Advanced Critical Care Techniques in the Field.

Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.

Bioinspired multiscale adaptive suction on complex dry surfaces enhanced by regulated water secretion.

Suction is a highly evolved biological adhesion strategy for soft-body organisms to achieve strong grasping on various objects. Biological suckers can adaptively attach to dry complex surfaces such as rocks and shells, which are extremely challenging for current artificial suction cups. Although the adaptive suction of biological suckers is believed to be the result of their soft body's mechanical deformation, some studies imply that in-sucker mucus secretion may be another critical factor in helping attach to complex surfaces, thanks to its high viscosity. Inspired by the combined action of biological suckers' soft bodies and mucus secretion, we propose a multiscale suction mechanism which successfully achieves strong adaptive suction on dry complex surfaces which are both highly curved and rough, such as a stone. The proposed multiscale suction mechanism is an organic combination of mechanical conformation and regulated water seal. Multilayer soft materials first generate a rough mechanical conformation to the substrate, reducing leaking apertures to micrometres (~10 µm). The remaining micron-sized apertures are then sealed by regulated water secretion from an artificial fluidic system based on the physical model, thereby the suction cup achieves long suction longevity on complex surfaces but minimal overflow. We discuss its physical principles and demonstrate its practical application as a robotic gripper on a wide range of complex dry surfaces. We believe the presented multiscale adaptive suction mechanism is a powerful unique adaptive suction strategy which may be instrumental in the development of versatile soft adhesion.

Whole-Body Health: Behavioral Approaches to Managing Depression in Primary Care.

Pediatricians are typically the first people families trust to discuss their child's mental health concerns and are uniquely positioned to help address the problem of limited access to mental health services. This article covers brief behavioral interventions pediatricians can use to help treat mild depressive symptoms in the primary care context. Interventions include strategies for talking about depression (eg, validating experiences, normalizing difficulties, and emphasizing whole-body health), educating patients and their families (eg, psychoeducation about signs, symptoms, and treatment options), using brief behavioral and cognitive interventions (eg, behavioral activation and cognitive coping), and including a family and culturally sensitive approach to symptom management. [Pediatr Ann. 2023;52(11):e413-e417.].

Treatment Adherence in Integrative Medicine-Part Two: Practitioner Insights.

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low-and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Treatment Adherence in Integrative Medicine-Part One: Review of Literature.

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

The Experience of Being Jewish: Living with Antisemitism

Abstract In an anonymous online study of 242 Jewish-identified participants (71 men, 163 women, 8 other; mean age = 37.8 years) living in ethnically diverse communities we found levels of antisemitism significantly associated with depression, survivor guilt proneness, and self-hate. Involvement in the Jewish community was significantly associated with life satisfaction even when adjusting for the effects of discrimination. A subsample of 124 responded to open ended questions with narratives. Thirty percent indicated feeling unsafe when identifying as Jewish.

Resumen En un estudio online y anónimo de 242 participantes identificados como judíos (71 hombres, 163 mujeres, 8 otros; media de edad = 37,8 años) que viven en comunidades étnicamente diversas, encontramos niveles de antisemitismo significativamente asociados con la depresión, la propensión a la culpa del sobreviviente y el odio a sí mismo. La participación en la comunidad judía se asoció significativamente con la satisfacción con la vida, incluso cuando se ajusta a los efectos de la discriminación. Una sub muestra de 124 personas respondió a preguntas abiertas con narrativas. El treinta por ciento indicó sentirse inseguro al identificarse como judío.

Development and Open Trial of a Psychosocial Intervention for Young Children With Chronic Tics: The CBIT-JR Study.

The Comprehensive Behavioral Intervention for Tic Disorders (CBIT) has demonstrated efficacy in large randomized controlled trials for children (≥9 yrs), adolescents and adults with Tourette Syndrome and Chronic Tic Disorders. Given the early age of onset for tic disorders, a large portion of affected individuals with chronic tic disorders are less than 9 years of age and appropriate developmental adaptations of behavioral treatment have not yet been tested. The goal of this study was to adapt and evaluate the acceptability and utility of a family-based adaptation of CBIT for children under 9 years of age. Children 5-8 years of age (N = 15) with chronic tics were recruited from three study sites. CBIT was adapted for use with young children and included habit reversal strategies introduced in a developmentally appropriate game format and function-based interventions to reduce family accommodation of and attention to tic symptoms. Children and parents described high level of treatment satisfaction and study retention rate was 100%. Treatment response rate was 54% (CGI-I = 1 or 2) with a significant decrease in the YGTSS total score (Cohen's d = 0.73) that was largely maintained at 3-month and 1-year follow-up assessments. Treatment was associated with reduction of some symptoms of tic-related comorbid syndromes and with changes in parental accommodation and attention to tics. Future research should determine if parental attention to tics and symptom accommodation are important mediators of treatment outcome, or if participating in this intervention at a younger age may prevent the chronic course of tic symptoms.

