Appendicitis in the COVID-19 era: a modern challenge for experienced hands.

INTRODUCTION: The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19. METHODS: Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system. RESULTS: Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798). CONCLUSIONS: Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.

Predictive value of Altmetric score on citation rates and bibliometric impact.

BACKGROUND: Bibliometric and Altmetric analyses provide different perspectives regarding research impact. This study aimed to determine whether Altmetric score was associated with citation rate independent of established bibliometrics. METHODS: Citations related to a previous cohort of 100 most cited articles in surgery were collected and a 3-year interval citation gain calculated. Citation count, citation rate index, Altmetric score, 5-year impact factor, and Oxford Centre for Evidence-Based Medicine levels were used to estimate citation rate prospect. RESULTS: The median interval citation gain was 161 (i.q.r. 83-281); 74 and 62 articles had an increase in citation rate index (median increase 2.8 (i.q.r. -0.1 to 7.7)) and Altmetric score (median increase 3 (0-4)) respectively. Receiver operating characteristic (ROC) curve analysis revealed that citation rate index (area under the curve (AUC) 0.86, 95 per cent c.i. 0.79 to 0.93; P < 0.001) and Altmetric score (AUC 0.65, 0.55 to 0.76; P = 0.008) were associated with higher interval citation gain. An Altmetric score critical threshold of 2 or more was associated with a better interval citation gain when dichotomized at the interval citation gain median (odds ratio (OR) 4.94, 95 per cent c.i. 1.99 to 12.26; P = 0.001) or upper quartile (OR 4.13, 1.60 to 10.66; P = 0.003). Multivariable analysis revealed only citation rate index to be independently associated with interval citation gain when dichotomized at the median (OR 18.22, 6.70 to 49.55; P < 0.001) or upper quartile (OR 19.30, 4.23 to 88.15; P < 0.001). CONCLUSION: Citation rate index and Altmetric score appear to be important predictors of interval citation gain, and better at predicting future citations than the historical and established impact factor and Oxford Centre for Evidence-Based Medicine quality descriptors.

Experimental infrared point-source detection using an iterative generalized likelihood ratio test algorithm.

This work documents the performance of a recently proposed generalized likelihood ratio test (GLRT) algorithm in detecting thermal point-source targets against a sky background. A calibrated source is placed above the horizon at various ranges and then imaged using a mid-wave infrared camera. The proposed algorithm combines a so-called "shrinkage" estimator of the background covariance matrix and an iterative maximum likelihood estimator of the point-source parameters to produce the GLRT statistic. It is clearly shown that the proposed approach results in better detection performance than either standard energy detection or previous implementations of the GLRT detector.

Range performance of the DARPA AWARE wide field-of-view visible imager.

In a prior paper, we described a new imaging architecture that addresses the need for wide field-of-view imaging combined with the resolution required to identify targets at long range. Over the last two years substantive improvements have been made to the system, both in terms of the size, weight, and power of the camera as well as to the optics and data management software. The result is an overall improvement in system performance, which we demonstrate via a maritime target identification experiment.

Characterization of the AWARE 10 two-gigapixel wide-field-of-view visible imager.

System requirements for many military electro-optic and IR camera systems reflect the need for both wide-field-of-view situational awareness as well as high-resolution imaging for target identification. In this work we present a new imaging system architecture designed to perform both functions simultaneously and the AWARE 10 camera as an example at visible wavelengths. We first describe the basic system architecture and user interface followed by a laboratory characterization of the system optical performance. We then describe a field experiment in which the camera was used to identify several maritime targets at varying range. The experimental results indicate that users of the system are able to correctly identify ~10 m targets at between 4 and 6 km with 70% accuracy.

Fludarabine as a risk factor for poor stem cell harvest, treatment-related MDS and AML in follicular lymphoma patients after autologous hematopoietic cell transplantation.

