Ten Years After Oak Creek: Federal Policy Recommendations to Protect Communities Targeted by Hate

2022 was a year marked with significant anniversaries of hate against the AAPI community both historic and recent, from the 40th anniversary of the hate-driven murder of Chinese American immigrant Vincent Chin to the one-year anniversary of recent mass shootings in Atlanta and Indianapolis. These commemorations, moreover, came amidst a series of hate crimes targeting Sikh men in Richmond Hill, Queens, and a years-long spike in violence against Asian Americans - particularly Asian American women - ignited by the COVID-19 pandemic. One anniversary in 2022, however, is both important on its own right as a marker in the history of targeted violence and useful for contextualizing recent trends of hate in the US: the 10-year remembrance of the shooting at a gurdwara, a Sikh house of worship, in Oak Creek WI.

Relationship between acne and the use of mask in doctors during the COVID-19 pandemic.

OBJECTIVE: To identify the characteristics of the use of masks and features of acne lesions and acne-like eruptions, among doctors involved in various clinical settings. MATERIALS AND METHODS: An observational, prospective, cross-sectional study was conducted from June to September 2020. The main tool of the study was a form designed with the Google forms platform, which has 17 items. RESULT(S): The responses of 150 participants from Mexico and Latin America were analyzed: 84 participants (56%) were female. The most frequent academic degree among the participants was Doctor of Medicine. The mask with the highest frequency of use was the N95 mask in 98 participants (65.3%);84% of the participants presented typical acne lesions, nodules were the most frequent lesions, only 24 patients did not present characteristic lesions. The topographic region where these lesions most frequently occurred was the chin region. CONCLUSION(S): The importance of the presence of acne and acne-like lesions in medical doctors who use personal protective equipment during their working hours is demonstrated, in order to issue future recommendations related to skin care during the SARS-CoV-2 pandemic.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.

"Hello, garden eel here:” insights from emerging humanature relations at the aquarium during COVID-19

Over one billion people worldwide were under social isolation restrictions between April and May 2020. While humans felt the weight of being isolated under lockdown, nonhuman animals accustomed to continuous human connection had minimized exposure at different animal tourism sites and institutions – such as zoos and aquariums. One interesting case comes from garden eels, which according to their caretakers, were particularly susceptible to isolation from humans and required immediate action: Facetime calls with humans. In this research insight, I explore the new technologically mediated humanimal communication practice between humans and garden eels at the Sumida Aquarium in Tokyo, Japan. "Remembering humans” is explored as a humanature cultural discourse that emerged from humanity's social distancing phenomena, seemingly bridging humanature connection amidst the multitude of discourses that removed humanity from nature. This discourse also functions within a form of tourist gaze in tourism institutions. Even though small in scope, this cultural discourse analysis brings to surface one way we have discursively engaged with our solitude during quarantine: mirroring it on more-than-human animals' experiences. Further investigations about this, and other humanature emerging communication practices, are needed to better understand how the social isolation phenomena impacted communication meanings about humanature relations.

Unilateral multiple facial angiofibromas as a solitary manifestation of tuberous sclerosis

We describe the case of a 12-year-old boy who presented via teledermatology with a 5-6-year history of multiple lesions on the right side of his face. They were unchanged since their initial appearance at 6 years of age but were slowly increasing in number across his right cheek and extending onto the chin. Although the lesions were asymptomatic, growing older had made him feel increasingly self-conscious. He was otherwise fit and well, and attended mainstream school, with no past medical history or family history of note. Perinatal and birth history were also uneventful. On examination, he had multiple, 1-2-mm, erythematous papules confined to the right cheek and right chin. Dermoscopy showed an unusual pattern of vessels with nonspecific globules in between. The rest of the skin, hair and nails were entirely normal in appearance. There were no systemic symptoms and a detailed general and systemic examination, as well as radiological imaging, did not reveal any abnormality. An excisional biopsy was taken of one of the lesions, with histological examination demonstrating focal superficial telangiectasia with associated bland round-tospindle cell proliferation, appearances most in keeping with an angiofibroma. This correlated well clinically, apart from unilateral facial angiofibromas being the solitary finding in our patient. Facial angiofibromas - also called adenoma sebaceum - are well described as part of the cutaneous manifestations of tuberous sclerosis (TSC). Classically, these appear as a facial rash in the form of small pink or red spots across the cheeks and nose in a butterfly distribution, at between 3 and 10 years of age, increasing in size and number until adolescence. TSC is an autosomal dominant disorder with defective mammalian target of rapamycin (mTOR) signalling, characterized by hamartomas in many organs, particularly the skin, central nervous system, renal and cardiovascular systems. The clinical presentation is variable, with other well known and frequently reported cutaneous findings such as shagreen patches, ash-leaf macules and periungual fibromas. Unilateral multiple facial angiofibromas in the absence of other cutaneous or systemic manifestations of TSC - as in our patient - are rare, with only 13 reported cases. These may form part of the clinical spectrum of TSC as a probable consequence of cutaneous mosaicism in which a postzygotic genetic mutation has occurred. Our patient was referred for genetic testing, but this has been delayed as a result of the COVID-19 pandemic. Topical sirolimus 1% - an mTOR inhibitor - has been used with good effect for facial angiofibromas, and our patient also responded well to this.