A Psychometric Evaluation of the Distress Intolerance Index for Youth.

Distress Intolerance (DI), defined as the perceived inability to tolerate negative mood states and experiential discomfort, has been posited as a vulnerability factor for several anxiety and emotional disorders. There is a relative paucity of research on DI in youth samples, in large part due to the absence of a psychometrically sound measure of DI in youth. The current study evaluated the psychometric properties of the Distress Intolerance Index for Youth (DII-Y) and the Distress Intolerance Index for Youth-Parent Report (DII-Y-P), which are downward extension adaptations of the adult-oriented Distress Intolerance Index (McHugh & Otto, 2012). Participants were 176 youth (ages 9-17) and their parents who were seeking treatment for child anxiety problems. The DII-Y and DII-Y-P demonstrated good-to-excellent internal consistency. Convergent validity of the DII-Y and the DII-Y-P was supported by large, significant associations with measures of intolerance of uncertainty, as well as with anxiety sensitivity in the case of the DII-Y. Discriminant validity of the DII-Y and the DII-Y-P was supported by the absence of significant direct relationships with a measure of defiant behavior. Results support the use of DII-Y and DII-Y-P as reliable and valid instruments for the assessment of youth DI, providing a practical and efficient tool to study DI as a potential factor in the etiology and maintenance of youth anxiety and emotional disorders.

Reducing Length of Stay after Microsurgical Breast Reconstruction with a Standardized Postoperative Protocol.

BACKGROUND: Despite widespread acceptance of enhanced recovery after surgery protocols in other surgical specialties, plastic surgery has been slow to adopt fast-track principles. Recently, however, studies have shown that patients undergoing microsurgical breast reconstruction may benefit from a comprehensive postoperative protocol. METHODS: All microsurgical breast reconstructions with abdominal free flaps performed by the senior author (A.K.) at a single institution from June 2009 to December 2013 were reviewed. Demographic information (e.g., age, body mass index, and comorbidities), operative details (e.g., laterality, type of flap), and postoperative data (e.g., complications, length of stay) were collected from patients' medical records. The authors employed a universal comprehensive protocol that dictated all postoperative care as it relates to diet, ambulation, flap monitoring, anticoagulation, analgesia, venous thromboembolism, antibiotic prophylaxis, and discharge criteria. RESULTS: During the study period, 161 patients underwent 289 free flaps. The average length of stay for all patients was 3.26 ± 1.19 days. The incidence of complications requiring return to the operating room was 4.35% (7 patients). The incidence of flap failure was 0.69% (2 of 289 flaps). Only one flap failure occurred after hospital discharge. Statistical analysis demonstrated that the presence of any complication requiring return to the operating room increased hospital course by an average of 1.37 days (p = 0.0027). CONCLUSION: The standardization of postoperative care for patients undergoing microsurgical breast reconstruction results in a short hospital length of stay without increasing the incidence of flap failure or postoperative complications requiring return to the operating room.

Pannexin channel and connexin hemichannel expression in vascular function and inflammation.

Control of blood flow distribution and tissue homeostasis depend on the tight regulation of and coordination between the microvascular network and circulating blood cells. Channels formed by connexins or pannexins that connect the intra- and extracellular compartments allow the release of paracrine signals, such as ATP and prostaglandins, and thus play a central role in achieving fine regulation and coordination of vascular function. This review focuses on vascular connexin hemichannels and pannexin channels. We review their expression pattern within the arterial and venous system with a special emphasis on how post-translational modifications by phosphorylation and S-nitrosylation of these channels modulate their function and contribute to vascular homeostasis. Furthermore, we highlight the contribution of these channels in smooth muscle cells and endothelial cells in the regulation of vasomotor tone as well as how these channels in endothelial cells regulate inflammatory responses such as during ischemic and hypoxic conditions. In addition, this review will touch on recent evidence implicating a role for these proteins in regulating red blood cell and platelet function.

Conducting hydrogels for edible electrodes.

