Reliability and Validity of Visual Estimation in Determining Thorax Rotation Mobility using the Quadruped Lumbar-Locked Position.

Background: Thoracic rotation mobility is crucial for athletes in rotational sports such as baseball, golf, and swimming to maintain the proper biomechanics associated with the sport. Accurate differentiation between normal mobility and active and passive physiological deficits in the thoracic region is critical for identifying the need for intervention to the thorax. Purpose: To establish the reliability and discriminant validity of visual estimation of thorax rotation range of motion across clinicians of differing experience levels in determining normal mobility and active or passive physiological deficits when utilizing the quadruped lumbar-locked position. Study Design: Cross-sectional. Methods: Thirty-eight subjects (21 female, 17 male) with a mean age of 27 years ± 6.67 were assessed with the quadruped lumbar-locked thorax rotation test by three examiners with various clinical experience in real-time and again one week later. Bilateral active and passive lumbar-locked thorax rotation mobility was assessed by all raters and categorized as "Unrestricted" (≥50°) or "Restricted" (<50°) while a research assistant simultaneously measured the motion with a digital inclinometer. All raters were blinded to the results. All results were analyzed for intra-rater reliability and agreement. Results: Test-retest intra-rater reliability ranged from 0.55-0.72 and percent absolute agreement ranged from 0.82-0.89. Inter-rater reliability ranged from 0.45-0.59 while percent absolute agreement between raters ranged from 0.74-0.84. There was a significant difference in range of motion between "Unrestricted" and "Restricted" categories for both active (Unrestricted=54.6-58.9; Restricted=40.4-44.4; p<0.001) and passive motion (Unrestricted=61.3-63.5; Restricted=39.2-39.7; p<0.001). The only interaction effect was for passive left rotation [Rater A Restricted x ® =34.3(30.4-38.2); Rater C Restricted (x ) ®=43.8(41.3-46.4); p=.000]. Conclusion: The quadruped lumbar-locked thorax rotation test demonstrates moderate to substantial test-retest intra-rater and inter-rater reliability regardless of clinical experience. The quadruped lumbar-locked thorax rotation test can accurately discriminate between individuals with active and passive physiological deficits regardless of rater experience using visual estimation. Level of Evidence: 3b.

Neuron-Astrocyte Interactions and Circadian Timekeeping in Mammals.

Almost every facet of our behavior and physiology varies predictably over the course of day and night, anticipating and adapting us to their associated opportunities and challenges. These rhythms are driven by endogenous biological clocks that, when deprived of environmental cues, can continue to oscillate within a period of approximately 1 day, hence circa-dian. Normally, retinal signals synchronize them to the cycle of light and darkness, but disruption of circadian organization, a common feature of modern lifestyles, carries considerable costs to health. Circadian timekeeping pivots around a cell-autonomous molecular clock, widely expressed across tissues. These cellular timers are in turn synchronized by the principal circadian clock of the brain: the hypothalamic suprachiasmatic nucleus (SCN). Intercellular signals make the SCN network a very powerful pacemaker. Previously, neurons were considered the sole SCN timekeepers, with glial cells playing supportive roles. New discoveries have revealed, however, that astrocytes are active partners in SCN network timekeeping, with their cell-autonomous clock regulating extracellular glutamate and GABA concentrations to control circadian cycles of SCN neuronal activity. Here, we introduce circadian timekeeping at the cellular and SCN network levels before focusing on the contributions of astrocytes and their mutual interaction with neurons in circadian control in the brain.

Assessing the difference in contamination of retail meat with multidrug-resistant bacteria using for-consumer package label claims that indicate on-farm antibiotic use practices- United States, 2016-2019.