Fludarabine is an effective treatment for follicular lymphoma (FL), but exposure to it negatively impacts stem cell mobilization and may increase the risk of subsequent myelodysplastic syndrome and acute myelogenous leukemia (t-MDS/AML). We hypothesized that the risk that fludarabine imparts to stem cell mobilization and t-MDS/AML would be affected by dose or timing. All patients with FL treated at Cleveland Clinic from 1991 to 2007 with autologous hematopoietic cell transplantation were evaluated. Recursive partitioning analysis was used to explore associations of fludarabine and mitoxantrone dose and timing with poor stem cell harvest and t-MDS/AML. We identified 171 patients, of whom 52 previously received fludarabine. Patients exposed to fludarabine prior to auto-HCT were more likely to require >5 days of leukapheresis (P<0.001) and second stem cell mobilization (P<0.001), especially at a cumulative dose >150 mg/m(2). Univariable risk factors for t-MDS/AML included the number of chemotherapy regimens before auto-HCT, the need for >5 days of leukapheresis to collect CD34+ cells and fludarabine exposure in a dose-dependent manner, particularly when >500 mg/m(2). A cumulative dose of fludarabine >150 mg/m(2) increases the risk for poor stem cell harvests and any exposure increases the risk of t-MDS/AML, with the greatest risk being at doses >500 mg/m(2).

Determination of an optimal dose of medetomidine-ketamine-buprenorphine for anaesthesia in the Cape ground squirrel (Xerus inauris).

The optimal dose of medetomidine-ketamine-buprenorphine was determined in 25 Cape ground squirrels (Xerus inauris) undergoing surgical implantation of a temperature logger into the abdominal cavity. At the end of anaesthesia, the squirrels were given atipamezole intramuscularly to reverse the effects of medetomidine. The mean dose of medetomidine was 67.6 +/- 9.2microg/kg, ketamine 13.6 +/- 1.9 mg/kg and buprenorphine 0.5 +/- 0.06 microg/kg. Induction time was 3.1 +/- 1.4 min. This produced surgical anaesthesia for 21 +/- 4.2 min. Atipamezole 232 +/- 92 microg/kg produced a rapid recovery. Squirrels were sternally recumbent in 3.5 +/- 2.2 min.

Alternative reproductive tactics in male Cape ground squirrels Xerus inauris.

In some animal societies, males vary in the strategies and tactics that they use for reproduction. Explanations for the evolution of alternative tactics have usually focussed on extrinsic factors such as social status, the environment or population density and have rarely examined proximate differences between individuals. Anecdotal evidence suggests that two alternative reproductive tactics occur in cooperatively breeding male Cape ground squirrels. Here we show that there is strong empirical support for physiological and behavioural differences to uphold this claim. 'Dispersed' males have higher resting metabolic rates and a heightened pituitary activity, compared with philopatric 'natal' males that have higher circulating cortisol levels. Dispersed males also spend more time moving and less time feeding than natal males. Additionally, lone males spend a greater proportion of their time vigilant and less of their time foraging than those that were in groups. The choice of whether to stay natal or become a disperser may depend on a number of factors such as age, natal group kin structure and reproductive suppression, and the likelihood of successful reproduction whilst remaining natal. Measuring proximate factors, such as behavioural and endocrine function, may provide valuable insights into mechanisms that underlie the evolution of alternative reproductive tactics.

Energetic costs of parasitism in the Cape ground squirrel Xerus inauris.

Parasites have been suggested to influence many aspects of host behaviour. Some of these effects may be mediated via their impact on host energy budgets. This impact may include effects on both energy intake and absorption as well as components of expenditure, including resting metabolic rate (RMR) and activity (e.g. grooming). Despite their potential importance, the energy costs of parasitism have seldom been directly quantified in a field setting. Here we pharmacologically treated female Cape ground squirrels (Xerus inauris) with anti-parasite drugs and measured the change in body composition, the daily energy expenditure (DEE) using doubly labelled water, the RMR by respirometry and the proportions of time spent looking for food, feeding, moving and grooming. Post-treatment animals gained an average 19g of fat or approximately 25kJd-1. DEE averaged 382kJd-1 prior to and 375kJd-1 post treatment (p>0.05). RMR averaged 174kJd-1 prior to and 217kJd-1 post treatment (p<0.009). Post-treatment animals spent less time looking for food and grooming, but more time on feeding. A primary impact of infection by parasites could be suppression of feeding behaviour and, hence, total available energy resources. The significant elevation of RMR after treatment was unexpected. One explanation might be that parasites produce metabolic by-products that suppress RMR. Overall, these findings suggest that impacts of parasites on host energy budgets are complex and are not easily explained by simple effects such as stimulation of a costly immune response. There is currently no broadly generalizable framework available for predicting the energetic consequences of parasitic infection.

