lower limb salvage for patients with no recipient vessels with the use of pedicle, free and cable bridge flaps. METHODS: A retrospective review from 1985 to 2017 of patients undergoing lower limb salvage using a contralateral pedicle cross leg (PCL) flaps, free cross leg (FCL) flaps, or free cable bridge (FCB) flaps was conducted. Demographics, etiology of the reconstruction, type of flap used, donor-site vessels, defect size, operating time, time of pedicle division, length of hospital stay, time to ambulation, and complications were analyzed. RESULTS: A total of 53 patients (48 males and 5 females) with an average age of 35 years (range, 29-38 years) were identified. The etiology for the reconstruction was trauma in 52 patients and oncological resection in 1 patient. There were 18 PCL, 25 FCL, and 10 FCB completed. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operating room times for PCL, FCL, and FCB flaps were 4, 9, and 10 hours, respectively. The average length of hospital stay was 5 weeks and average time to ambulation was 4 weeks. The average follow-up time was 7.5 years (range, 3-12 years). Complications encountered were hematoma (six), prolonged pain (six), total flap loss (two), reoperation (five), and infection (four). Limb salvage rates were 96.2%. CONCLUSION: When ipsilateral limb vessels are not available, and other reconstructive options have been exhausted, cross leg flaps can be a viable option for limb salvage in the setting of extensive defects.

Global Public Health Threats: The Role of Vaccinations.

Globalization has connected people culturally, economically and socially in a highly mobile, interdependent world. The result: Infectious diseases spread geographically much faster than at any time in history. The World Health Organization has identified more than 1,100 epidemics worldwide in a five-year span.1 The International Air Transport Association estimates 3.7 billion passengers will travel in 2016, a rate expected to double over the next 20 years.2 The constantly increasing number of international travelers plus the continual presence of infectious diseases means an outbreak or epidemic anywhere could become an imminent threat across the world.

Equipotent subanesthetic concentrations of sevoflurane and xenon preventing cold-stimulated vocalization of neonatal rats.

BACKGROUND: The effects of inhaled anesthetics on the developing brain are studied using neonatal rodents exposed to fractions of minimum alveolar concentration (to avoid cardiorespiratory compromise). However, these fractions cannot be assumed to be equipotent. Xenon's anesthetic and neuroprotective properties warrant investigation in these models. Therefore, equipotent, subanesthetic concentrations of inhaled anesthetics are needed. METHODS: Forty-eight Wistar rats (Charles River Laboratories, Kent, United Kingdom) on postnatal day 9 were randomized to eight concentrations of inhaled anesthetics: isoflurane, sevoflurane, or xenon. Exposure was closely monitored in individual metal-based chambers resting on a 35°C mat to maintain normothermia. A 25°C mat was used to stimulate vocalization and a sound recording made (1 min, 1 to 100 kHz). Rectal temperature or partial pressure of carbon dioxide and pH of mixed arteriovenous blood were measured immediately after the exposure. Concentration-response models were constructed using logistic regression (dependent variable: vocalization and explanatory variable: concentration). The effects of all other explanatory variables were assessed by inserting them individually into the model. RESULTS: The effective inhaled concentrations preventing cold-stimulated vocalization in 50 and 95% of neonatal rats (EiC50 and EiC95) on postnatal day 9 were 0.46 and 0.89% sevoflurane and 20.15 and 34.81% xenon, respectively. The effect on the EiC50 of all other explanatory variables, including duration, was minimal. Stability of EiC50 isoflurane was not achieved over three durations (40, 80, and 120 min exposure). Partial pressure of carbon dioxide and pH in mixed arteriovenous blood appeared normal. CONCLUSIONS: The authors report equipotent subanesthetic concentrations of sevoflurane and xenon in neonatal rats with preserved cardiopulmonary function. This may be useful in designing neonatal rodent models of anesthesia.

Neither xenon nor fentanyl induces neuroapoptosis in the newborn pig brain.