BACKGROUND: Antibiotic use in food-producing animals can select for antibiotic resistance in bacteria that can be transmitted to people through contamination of food products during meat processing. Contamination resulting in foodborne illness contributes to adverse health outcomes. Some livestock producers have implemented antibiotic use reduction strategies marketed to consumers on regulated retail meat packaging labels ("label claims"). OBJECTIVE: We investigated whether retail meat label claims were associated with isolation of multidrug-resistant organisms (MDROs, resistant to ≥3 classes of antibiotics) from U.S. meat samples. METHODS: We utilized retail meat data from the U.S. Food and Drug Administration National Antimicrobial Resistance Monitoring System (NARMS) collected during 2016-2019 for bacterial contamination of chicken breast, ground turkey, ground beef, and pork chops. We used modified Poisson regression models to compare the prevalence of MDRO contamination among meat samples with any antibiotic restriction label claims versus those without such claims (i.e., conventionally produced). RESULTS: In NARMS, 62,338 meat samples were evaluated for bacterial growth from 2016-2019. Of these, 24,446 (39%) samples had label claims that indicated antibiotic use was restricted during animal production. MDROs were isolated from 2252 (4%) meat samples, of which 71% (n = 1591) were conventionally produced, and 29% (n = 661) had antibiotic restriction label claims. Compared with conventional samples, meat with antibiotic restriction label claims had a statistically lower prevalence of MDROs (adjusted prevalence ratio: 0.66; 95% CI: 0.61, 0.73). This relationship was consistent for the outcome of any bacterial growth. IMPACT: This repeated cross-sectional analysis of a nationally representative retail meat surveillance database in the United States supports that retail meats labeled with antibiotic restriction claims were less likely to be contaminated with MDROs compared with retail meat without such claims during 2016-2019. These findings indicate the potential for the public to become exposed to bacterial pathogens via retail meat and emphasizes a possibility that consumers could reduce their exposure to environmental reservoirs of foodborne pathogens that are resistant to antibiotics.

The Irish Trainee Emergency Research Network (ITERN): five years of collaboration.

In 2018, a group of Irish emergency medicine (EM) trainees recognised their common interest in collaborative research and the difficulties that trainees can encounter when trying to broaden their research capacity, prompting the beginning of the Irish Trainee Emergency Research Network (ITERN) journey. Trainee-led collaboratives have been shown to be feasible and have the potential to deliver impactful research projects, generating an evidence base that may not have been possible without collaboration. This article describes the successes and achievement of ITERN and describes the processes and challenges that a trainee-led research network can encounter. The authors believe that trainee-led collaboratives can deliver powerful and impactful research for patients and broaden the research capacity of individuals, hospitals, and groups of healthcare professionals.

Distance and destination of retail meat alter multidrug resistant contamination in the United States food system.

Antibiotic-resistant infections are a global concern, especially those caused by multidrug-resistant (MDR) bacteria, defined as those resistant to more than three drug classes. The animal agriculture industry contributes to the antimicrobial resistant foodborne illness burden via contaminated retail meat. In the United States, retail meat is shipped across the country. Therefore, understanding geospatial factors that influence MDR bacterial contamination is vital to protect consumers and inform interventions. Using data available from the United States Food and Drug Administration's National Antimicrobial Resistance Monitoring System (NARMS), we describe retail meat shipping distances using processor and retailer locations and investigated this distance as a risk factor for MDR bacteria meat contamination using log-binomial regression. Meat samples collected during 2012-2014 totaled 11,243, of which 4791 (42.61%) were contaminated with bacteria and 835 (17.43%) of those bacteria were MDR. All examined geospatial factors were associated with MDR bacteria meat contamination. After adjustment for year and meat type, we found higher prevalence of MDR contamination among meat processed in the south (relative adjusted prevalence ratio [aPR] 1.35; 95% CI 1.06-1.73 when compared to the next-highest region), sold in Maryland (aPR 1.12; 95% CI 0.95-1.32 when compared to the next-highest state), and shipped from 194 to 469 miles (aPR 1.59; 95% CI 1.31-1.94 when compared to meats that traveled < 194 miles). However, sensitivity analyses revealed that New York sold the meat with the highest prevalence of MDR Salmonella contamination (4.84%). In this secondary analysis of NARMS data, both geographic location where products were sold and the shipping distance were associated with microbial contamination on retail meat.

