Topping-Off a Long Thoracic Stabilization With Semi-Rigid Constructs May Have Favorable Biomechanical Effects to Prevent Proximal Junctional Kyphosis: A Biomechanical Comparison.

STUDY DESIGN: In-vitro cadaveric biomechanical study. OBJECTIVES: Long posterior spinal fusion is a standard treatment for adult spinal deformity. However, these rigid constructs are known to alter motion and stress to the adjacent non-instrumented vertebrae, increasing the risk of proximal junctional kyphosis (PJK). This study aimed to biomechanically compare a standard rigid construct vs constructs "topped off" with a semi-rigid construct. By understanding semi-rigid constructs' effect on motion and overall construct stiffness, surgeons and researchers could better optimize fusion constructs to potentially decrease the risk of PJK and the need for revision surgery. METHODS: Nine human cadaveric spines (T1-T12) underwent non-destructive biomechanical range of motion tests in pure bending or torsion and were instrumented with an all-pedicle-screw (APS) construct from T6-T9. The specimens were sequentially instrumented with semi-rigid constructs at T5: (i) APS plus sublaminar bands; (ii) APS plus supralaminar hooks; (iii) APS plus transverse process hooks; and (iv) APS plus short pedicle screws. RESULTS: APS plus transverse process hooks had a range of motion (ie, relative angle) for T4-T5 and T5-T6, as well as an overall mechanical stiffness for T1-T12, that was more favourable, as it reduced motion at adjacent levels without a stark increase in stiffness. Moreover, APS plus transverse process hooks had the most linear change for range of motion across the entire T3-T7 range. CONCLUSIONS: Present findings suggest that APS plus transverse process hooks has a favourable biomechanical effect that may reduce PJK for long spinal fusions compared to the other constructs examined.

Surveillance system integration: reporting the results of a global multicountry survey.

OBJECTIVES: Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs). STUDY DESIGN: This was a cross-sectional survey of NPHIs. METHODS: A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status. RESULTS: Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability. CONCLUSIONS: Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

A cluster of neuropeptide S neurons regulates breathing and arousal.

Neuropeptide S (NPS) is a highly conserved peptide found in all tetrapods that functions in the brain to promote heightened arousal; however, the subpopulations mediating these phenomena remain unknown. We generated mice expressing Cre recombinase from the Nps gene locus (NpsCre) and examined populations of NPS+ neurons in the lateral parabrachial area (LPBA), the peri-locus coeruleus (peri-LC) region of the pons, and the dorsomedial thalamus (DMT). We performed brain-wide mapping of input and output regions of NPS+ clusters and characterized expression patterns of the NPS receptor 1 (NPSR1). While the activity of all three NPS+ subpopulations tracked with vigilance state, only NPS+ neurons of the LPBA exhibited both increased activity prior to wakefulness and decreased activity during REM sleep, similar to the behavioral phenotype observed upon NPSR1 activation. Accordingly, we found that activation of the LPBA but not the peri-LC NPS+ neurons increased wake and reduced REM sleep. Furthermore, given the extended role of the LPBA in respiration and the link between behavioral arousal and breathing rate, we demonstrated that the LPBA but not the peri-LC NPS+ neuronal activation increased respiratory rate. Together, our data suggest that NPS+ neurons of the LPBA represent an unexplored subpopulation regulating breathing, and they are sufficient to recapitulate the sleep/wake phenotypes observed with broad NPS system activation.

RTI-263, a biased neuropeptide S receptor agonist that retains an anxiolytic effect, attenuates cocaine-seeking behavior in rats.