Central Venous Catheter Placement in a Prone Positioned Patient: Posterior Lateral Approach

INTRODUCTION: A significant number of patients with ARDS secondary to Covid-19 pneumonia require prone positioning. Common practice is to return patients to a supine position prior to performing invasive bedside procedures such as central venous access. This may present prohibitive risk in patients with refractory hypoxemia. DESCRIPTION: We present the case of a 46 year old male, admitted to the ICU with Covid-19 pneumonia complicated by ARDS. Intermittent prone positioning was initiated. The patient remained with refractory hypoxemia despite prone positioning, optimal ventilator settings and inhaled epoprostenol. The length of time the patient could be supine progressively decreased. The patient developed AKI necessitating hemodialysis (HD) catheter placement. Attempts to supine patient to perform HD catheter placement resulted in near cardiorespiratory arrest. It was decided to attempt HD catheter placement in the RIJ vein via a posterior lateral approach with the patient prone. Patient was brought to the head of the bed allowing the chin to rest on the edge of the bed with head turned laterally and endotracheal tube supported by the respiratory therapist. The patient was placed in an oblique "swimming position" by aid of a pillow under the center torso and right shoulder girdle. An optimal insertion site was selected via real time ultrasound guidance. Utilizing a micropuncture needle, guidewire, and dilator, a 15cm 12 Fr BARD hemodialysis catheter was placed using a standard Seldinger technique. DISCUSSION: Our experience indicates that a posterior lateral approach for CVC placement is a viable option. Given the complexity of this procedure and the paucity of case reports describing it, we felt it prudent to share our approach. Structures of interest to avoid in posterior approach to the RIJ include the phrenic nerve traveling along the scalenus anterior muscle tissue posterior to the internal jugular vein. Accessing the vein below the omohyoid muscle offers the best opportunity to avoid the phrenic nerve and the scalenus. A steep 90 degree angle to access the RIJ was intentionally attempted to minimize the amount of soft tissue to dilate. Utilizing this approach allowed us to safely and effectively place the line without immediate complications.

Novel Conservative Management For Recurrent Temporomandibular Joint Dislocation

Introduction/Aims: We present the difficulties of managing a medically compromised patient with recurrent Temporomandibular Joint Dislocation who presented to us during the COVID-19 pandemic. We describe the novel use of an anti-snore head strap, in conjunction with a soft cervical collar which was successful in preventing further TMJ dislocations. To our knowledge, this has not been previously reported in the literature. It is important that clinicians must explore all options in patients with limited scope for surgical management when treating recurrent TMJ dislocations. Material(s) and Method(s): An anti-snore device was acquired online and in conjuction with a soft cervical collar was used to maintain the TMJ in it's position and prevent further recurrent dislocations. Results/Statistics: This simple, cost-effective and comfortable device reduced the number of hospital admissions for the patient, thereby additionally reducing her risk of contracting COVID-19. Prior to this intervention, the patient had presented for admission 10 times, resulting in a total stay of 65 days - the cost for this was 66,121.09. The anti-snore head device cost 11.99. Conclusions/Clinical Relevance: We present a novel technique in managing TMJ dislocation in a patient with severe morbidity who is limited with surgical treatment options. Therefore, we suggest the use of an anti-snore chin strap in conjunction with a soft cervical collar as a conservative management in medically compromised recurrent TMJ dislocations. Copyright © 2022

