Clinical Outcomes Associated with a Remote Postpartum Hypertension Monitoring Program.

OBJECTIVE: To evaluate differences in health care utilization and guideline adherence for postpartum individuals with hypertensive disorders of pregnancy (HDP) who are engaged in a remote monitoring program, compared with usual care. METHODS: This was a retrospective cohort study of postpartum individuals with HDP who delivered between March 2019 and June 2023 at a single institution. The primary exposure was enrollment in a remote hypertension management program that relies on patient home blood pressure (BP) measurement and centralized nursing team management. Patients enrolled in the program were compared with those receiving usual care. Outcomes included postpartum readmission, office visit within 6 weeks postpartum, BP measurement within 10 days, and initiation of antihypertensive medication. We performed multivariable logistic and conditional regression in a propensity score matched cohort. Propensity scores, generated by modeling likelihood of program participation, were assessed for even distribution by group, ensuring standardized bias of less than 10% after matching. RESULTS: Overall, 12,038 eligible individuals (6,556 participants, 5,482 in the control group) were included. Program participants were more likely to be White, commercially insured, be diagnosed with preeclampsia, and have higher prenatal and inpatient postpartum BPs. Differences in baseline factors were well-balanced after implementation of propensity score. Program enrollment was associated with lower 6-week postpartum readmission rates, demonstrating 1 fewer readmission for every 100 individuals in the program (propensity score-matched adjusted risk difference [aRD] -1.5, 95% CI, -2.6 to -0.46; adjusted risk ratio [aRR] 0.78, 95% CI, 0.65-0.93). For every 100 individuals enrolled in the program, 85 more had a BP recorded within 10 days (propensity score-matched aRD 85.4, 95% CI, 84.3-86.6), and six more had a 6-week postpartum office visit (propensity score-matched aRD 5.7, 95% CI, 3.9-7.6). Program enrollment was also associated with increased initiation of an antihypertensive medication postpartum (propensity score-matched aRR 4.44, 95% CI, 3.88-5.07). CONCLUSION: Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use.

Superelectrophilic Nonclassical Carbocations.

The chemistry of dicationic and tricationic 2-norbornyl cations has been studied. A series of N-heterocyclic functionalized norborneol substrates were prepared and ionization of these compounds in superacid provided superelectrophilic species. These highly charged 2-norbornyl cations were found to react with arene nucleophiles in high yields and stereoselectivity. Density functional theory computational studies suggest that increasing positive charge on the structures tends to enhance the degree of nonclassical (or 3-center-2-electron) bonding through separation of the cationic charges.

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease.

BACKGROUND: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention. METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed. RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%). CONCLUSION: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications. TYPE OF STUDY: Original research, retrospective cohort. LEVEL OF EVIDENCE: III.

Plasmacytoid Dendritic Cells Mediate CpG-ODN Induced Increase in Survival in a Mouse Model of Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a devastating disease primarily found in women of reproductive age that leads to cystic destruction of the lungs. Recent work has shown that LAM causes immunosuppression and that checkpoint inhibitors can be used as LAM treatment. Toll-like receptor (TLR) agonists can also re-activate immunity and the TLR9 agonist, CpG-ODN, has been effective in treating lung cancer in animal models. Here we investigate the use of TLR9 agonist CpG-ODN as LAM immunotherapy in combination with checkpoint inhibitor, anti-PD1, standard of care rapamycin and determine the immune mechanisms underlying therapeutic efficacy. We used survival studies, flow cytometry, ELISA, and histology to assess immune response and survival after intranasal treatment with CpG-ODN in combination with rapamycin or anti-PD1 therapy in a mouse model of metastatic LAM. We found that local administration of CpG-ODN enhances survival in a mouse model of LAM. We found that a lower dose led to longer survival likely due to fewer local side effects but increased LAM nodule count and size compared to the higher dose. CpG-ODN treatment also reduced regulatory T cells and increased the number of Th17 helper T cells as well as cytotoxic T cells. These effects appear to be mediated in part by plasmacytoid dendritic cells (pDCs), as depletion of pDCs reduces survival and abrogates Th17 T cell response. Finally, we found that CpG-ODN treatment is effective in early stage and progressive disease and is additive with anti-PD1 therapy and rapamycin. In summary, we have found that TLR9 agonist CpG-ODN can be used as LAM immunotherapy and effectively synergizes with rapamycin and anti-PD1 therapy in LAM.