Effects of storage treatment on fecal steroid hormone concentrations of a rodent, the Cape ground squirrel (Xerus inauris).

Fecal steroid analysis is an increasingly common non-invasive technique used in both captive and field studies to measure an animal's approximate hormonal levels and corresponding physiological state. Fecal collection in the field necessitates storage and transportation methods that will prevent the degradation of hormonal metabolites by fecal bacteria. To determine the most stable and therefore preferred method of storage, 48 fecal samples were collected from six captive female Cape ground squirrels (Xerus inauris). Each sample was randomly divided into three sub-samples to be processed for storage through freezing, drying, or preservation in ethanol. Frozen samples were stored at -20 degrees C, dried-treated samples were desiccated in a conventional oven at 40 degrees C for 4 h, and alcohol-treated samples were preserved in 3 ml of 95% ethanol. Samples were stored for 330 days followed by enzyme immunoassay analysis (EIA) to determine their progestogen and estrone conjugate (E(1)C) concentrations. Validations were performed to establish that the progestogen and E(1)C assays accurately measure fecal progestogen and estrone conjugate concentrations and were sensitive enough to detect biologically meaningful differences in these steroid metabolite concentrations in female X. inauris. Validation results showed a significant difference in progestogen concentrations of gravid females compared to sub-adults and non-gravid females. There was also a significant difference in estrone conjugates between sub-adult and adult females. Duration of storage time did not affect progestogen or estrone metabolite concentrations after being frozen for 3 months. Storage treatment results showed no significant difference between frozen and dried samples, but a significant difference was found between frozen and ethanol samples in both progestogen and estrone conjugate concentrations demonstrating that drying feces provides a reliable method for long-term preservation of fecal steroid concentrations and is the better alternative when freezing is not a viable option.

Phylogeny and historical biogeography of African ground squirrels: the role of climate change in the evolution of Xerus.

We used phylogenetic and phylogeographical methods to infer relationships among African ground squirrels of the genus Xerus. Using Bayesian, maximum-parsimony, nested clade and coalescent analyses of cytochrome b sequences, we inferred interspecific relationships, evaluated the specific distinctness of Cape (Xerus inauris) and mountain (Xerus princeps) ground squirrels, and tested hypotheses for historical patterns of gene flow within X. inauris. The inferred phylogeny supports the hypothesized existence of an 'arid corridor' from the Horn of Africa to the Cape region. Although doubts have been raised regarding the specific distinctness of X. inauris and X. princeps, our analyses show that each represents a distinct well-supported, monophyletic lineage. Xerus inauris includes three major clades, two of which are geographically restricted. The distributions of X. inauris populations are concordant with divergences within and disjunctions between other taxa, which have been interpreted as results of Plio-Pleistocene climate cycles. Nested clade analysis, coalescent analyses, and analyses of genetic structure support allopatric fragmentation as the cause of the deep divergences within this species.

Helping foster parents cope with separation, loss, and grief.

Major changes in planning for children in foster care have resulted in significant changes in the roles of and expectations for foster parents, accompanied by even less attention to the issues of foster families' grief and loss. This article focuses on (1) the many ways foster parents encounter loss and grief on a continuous basis; (2) factors that affect the intensity of the loss and the healthy expression and resolution of grief; (3) problems that can result when the grief of foster parents is not adequately addressed; and (4) ways in which professionals can be helpful to these caregivers around loss and grief.

Training of acute confusion resource nurses. Knowledge, perceived confidence, and role.