BACKGROUND: Some inhalation anesthetics increase apoptotic cell death in the developing brain. Xenon, an inhalation anesthetic, increases neuroprotection when combined with therapeutic hypothermia after hypoxic-ischemic brain injury in newborn animals. The authors, therefore, examined whether there was any neuroapoptotic effect of breathing 50% xenon with continuous fentanyl sedation for 24 h at normothermia or hypothermia on newborn pigs. METHODS: Twenty-six healthy pigs (<24-h old) were randomized into four groups: (1) 24 h of 50% inhaled xenon with fentanyl at hypothermia (Trec = 33.5 °C), (2) 24 h of 50% inhaled xenon with fentanyl at normothermia (Trec = 38.5 °C), (3) 24 h of fentanyl at normothermia, or (4) nonventilated juvenile controls at normothermia. Five additional nonrandomized pigs inhaled 2% isoflurane at normothermia for 24 h to verify any proapoptotic effect of inhalation anesthetics in our model. Pathological cells were morphologically assessed in cortex, putamen, hippocampus, thalamus, and white matter. To quantify the findings, immunostained cells (caspase-3 and terminal deoxynucleotidyl transferase-mediated deoxyuridine-triphosphate nick-end labeling) were counted in the same brain regions. RESULTS: For groups (1) to (4), the total number of apoptotic cells was less than 5 per brain region, representing normal developmental neuroapoptosis. After immunostaining and cell counting, regression analysis showed that neither 50% xenon with fentanyl nor fentanyl alone increased neuroapoptosis. Isoflurane caused on average a 5- to 10-fold increase of immunostained cells. CONCLUSION: At normothermia or hypothermia, neither 24 h of inhaled 50% xenon with fentanyl sedation nor fentanyl alone induces neuroapoptosis in the neonatal pig brain. Breathing 2% isoflurane increases neuroapoptosis in neonatal pigs.

Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. METHODS: This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. RESULTS: In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. CONCLUSIONS: Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Automated hand hygiene compliance system's audible alert reminder increases healthcare worker hand hygiene compliance.

OBJECTIVE: To evaluate the effectiveness of an automated hand hygiene compliance system (AHHCS) audible alert and vibration for increasing hand hygiene compliance. DESIGN: A nonrandomized, before-and-after, quasi-experimental study of an AHHCS was implemented in several inpatient units. Over a 51-day period, the system's real-time audible alert was turned on, off, and back on. Overall, hand hygiene compliance was compared between days with activated and deactivated alerts and vibration. SETTING: This study was conducted at a level 1 trauma center, a regional academic health system with 1,564 beds. PARTICIPANTS: The AHHCS was implemented in 9 inpatient units: 3 adult medical-surgical step-down units, and 6 adult intensive care units. The AHHCS badges were assigned to patient care assistants, registered nurses, physical therapists, occupational therapists, speech therapists, respiratory therapists, and physicians. INTERVENTION: In the 9 inpatient units, selected healthcare staff were issued wearable badges that detected entry into and exit from a patient room. The audible alert was turned on for 16 days, turned off for 17 days, and then turned back on for 18 days, for a total of 51 days. RESULTS: Utilization of the AHHCS real-time audible alert reminder resulted in sustained HH compliance ≥90%. When the alert and vibration were deactivated, HH compliance dropped to an average of 74% (range, 62%-78%). Once the alert resumed, HH compliance returned to ≥90%. CONCLUSION: Utilization of an AHHCS with real-time reminder audible alerts may be an effective method to increase healthcare worker HH compliance to ≥90%. Users of AHHCSs should consider the use of real-time reminders to improve HH compliance.

The Effects of Intermittent Diet Breaks during 25% Energy Restriction on Body Composition and Resting Metabolic Rate in Resistance-Trained Females: A Randomized Controlled Trial.