The development of highly swollen, strong, conductive hydrogel materials is necessary for the advancement of edible device research. Using a gellan gum/gelatin ionic-covalent entanglement (ICE) hydrogel, a simple method of producing conductive, edible hydrogels is described. ICE gels containing NaCl or CsCl were developed which exhibited conductivities of 200 ± 20 mS cm-1 and 380 ± 30 mS cm-1, respectively. Furthermore, the potential of food grade products for use as edible electrodes was examined by analysing the electrical properties of alginate-gelatin hydrogels, Vegemite, Marmite, jelly and gold leaf. Lastly, these edible ICE gels were used to demonstrate a capacitive pressure sensor from consumable materials, which displayed a sensitivity of 0.80 ± 0.06 pF kPa-1 for a range of 4-20 kPa. The pressure exerted by the GI tract on its contents is standardly 0.7 kPa to 6.3 kPa. This suggests potential for application in the detection of digestive pressure abnormalities such as intestinal motility disorders.

The future of tic disorder treatment.

Competing theories on the etiology and treatment of chronic tic disorders and Tourette syndrome have long made the search for efficacious intervention more challenging for patients and families seeking to reduce functional impairment related to tic symptoms. These symptoms were historically posited to be either psychological in origin, leading to the long tradition of psychoanalytic psychotherapy for tics, or biological in nature, particularly since the advent of successful treatments using neuroleptic medications. Current thinking about the phenomenology of tic disorders comes from growing empirical evidence as well as advances in neuroscience and genetics research and reveals a biological vulnerability that is exacerbated by physiological arousal related to environmental or interpersonal stress. This manuscript summarizes the evolution of this knowledge base and describes current best-practice recommendations for patients, families, and clinicians.

Noninvasive tissue oximetry.

Noninvasive tissue oximetry is playing an important role in postoperative monitoring of autologous tissue breast reconstruction flaps. It is increasingly being used intraoperatively to assist in perforator selection, tissue mapping, and assessment of mastectomy skin flap viability. This article reviews the use of tissue oximetry for intraoperative decision making, flap physiology, and postoperative monitoring, and also comments on common flap complications.

Identification of flame retardants in polyurethane foam collected from baby products.

With the phase-out of PentaBDE in 2004, alternative flame retardants are being used in polyurethane foam to meet flammability standards. However, insufficient information is available on the identity of the flame retardants currently in use. Baby products containing polyurethane foam must meet California state furniture flammability standards, which likely affects the use of flame retardants in baby products throughout the U.S. However, it is unclear which products contain flame retardants and at what concentrations. In this study we surveyed baby products containing polyurethane foam to investigate how often flame retardants were used in these products. Information on when the products were purchased and whether they contained a label indicating that the product meets requirements for a California flammability standard were recorded. When possible, we identified the flame retardants being used and their concentrations in the foam. Foam samples collected from 101 commonly used baby products were analyzed. Eighty samples contained an identifiable flame retardant additive, and all but one of these was either chlorinated or brominated. The most common flame retardant detected was tris(1,3-dichloroisopropyl) phosphate (TDCPP; detection frequency 36%), followed by components typically found in the Firemaster550 commercial mixture (detection frequency 17%). Five samples contained PBDE congeners commonly associated with PentaBDE, suggesting products with PentaBDE are still in-use. Two chlorinated organophosphate flame retardants (OPFRs) not previously documented in the environment were also identified, one of which is commercially sold as V6 (detection frequency 15%) and contains tris(2-chloroethyl) phosphate (TCEP) as an impurity. As an addition to this study, we used a portable X-ray fluorescence (XRF) analyzer to estimate the bromine and chlorine content of the foam and investigate whether XRF is a useful method for predicting the presence of halogenated flame retardant additives in these products. A significant correlation was observed for bromine; however, there was no significant relationship observed for chlorine. To the authors knowledge, this is the first study to report on flame retardants in baby products. In addition, we have identified two chlorinated OPFRs not previously documented in the environment or in consumer products. Based on exposure estimates conducted by the Consumer Product Safety Commission (CPSC), we predict that infants may receive greater exposure to TDCPP from these products compared to the average child or adult from upholstered furniture, all of which are higher than acceptable daily intake levels of TDCPP set by the CPSC. Future studies are therefore warranted to specifically measure infants exposure to these flame retardants from intimate contact with these products and to determine if there are any associated health concerns.

More than maths and mindreading: sex differences in empathizing/systemizing covariance.