Neuropeptide S (NPS) is a neuromodulatory peptide that acts via a G protein-coupled receptor. Centrally administered NPS suppresses anxiety-like behaviors in rodents while producing a paradoxical increase in arousal. In addition, NPS increases drug-seeking behavior when administered during cue-induced reinstatement. Conversely, an NPS receptor (NPSR) antagonist, RTI-118, decreases cocaine-seeking behavior. A biased NPSR ligand, RTI-263, produces anxiolytic-like effects and has memory-enhancing effects similar to those of NPS but without the increase in arousal. In the present study, we show that RTI-263 decreased cocaine seeking by both male and female rats during cue-induced reinstatement. However, RTI-263 did not modulate the animals' behaviors during natural reward paradigms, such as palatable food intake, feeding during a fasting state, and cue-induced reinstatement of sucrose seeking. Therefore, NPSR biased agonists are a potential pharmacotherapy for substance use disorder because of the combined benefits of decreased drug seeking and the suppression of anxiety.

Effect of muscle pre-tension and pre-impact neck posture on the kinematic response of the cervical spine in simulated low-speed rear impacts.

Computational human body models (HBMs) can identify potential injury pathways not easily accessible through experimental studies, such as whiplash induced injuries. However, previous computational studies investigating neck response to simulated impact conditions have neglected the effect of pre-impact neck posture and muscle pre-tension on the intervertebral kinematics and tissue-level response. The purpose of the present study was addressing this knowledge gap using a detailed neck model subjected to simulated low-acceleration rear impact conditions, towards improved intervertebral kinematics and soft tissue response for injury assessment. An improved muscle path implementation in the model enabled the modeling of muscle pre-tension using experimental muscle pre-stretch data determined from previous cadaver studies. Cadaveric neck impact tests and human volunteer tests with the corresponding cervical spine posture were simulated using a detailed neck model with the reported boundary conditions and no muscle activation. Computed intervertebral kinematics of the model with pre-tension achieved, for the first time, the S-shape behavior of the neck observed in low severity rear impacts of both cadaver and volunteer studies. The maximum first principal strain in the muscles for the model with pre-tension was 27% higher than that without pre-tension. Although, the pre-impact neck posture was updated to match the average posture reported in the experimental tests, the change in posture was generally small with only small changes in vertebral kinematics and muscle strain. This study provides a method to incorporate muscle pre-tension in HBM and quantifies the importance of pre-tension in calculating tissue-level distractions.

Improving the Quality of Publications in and Advancing the Paradigms of Clinical and Social Pharmacy Practice Research: The Granada Statements / Mejorando la calidad de las publicaciones y avanzando en todos los paradigmas de la investigación de la farmacia asistencial, clínica y social: las declaraciones de Granada

Pharmacy and pharmaceutical sciences embrace a series of different disciplines. Pharmacy practice has been defined as “the scientific discipline that studies the different aspects of the practice of pharmacy and its impact on health care systems, medicine use, and patient care”. Thus, pharmacy practice studies embrace both clinical pharmacy and social pharmacy elements. Like any other scientific discipline, clinical and social pharmacy practice disseminates research findings using scientific journals. Clinical pharmacy and social pharmacy journal editors have a role in promoting the discipline by enhancing the quality of the articles published. As has occurred in other health care areas (i.e., medicine and nursing), a group of clinical and social pharmacy practice journal editors gathered in Granada, Spain to discuss how journals could contribute to strengthening pharmacy practice as a discipline. The result of that meeting was compiled in these Granada Statements, which comprise 18 recommendations gathered into six topics: the appropriate use of terminology, impactful abstracts, the required peer reviews, journal scattering, more effective and wiser use of journal and article performance metrics, and authors’ selection of the most appropriate pharmacy practice journal to submit their work (AU)

Antimicrobial stewardship programme implementation in the UAE: perspectives of key stakeholders using Consolidated Framework for Implementation Research.