Endovascular (stent-graft)-assisted open vascular anastomosis.

Endovascular and open surgical approaches are an integral part of treating patients with complex vascular disease and are often considered separately. In some situations, traditional open surgical techniques can be used to facilitate an endovascular approach, as example: iliac conduit use for EVAR/TEVAR, subclavian or axillary conduits for complex endovascular aortic repairs (chimney, B-FEVAR), and bypass to great vessels or visceral artery (celiac, superior mesenteric and renal arteries) debranching. As devices and techniques evolve, the open and endovascular approaches can be utilized in more complimentary fashion. This paper describes the use of endovascular procedures to assist difficult open surgical situations such as iliofemoral bypass, aortic arch debranching involving the left subclavian artery, and distal right iliac artery management during open thoracoabdominal aortic aneurysm (TAAA) repair.

Effect of Preoperative Motor Weakness on Postoperative Clinical Outcomes in Patients Undergoing Cervical Disk Replacement.

STUDY DESIGN: This is a retrospective review. OBJECTIVE: To examine the effect of preoperative motor weakness on clinical outcomes in patients undergoing cervical disk replacement (CDR). SUMMARY OF BACKGROUND DATA: Studies examining the effect of preoperative motor weakness on postoperative clinical outcomes in CDR are limited. METHODS: Patient cohorts were based on documented upper-extremity motor weakness on physical exam versus no motor weakness. Demographics, perioperative characteristics, and preoperative patient-reported outcome measures (PROMs) were compared using univariate inferential statistics. PROMs consisted of Visual Analog Pain Scale-Neck (VAS-N), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), VAS-Arm (VAS-A), 12-Item Short Form (SF-12) Physical Component Score (PCS), Oswestry Neck Disability Index (NDI), and SF-12 Mental Component Score (MCS). Postoperative PROMs were collected at the 6-week, 12-week, 6-month, and final follow-up up to 1-yeartime points, and intercohort minimum clinically important difference (MCID) achievement was compared through multivariable linear logistic regression adjusting for significant differences in preoperative characteristics. RESULTS: A total of 118 patients formed cohorts based on documented upper-extremity weakness (n=73) versus no weakness (n=45). The average time to postoperative follow-up was 9.7±7.0 mo. The differences in insurance type between the 2 cohorts were significant (P<0.042). Perioperative diagnosis of foraminal stenosis was significantly more common in the motor weakness cohort (P<0.013). There were no differences in reported PROMs between cohorts. Patients with motor weakness reported significant MCID achievement for PROMIS-PF at 6-/12-weeks (P<0.012, P<0.041 respectively), SF-12 PCS at 6-months (P<0.042), VAS-N at final follow-up (P<0.021), and NDI at final follow-up (P<0.013). CONCLUSIONS: CDR patients with preoperative muscle weakness achieved MCID across several PROMs compared with patients without muscle weakness. Patients with motor weakness reported greater improvement in mental health, pain, and disability as early as 6 weeks and up to 1 year after CDR. This information serves to inform physicians that motor weakness may not indicate a negative overall outcome.

Effects of high dose aspartame-based sweetener on the gut microbiota and bone strength in young and aged mice.

In a recent study examining the effects of manipulating the gut microbiome on bone, a control group of mice in which the microbiome was altered using a non-caloric, aspartame-based sweetener resulted in whole bone strength being 40% greater than expected from geometry alone, implicating enhanced bone tissue strength. However, the study was not designed to detect changes in bone in this control group and was limited to young male mice. Here we report a replication study examining how changes in the gut microbiome caused by aspartame-based sweetener influence bone. Male and female C57Bl/6 J mice were untreated or treated with a high dose of sweetener (10 g/L) in their drinking water from either 1 to 4 mo of age (young cohort; n = 80) or 1 to 22 mo of age (aged cohort; n = 52). Sweetener did not replicate the modifications to the gut microbiome observed in the initial study and did not result in an increase in bone tissue strength in either sex at either age. Aged male mice dosed with sweetener had larger bones (+17% femur section modulus, p<.001) and greater whole bone strength (+22%, p=.006) but the increased whole bone strength was explained by the associated increase in body mass (+9%, p<.001). No differences in body mass, whole bone strength, or femoral geometry were associated with sweetener dosing in males from the young cohort or females at either age. As we were unable to replicate the gut microbiota observed in the initial experiment, it remains unclear if changes in the gut microbiome can enhance bone tissue strength. Although prior work studying gut microbiome-induced changes in bone with oral antibiotics has been highly repeatable, the current study highlights the variability of nutritional manipulations of the gut microbiota in mice.