Large-scale heterogeneities can alter the characteristics of compressive failure and accelerated seismic release.

Externally stressed brittle rocks fail once the stress is sufficiently high. This failure is typically preceded by a pronounced increase in the total energy of acoustic emission (AE) events, the so-called accelerated seismic release. Yet, other characteristics of approaching the failure point such as the presence or absence of variations in the AE size distribution and, similarly, whether the failure point can be interpreted as a critical point in a statistical physics sense differs across experiments. Here, we show that large-scale stress heterogeneities induced by a notch fundamentally change the characteristics of the failure point in triaxial compression experiments under a constant displacement rate on Westerly granite samples. Specifically, we observe accelerated seismic release without a critical point and no change in power-law exponent ε of the AE size distribution. This is in contrast to intact samples, which exhibit a significant decrease in ε before failure. Our findings imply that the presence or absence of large-scale heterogeneities play a significant role in our ability to predict compressive failure in rock.

The Mammalian Circadian Time-Keeping System.

Our physiology and behavior follow precise daily programs that adapt us to the alternating opportunities and challenges of day and night. Under experimental isolation, these rhythms persist with a period of approximately one day (circadian), demonstrating their control by an internal autonomous clock. Circadian time is created at the cellular level by a transcriptional/translational feedback loop (TTFL) in which the protein products of the Period and Cryptochrome genes inhibit their own transcription. Because the accumulation of protein is slow and delayed, the system oscillates spontaneously with a period of ∼24 hours. This cell-autonomous TTFL controls cycles of gene expression in all major tissues and these cycles underpin our daily metabolic programs. In turn, our innumerable cellular clocks are coordinated by a central pacemaker, the suprachiasmatic nucleus (SCN) of the hypothalamus. When isolated in slice culture, the SCN TTFL and its dependent cycles of neural activity persist indefinitely, operating as "a clock in a dish". In vivo, SCN time is synchronized to solar time by direct innervation from specialized retinal photoreceptors. In turn, the precise circadian cycle of action potential firing signals SCN-generated time to hypothalamic and brain stem targets, which co-ordinate downstream autonomic, endocrine, and behavioral (feeding) cues to synchronize and sustain the distributed cellular clock network. Circadian time therefore pervades every level of biological organization, from molecules to society. Understanding its mechanisms offers important opportunities to mitigate the consequences of circadian disruption, so prevalent in modern societies, that arise from shiftwork, aging, and neurodegenerative diseases, not least Huntington's disease.

Astrocytic control of extracellular GABA drives circadian timekeeping in the suprachiasmatic nucleus.

The hypothalamic suprachiasmatic nucleus (SCN) is the master mammalian circadian clock. Its cell-autonomous timing mechanism, a transcriptional/translational feedback loop (TTFL), drives daily peaks of neuronal electrical activity, which in turn control circadian behavior. Intercellular signals, mediated by neuropeptides, synchronize and amplify TTFL and electrical rhythms across the circuit. SCN neurons are GABAergic, but the role of GABA in circuit-level timekeeping is unclear. How can a GABAergic circuit sustain circadian cycles of electrical activity, when such increased neuronal firing should become inhibitory to the network? To explore this paradox, we show that SCN slices expressing the GABA sensor iGABASnFR demonstrate a circadian oscillation of extracellular GABA ([GABA]e) that, counterintuitively, runs in antiphase to neuronal activity, with a prolonged peak in circadian night and a pronounced trough in circadian day. Resolving this unexpected relationship, we found that [GABA]e is regulated by GABA transporters (GATs), with uptake peaking during circadian day, hence the daytime trough and nighttime peak. This uptake is mediated by the astrocytically expressed transporter GAT3 (Slc6a11), expression of which is circadian-regulated, being elevated in daytime. Clearance of [GABA]e in circadian day facilitates neuronal firing and is necessary for circadian release of the neuropeptide vasoactive intestinal peptide, a critical regulator of TTFL and circuit-level rhythmicity. Finally, we show that genetic complementation of the astrocytic TTFL alone, in otherwise clockless SCN, is sufficient to drive [GABA]e rhythms and control network timekeeping. Thus, astrocytic clocks maintain the SCN circadian clockwork by temporally controlling GABAergic inhibition of SCN neurons.