BACKGROUND: Many studies report antimicrobial stewardship programme (ASP) implementation, but these are limited by a lack of theoretical underpinning. This may lead to missing key factors that are likely to influence the successful or unsuccessful implementation. AIM: To explore key stakeholders' perspectives of ASP implementation in UAE hospitals, with a focus on facilitators and barriers. METHODS: The study employed a qualitative approach using semi-structured interviews conducted with ASP stakeholders involved in clinical use of antimicrobials at the individual patient level and including ASP team members and non-members. An interview schedule based on published literature and grounded in the Consolidated Framework for Implementation Research (CFIR) was developed, reviewed, and piloted. Recruitment was via purposive and snowball sampling. Interviews were recorded, transcribed, and thematically analysed by two independent researchers using CFIR as a coding framework. FINDINGS: Data saturation was achieved at 31 interviews. Multiple CFIR constructs were identified as implementation facilitators or barriers. Facilitators included external policy requirements (both national and international), leadership support, stakeholders' engagement, collaborative culture, effective communication, and forward planning. Barriers included blame culture, complexity of ASP implementation, and a shortage of expert personnel. CONCLUSION: Numerous facilitators and barriers to ASP implementation from a stakeholders' perspective were identified in this research. The value of early leadership engagement to support provision of required resources, a need for effective planning and establishment of multiple engagement techniques, and valuable communication with healthcare providers are the main recommendations emerging to support improvement in clinical practice.

A repeatable CT protocol for quantifying caudal vena cava growth in medium and large breed dogs.

Developmental malformations can cause stunted or abnormal growth and clinical disease in dogs. In humans, measurements of the inferior vena cava are used as methods for detecting abnormal growth trajectories. The objectives of this retrospective, multicenter, analytical, cross-sectional study were to develop a repeatable protocol to measure the caudal vena cava (CVC) and generate growth curves in medium and large-breed dogs during development. Contrast-enhanced CT DICOM images from 438 normal dogs, aged from 1 to 18 months, from five specific breeds were included. A "best guess" measurement protocol was created. Dogs were stratified into medium or large breed groups based on growth rate trajectories. Linear regression models and logarithmic trend lines were used to evaluate the CVC growth over time. The CVC measurements were analyzed from four anatomical regions: thorax, diaphragm, intra-hepatic, and renal. The thoracic segment produced the most repeatable measurements with the highest explanatory power. The CVC thoracic circumference ranged from 2.5 to 4.9 cm from 1 to 18 months of age. Medium and large breeds had similar CVC growth trajectories, with comparable estimated marginal means, however medium dogs reached 80% of predicted final CVC size approximately 4 weeks earlier than large breed dogs. This new protocol provides a standardized technique for evaluation of the CVC circumference over time using contrast-enhanced CT and is most repeatable when taken at the thoracic level. This approach could be adapted for other vessels to predict their growth trajectories, generating healthy reference population data for comparison against patients with vascular anomalies.

Implementation frameworks for polypharmacy management within healthcare organisations: a scoping review.

BACKGROUND: Several guidelines support polypharmacy management in individual patients. More organisational-level focus is needed on the use of implementation frameworks. AIM: To characterise the peer reviewed literature on implementation frameworks, focussing on barriers and facilitators to implementation at organisational level in the context of polypharmacy management. METHOD: A scoping review protocol was devised, supporting retrieval of studies published in English, reporting from any sector of practice. Medline, International Pharmaceutical Abstracts, Cumulative Index of Nursing and Allied Health Literature and Business Source Complete were searched to January 2022 using Medical Subject Headings including: 'polypharmacy', 'deprescriptions', 'strategic planning' and 'organizational innovation'. A narrative approach to data synthesis was applied. Searching, data extraction and synthesis were undertaken independently by two reviewers. RESULTS: After screening 797 records eight papers remained. Two were descriptive outlining details of specific initiatives, six used qualitative methods to explore determinants for implementation including barriers and enablers. Organisation level barriers included: poor organisational culture with a lack of sense of urgency and national plans, resource availability and communication issues including patient information and at transitions of care. Organisational facilitators included availability of government funding and regulatory environment promoting patient safety, a national emphasis on quality of care for older adults, co-ordinated national efforts and local evidence. CONCLUSION: Limited literature focusses on the use of implementation frameworks at organisational levels. This review highlights the need for further work on implementation frameworks in this context to help achieve effective organisational change.