Most nurses function as generalists; however, some function in "expert" roles based on informal training as Resource Nurses. Training usually focuses on assessment and management of a specific problem, with the goal of creating a readily available "expert" for every unit. The primary activity of the Resource Nurse is to provide expert care, education, and consultation for patients, families, and staff. The Iowa-Veterans Affairs Nursing Research Consortium (IVANRC) addressed the need to manage acutely confused/delirious clients by training staff nurse volunteers (N = 129) from all units of the four Iowa Veterans Affairs facilities to act as unit-based acute confusion Resource Nurses (ACRNs). A day-long workshop included didactic content addressing etiology and presentation of acute confusion (AC), use of the IVANRC protocol to assess for AC, and basic information on treatment and management of AC. The nurses also participated in an efficacy-based experiential learning program on AC assessment that involved demonstrating assessment of AC and role enactment practice exercises in which ACRNs practiced the assessment. A test of knowledge of AC and perceived level of confidence in assessing acutely confused patients was administered before and after completion of the program. Paired t tests comparing pre- and posttest scores showed that knowledge and confidence significantly increased for the nurses as a result of their participation in the educational program. Eighteen months later, a second program was conducted to update current ACRNs and train additional RNs to enact this role. Pre- and posttest scores were obtained, with paired t tests showing a significant increase in knowledge for the participants. Twenty-four (49%) of the second program attendees had attended the first program. These participants had significantly higher scores on the second program pretest than those participants who had not attended the previous program, indicating a retention of knowledge from the first program.

Experiences, concerns, and service needs of families adopting children with prenatal substance exposure: summary and recommendations.

Parents who adopted children from out-of-home care with prenatal substance exposure were interviewed four months after the child's placement in the home, and again after the first year regarding their experience with adoption and their concerns about their child's development, attachment, and behavior; aspects of parenting and the adoption process; effects of prenatal substance exposure; and availability and helpfulness of resources. Adoptive parents found parenting children with prenatal substance exposure to be both more rewarding and more difficult than they had imagined.

Unit-based acute confusion resource nurse: an educational program to train staff nurses.

Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.

Posttraumatic stress disorder among female juvenile offenders.

OBJECTIVE: While there is a growing body of evidence that psychopathology is common among incarcerated boys, relatively little is known about the prevalence and manifestations of mental health problems among incarcerated girls. This study examines the incidence of posttraumatic stress disorder (PTSD) in a sample of 96 adolescent female offenders and its relation to socioemotional adjustment. METHOD: Self-report questionnaires were used to tap socioemotional adjustment, and a semistructured interview was conducted to determine PTSD symptomatology. RESULTS: The results indicate that the rate of PTSD among incarcerated female delinquents not only is higher than that in the general population but surpasses the incidence of PTSD among incarcerated male delinquents. In addition, those who suffer from PTSD also tend to exhibit higher levels of distress and lower levels of self-restraint. CONCLUSIONS: These findings provide a starting point for more detailed investigations of the relations between trauma, psychopathology, and violence and suggest that the study of trauma may offer a new way of looking at links between victim and perpetrator.

ATM-dependent activation of p53 involves dephosphorylation and association with 14-3-3 proteins.

The p53 tumour-suppressor protein is a sequence-specific DNA-binding transcription factor that induces cell cycle arrest or apoptosis in response to genotoxic stress. Activation of p53 by DNA-damaging agents is critical for eliminating cells with damaged genomic DNA and underlies the apoptotic response of human cancers treated with ionizing radiation (IR) and radiomimetic drugs. The molecular mechanisms by which DNA damage activates p53 have not been elucidated. Both the levels of p53 protein and its affinity for specific DNA sequences increase in response to genotoxic stress. In vitro, the affinity of p53 for DNA is regulated by its carboxy-terminus. We therefore examined whether this region of p53 is targeted by DNA-damage signalling pathways in vivo. In nonirradiated cells, serines 376 and 378 of p53 were phosphorylated. IR led to dephosphorylation of Ser376, creating a consensus binding site for 14-3-3 proteins and leading to association of p53 with 14-3-3. In turn, this increased the affinity of p53 for sequence-specific DNA. Consistent with the lack of p53 activation by IR in ataxia telangiectasia (AT; refs 14,15), neither Ser376 dephosphorylation, nor the interaction of p53 with 14-3-3 proteins occurred in AT cells.