Non-linear probabilistic calibration of low-cost environmental air pollution sensor networks for neighborhood level spatiotemporal exposure assessment.

BACKGROUND: Low-cost sensor networks for monitoring air pollution are an effective tool for expanding spatial resolution beyond the capabilities of existing state and federal reference monitoring stations. However, low-cost sensor data commonly exhibit non-linear biases with respect to environmental conditions that cannot be captured by linear models, therefore requiring extensive lab calibration. Further, these calibration models traditionally produce point estimates or uniform variance predictions which limits their downstream in exposure assessment. OBJECTIVE: Build direct field-calibration models using probabilistic gradient boosted decision trees (GBDT) that eliminate the need for resource-intensive lab calibration and that can be used to conduct probabilistic exposure assessments on the neighborhood level. METHODS: Using data from Plantower A003 particulate matter (PM) sensors deployed in Baltimore, MD from November 2018 through November 2019, a fully probabilistic NGBoost GBDT was trained on raw data from sensors co-located with a federal reference monitoring station and compared against linear regression trained on lab calibrated sensor data. The NGBoost predictions were then used in a Monte Carlo interpolation process to generate high spatial resolution probabilistic exposure gradients across Baltimore. RESULTS: We demonstrate that direct field-calibration of the raw PM2.5 sensor data using a probabilistic GBDT has improved point and distribution accuracies compared to the linear model, particularly at reference measurements exceeding 25 µg/m3, and also on monitors not included in the training set. SIGNIFICANCE: We provide a framework for utilizing the GBDT to conduct probabilistic spatial assessments of human exposure with inverse distance weighting that predicts the probability of a given location exceeding an exposure threshold and provides percentiles of exposure. These probabilistic spatial exposure assessments can be scaled by time and space with minimal modifications. Here, we used the probabilistic exposure assessment methodology to create high quality spatial-temporal PM2.5 maps on the neighborhood-scale in Baltimore, MD. IMPACT STATEMENT: We demonstrate how the use of open-source probabilistic machine learning models for in-place sensor calibration outperforms traditional linear models and does not require an initial laboratory calibration step. Further, these probabilistic models can create uniquely probabilistic spatial exposure assessments following a Monte Carlo interpolation process.

Cryptochrome 1 as a state variable of the circadian clockwork of the suprachiasmatic nucleus: Evidence from translational switching.

The suprachiasmatic nucleus (SCN) of the hypothalamus is the principal clock driving circadian rhythms of physiology and behavior that adapt mammals to environmental cycles. Disruption of SCN-dependent rhythms compromises health, and so understanding SCN time keeping will inform management of diseases associated with modern lifestyles. SCN time keeping is a self-sustaining transcriptional/translational delayed feedback loop (TTFL), whereby negative regulators inhibit their own transcription. Formally, the SCN clock is viewed as a limit-cycle oscillator, the simplest being a trajectory of successive phases that progresses through two-dimensional space defined by two state variables mapped along their respective axes. The TTFL motif is readily compatible with limit-cycle models, and in Neurospora and Drosophila the negative regulators Frequency (FRQ) and Period (Per) have been identified as state variables of their respective TTFLs. The identity of state variables of the SCN oscillator is, however, less clear. Experimental identification of state variables requires reversible and temporally specific control over their abundance. Translational switching (ts) provides this, the expression of a protein of interest relying on the provision of a noncanonical amino acid. We show that the negative regulator Cryptochrome 1 (CRY1) fulfills criteria defining a state variable: ts-CRY1 dose-dependently and reversibly suppresses the baseline, amplitude, and period of SCN rhythms, and its acute withdrawal releases the TTFL to oscillate from a defined phase. Its effect also depends on its temporal pattern of expression, although constitutive ts-CRY1 sustained (albeit less stable) oscillations. We conclude that CRY1 has properties of a state variable, but may operate among several state variables within a multidimensional limit cycle.