Model validation for a knowledge and practices survey towards prevention of soil-transmitted helminth infections in rural villages in Indonesia.

The rate of soil-transmitted helminth (STH) infection is estimated to be around 20% in Indonesia. Health promotion and health education are cost-effective strategies to supplement STH prevention and control programs. Existing studies suggest that quantitative tools for knowledge, attitudes and practices (KAP) are important to monitor effective community-based STH interventions. However, evidence is limited regarding the applicability of such tools. This study aims to identify the socio-demographic predictors for STH-related knowledge and practices and validate the quantitative tools in population use. A cross-sectional study design was conducted among residents of 16 villages in Central Java, Indonesia. Adult and child respondents were interviewed to assess general knowledge and practices in relation to STH. Two mixed effects models identified the significant factors in predicting knowledge and practice scores. The model predicted knowledge and practice scores were compared with the observed scores to validate the quantitative measurements developed in this study. Participants' socio-demographic variables were significant in predicting an individual's STH-related knowledge level and their hand washing and hygiene practices, taking into account household-level variability. Model validation results confirmed that the quantitative measurement tools were suitable for assessing STH associated knowledge and behaviour. The questionnaire developed in this study can be used to support school- and community-based health education interventions to maximize the effect of STH prevention and control programs.

Characterizing In-Situ Metatarsal Fracture Risk During Simulated Workplace Impact Loading.

Metatarsal fractures represent the most common traumatic foot injury; however, metatarsal fracture thresholds remain poorly characterized, which affects performance targets for protective footwear. This experimental study investigated impact energies, forces, and deformations to characterize metatarsal fracture risk for simulated in situ workplace impact loading. A drop tower setup conforming to ASTM specifications for testing impact resistance of metatarsal protective footwear applied a target impact load (22-55 J) to 10 cadaveric feet. Prior to impact, each foot was axially loaded through the tibia with a specimen-specific bodyweight load to replicate a natural weight-bearing stance. Successive iterations of impact tests were performed until a fracture was observed with X-ray imaging. Descriptive statistics were computed for force, deformation, and impact energy. Correlational analysis was conducted on donor age, BMI, deformation, force, and impact energy. A survival analysis was used to generate injury risk curves (IRC) using impact energy and force. All 10 specimens fractured with the second metatarsal being the most common fracture location. The mean peak energy, force, and deformation during fracture were 46.6 J, 4640 N, 28.9 mm, respectively. Survival analyses revealed a 50% fracture probability was associated with 35.8 J and 3562 N of impact. Foot deformation was not significantly correlated (p = 0.47) with impact force, thus deformation is not recommended to predict metatarsal fracture risk. The results from this study can be used to improve test standards for metatarsal protection, provide performance targets for protective footwear developers, and demonstrate a methodological framework for future metatarsal fracture research.

The reach and benefits of a digital intervention to improve physical activity in people with a musculoskeletal condition delivered during the COVID-19 pandemic in the UK.

AIM: To evaluate a digital intervention to improve physical activity in people in the UK with a musculoskeletal condition delivered during movement restrictions brought about because of the COVID-19 pandemic. METHOD: Service evaluation data collected from 26,041 participants over 5 months was assessed against national datasets to understand the reach and representativeness of the digital physical activity intervention. Measures to restrict the movement and interaction of people were in place during these 5 months. Cross-sectional data from 2752 participants across different stages of the 12-week programme assessed levels of physical activity and the components of behaviour as defined by the COM-B model (Capability, Opportunity, Motivation = Behaviour). Regression analysis investigated the relationship between programme stage and physical activity and the components of behaviour. RESULTS: In comparison to the UK population of people with a musculoskeletal condition, the intervention participants were over-represented by females, White, and inactive people. A cross-sectional analysis suggested that the number of participants regularly active increased by programme stage. Scores for the behavioural components of automatic and reflective motivation, physical and psychological capability, and physical opportunity were also improved by programme stage. CONCLUSION: The service evaluation suggests that the digital intervention, designed to improve physical activity in people with a musculoskeletal condition, could be beneficial during measures to restrict movement to slow the spread of infectious disease in those who are already motivated to become or stay active.