CHRONIC EMPYEMA MANAGED WITH TUBE THORACOSTOMY

SESSION TITLE: Problems in the Pleura Case Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hematologic malignancies can often be complicated by pleural effusion due to leukemic infiltration of the pleura (1). Long term management of resulting chronic plural effusion can be complicated when there is evidence of trapped lung. Subsequent infection may lead to development of chronic empyema which can be difficult to manage in chronically ill patients (2). CASE PRESENTATION: A 65-year-old male with history of chronic myeloid leukemia status post stem cell transplant was admitted with dyspnea and cough. Computed tomography (CT) chest imaging revealed increased volume loss on the left with new air fluid level in a chronic left pleural effusion. (Image 1) Patient's history was significant for chronic left pleural effusion, which was first identified in 2015 and found to be a malignant effusion with evidence of leukemia involvement. Repeat imaging in 2018 (Image 2) revealed continued chronic pleural effusion. Patient was admitted in August 2021 with COVID-19 pneumonia and CT Chest showed chronic loculated left sided pleural effusion. Patient elected to continue to monitor the chronic effusion, which was completed as outpatient every 4 to 6 weeks (Image 3). He remained clinically stable until the presentation to a hospital in January 2022. The chronic empyema was initially managed with tube thoracostomy, intrapleural fibrinolytics and antibiotics. Cultures were significant for Moraxella catarrhalis and Streptococcus pneumoniae. He was determined to be a poor surgical candidate for decortication and treatment with empyema tube was initiated. The empyema tube was incrementally withdrawn as an outpatient and subsequently removed with good clinical recovery. DISCUSSION: Chronic empyema is characterized by thickened parietal and visceral pleura which limits the ability of the lung to re-expand. Surgical management with decortication is the definitive management, however, in poor surgical candidates, management becomes more complicated. Open pleural drainage with an open pleural window can be considered. An alternative option converts tube thoracostomy to open pleural drainage, as was utilized in this patient (2). While comparison of surgical vs non-surgical management of empyema suggests similar mortality (3), non-surgical management of chronic empyema needs more investigation to determine the optimal treatment modality. CONCLUSIONS: Empyema remains a difficult condition to manage. Treatment modalities of chronic empyema are limited in those patients who remain poor surgical candidates. Reference #1: Faiz SA, Sahay S, Jimenez CA. Pleural effusions in acute and chronic leukemia and myelodysplastic syndrome. Curr Opin Pulm Med. 2014 Jul;20(4):340-6. Reference #2: Biswas A, Jantz MA, Penley AM, Mehta HJ. Management of chronic empyema with unexpandable lung in poor surgical risk patients using an empyema tube. Lung India. 2016;33(3):267-271. Reference #3: Redden MD, Chin TY, van Driel ML. Surgical versus non-surgical management for pleural empyema. Cochrane Database Syst Rev. 2017;3(3):CD010651. Published 2017 Mar 17. DISCLOSURES: No relevant relationships by Shannon Burke No relevant relationships by Abigail Go No relevant relationships by Jen Minoff no disclosure on file for Ravi Nayak;