Implementing delirium screening in the emergency department: a quality improvement project.

INTRODUCTION: Delirium is a serious medical condition that is common in older adults in acute settings. Clinical practice guidelines recommend that all older patients in acute care settings should be screened for delirium using standardised outcome measures. PROBLEM: In our institution, an audit showed that only 16% of older adults presenting to the emergency department were screened for delirium. The goal of this project was to increase the number of patients being screened for delirium using Lean Six Sigma (LSS) methodology and tools and a multidisciplinary approach. METHOD: A multidisciplinary team in the emergency department used LSS tools and methodology over a 12-week period to first identify why patients were not being screened for delirium using root cause analysis and second to implement a multifaceted intervention including education, audits and feedback, documentation changes and team huddles. An audit was performed at the 11th week of the project to measure how many patients were being screened for delirium post project intervention. RESULTS: Results at 5 weeks post intervention (11th week of project) showed that the percentage of patients being screened for delirium had increased from 16% to 82%. A follow-up audit at 17 weeks post intervention showed a further improvement in delirium screening to 92%. CONCLUSION: Applying LSS tools and methodology resulted in a healthcare quality improvement. Delirium screening in an emergency department can be improved through multifaceted interventions including education, documentation changes and team huddle changes.

Astrocytes sustain circadian oscillation and bidirectionally determine circadian period, but do not regulate circadian phase in the suprachiasmatic nucleus.

The suprachiasmatic nucleus (SCN) is the master circadian clock of mammals, generating and transmitting an internal representation of environmental time that is produced by the cell-autonomous transcriptional/post-translational feedback loops (TTFL) of the 10,000 neurons and 3,500 glial cells. Recently, we showed that TTFL function in SCN astrocytes alone is sufficient to drive circadian timekeeping and behaviour, raising questions about the respective contributions of astrocytes and neurons within the SCN circuit. We compared their relative roles in circadian timekeeping in mouse SCN explants, of either sex. Treatment with the glial-specific toxin fluorocitrate revealed a requirement for metabolically competent astrocytes for circuit-level timekeeping. Recombinase-mediated genetically complemented Cryptochrome (Cry) proteins in Cry1- and/or Cry2-deficient SCN, were used to compare the influence of the TTFLs of neurons or astrocytes in the initiation of de novo oscillation or in pacemaking. While neurons and astrocytes both initiated de novo oscillation and lengthened period equally, their kinetics were different: astrocytes taking twice as long. Furthermore, astrocytes could shorten period, but not as potently as neurons. Chemogenetic manipulation of Gi- and Gq-coupled signalling pathways in neurons acutely advanced or delayed ensemble phase, respectively. In contrast, comparable manipulations in astrocytes were without effect. Thus, astrocytes can initiate SCN rhythms and bi-directionally control SCN period, albeit with lower potency than neurons. Nevertheless, their activation does not influence SCN phase. The emergent SCN properties of high amplitude oscillation, initiation of rhythmicity, pacemaking and phase are differentially regulated: astrocytes and neurons sustain the ongoing oscillation, but its phase is determined by neurons.Significance Statement:The hypothalamic suprachiasmatic nucleus (SCN) encodes and disseminates time-of-day information to allow mammals to adapt their physiology to daily environmental cycles. Recent investigations have revealed a role for astrocytes, in addition to neurons, in regulation of this rhythm. Using pharmacology, genetic complementation and chemogenetics, we compared the abilities of neurons and astrocytes in determining the emergent SCN properties of high amplitude oscillation, initiation of rhythmicity, pacemaking and determination of phase. These findings parameterise the circadian properties of the astrocyte population in the SCN, and reveal the types of circadian information astrocytes and neurons can contribute within their heterogeneous cellular network.

Probabilistic Machine Learning with Low-Cost Sensor Networks for Occupational Exposure Assessment and Industrial Hygiene Decision Making.

