7-year outcomes of the first successful pediatric bilateral hand transplantation

Introduction: The purpose of this case report is to describe the 7-year functional outcomes and health-related quality of life (HRQOL) of the first successful pediatric bilateral hand transplantation. The report focuses on activity and participation. The authors suggest assessment methods that can be applied to future cases. Method(s): The child underwent quadrimembral amputation at age two years and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes assessments, patientreported and parent-reported outcome questionnaires were repeated over a 7-year period. Result(s): At 7-years post transplantation, the adolescent and his mother reported a high level of satisfaction with the outcomes. Therapist observed assessments showed the adolescent achieved functional gross motor dexterity with each upper extremity. Although left gross and fine dexterity was superior to the right at all timepoints observed, the adolescent used his right upper extremity as dominant and incorporated both extremities as appropriate for bimanual tasks. The adolescent achieved modified independence to full independence with self-care activities. The adolescent participated in diverse activities with a high level of enjoyment. Participation was more diverse, social, and communitybased prior to and after the initial COVID-19 pandemic restrictions. At 7-years post transplantation when the adolescent was 15-years of age, the parent rated more instrumental activities of daily living as somewhat difficult. Discussion and Conclusion(s): Therapist observed outcomes assessments, patient-reported and parent-reported outcome questionnaires, showed the child had incorporated his hands into various activities, was completing daily activities independently, and HRQOL outcomes in social, emotional, cognitive, and physical domains were favorable. Most results were stable over time. The decrease in right hand dexterity scores might reflect small kinesiological changes in the right hand. Difficulty with some instrumental activities of daily living were likely due to new activities typical of child development for this now 15-year-old patient.

Strategies for Deficit Recovery for the Orthopaedic Service Line: Lessons Learned from the COVID-19 Pandemic: AOA Critical Issues Symposium.

ABSTRACT: The COVID-19 pandemic and the mandated cessation of surgical procedures for a substantial portion of the 2020 year placed tremendous strain, both clinically and financially, on the health-care system in the United States. As a surgical specialty that accounts for nearly a quarter of all hospital net income, the revenue recovery of orthopaedic service lines (OSLs) is of particular importance to the financial recovery of their broader health-care institutions. In this American Orthopaedic Association (AOA) symposium report, the OSL leaders from 4 major academic medical institutions explain and reflect on their approaches to address their revenue deficits. Cost-reduction strategies, such as tightening budgets, adopting remote-work models, and limiting costs of human capital, were vital to stabilizing departmental finances at the onset of the pandemic, while strategies that focused on expanding surgical volume, such as those that improve efficiency in clinical and surgical settings, were important in growing revenue once elective procedures resumed. Institutional policy, payer administrative procedures, and the overall context of an ongoing public health crisis all placed limitations on recovery efforts, but engaging relevant stakeholders and working with available resources helped OSLs overcome these limitations. Due to clear strategic actions that were taken to address their deficits, each OSL represented in this AOA symposium saw substantial improvement in its year-end financial performance compared with its financial status at the end of the period of mandatory cessation of elective surgical cases.

Incidence and Severity of Type 1 Diabetes Mellitus during COVID-19 Pandemic

Background. The COVID-19 pandemic continues to impact healthcare overall particularly in relation to diabetes. Initial studies showed delays in emergent healthcare utilization, decreased preventative care visits, and more severe presentations of new onset diabetes. However, the pathophysiologic relationship between COVID-19 and type 1 diabetes is not yet well understood. Objective(s): Our primary objective was to compare the annual rates of new type 1 diabetes diagnoses between the pre-pandemic (1/2015-12/2019) and pandemic (1/2020-12/2021) periods. We hypothesized that the number of new-onset pediatric cases of type 1 diabetes increased during the COVID-19 pandemic compared to the preceding 5-year period. Method(s): We performed a retrospective review of EMR data from one pediatric tertiary care center from 1/1/2015 to 12/31/2021. Initial data were extracted based on ICD-10 codes (E08, E09, E10, E11, E13). Data were validated and excluded according to the following criteria: age >21 years at diagnosis, diagnosis date outside of study period, confirmed other form of diabetes, complex disease without confirmed auto-antibodies, and inadequate data at time of diagnosis. Result(s): Ultimately 1,057 patients met inclusion criteria. In the pre-pandemic period annual new onset cases ranged from 120-147 cases/year with a mean of 135.4 (Table 1). During the COVID-19 pandemic a mean of 182.5 cases/year were diagnosed (168 in 2020 and 197 in 2021). Cases increased 16% from 2019 to 2020 and further increased 17% from 2020 to 2021. Overall, cases increased 35% during the pandemic period (2020-2021) compared to the pre-pandemic period. Prior to the sharp rise in cases, new diagnoses declined in February-May 2020 (4 cases/ month in May 2020 compared to pre-pandemic average of 11.6 cases/month). Discussion(s): Quantifying the increase in new diagnoses of type 1 diabetes during the COVID-19 pandemic is important to understand the true impact of the global health crisis on this population. The increase in cases during the pandemic is likely multifactorial and continuing to understand this relationship may have important implications for public health policy and understanding type 1 diabetes pathophysiology in the future.