SHC-3: a previously unidentified C. elegans Shc family member functions in the insulin-like signaling pathway to enhance survival during L1 arrest.

Shc proteins function in many different signaling pathways where they mediate phosphorylation-dependent protein-protein interactions. These proteins are characterized by the presence of two phosphotyrosine-binding domains, an N-terminal PTB and a C-terminal SH2. We describe a previously unrecognized C. elegans Shc gene, shc-3 and characterize its role in stress response. Both shc-3 and shc-1 are required for long-term survival in L1 arrest and survival in heat stress, however, they do not act redundantly but rather play distinct roles in these processes. Loss of shc-3 did not further decrease survival of daf-16 mutants in L1 arrest, suggesting that like SHC-1, SHC-3 functions in the Insulin-like signaling pathway. In the absence of SHC-3, DAF-16 nuclear entry and exit are slowed, suggesting that SHC-3 is required for rapid changes in DAF-16 signaling.

Admission Total Leukocyte Count as a Predictor of Mortality in Cardiac Intensive Care Unit Patients.

Background: Inflammation is a sequela of cardiovascular critical illness and a risk factor for mortality. Objectives: This study aimed to evaluate the association between white blood cell count (WBC) and mortality in a broad population of patients admitted to the cardiac intensive care unit (CICU). Methods: This retrospective cohort study included patients admitted to the Mayo Clinic CICU between 2007 and 2018. We analyzed WBC as a continuous variable and then categorized WBC as low (<4.0 × 103/mL), normal (≥4.0 to <11.0 × 103/mL), high (≥11.0 to <22.0 × 103/mL), or very high (≥22.0 × 103/mL). The association between WBC and in-hospital mortality was evaluated using multivariable logistic regression and random forest models. Results: We included 11,699 patients with a median age of 69.3 years (37.6% females). Median WBC was 9.6 (IQR: 7.4-12.7). Mortality was higher in the low (10.5%), high (12.0%), and very high (33.3%) WBC groups relative to the normal WBC group (5.3%). A rising WBC was incrementally associated with higher in-hospital mortality after adjustment (AICc adjusted OR: 1.03 [95% CI: 1.02-1.04] per 1 × 103 increase in WBC). After adjustment, only the high (AICc adjusted OR: 1.37 [95% CI: 1.15-1.64]) and very high (AICc adjusted OR: 1.99 [1.47-2.71]) WBC groups remained associated with increased risk of in-hospital mortality. Conclusions: Leukocytosis is associated with an increased mortality risk in a diverse cohort of CICU patients. This readily available marker of systemic inflammation may be useful for risk stratification within the increasingly complex CICU patient population.

Impact of Early Depressive Burden on Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate mental health influence on minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. SUMMARY OF BACKGROUND DATA: Poor mental health has been postulated to indicate inferior patient perceptions of surgical outcomes in spine literature. Few studies have assessed mental health as a dynamic metric throughout the perioperative period. METHODS: A single-surgeon database was retrospectively searched for patients who underwent primary, elective MIS-TLIF for degenerative or isthmic spondylolisthesis. Summative depressive burden (SDB) was defined by the sum of preoperative and 6-week postoperative 9-item Patient Health Questionnaire (PHQ-9), with Lesser Burden (LB, SDB<10) and Greater Burden (GB, SDB≥10) cohorts. Patient-reported outcomes measures (PROMs) were compared preoperatively, at 6 weeks, and at final postoperative follow-up (11.4±10.9 mo), using Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Oswestry disability index (ODI), visual analog scale-back (VAS-B), VAS-leg (VAS-L), and PHQ-9. Improvements at 6-week (∆PROM-6W), final follow-up (∆PROM-FF), and minimum clinically important difference (MCID) achievement were compared. RESULTS: The GB cohort consisted of 44 of 105 patients. Demographic variations included older age, higher Charlson comorbidity index, increased hypertension prevalence, and private insurance in the LB cohort (P≤0.018). The LB cohort demonstrated better baseline and 6-week PROMIS-PF/ODI/VAS-L (P≤0.032) and better final PROMIS-PF/ODI/VAS-L/PHQ-9 (P≤0.031). Both cohorts improved in all PROMs at 6 weeks and final follow-up (P≤0.029), except for PROMIS-PF at 6 weeks in the GB cohort. ∆PROM-6W, ∆PROM-FF, and MCID achievement rate for PHQ-9 were greater in the GB cohort (P≤0.001). CONCLUSION: On average, patients undergoing MIS-TLIF for degenerative or isthmic spondylolisthesis improved in all PROMs by final follow-up. Patients with GB suffered inferior perceptions of physical function, disability, and leg pain. MCID rates in mental health were higher for GB cohort. Surgeons are encouraged to adopt a compassionate understanding of depressive burden and educate the patient on possible consequential postoperative outcomes.