LUCINACTANT, A SYNTHETIC SURFACTANT FOR TREATMENT OF COVID-19-ASSOCIATED ARDS

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The SARS-CoV-2 virus preferentially attacks alveolar Type 2 cells that have the membrane ACE2 receptors. Type 2 cells are the surfactant producing cells in the lung. Damage to Type 2 cells can result in decreased/abnormal surfactant production leading to ARDS and respiratory failure. Surfactant is further inactivated by inflammatory proteins during ARDS. We sought to evaluate the feasibility, safety and tolerability of surfactant therapy in COVID-19 associated ARDS using a synthetic surfactant, lucinactant. METHODS: Open-label, single arm, multicenter study (NCT04389671) in adults with COVID-19 associated ARDS, who have been intubated and on mechanical ventilation (MV) with a P/F ratio <= 300. COVID-19 infection was confirmed by PCR. Lucinactant at a dose of 160 ml (∼80 mg TPL/kg lean body weight) was delivered intratracheally within 7 days of intubation. Retreatment was allowed at >= 6-hour intervals if subjects remained on MV. Assessments included time to deliver the dose, physiologic parameters of oxygenation (P/F, OI, PaO2), FiO2, PaCO2, lung compliance (CL) from baseline (pre-dosing) through day 5 post-dosing. Safety parameters included peri-dosing (PD) events (bradycardia, desaturation, hypotension, regurgitation) and adverse events through 30 days post dosing. RESULTS: 20 subjects were enrolled and 19 received at least one dose. Five subjects received 2 doses of lucinactant. The mean age of subjects was 49 years, 80% were male, 60% were white. The mean time to administer the dose was 31 minutes. FiO2 requirements, PaO2 and PCO2 remained stable throughout the 5-day period post dosing. Baseline mean P/F ratio and standard deviation (SD) was 196 (68), 179 (57) at 12 hours and 193 (61) at day 1 post-dosing, followed by a gradual increase to 223 (105) at day 5. Mean CL increased from 40.5 (16) at baseline to 49.8 (23) at day 5. Seven subjects (37%) died, 6 due to secondary infection and sepsis > 13 days after dosing. Two subjects experienced transient PD events (desaturation, regurgitation). Lucinactant administration in severe ARDS due to COVID-19 was safe and generally well tolerated. The incidence of PD events was low. Stable to improved physiologic parameters of oxygenation were observed post dosing. Increasing the dose and number of administrations may provide additional benefit. CLINICAL IMPLICATIONS: The data support continued study of lucinactant in ARDS patients. DISCLOSURES: Consultant relationship with Windtree Therapeutics Please note: August 2000 Added 03/31/2022 by Carlos Guardia, value=Consulting fee Consultant relationship with Windtree Therapeutics Inc. Please note: August 2000 Added 03/31/2022 by Carlos Guardia, value=Consulting fee Removed 03/31/2022 by Carlos Guardia Advisory Committee Member relationship with Windtree, inc Please note: 4/2021-2/2022 Added 04/04/2022 by Yuh-Chin Huang, value=Grant/Research No relevant relationships Added 04/04/2022 by Peter Morris, value=Consulting fee Removed 04/04/2022 by Peter Morris Employee relationship with Windtree Therapeutics, Inc. Please note: 2008-2022 Added 04/04/2022 by Phillip Simmons, value=Salary Employee relationship with Windtree Therapeutics Please note: 2014 to present Added 04/14/2022 by Steven Simonson, value=Salary

Personal Protection Equipment and Slit-lamp Breath Shield in the Ophthalmology Office Setting

Purpose : COVID-19 pandemic has become a major global public health challenge. The ophthalmology office setting involves close encounters between the patient and the health care workers increasing risk of viral transmission. Use of PPE decreases risk of person-to-person viral transmission. The purpose of the study was to evaluate breath-induced air currents in subjects without a facemask, with a procedure mask, with an improvised face, and in the setting of slit-lamp examination. Methods : Breath-induced air currents were studied in healthy volunteers utilizing a vape pod system and videography during gentle and heavy breathing simulation. Video frames at 2 seconds after the initiation of expiration were captured and analyzed. Results : A total of 210 recordings were made for 7 settings. Without a face mask, the aerosol moved forwards and spread vertically and horizontally reaching a mean distance of 23.1 inches for gentle, and 36.1 inches for heavy breathing at 2 seconds (P< 0.001). Using PPE the airflow patterns included: a) procedure mask- forward 0 cases, upward 19 (63%) cases, side 28 (93%) cases, downward 22 (73%) cases, and backward 22 (73%) cases. Adding a tape at the upper border of the mask eliminated upward flow in all cases. b) Improvised face mask- forward 0 cases, upward 0 cases, side 30 (100%) cases, downward 30 (100%) cases, and backward 17 (57%) cases. In 14 (47%) cases trace of aerosol was detected adjacent to the front surface of the mask. Adding a second layer eliminated the trace of aerosol in all cases. In the setting of simulated slit-lamp examination without the breath shield, the aerosol reached the chin rest in 9 (60%) cases during gentle breathing and in all cases during heavy breathing. The breath shield was effective in blocking forward airflow in all cases. Conclusions : Use of a procedure mask by patients, while effective in blocking forward breath-induced airflow, redirects the flow upwards, potentially increasing the risk of contamination during an office procedure. An improvised facemask alters breath-induced air currents favorably and partially absorbs respiratory droplets.