The purpose of this study was to examine the effects of intermittent versus continuous energy restriction on body composition, resting metabolic rate, and eating behaviors in resistance-trained females. Thirty-eight resistance-trained females (mean ± standard deviation age: 22.3 ± 4.2 years) were randomized to receive either six weeks of a continuous 25% reduction in energy intake (n = 18), or one week of energy balance after every two weeks of 25% energy restriction (eight weeks total; n = 20). Participants were instructed to ingest 1.8 g protein/kilogram bodyweight per day and completed three weekly supervised resistance training sessions throughout the intervention. There were no differences between groups for changes over time in body composition, resting metabolic rate, or seven of the eight measured eating behavior variables (p > 0.05). However, a significant group-by-time interaction for disinhibition (p < 0.01) from the Three-Factor Eating Questionnaire was observed, with values (± standard error) in the continuous group increasing from 4.91 ± 0.73 to 6.17 ± 0.71, while values in the intermittent group decreased from 6.80 ± 0.68 to 6.05 ± 0.68. Thus, diet breaks do not appear to induce improvements in body composition or metabolic rate in comparison with continuous energy restriction over six weeks of dieting, but may be employed for those who desire a short-term break from an energy-restricted diet without fear of fat regain. While diet breaks may reduce the impact of prolonged energy restriction on measures of disinhibition, they also require a longer time period that may be less appealing for some individuals.

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series.

BACKGROUND: Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections. METHODS: A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed. RESULTS: Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent. CONCLUSION: The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effect of chronic transfusion therapy on progression of neurovascular pathology in pediatric patients with sickle cell anemia.

BACKGROUND: Chronic blood transfusion (CBT) is currently the standard of care for primary and secondary stroke prevention in children with sickle cell anemia (SCA). However, the effect of CBT on cerebrovascular pathology is not well known. METHODS: We reviewed children with SCA receiving CBT for abnormal transcranial Doppler (TCD) [n=12] or cerebrovascular accident (CVA) [n=22]. Baseline cerebral magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) were compared with the most recent scans available for each patient and independently scored by a neuroradiologist. RESULTS: Thirty-four patients with a mean age of 6.5years at the time of baseline MRI/MRA were studied. Average elapsed time from baseline to most recent scans was 7.3years. Overall, patients experienced worsening vasculopathy, as measured by mean increases in their baseline MRI and MRA scores of +0.76 and +1.03. There was a significant difference in the mean change of MRI/MRA scores between patients who had CVA and abnormal TCD (MRI; +1.23 vs. -0.08, p=0.001 and MRA; +1.54 vs. +0.08, p=0.02). Patients with abnormal baseline MRA had worsening scores compared to those with normal baseline MRA (54% vs. 9.5%, p=0.01). Also, patients who had CVA were more likely to have an abnormal baseline MRA and worsening scores compared to abnormal TCD patients. CONCLUSION: We show that children with CVA experience progression of cerebral vasculopathy despite CBT. In contrast, CBT for abnormal TCD confers protection against the development and/or progression of cerebral vasculopathy. This effect appears to be real given our large cohort of patients with longer follow up as compared to previous studies.

Minimally invasive robotic breast reconstruction surgery.

The rising popularity of robotic surgery has enabled surgeons to continue to expand the uses of robotic surgery. Robotic surgery offers minimally invasive approaches coupled with tremor elimination, up to seven degrees of freedom, ergonomic positioning, 3D magnified vision and improved resolution. We describe robotic surgery techniques for nipple-sparing mastectomies, latissimus dorsi muscle flap harvest, deep inferior epigastric perforator (DIEP) flap pedicle harvest, and robotic microsurgical anastomoses. By using a robotic system the surgeon is able to offer not only a minimally invasive approach to the patient but the surgeon's ability can be improved upon as well. This improved ability is best characterized in the robotic supermicrosurgical anastomosis where even the faintest surgeon's tremor is exploited. However, within the robotic system tremor is eliminated. We are now able to offer patients a completely minimally invasive approach to ablative breast surgery and breast reconstruction. A patient could have a robotic nipple-sparing mastectomy, followed by a robotic DIEP reconstruction with a robotic microsurgical anastomosis. The patient could even have robotic lymphovenous bypass to address lymphedema that could have arisen after an axillary dissection. A completely robotic surgical approach maximizes both utilization of the robotic system and patient benefit. By using robotic techniques in flap harvest the morbidity of traditional open surgeries is minimized and the use of robotic anastomoses expands the limits of human precision.