Outcomes After Exoscopic Versus Microscopic Type 1 Tympanoplasty.

OBJECTIVE: To analyze the outcomes of exoscopic versus microscopic type 1 tympanoplasty. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care otology-neurotology practice. PATIENTS: Adult subjects with a diagnosis of tympanic membrane perforation from 2018 to 2022. INTERVENTION: Exoscopic or microscopic tympanoplasty with cartilage + perichondrium or perichondrium/fascia graft. MAIN OUTCOME MEASURES: Primary outcomes were graft success rate (1 wk, 3 wk, 3 mo, and 6 mo postoperatively) and operative time. Secondary outcomes included audiometric outcomes of postoperative air-bone gap (ABG), change in ABG, pure tone average (PTA), speech reception threshold (SRT), and word recognition score (WRS) at 6-month follow-up and complication rates of cerebrospinal fluid leak, facial nerve injury, persistent tinnitus, and persistent vertigo. RESULTS: Seventy-one patients underwent type 1 tympanoplasty by a single surgeon. Thirty-six patients underwent exoscopic tympanoplasty, and 35 patients underwent microscopic tympanoplasty. Cartilage and perichondrium were utilized in 27 subjects (75.0%) in the exoscopic group and in 25 subjects (71.4%) in the microscopic group (p = 0.7, Cramer's V = 0.04). Graft success rate was as follows (exoscope versus microscope): 100% (36/36) versus 100% (35/35) at 1 week (p = 1.0, Cramer's V = 0.0), 97.2% (35/36) versus 100% (35/35) at 3 weeks (p = 1.0, Cramer's V = 0.1), 97.2% (35/36) versus 94.3% (33/35) at 3 months (p = 1.0, Cramer's V = 0.07), and 91.7% (33/36) versus 91.4% (32/35) at 6 months (p = 0.7, Cramer's V = 0.0). Operative time was 57.7 minutes for the exoscopic group and 65.4 minutes for the microscopic group (p = 0.08, 95% CI [-16.4, 0.9], Cohen's d = 0.4). There were no serious complications. All preoperative and postoperative audiometric outcomes were comparable. CONCLUSIONS: The outcomes after exoscopic versus microscopic type 1 tympanoplasty are comparable.

A Mobile Post Anesthesia Care Unit Order Reminder System Improves Timely Order Entry.

Transition to the postanesthesia care unit (PACU) requires timely order placement by anesthesia providers. Computerized ordering enables automated order reminder systems, but their value is not fully understood. We performed a single-center, retrospective cohort study to estimate the association between automated PACU order reminders and primary outcomes (1) on-time order placement and (2) the degree of delay in placement. As a secondary post-hoc analysis, we studied the association between late order placement and PACU outcomes. We included patients with a qualifying postprocedure order from January 1, 2019, to May 31, 2023. We excluded cases transferred directly to the ICU, whose anesthesia provider was involved in the pilot testing of the reminder system, or those with missing covariate data. Order reminder system usage was defined by the primary attending anesthesiologist's receipt of a push notification reminder on the day of surgery. We estimated the association between reminder system usage and timely order placement using a logistic regression. For patients with late orders, we performed a survival analysis of order placement. The significance level was 0.05. Patient (e.g., age, race), procedural (e.g., anesthesia duration), and provider-based (e.g., ordering privileges) variables were used as covariates within the analyses. Reminders were associated with 51% increased odds of order placement prior to PACU admission (Odds Ratio: 1.51; 95% Confidence Interval: 1.43, 1.58; p ≤ 0.001), reducing the incidence of late PACU orders from 17.5% to 12.6% (p ≤ 0.001). In patients with late orders, the reminders were associated with 10% quicker placement (Hazard Ratio: 1.10; 95% CI 1.05, 1.15; p < 0.001). On-time order placement was associated with decreased PACU duration (p < 0.001), decreased odds of peak PACU pain score (p < 0.001), and decreased odds of multiple administration of antiemetics (p = 0.02). An order reminder system was associated with an increase in order placement prior to PACU arrival and a reduction in delay in order placement after arrival.