Intra-oral kinking of a micro-cuff endotracheal tube: an unusual cause of difficult ventilation

Background: Intra-oral kinking of endotracheal tube is a rare but not unheard of complication. It could be lifethreatening if left unrecognised. Case presentation: A ten-year-old boy with developmental delay, scoliosis and recurrent chest infections was transferred to our paediatric intensive care (PIC) with SARS-CoV-2 pneumonia. The child was intubated with a size 5.5 micro-cuff endotracheal tube for critical hypoxic respiratory failure at his local hospital. The intubation was reported to be straightforward, with a grade 1 laryngoscopy view, but he was notably difficult to ventilate and oxygenate on the ventilator. He was transferred by road and was requiring a fraction of inspired oxygen of 0.8 and inhaled nitric oxide at 20 parts per million to maintain oxygen saturations of greater than 94%. The retrieval team also reported that he required a peak inspiratory pressure of as high as 49 cmH2O and positive end-expiratory pressure of 8 cmH2O with a 1:1 I: E ratio to maintain tidal volume of 6 ml/kg for his weight of 30kg. He was fully sedated and paralysed. The child was examined on arrival to PIC. His trachea was central and there was no wheeze or abdominal distension. The capnography waveforms were of normal appearance. A chest X-ray was also done to exclude endobronchial intubation and obvious pneumothorax. He was noted to be unusually difficult to bag ventilate, and the delivery of tidal volumes were hugely variable with any change in head positioning. He was best ventilated with head-tilt and chin-lift. Our concerns were escalated when the 'red-flag' of inability to pass the suction catheter was highlighted by the nursing team. The course of his tracheal tube was immediately palpated, and a twist was felt in the oropharynx. This finding was confirmed on laryngoscopy, which revealed a significant kink at letter C of this micro-cuff tube (Figure 1). The airway was swiftly exchanged, and immediate improvements of both ventilation and gas exchanged were observed. Conclusion: The polyvinyl polymers of endotracheal tubes are known to soften at body temperature and have a higher tendency to bent at acute angles,1 where the pilot tubing exists2;and when bending forces are applied away from the anatomical curvature, also known as the Magill curve (radius of approximately 140 millimetres), of most conventional tracheal tubes.2-5 Kinking of endotracheal tube at blind spots such as within the pharynx may happen more frequently in paediatrics than in adult critical care practice due to the use of straighter tracheal tubes with smaller wall thickness. We would like to raise awareness of this unusual case of difficult bag ventilation and high airway pressure ventilation. If a well-secured tracheal tube suddenly becomes problematic following, or in relation to positional changes, tube malfunction should be suspected. The integrity of the endotracheal tube must also be interrogated.

Facial dermatoses due to increased use of masks in medical students during COVID-19 pandemic: A cross sectional study from JSMU

Objective To determine the frequency of skin manifestations associated with prolonged mask wearing during the course of ongoing COVID-19 pandemic. Methods A cross-sectional study was conducted at Jinnah Sindh Medical University (JSMU), Karachi. A total of 138 medical students, who gave history of wearing masks were enrolled. The demographic data including age, gender, and their year of education was collected. A total of 20 questions were asked related to the type of mask, duration of wearing mask, associated and underlying skin disorders, etc. All information was carefully recorded on Google forms. Results This study included 138 participants, 124 (89.9%) females and 14 (10.1%) males. The type of masks used by the medical students varied, however 84.8% used surgical masks. The average duration of mask wear was 4 hours for 72.4% of the participants. There was no significant relation between skin changes and the type and duration of mask wear. The common skin manifestations reported in this study were itching (24.6 %), redness (27.5%), rash (10.1%), burning sensation (12.3%), acne (24.6%), pimples (37.7%), pigmentation (8.7), cracked skin (1.4%), scaling of skin (2.9%), and 29.7% reported no changes. The most frequently affected locations were cheeks (41.3%), followed by chin (13.8%), nasal bridge (10.1%) and perioral area (8%). Participants with history of atopic dermatitis were affected slightly more by itching, redness, rash, burning sensation, acne than those without a history of atopic dermatitis however these manifestations had no significant relation (p>0.05). Pressure bruises were reported in 23.9% of the participants and there was no significant relation with the skin manifestations. About 33% of the females who use makeup under the mask found it inconvenient due to pimples and itching. (p<0.05). Relationship between different skin types and use of cleansers for maintaining skin hygiene generally (p=0.006) and after taking mask off is significant (p=0.034). Significant relation exists between people experiencing pimples after taking off masks and using oral/systemic drugs (p=0.003), and other products (ice cubes, day cream, steroids, skincare regime) for management (p=0.012). Significant relation exists between acne after taking off mask and use of topical drugs (p=0.034). Conclusion The increase in skin manifestations is associated with the increased use of face masks during the COVID 19 pandemic among medical students. As mask wearing can't be compromised due to the nature of the working environment, certain guidelines need to be established to prevent or reduce the occurrence of such manifestations.