Surveillance testing reveals a significant proportion of hospitalized patients with SARS-CoV-2 are asymptomatic.

BACKGROUND: The proportion of positive patients admitted to acute-care hospitals for reasons other than coronavirus disease-19 (COVID-19) is unknown. These patients potentially put other patients and healthcare workers at risk of infection. OBJECTIVE: The objective of this study was to define the proportion of asymptomatic patients admitted with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Secondary objectives were to define the positivity rate, reasons for admission, and the geographic distribution in the region. METHODS: Universal surveillance testing for SARS-CoV-2 was performed on patients admitted to this hospital over a 12-week period from April 9, 2020 to July 1, 2020. Positive patients were categorized as either symptomatic or asymptomatic as defined by the 11 criteria per the Centers for Disease Control and Prevention. The positivity rate, proportion with and without symptoms, reasons for admission, and geographic distribution in the region were recorded. RESULTS: The positivity rate ranged from 0.8% to 6.2%. The proportion of asymptomatic patients with SARS-CoV-2 was 37%. Asymptomatic patients primarily presented to the hospital because of either trauma or labor. Some clusters in the region were identified of both symptomatic and asymptomatic patients. CONCLUSIONS: The proportion of asymptomatic patients admitted with SARS-CoV-2 was significant. Identifying and isolating asymptomatic patients likely prevented exposure and development of hospital-acquired COVID-19 cases among healthcare workers and other patients, supporting the universal surveillance of all admitted patients.

Pegasus, a small extracellular peptide enhancing short-range diffusion of Wingless.

Small Open Reading Frames (smORFs) coding for peptides of less than 100 amino-acids are an enigmatic and pervasive gene class, found in the tens of thousands in metazoan genomes. Here we reveal a short 80 amino-acid peptide (Pegasus) which enhances Wingless/Wnt1 protein short-range diffusion and signalling. During Drosophila wing development, Wingless has sequential functions, including late induction of proneural gene expression and wing margin development. Pegasus mutants produce wing margin defects and proneural expression loss similar to those of Wingless. Pegasus is secreted, and co-localizes and co-immunoprecipitates with Wingless, suggesting their physical interaction. Finally, measurements of fixed and in-vivo Wingless gradients support that Pegasus increases Wingless diffusion in order to enhance its signalling. Our results unveil a new element in Wingless signalling and clarify the patterning role of Wingless diffusion, while corroborating the link between small open reading frame peptides, and regulation of known proteins with membrane-related functions.

Implementing an electronic hand hygiene system improved compliance in the intensive care unit.

BACKGROUND: Hand hygiene (HH) compliance is low and difficult to improve among health care workers. We aim to validate an electronic HH system and assess the impact of this system on HH compliance and quality changes over time at both group and individual levels. METHODS: An automated electronic HH system was installed in a 10-bed surgical intensive care unit. RESULTS: The full HH compliance rate increased significantly from 8.4% in week 1 to 20.5% in week 16 with week 10 being the highest (27.4%). The partial compliance rate maintained relative consistency between 13.2% and 20.0%. The combined compliance rate (full compliance rate + partial compliance rate) increased from 23.5% in week 1 to 34.6% in week 16 with week 10 being the highest (41.4%). DISCUSSION: We found significant variations among providers in terms of HH opportunities per shift, full compliance, partial compliance and combined compliance rates. The average duration of hand rubbing over time in partial compliance occurrences did not change significantly over time. CONCLUSIONS: A sensor-based platform with automated HH compliance and quality monitoring, real time feedback and comprehensive individual level analysis, improved providers' HH compliance in an intensive care unit. There were significant variations among individual providers.