Occupational exposure assessments are dominated by small sample sizes and low spatial and temporal resolution with a focus on conducting Occupational Safety and Health Administration regulatory compliance sampling. However, this style of exposure assessment is likely to underestimate true exposures and their variability in sampled areas, and entirely fail to characterize exposures in unsampled areas. The American Industrial Hygiene Association (AIHA) has developed a more realistic system of exposure ratings based on estimating the 95th percentiles of the exposures that can be used to better represent exposure uncertainty and exposure variability for decision-making; however, the ratings can still fail to capture realistic exposure with small sample sizes. Therefore, low-cost sensor networks consisting of numerous lower-quality sensors have been used to measure occupational exposures at a high spatiotemporal scale. However, the sensors must be calibrated in the laboratory or field to a reference standard. Using data from carbon monoxide (CO) sensors deployed in a heavy equipment manufacturing facility for eight months from August 2017 to March 2018, we demonstrate that machine learning with probabilistic gradient boosted decision trees (GBDT) can model raw sensor readings to reference data highly accurately, entirely removing the need for laboratory calibration. Further, we indicate how the machine learning models can produce probabilistic hazard maps of the manufacturing floor, creating a visual tool for assessing facility-wide exposures. Additionally, the ability to have a fully modeled prediction distribution for each measurement enables the use of the AIHA exposure ratings, which provide an enhanced industrial decision-making framework as opposed to simply determining if a small number of measurements were above or below a pertinent occupational exposure limit. Lastly, we show how a probabilistic modeling exposure assessment with high spatiotemporal resolution data can prevent exposure misclassifications associated with traditional models that rely exclusively on mean or point predictions.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine.

BACKGROUND: Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team's service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. METHODS: The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team's first 12 months of operation using the prospectively maintained service database. RESULTS: Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. CONCLUSION: Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Single-cell transcriptomics of suprachiasmatic nuclei reveal a Prokineticin-driven circadian network.

Circadian rhythms in mammals are governed by the hypothalamic suprachiasmatic nucleus (SCN), in which 20,000 clock cells are connected together into a powerful time-keeping network. In the absence of network-level cellular interactions, the SCN fails as a clock. The topology and specific roles of its distinct cell populations (nodes) that direct network functions are, however, not understood. To characterise its component cells and network structure, we conducted single-cell sequencing of SCN organotypic slices and identified eleven distinct neuronal sub-populations across circadian day and night. We defined neuropeptidergic signalling axes between these nodes, and built neuropeptide-specific network topologies. This revealed their temporal plasticity, being up-regulated in circadian day. Through intersectional genetics and real-time imaging, we interrogated the contribution of the Prok2-ProkR2 neuropeptidergic axis to network-wide time-keeping. We showed that Prok2-ProkR2 signalling acts as a key regulator of SCN period and rhythmicity and contributes to defining the network-level properties that underpin robust circadian co-ordination. These results highlight the diverse and distinct contributions of neuropeptide-modulated communication of temporal information across the SCN.

Low mental health scores are associated with worse patient-reported outcomes and difficulty with return to work and sport after distal biceps repair.