COVID-19 and the impact on youth onset type 2 diabetes new diagnoses and severity

Introduction: Initial studies of pediatric diabetes and COVID-19 focused on type 1 diabetes with some initial reports showing an increase in youth onset type 2 diabetes (T2D). We aim to expand on this initial evidence in a larger population over a longer period. Objectives: The purpose of our study was to describe the amount, the severity, and the demographics of youth onset T2D diagnoses during the COVID-19 pandemic compared to the five years prior. Methods: We performed a retrospective cross-sectional review of youth (age≤21) diagnosed with T2D during the COVID-19 pandemic (5/1/2020 to 4/30/2021) and the five years prior (5/1/2015- 4/30/2020) at a pediatric tertiary care center. Children were identified by ICD codes (ICD9 250.00, ICD10 E13.9 or E11.9). Charts were reviewed to confirm diagnosis and exclude those with medication induced diabetes, MODY, >1 positive autoantibody, or BMI<85%. Chi-squared, t-tests, and fisher's exact tests were used for analyses. Results: In the pre-pandemic era annual diagnoses of T2D ranged from 39-66 (mean=52). During the pandemic 155 children were diagnosed with T2D, an increase of 298% from the pre-pandemic mean. New diagnoses increased 455% in Black patients and 248% in Hispanic patients. The average A1C at presentation was higher during the pandemic (9.47%±2.57) than prior (8.69% ±2.09) (p=0.001). Rates of acidosis (pH<7.3) were similar before (7.3%) and during (6.4%) the pandemic (p=0.741). Rates of hyperosmolarity (serum osm ≥330 and glucose >600) were also similar, 1.9% vs 0.6% respectively (p=0.418). Of those diagnosed during the pandemic, 56% were tested for COVID-19 and three tested positive. Conclusions: New diagnoses of T2D increased during the COVID-19 pandemic particularly among Black youth. A1C values at diagnosis increased, but rates of acidosis and hyperosmolarity did not. Clinical COVID infection was very uncommon. The findings display the significant effect of the COVID-19 pandemic on youth, specifically Black youth. Given the lack of COVID-19 positivity, the increase may be tied to social-distancing practices and behavioral changes. (Figure Presented).

Marine Genetic Resources in Areas Beyond National Jurisdiction: Promoting Marine Scientific Research and Enabling Equitable Benefit Sharing

Growing human activity in areas beyond national jurisdiction (ABNJ) is driving increasing impacts on the biodiversity of this vast area of the ocean. As a result, the United Nations General Assembly committed to convening a series of intergovernmental conferences (IGCs) to develop an international legally-binding instrument (ILBI) for the conservation and sustainable use of marine biological diversity of ABNJ [the biodiversity beyond national jurisdiction (BBNJ) agreement] under the United Nations Convention on the Law of the Sea. The BBNJ agreement includes consideration of marine genetic resources (MGR) in ABNJ, including how to share benefits and promote marine scientific research whilst building capacity of developing states in science and technology. Three IGCs have been completed to date with the fourth delayed by the Covid pandemic. This delay has allowed a series of informal dialogues to take place between state parties, which have highlighted a number of areas related to MGR and benefit sharing that require technical guidance from ocean experts. These include: guiding principles on the access and use of MGR from ABNJ;the sharing of knowledge arising from research on MGR in ABNJ;and capacity building and technology transfer for developing states. In this paper, we explain what MGR are, the methods required to collect, study and archive them, including data arising from scientific investigation. We also explore the practical requirements of access by developing countries to scientific cruises, including the sharing of data, as well as participation in research and development on shore whilst promoting rather than hindering marine scientific research. We outline existing infrastructure and shared resources that facilitate access, research, development, and benefit sharing of MGR from ABNJ;and discuss existing gaps. We examine international capacity development and technology transfer schemes that might facilitate or complement non-monetary benefit sharing activities. We end the paper by highlighting what the ILBI can achieve in terms of access, utilization, and benefit sharing of MGR and how we might future-proof the BBNJ Agreement with respect to developments in science and technology. © Copyright © 2021 Rogers, Baco, Escobar-Briones, Gjerde, Gobin, Jaspars, Levin, Linse, Rabone, Ramirez-Llodra, Sellanes, Shank, Sink, Snelgrove, Taylor, Wagner and Harden-Davies.

Evolving the narrative for protecting a rapidly changing ocean, post-COVID-19.

The ocean is the linchpin supporting life on Earth, but it is in declining health due to an increasing footprint of human use and climate change. Despite notable successes in helping to protect the ocean, the scale of actions is simply not now meeting the overriding scale and nature of the ocean's problems that confront us.Moving into a post-COVID-19 world, new policy decisions will need to be made. Some, especially those developed prior to the pandemic, will require changes to their trajectories; others will emerge as a response to this global event. Reconnecting with nature, and specifically with the ocean, will take more than good intent and wishful thinking. Words, and how we express our connection to the ocean, clearly matter now more than ever before.The evolution of the ocean narrative, aimed at preserving and expanding options and opportunities for future generations and a healthier planet, is articulated around six themes: (1) all life is dependent on the ocean; (2) by harming the ocean, we harm ourselves; (3) by protecting the ocean, we protect ourselves; (4) humans, the ocean, biodiversity, and climate are inextricably linked; (5) ocean and climate action must be undertaken together; and (6) reversing ocean change needs action now.This narrative adopts a 'One Health' approach to protecting the ocean, addressing the whole Earth ocean system for better and more equitable social, cultural, economic, and environmental outcomes at its core. Speaking with one voice through a narrative that captures the latest science, concerns, and linkages to humanity is a precondition to action, by elevating humankind's understanding of our relationship with 'planet Ocean' and why it needs to become a central theme to everyone's lives. We have only one ocean, we must protect it, now. There is no 'Ocean B'.