Spinal Cord Boundary Conditions Affect Brain Tissue Strains in Impact Simulations.

Brain and spinal cord injuries have devastating consequences on quality of life but are challenging to assess experimentally due to the traumatic nature of such injuries. Finite element human body models (HBM) have been developed to investigate injury but are limited by a lack of biofidelic spinal cord implementation. In many HBM, brain models terminate with a fixed boundary condition at the brain stem. The goals of this study were to implement a comprehensive representation of the spinal cord into a contemporary head and neck HBM, and quantify the effect of the spinal cord on brain deformation during simulated impacts. Spinal cord tissue geometries were developed, based on 3D medical imaging and literature data, meshed, and implemented into the GHBMC 50th percentile male model. The model was evaluated in frontal, lateral, rear, and oblique impact conditions, and the resulting maximum principal strains in the brain tissue were compared, with and without the spinal cord. A new cumulative strain curve metric was proposed to quantify brain strain distribution. Presence of the spinal cord increased brain tissue strains in all simulated cases, owing to a more compliant boundary condition, highlighting the importance of the spinal cord to assess brain response during impact.

Negative Association of Smoking History With Clinically Manifest Cardiac Sarcoidosis: A Case-Control Study.

Background: The etiology of sarcoidosis is still unknown and is likely related to a genetic susceptibility to unidentified environmental trigger(s). Our group and others have extensively described a specific phenotype of primarily Caucasian patients who have clinically manifest cardiac sarcoidosis (CS). In this study, we sought to explore whether smoking is associated with this specific phenotype of sarcoidosis. Methods: We performed a case-control study. Cases with clinically manifest CS were prospectively enrolled in the Cardiac Sarcoidosis Multi-Center Prospective Cohort Study (CHASM-CS registry; NCT01477359) and answered a standardized smoking history questionnaire. Cases were matched 10:1 with controls from the Ontario Health Study. Pretreatment positron emission tomography scans with 18F-fluorodeoxyglucose were compared for smokers vs nonsmokers. Results: Eighty-seven cases met the inclusion criteria. A total of 82 of 87 (94.3%) answered the questionnaire and were matched with 820 controls. A clear negative association of sarcoidosis and smoking was found, with 23 of 82 CS cases (28.0%) being current or ex-smokers, vs 392 of 820 controls (47.8%; P = 0.0006). CS patients with a smoking history had significantly less lifetime consumption (8.31 ± 9.20 pack-years) than the controls (15.34 ± 10.84 pack-years; P < 0.003). On 18F-fluorodeoxyglucose-positron emission tomography scan, the mean standardized uptake value of the left ventricle was 4.2 ± 8.98 in lifetime nonsmokers vs 2.89 ± 2.07 in patients with a smoking history (P < 0.0001). Conclusions: We describe a strong negative association between smoking history and clinically manifest CS. Nonsmokers had more severe myocardial inflammation (greater mean standardized uptake value of the left ventricle) than did patients with a smoking history. Further research is needed to understand these associations and whether they have therapeutic potential.