Clinical Outcomes and Complication Rates for Noncontiguous Anterior Cervical Discectomy and Fusion, Cervical Disc Arthroplasty, and Hybrid Cervical Surgery: A Systematic Review.

OBJECTIVE: This study examined clinical outcomes associated with 3 types of noncontiguous cervical surgeries - anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and hybrid cervical surgery (HCS) - to improve surgeon decision-making. METHODS: A systematic review was performed using PubMed, CINAHL, MEDLINE, and Web of Science from database inception until June 6th, 2023. Inclusion criteria were studies that reported any type of clinical outcome, examined noncontiguous ACDF, noncontiguous CDA, and/or noncontiguous HCS. RESULTS: Ten articles out of 523 articles initially retrieved were included. Patients (n = 388) had a mean age of 52 ± 5.1 years and a mean follow-up time of 33 ± 6.0 months. Overall, 119 patients underwent noncontiguous HCS, 65 underwent noncontiguous CDA, and 204 underwent noncontiguous ACDF. There appears to be no clinically meaningful difference in Neck Disability Index score, Japanese Orthopedic Association score, and improvement in pain based on surgery type. There were a total of 83 complications (21% of cases) with noncontiguous ACDF having a higher absolute rate of dysphagia (20%) as compared to noncontiguous HCS (6.7%) or noncontiguous CDA (6.2%). Noncontiguous ACDF had a higher absolute rate of adjacent segment degeneration anterior cervical discectomy and fusion as a reported complication (6.4%) as compared to noncontiguous HCS (1.7%) and noncontiguous CDA (0.0%). CONCLUSIONS: There may be no clinically meaningful difference in many clinical outcomes for different noncontiguous surgical interventions for noncontiguous (cervical degenerative disc disease). However, complication rates, such as dysphagia and anterior cervical discectomy and fusion, appear higher for noncontiguous ACDF as compared to noncontiguous CDA or HCS.

Overdrive is essential for targeted sperm elimination by Segregation Distorter.

Intra-genomic conflict driven by selfish chromosomes is a powerful force that shapes the evolution of genomes and species. In the male germline, many selfish chromosomes bias transmission in their own favor by eliminating spermatids bearing the competing homologous chromosomes. However, the mechanisms of targeted gamete elimination remain mysterious. Here, we show that Overdrive (Ovd), a gene required for both segregation distortion and male sterility in Drosophila pseudoobscura hybrids, is broadly conserved in Dipteran insects but dispensable for viability and fertility. In D. melanogaster, Ovd is required for targeted Responder spermatid elimination after the histone-to-protamine transition in the classical Segregation Distorter system. We propose that Ovd functions as a general spermatid quality checkpoint that is hijacked by independent selfish chromosomes to eliminate competing gametes.

Impact of discontinuation of contact precautions on surveillance- and whole genome sequencing-defined methicillin-resistant Staphylococcus aureus healthcare-associated infections.

Objective: Prior studies evaluating the impact of discontinuation of contact precautions (DcCP) on methicillin-resistant Staphylococcus aureus (MRSA) outcomes have characterized all healthcare-associated infections (HAIs) rather than those likely preventable by contact precautions. We aimed to analyze the impact of DcCP on the rate of MRSA HAI including transmission events identified through whole genome sequencing (WGS) surveillance. Design: Quasi experimental interrupted time series. Setting: Acute care medical center. Participants: Inpatients. Methods: The effect of DcCP (use of gowns and gloves) for encounters among patients with MRSA carriage was evaluated using time series analysis of MRSA HAI rates from January 2019 through December 2022, compared to WGS-defined attributable transmission events before and after DcCP in December 2020. Results: The MRSA HAI rate was 4.22/10,000 patient days before and 2.98/10,000 patient days after DcCP (incidence rate ratio [IRR] 0.71 [95% confidence interval 0.56-0.89]) with a significant immediate decrease (P = .001). There were 7 WGS-defined attributable transmission events before and 11 events after DcCP (incident rate ratio 0.90 [95% confidence interval 0.30-2.55]). Conclusions: DcCP did not result in an increase in MRSA HAI or, in WGS-defined attributable transmission events. Comprehensive analyses of the effect of transmission prevention measures should include outcomes specifically measuring transmission-associated HAI.