The impact of high and low volume suction devices on aerosol mitigation in a dental setting

Background & Aim: The COVID-19 pandemic changed the approach to aerosol mitigation in dentistry, although there is limited evidence and notable inconsistency among measures implemented in different countries. The aim of this study was to investigate aerosol mitigation by different high and low volume suction devices (HVE/LVE) during two distinct aerosol generating procedures (AGPs): a full mouth ultrasonic scaling (USS) and an anterior crown preparation with a high speed handpiece. Methods: Two different sensor set ups were optimized;a single sensor in a funnel positioned above the mouth and a two-sensor set up with sensors positioned at the patient's nose and chin. The particulate sensors (Plantower PMS5003) quantified aerosol concentration, expressed as the number of >0.3 μm particles/0.1 L of air. Defined dental procedures were carried out on a dental phantom head. Aerosol generation was measured throughout the procedures. Efficacy of different suction devices was assessed. Statistical analysis was performed using the mean normalized area under the curve of five independent experiments. Results: The high speed handpiece generated 3.4 times more aerosol/ min than ultrasonics when measured with the single sensor funnel device, and comparable amount of aerosol when measured with the two-sensor set up. HVE devices, that are moved around the mouth, provided consistent reduction of aerosol - to background levels - when carrying out ultrasonic scaling or crown preparation. We evaluated both HVE and LVE 'static' devices that are placed in the patient's mouth in a predetermined position for the duration of the procedure. These 'static' devices offered reduction of aerosol but with consistent 'spikes' recorded during procedures when aerosol escaped. Conclusions: In this simulated test system, either HVE or LVE 'static' devices provide inconsistent reduction of aerosols when conducting ultrasonic instrumentation. By contrast, an appropriately used HVE could reduce detectable aerosol to background levels during ultrasonic instrumentation in this test system.

A Multimetric Readability Analysis of Online Patient Educational Materials for Submental Fat Reduction.

BACKGROUND: Patients often utilize the Internet to seek information related to their care. This study assesses the readability of online patient educational materials for submental fat reduction. METHODS: Patient educational materials from the 12 most popular websites related to submental fat reduction were downloaded and assessed for readability grade level using 10 unique scales. RESULTS: Analysis of the 12 most popular websites (and corresponding 47 articles) revealed that patient educational materials were written, on average, at an 11th grade reading level. The Flesch Reading Ease score was 48.9 (range 39.8-59.2), representing a "difficult" level of reading. Mean readability grade levels (range 9-13th grade for individual websites) were as follows: Coleman-Liau, 11.1; Flesch-Kincaid, 10.8; FORCAST, 10.8; Fry Graph, 10.1; Gunning Fog, 12.7; New Dale-Chall, 10.1; New Fog Count, 11.8; Simple Measure of Gobbledygook, 11.7; Raygor, 6.7. No website was at the 6th grade reading level for patient educational materials recommended by the American Medical Association and National Institutes of Health. CONCLUSIONS: Online patient educational materials for submental fat reduction are written well above the recommended reading level. Recognition of disparities in health literacy is necessary to enable patients to make informed decisions and become active participants in their own care. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266.