Introduction: L'étiologie de la sarcoïdose est encore inconnue et est possiblement liée à une susceptibilité génétique à un ou des déclencheurs environnementaux inconnus. Notre groupe et d'autres groupes ont exposé sous tous ses aspects un phénotype particulier chez des patients principalement blancs qui ont une sarcoïdose cardiaque (SC) manifeste sur le plan clinique. Dans la présente étude, nous avons cherché à explorer si le tabagisme est associé à ce phénotype particulier de la sarcoïdose. Méthodes: Nous avons réalisé une étude cas témoins. Les cas qui avaient une SC manifeste sur le plan clinique ont été inscrits de façon prospective à l'étude CHASM-CS (Cardiac Sarcoidosis Multi-Center Prospective Cohort Study, registre CHASM-CS; NCT01477359) et ont répondu à un questionnaire standardisé sur les antécédents de tabagisme. Les cas ont été appariés 10:1 aux témoins de l'Étude sur la santé Ontario. Nous avons comparé avant le traitement la tomographie par émission de positons au 18F-fluorodéoxyglucose des fumeurs vs des non-fumeurs. Résultats: Quatre-vingt-sept cas répondaient aux critères d'inclusion. Un total de 82 sur 87 (94,3 %) cas ont rempli le questionnaire et ont été appariés à 820 témoins. Nous avons observé une association négative claire entre la sarcoïdose et le tabagisme, soit 23 sur 82 cas de SC (28,0 %) qui fumaient actuellement ou étaient des ex-fumeurs vs 392 sur 820 témoins (47,8 % ; P = 0,0006). Les patients atteints de SC qui avaient des antécédents de tabagisme avaient une consommation significativement moindre durant leur vie (8,31 ± 9,20 paquets-années) que les témoins (15,34 ± 10,84 paquets-années ; P < 0,003). À la tomographie par émission de positons au 18F-fluorodéoxyglucose, la valeur moyenne de fixation normalisée du ventricule gauche était de 4,2 ± 8,98 chez les non-fumeurs de toujours vs 2,89 ± 2,07 chez les patients qui avaient des antécédents de tabagisme (P < 0,0001). Conclusions: Nous démontrons une forte association négative entre les antécédents de tabagisme et la SC manifeste sur le plan clinique. Les non-fumeurs avaient plus d'inflammation myocardique grave (une plus grande valeur moyenne de fixation normalisée du ventricule gauche) que les patients qui avaient des antécédents de tabagisme. D'autres recherches sont nécessaires pour comprendre ces associations et savoir s'ils ont un potentiel thérapeutique.

The impact of COVID-19 on antimicrobial stewardship programme implementation in hospitals - an exploration informed by the Consolidated Framework for Implementation Research.

INTRODUCTION AND OBJECTIVES: The disruption of antimicrobial stewardship programmes (ASPs) caused by coronavirus disease 2019 (COVID-19) has been recognized but not explored in depth. This study used a theoretical, qualitative approach to understand the impact of COVID-19 on ASP implementation in hospitals. METHODS: Semi-structured online interviews, informed by the Consolidated Framework for Implementation Research (CFIR), were conducted with ASP team members and non-members in hospitals. Participants were recruited via purposeful and snowball sampling with interviews video recorded, transcribed and analysed independently by two researchers based on mapping against CFIR constructs. RESULTS: Thirty-one interviews were conducted across 11 hospitals. The following themes were identified: (i) increased complexity of ASP implementation and changes in prescribing behaviour influenced by COVID-19; (ii) adaptations, networking and cosmopolitanism to enhance integration of COVID-19 management into ASP services; and (iii) adaptations and networking to support continuity of the ASP implementation process. A disruption to pre-pandemic ASP activities was reported, with complexity of COVID-19 overwhelming the healthcare system. ASP team members and services showed an ability to adapt and repurpose roles to respond to the pandemic. Interventions included developing national guidelines for treatment of patients with COVID-19 and contributing to guideline management and monitoring. A gradual restoration of ASP activities was perceived. Technological adaptations and enhancements in networking were reported as positive impacts of the pandemic. CONCLUSION: Despite the initial disruption of ASP implementation caused by the pandemic, successful adaptation and evolution of ASP services reflects the high value and adaptability of ASP implementation in hospitals in the United Arab Emirates.

Biomechanical Comparison of a 3-Loop Pulley and a 4-Loop Pulley Suture for Tenorrhaphy in the Canine Gastrocnemius Tendon.