Peptides encoded by short ORFs control development and define a new eukaryotic gene family.

Despite recent advances in developmental biology, and the sequencing and annotation of genomes, key questions regarding the organisation of cells into embryos remain. One possibility is that uncharacterised genes having nonstandard coding arrangements and functions could provide some of the answers. Here we present the characterisation of tarsal-less (tal), a new type of noncanonical gene that had been previously classified as a putative noncoding RNA. We show that tal controls gene expression and tissue folding in Drosophila, thus acting as a link between patterning and morphogenesis. tal function is mediated by several 33-nucleotide-long open reading frames (ORFs), which are translated into 11-amino-acid-long peptides. These are the shortest functional ORFs described to date, and therefore tal defines two novel paradigms in eukaryotic coding genes: the existence of short, unprocessed peptides with key biological functions, and their arrangement in polycistronic messengers. Our discovery of tal-related short ORFs in other species defines an ancient and noncanonical gene family in metazoans that represents a new class of eukaryotic genes. Our results open a new avenue for the annotation and functional analysis of genes and sequenced genomes, in which thousands of short ORFs are still uncharacterised.

Theoretical analysis of initial adsorption of high-κ metal oxides on In(x)Ga(1-x)As(0 0 1)-(4×2) surfaces.

Ordered, low coverage to monolayer, high-κ oxide adsorption on group III rich InAs(0 0 1)-(4×2) and In(0.53)Ga(0.47)As(0 0 1)-(4×2) was modeled via density functional theory (DFT). Initial adsorption of HfO(2) and ZrO(2) was found to remove dangling bonds on the clean surface. At full monolayer coverage, the oxide-semiconductor bonds restore the substrate surface atoms to a more bulklike bonding structure via covalent bonding, with the potential for an unpinned interface. DFT models of ordered HfO(2)/In(0.53)Ga(0.47)As(0 0 1)-(4×2) show it fully unpins the Fermi level.

Initiation of a passivated interface between hafnium oxide and In(Ga)As(0 0 1)-(4x2).

Hafnium oxide interfaces were studied on two related group III rich semiconductor surfaces, InAs(0 0 1)-(4x2) and In(0.53)Ga(0.47)As(0 0 1)-(4x2), via two different methods: reactive oxidation of deposited Hf metal and electron beam deposition of HfO(2). The interfaces were investigated with scanning tunneling microscopy and spectroscopy (STS). Single Hf atom chemisorption sites were identified that are resistant to oxidation by O(2), but Hf islands are reactive to O(2). After e(-) beam deposition of <<1 ML of HfO(2), single chemisorption sites were identified. At low coverage (<1 ML), the n-type and p-type HfO(2)/InGaAs(0 0 1)-(4x2) interfaces show p-type character in STS, which is typical of clean InGaAs(0 0 1)-(4x2). After annealing below 200 degrees C, full coverage HfO(2)/InGaAs(0 0 1)-(4x2) (1-3 ML) has the surface Fermi level shifted toward the conduction band minimum for n-type InGaAs, but near the valence band maximum for p-type InGaAs. This is consistent with the HfO(2)/InGaAs(0 0 1)-(4x2) interface being at least partially unpinned, i.e., a low density of states in the band gap. The partially unpinned interface results from the modest strength of the bonding between HfO(2) and InGaAs(0 0 1)-(4x2) that prevents substrate atom disruption. The fortuitous structure of HfO(2) on InAs(0 0 1)-(4x2) and InGaAs(0 0 1)-(4x2) allows for the elimination of the partially filled dangling bonds on the surface, which are usually responsible for Fermi level pinning.