Development and Initial Evaluation of a Cost-Effective Force Sensor for Ureteroscopic Application.

Purpose: Retrograde intrarenal surgery is the gold-standard treatment for most kidney stones. During ureteroscopy, ureteral access sheath insertion at forces greater than 8.0 Newtons (N) risks high-grade ureteral injury. To monitor force, our institution utilizes a unique, Bluetooth-equipped device (i.e., the University of California-Irvine Force Sensor). Given the unique nature of the force sensor, we sought to develop an inexpensive and accessible force sensor based on Boyle's law and the specific amount of force required to compress an occluded 1.0 mL syringe. Materials and Methods: We evaluated three brands of 1.0 mL syringes. After setting the plunger at 1.0 mL, the syringe was occluded, and the syringe plunger was compressed. The syringe volume was recorded when the applied force on the plunger reached 4.0 N, 6.0 N, and 8.0 N. Multiple trials were performed to assess reliability and reproducibility. A method for applying this clinically was also developed. Results: The precise force thresholds identified for a 1.0 mL Luer-Lok™ Syringe (Becton Dickinson, Franklin Lakes, NJ) were 0.30 mL for 4.00 N, 0.20 mL for 6.00 N, and 0.15 mL for 8.00 N. The 1.0 mL Tuberculin Syringe and 1.0 mL Luer Slip Syringe were less precise, but compression from 1.0 to 0.40 mL, 0.25 mL, and 0.20 mL corresponded to force sensor readings that did not exceed 4.00 N, 6.00 N, and 8.00 N, respectively. Conclusions: Based on volume changes, 4.00 N, 6.00 N, and 8.00 N of force can be reliably and reproducibly achieved using an occluded 1.0 mL syringe.

Worse Preoperative 12-Item Veterans Rand Physical Component Scores Prognosticate Inferior Outcomes Following Outpatient Lumbar Decompression.

STUDY DESIGN: Retrospective Review. OBJECTIVE: Evaluate the influence of the 12-Item veterans Rand (VR-12) physical component score (PCS) on patient-reported outcome measures (PROMs) in an outpatient lumbar decompression (LD) cohort. SUMMARY OF BACKGROUND DATA: The influence of baseline VR-12 PCS on postoperative clinical outcomes has not been evaluated in patients undergoing outpatient LD. METHODS: Patients undergoing primary, elective, 1/2-level outpatient LD with baseline VR-12 PCS scores were retrospectively identified from a prospectively maintained single-surgeon database. Cohorts were preoperative VR-12 PCS<30 and VR-12 PCS≥30. Patient/perioperative characteristics and preoperative/postoperative 6-week/final follow-up (FF) PROMs were collected. Physical health PROMs included the VR-12 PCS, 12-Item Short Form (SF-12) PCS, patient-reported outcome measure information system-physical function (PROMIS-PF), visual analog scale (VAS)-back/leg, and Oswestry disability index (ODI). Mental health PROMs included the VR-12/SF-12 mental component score (MCS) and the patient-health questionnaire-9 (PHQ-9). Average FF was 13.8±8.9 months postoperatively. PROM improvements at 6 weeks/FF and minimal clinically important difference (MCID) achievement rates were determined. χ2 analysis and the Student's t tests compared demographics, perioperative data, and preoperative PROMs. Multivariate linear/logistic regression compared postoperative PROMs, PROM improvements, and MCID achievement rates. RESULTS: Six weeks postoperatively, VR-12 PCS<30 reported worse baseline PROMs (P≤0.042, all) and worse scores except VR-12/SF-12 MCS (P≤0.043, all). Compared with VR-12 PCS≥30, VR-12 PCS<30 had worse FF VR-12 PCS, SF-12 PCS/MCS, PROMIS-PF, PHQ-9, and VAS-Back (P≤0.033, all). VR-12 PCS<30 experienced greater 6-week improvements in VR-12/SF-12 PCS, PHQ-9, VAS-Back, and ODI (P≤0.039, all). VR-12 PCS<30 had greater FF improvements in VR-12/SF-12 PCS, PHQ-9, and ODI (P≤0.001, all) and greater overall MCID achievement in VR-12 PCS/MCS, SF-12 PCS, PHQ-9, and ODI (P≤0.033, all). CONCLUSIONS: VR-12 PCS<30 patients-reported worse baseline/postoperative mental/physical health scores. However, they reported greater improvements in physical function, depressive burden, back pain, and disability by 6 weeks and FF and experienced greater MCID achievement for physical functioning, mental health, and disability scores.