OBJECTIVE: The aim of this study was to compare a 3-loop pulley (3LP) suture pattern with a 4-loop pulley (4LP) suture pattern for the tenorrhaphy of the canine gastrocnemius tendon STUDY DESIGN: Randomized, cadaveric, biomechanical study of 30 canine gastrocnemius tendons. Tendons were transected and repaired with either 3LP or 4LP suture pattern with 2-0 polypropylene. A tensile load was applied at 25 mm/min until construct failure. The load required to form a 1 mm gap, 3 mm gap and maximum load at failure was recorded and compared between groups. RESULTS: The estimated mean load to form a 1 mm gap for the 3LP and 4LP was 28.4 N (95% confidence interval [CI]: 24.0-32.6N) and 45.5 N (95% CI: 40.7-50.1N) respectively. The 4LP mean load to form a 1 mm gap was 17.1 N (95% CI: 11.7-22.5N) greater than the 3LP. The estimated mean load to form a 3mm gap for the 3LP and 4LP was 39.7 N (95% CI: 34.1-45.4N) and 55.0 N (95% CI: 49.3-60.9N) respectively. The mean load to form a 3mm gap was 15.3 N (95% CI: 8.5-21.9N) greater in the 4LP than the 3LP. The estimated mean load for failure in the 3LP and 4LP was 41.2 N (95% CI: 35.6-46.9 N) and 54.3 N (95% CI: 48.7-60.3 N) respectively. CONCLUSION: A 4LP pattern was biomechanically superior to a 3LP pattern, as demonstrated by a greater load required to form both a 1 and 3 mm gap and a greater load for failure CLINICAL SIGNIFICANCE: A 4LP suture pattern better resists gap formation and requires greater load prior to construct failure compared with a 3LP, in this canine gastrocnemius model.

Examination of Genetic Susceptibility in Radiation-Associated Meningioma.

Previous epidemiological studies have demonstrated elevated susceptibility to ionizing radiation in some families, thus suggesting the presence of genetic components that conferred increased rate of radiation-associated meningioma (RAM). In this study, we exome-sequenced and investigated the segregation pattern of rare deleterious variants in 11 RAM pedigrees. In addition, we performed a rare-variant association analysis in 92 unrelated familial cases of RAM that were ancestry-matched with 88 meningioma-free controls. In the pedigree analysis, we found that each family carried mostly a unique set of rare deleterious variants. A follow-up pathway analysis of the union of the genes that segregated within each of the 11 pedigrees identified a single statistically significant (q value = 7.90E-04) "ECM receptor interaction" set. In the case-control association analysis, we observed no statistically significant variants or genes after multiple testing correction; however, examination of ontological categories of the genes that associated with RAM at nominal P values <0.01 identified biologically relevant pathways such as DNA repair, cell cycle and apoptosis. These results suggest that it is unlikely that a small number of highly penetrant genes are involved in the pathogenesis of RAM. Substantially larger studies are needed to identify genetic risk variants and genes in RAM.

Investigating clinicians' determinants of antimicrobial prescribing behaviour using the Theoretical Domains Framework.

AIM: To identify and quantify potential determinants of antimicrobial prescribing behaviour, using the Theoretical Domains Framework (TDF). METHODS: A cross-sectional survey involving doctors (∼4000) and pharmacists (∼400) working within Hamad Medical Corporation (HMC), Qatar. An online questionnaire, developed with reference to the TDF, included: personal and practice demographics, and Likert statements on potential determinants of antimicrobial prescribing practice. Analysis included principal component analysis (PCA), descriptive and inferential statistics. RESULTS: In total, 535 responses were received, 339 (63.4%) from doctors. Respondents were predominantly male, 346 (64.7%). Just over half (N = 285, 53.3%) had ≤5 years' experience. PCA showed a three-component (C) solution: 'Guidelines compliance' (C1), 'Influences on practice' (C2) and 'Self-efficacy' (C3). The scales derived for each component had high internal consistency (Cronbach's alphas >0.7), indicating statistical appropriateness for developing scales. Respondents generally scored highly for 'Guidelines compliance' and 'Self-efficacy'. The lowest levels of positive scores were in relation to the items within the 'Influences on practice' component, with particular focus on TDF domains, environmental context and resources, and social influences. Inferential analysis comparing component scores across demographic characteristics showed that doctors, the more qualified and those with greater experience, were more likely to be positive in responses. CONCLUSIONS: This study has identified that environmental context and resources, and social influences, with an emphasis on pharmacists and early career clinicians, may be useful targets for behaviour change interventions to improve clinicians' antimicrobial prescribing, thereby reducing antimicrobial resistance rates. Such interventions should focus on appropriate linked behaviour-change techniques.