BACKGROUND: Most patients have successful outcomes with minimal limitations after distal biceps repair, but a minority continues experiencing functional constraints. We hypothesize that low scores on a validated mental health measure correlate with worse patient-reported outcomes and increased difficulty with return to work and sport. METHODS: We conducted a retrospective review of a consecutive series of patients who underwent distal biceps repair with a single-incision cortical button technique and immediate mobilization. Patient-reported outcome data were available at 1 year or later for 33 (85%) patients. The primary outcomes were American Shoulder and Elbow Surgeons-Elbow (ASES-E) score, Single Assessment Numeric Evaluation score, Visual Analog Scale for pain, Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), and Veterans RAND 12 (VR-12) quality-of-life assessment. RESULTS: All patients were male, with a median age of 49 years (range, 28-65). None had reruptures, and 1 (3%) had superficial wound dehiscence that healed without further surgery. Eleven (33%) had postoperative neuropraxia, 6 of which resolved completely. At latest follow-up, the median Visual Analog Scale was 0 (range, 0-5; mean, 1), and median ASES-E functional score was 36 (range, 24-36; mean, 34). Median Single Assessment Numeric Evaluation score was 92 (range, 41-100). The median QuickDASH was 5 (range, 0-50; mean, 11). More than half of the patients with VR-12 mental component score (MCS) < 50 (5 of 9, 56%) reported difficulty with work activities, compared with 4% (1 of 24) of patients with an MCS ≥ 50 (P = .001). Most patients (8 of 9, 89%) with an MCS < 50 also reported difficulty with return to sporting activities, compared with only 8% (2 of 24) of patients with MCS ≥ 50 (P < .0001). Patients with an MCS < 50 (n = 9) had significantly worse ASES-E functional scores (median, 34; range, 27-36) and QuickDASH scores (median 23, range 0-43), compared with those with an MCS ≥ 50 (ASES-E: median, 36; range, 24-36; P = .033; QuickDASH: median, 2; range, 0-50; P = .026). Most patients (17 of 24, 71%) with MCS ≥ 50 had a perfect score of 36 on the ASES-E functional outcome score, compared with only 22% (2 of 9) among patients with MCS < 50. CONCLUSION: Patients who undergo distal biceps repair show excellent functional patient-reported outcomes at 1-year and later follow-up. Lower scores on the VR-12 MCS are associated with worse patient-reported outcome scores and difficulty with return to work and sporting activities.

Contamination of Retail Meat Samples with Multidrug-Resistant Organisms in Relation to Organic and Conventional Production and Processing: A Cross-Sectional Analysis of Data from the United States National Antimicrobial Resistance Monitoring System, 2012-2017.

BACKGROUND: During food animal production, animals are exposed to, colonized by, and sometimes infected with bacteria that may contaminate animal products with susceptible and multidrug-resistant organisms (MDRO). The United States' Organic Foods Production Act resulted in decreased antibiotic use in some animal production operations. Some studies have reported that decreased antibiotic use is associated with reduced MDRO on meat. OBJECTIVES: The aim of this study was to investigate associations of meat production and processing methods with MDRO and overall bacterial contamination of retail meats. METHODS: Bacterial contamination data from 2012 to 2017 for chicken breast, ground beef, ground turkey, and pork chops were downloaded from the National Antimicrobial Resistance Monitoring System. Poisson regression models with robust variance were used to estimate associations with MDRO contamination and any contamination (adjusted for year and meat type) overall, and according to bacteria genus (Salmonella, Campylobacter, Enterococcus, Escherichia coli) and meat type. RESULTS: A total of 39,349 retail meat samples were linked to 216 conventional, 123 split (conventional and organic), and three organic processing facilities. MDRO contamination was similar in conventionally produced meats processed at split vs. conventional facilities but was significantly lower in organically produced meats processed at split facilities [adjusted prevalance ratio (aPR)=0.43; 95% CI: 0.30, 0.63]. Meat processed by split vs. conventional processors had higher or similar MDRO contamination for all tested bacterial genera except Campylobacter (aPR=0.29; 95% CI: 0.13, 0.64). The prevalence of any contamination was lower in samples processed at split vs. conventional facilities for aggregated samples (aPR=0.70; 95% CI: 0.68, 0.73) and all meat types and bacterial genera. DISCUSSION: Organically produced and processed retail meat samples had a significantly lower prevalence of MDRO than conventionally produced and processed samples had, whereas meat from split processors had a lower prevalence of any contamination than samples from conventional processors had. Additional studies are needed to confirm findings and clarify specific production and processing practices that might explain them. https://doi.org/10.1289/EHP7327.

Benzene Exposure and Cancer Risk from Commercial Gasoline Station Fueling Events Using a Novel Self-Sampling Protocol.