Validation of Non-invasive Detection of Hyperkalemia by Artificial Intelligence Enhanced Electrocardiography in High Acuity Settings.

BACKGROUND: Artificial intelligence (AI) electrocardiogram (ECG) analysis can enable detection of hyperkalemia. In this validation, we assessed the algorithm's performance in two high acuity settings. METHODS: An emergency department (ED) cohort (February-August 2021) and a mixed intensive care unit (ICU) cohort (August 2017-February 2018) were identified and analyzed separately. For each group, pairs of laboratory-collected potassium and 12 lead ECGs obtained within four hours of each other were identified. The previously developed AI ECG algorithm was subsequently applied to leads I and II of the 12 lead ECGs to screen for hyperkalemia (potassium > 6.0 mEq/L). RESULTS: The ED cohort (N=40,128) had a mean age of 60 years, 48% were male, and 1% (N=351) had hyperkalemia. The area under the curve (AUC) of the AI-ECG to detect hyperkalemia was 0.88, with sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of, 80%, 80%, 3%, 99.8% and 4.0, respectively, in the ED cohort. Low-eGFR (<30 ml/min) subanalysis yielded AUC, sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of 0.83, 86%, 60%, 15%, 98% and 2.2, respectively, in the ED cohort. The ICU cohort (N=2,636) had a mean age of 65 years, 60% were male, and 3% (N=87) had hyperkalemia. The AUC for the AI-ECG was 0.88 and yielded sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of 82%, 82%, 14%, 99% and 4.6, respectively in the ICU cohort. Low-eGFR subanalysis yielded AUC, sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio of 0.85, 88%, 67%, 29%, 97% and 2.7, respectively in the ICU cohort. CONCLUSION: The AI-ECG algorithm demonstrated a high negative predictive value, suggesting that it is useful for ruling out hyperkalemia, but a low positive predictive value, suggesting that it is insufficient for treating hyperkalemia.

Correction: Wilderink et al. A Theoretical Perspective on Why Socioeconomic Health Inequalities Are Persistent: Building the Case for an Effective Approach. Int. J. Environ. Res. Public Health 2022, 19, 8384.

In the original publication [...].

Ecological niche divergence or ecological niche partitioning in a widespread Neotropical bird lineage.

Ecological niche divergence is generally considered to be a facet of evolution that may accompany geographic isolation and diversification in allopatry, contributing to species' evolutionary distinctiveness through time. The null expectation for any two diverging species in geographic isolation is that of niche conservatism, wherein populations do not rapidly shift to or adapt to novel environments. Here, I test ecological niche divergence for a widespread, pan-American lineage, the avian genus of martins (Progne). The genus Progne includes migrant and resident species, as well as geographically restricted taxa and widespread, intercontinentally distributed taxa, thus providing an ideal group in which to study the nature of niche divergence within a broad geographic mosaic. I obtained distributional information for the genus from publicly available databases and created ecological niche models for each species to create pairwise comparisons of environmental space. I combined these data with the most up-to-date phylogeny of Progne currently available to examine the patterns of niche evolution within the genus. I found limited evidence for niche divergence across the breeding distributions of Progne, and much stronger support for niche conservatism with patterns of niche partitioning. The ancestral Progne had a relatively broad ecological niche, like extant basal Progne lineages, and several geographically localized descendant species occupy only portions of this larger ancestral niche. I recovered strong evidence of breeding niche divergence for four of 36 taxon pairs but only one of these divergent pairs involved two widespread species (Southern Martin P. elegans vs. Gray-breasted Martin P. chalybea). Potential niche expansion from the ancestral species was observed in the most wide-ranging present-day species, namely the North American Purple Martin P. subis and P. chalybea. I analyzed populations of P. subis separately, as a microcosm of Progne evolution, and again found only limited evidence of niche divergence. This study adds to the mounting evidence for niche conservatism as a dominant feature of diversifying lineages, and sheds light on the ways in which apparently divergent niches may arise through allopatry while not involving any true niche shifts through evolutionary time. Even taxa that appear unique in terms of habitat or behavior may not be diversifying with respect to their ecological niches, but merely partitioning ancestral niches among descendant taxa.