Age, Not Sex, Modifies the Effect of Frailty on Long-term Outcomes After Cardiac Surgery.

OBJECTIVE: To examine the prevalence of frailty in surgical patients and determine whether age and sex modify the relationship between frailty and long-term mortality. BACKGROUND: Frailty is a complex and prevalent clinical syndrome. The cardiac surgery literature consists mostly of small, single-center studies, and the epidemiology of frailty remains to be fully elucidated in a real-world surgical population. METHODS: This retrospective cohort study included patients who underwent coronary artery bypass grafting, and/or aortic, mitral or tricuspid valve surgery in Ontario, Canada, between 2008 and 2016. The primary outcome was all-cause mortality. Survival probabilities were calculated using the Kaplan-Meier method, and the association of covariates with the hazard of death was assessed using multivariable Cox proportional hazard models. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. RESULTS: Of 72,824 patients, 11,685 (16%) were frail. At median 5 ±â€Š2 years of follow-up, 2921 (25.0%) frail patients and 8637 (14.1%) non-frail patients had died [adjusted hazard ratio 1.60; 95% confidence interval (CI), 1.53-1.68]. The adjusted hazard ratio was highest in patients who underwent isolated mitral (2.18; 95% CI, 1.71-2.77) and mitral + aortic valve surgery (1.85; 95% CI, 1.33-2.58) and lowest after coronary artery bypass grafting + mitral valve surgery (1.38; 95% CI, 1.11-1.70). Age, but not sex, modified the effect of frailty on mortality; such that the rate of death decreased linearly with increasing patient age. CONCLUSIONS: We observed a high prevalence of frailty in patients undergoing cardiac surgery, and a statistically significant association between frailty and long-term mortality after cardiac procedures. Importantly, the rate of death was inversely proportional to age, such that frailty had a stronger adverse impact on younger patients. Our findings highlight the need to incorporate frailty into the preoperative risk stratification and investigate strategies to support younger patients who are frail.

Nursing - a core element of rehabilitation.

AIM: 2020 was been acknowledged by the World Health Organization as the International Year of the Nurse and the Midwife. On this occasion, the Global Rehabilitation Alliance and the International Council of Nurse would like to conceptually reflect the role of nurses in rehabilitation. BACKGROUND: Rehabilitation and nursing are strictly ingrained. Rehabilitation aims at improving, reaching and maintaining optimal functioning of persons with disability and persons with health conditions experiencing disability. Nursing is defined as use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life. Nursing has a crucial role in all phases of rehabilitation care (acute, post-acute and long-term rehabilitation). Nurses deliver rehabilitation in many settings, in nursing homes and community-based rehabilitation. The main principle is not to deliver care for the patient but deliver care with the patient. This includes explaining, demonstrating and practising with the goal to help the patient to (re-)gain independence. DISCUSSION: Nurses play an important role in delivering rehabilitation and are involved in all aspects of the multidimensional rehabilitation process. One of the important points is that in most settings, nurses are the professionals with a prolonged relationship with patients and families, and may have the best insight into the patients' personal and contextual factors with regard to the rehabilitation process. CONCLUSION AND IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY: Strengthening nursing in rehabilitation is a vital factor to deliver high-quality rehabilitation and to achieve optimum outcomes. For this reason, we urge all relevant stakeholders at governmental and rehabilitation service provider levels to work towards these goals.