Tens of millions of individuals go to gasoline stations on a daily basis in the United States. One of the constituents of gasoline is benzene, a Group 1 carcinogen that has been strongly linked to both occupational and non-occupational leukemias. While benzene content in gasoline is federally regulated, there is approximately a thirty-year data gap in United States research on benzene exposures from pumping gasoline. Using a novel self-sampling protocol with whole air canisters, we conducted a gasoline pumping exposure assessment for benzene, toluene, ethylbenzene, and xylene (BTEX) on Baltimore, MD consumers. Geometric mean exposures (geometric standard deviations) were 3.2 (2.7) ppb,9.5 (3.5) ppb, 2.0 (2.8) ppb, and 7.3 (3.0) ppb, respectively, on 32 samples. Using the benzene exposures, we conducted consumer and occupational probabilistic risk assessments and contextualized the risk with ambient benzene exposure risk. We found that the consumer scenarios did not approach the 1:1,000,000 excess risk management threshold and that the occupational scenario did not exceed the 1:10,000 excess risk management threshold. Further, in all Monte Carlo trials, the ambient risk from benzene exposure exceeded that of pumping risk for consumers, but that in approximately 30% of occupational trials, the pumping risk exceeded the ambient risk.

The VIP-VPAC2 neuropeptidergic axis is a cellular pacemaking hub of the suprachiasmatic nucleus circadian circuit.

The hypothalamic suprachiasmatic nuclei (SCN) are the principal mammalian circadian timekeeper, co-ordinating organism-wide daily and seasonal rhythms. To achieve this, cell-autonomous circadian timing by the ~20,000 SCN cells is welded into a tight circuit-wide ensemble oscillation. This creates essential, network-level emergent properties of precise, high-amplitude oscillation with tightly defined ensemble period and phase. Although synchronised, regional cell groups exhibit differentially phased activity, creating stereotypical spatiotemporal circadian waves of cellular activation across the circuit. The cellular circuit pacemaking components that generate these critical emergent properties are unknown. Using intersectional genetics and real-time imaging, we show that SCN cells expressing vasoactive intestinal polypeptide (VIP) or its cognate receptor, VPAC2, are neurochemically and electrophysiologically distinct, but together they control de novo rhythmicity, setting ensemble period and phase with circuit-level spatiotemporal complexity. The VIP/VPAC2 cellular axis is therefore a neurochemically and topologically specific pacemaker hub that determines the emergent properties of the SCN timekeeper.

Burnout Among United States Orthopaedic Surgery Residents.

OBJECTIVE: There is growing interest in the problem of burnout among physicians. Here, we examine the factors associated with burnout in orthopedic surgical training. DESIGN: An Internet-based anonymous survey assessing workload, work-life balance, education, and resident-specific factors such as marital status and postgraduate year was developed. The survey was distributed to United States orthopedic surgery residency directors in September 2018, and program directors were asked to forward the survey to their trainees. Multivariable analysis assessed correlations with burnout. SETTING: All 161 Accreditation Council for Graduate Medical Education (ACGME)-accredited United States orthopedic surgery residency programs. PARTICIPANTS: Two hundred and three United States orthopedic surgery residents. RESULTS: Thirty-eight percent of respondents reported symptoms of burnout. Even so, the vast majority did not regret choosing a medical career (95%) or their choice of residency program (90%). Greater than half of trainees who responded reported educational debt over $200,000. Thirteen percent reported receiving verbal abuse from faculty more than rarely. On multivariable analysis, 3 factors emerged that were associated with higher burnout: working more than 80 hours per week (odds ratio [OR] 2.8; range, 1.1-7.8), use of electronic medical record more than 20 hours per week (OR 2.1; range 1.0-4.5), and receiving verbal abuse from faculty more than rarely (OR 3.7; range, 1.3-11.5). The perception of adequate nursing support was associated with lower burnout (OR 0.2; range, 0.04-0.5). CONCLUSIONS: More than one-third of orthopedic trainees are experiencing burnout, but most still maintain high levels of career satisfaction. The key factors strongly associated with resident burnout are modifiable. Targeted interventions related to these factors should be evaluated for their potential to reduce burnout in orthopedic surgery residents. CLINICAL RELEVANCE: Strategies to reduce the development of burnout have the potential to improve quality of care and decrease medical errors.