Empathizing-Systemizing theory posits a continuum of cognitive traits extending from autism into normal cognitive variation. Covariance data on empathizing and systemizing traits have alternately suggested inversely dependent, independent, and sex-dependent (one sex dependent, the other independent) structures. A total of 144 normal undergraduates (65 men, 79 women) completed the Reading the Mind in the Eyes, Embedded Figures, and Benton face recognition tests, the Autism Spectrum Quotient, and measures of digit length ratio and field of study; some also completed tests of motion coherence threshold (64) and go/no-go motor inhibition (128). Empathizing and systemizing traits were independent in women, but largely dependent in men. In men, level of systemizing skill required by field of study was directly related to social interactive and mindreading deficits; men's social impairments correlated with prolonged go/no-go response times, and men tended to apply systemizing strategies to solve problems of empathizing or global processing: rapid perceptual disembedding predicted heightened sensitivity to facial emotion. In women, level of systemizing in field was related to male-typical digit ratios and autistic superiorities in detail orientation, but not to autistic social and communicative impairments; and perceptual disembedding was related to social interactive skills but independent of facial emotion and visual motion perception.

A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements.

The purpose of the study was to evaluate the detection of vascular complications earlier than clinical evidence using a noninvasive near-infrared tissue oximeter monitor. Early detection of circulatory compromise allows for earlier re-exploration and better outcomes. The monitoring method studied was the ViOptix T.Ox Tissue Oximeter (ViOptix Inc., Fremont, CA). The device uses an optical tissue characterization based on measuring scattering and absorption of near infrared light. Tissue oxygen saturation and its derivates were evaluated as candidates for a more sensitive algorithm to predict vascular flap complications. Criteria studied in various combinations were the absolute value of tissue oxygen saturation (StO2), the amount of its change (DeltaStO2) and the rate of its change (DeltaStO2/Deltat). There were 208 monitored breast flaps in 145 patients (62 bilateral and 83 unilateral). In 1 patient, 2 flaps were used to make a single breast. Patients were monitored intraoperatively and postoperatively for 36 hours. No flap being monitored was lost. Among the 208 flaps monitored, 5 patients exhibited complications that were predicted by the tissue oximeter before clinical signs were evident. If blood flow was completely occluded by either venous or arterial thrombosis, the tissue oximeter provided information that enabled diagnosis to be made in about 1 hour. The drop rate indicator DeltaStO2/Deltat, when it is equal to or greater than 20% per hour sustained more than 30 minutes predicted vascular complications. The use of the new diagnostic algorithm with the T.Ox Tissue Oximeter monitor was successful in predicting flap complication within 1 hour of the onset of the occlusive event with a high diagnostic accuracy in the 208 flap procedures.

A theoretical model describing arterial flow in the DIEP flap related to number and size of perforator vessels.

BACKGROUND: The deep inferior epigastric perforator flap is rapidly becoming a more widely employed method of autologous breast reconstruction. The technical considerations involved in the execution of the flap are many and include the selection of perforators to be incorporated in the flap. We attempt to give a mathematical explanation, based on the physics of flow through vessels and the properties of circuits with multiple resistances in parallel, for the clinical observations which have been arrived at through clinical experience. METHODS: We compare the system of perforators to a circuit with multiple resistances in parallel. Each of these resistances represents a perforator vessel. In the event that there is only one perforator vessel, this simplifies to a single resistance in series with the capillary bed perfusing the flap. RESULTS: The flow through the flap is optimized by incorporation of the largest diameter perforator. Inclusion of other smaller perforators in addition to the largest diameter perforator will reduce the overall resistance, but this reduction in resistance is dependent on the diameter of the additional perforator and may not be worth the additional trauma of dissection and increased operative time. Incorporating several smaller perforators at the expense of excluding the largest diameter perforator appears to increase the overall resistance, unless the smaller perforators are only slightly smaller. CONCLUSIONS: We conclude that the best perfused flap involves use of the largest diameter vessel, that although adding additional perforators will decrease the resistance and increase flow, the magnitude of the benefit depends largely on the calibre of the additional perforator, and that this benefit needs to be weighed against the downside of increased muscle and facial trauma.

Noninvasive tissue oximetry for flap monitoring: an initial study.

The ideal monitoring tool to evaluate free flap success should be noninvasive, continuous, and reliable. A new device, the ViOptix Tissue Oximeter (ODISsey) based on near-infrared spectroscopy was evaluated in 30 patients undergoing autologous tissue perforator free flap breast reconstruction with continuous monitoring of the flap during elevation, transfer, and the postoperative period. The device accurately reflected the ischemic drop in oxygen saturation during flap transfer, and the hyperemic response after flow was reestablished. There were no flap failures, but in two patients, the device indicated a venous thrombosis before it was clinically obvious and allowed for expeditious flap salvage. The noninvasive nature of the device, the ability to replace and move the probe in the postoperative period, and the measurement of end organ oxygenation are all advantages over other currently available techniques.