Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches.

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review.

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Dietary isoacids effects on growth, nitrogen, and energy digestibility, and fecal VFA and microbial ecology in finishing pigs.

Isoacids are branched ketoacids which when fed to ruminants have been shown to enhance the growth of fiber-digesting organisms. Ninety finishing gilts were individually fed dietary treatments consisting of diet type: corn-soybean meal (CSBM), a diet containing 40% distillers dried grains with solubles (DDGS), or a diet containing 40% sugar beet pulp (SBP); in combination with either no feed additive (CNT), the addition of 0.50% isobutyrate (IB), or the addition of a 0.88% mix of isobutyrate, isovalerate, and 2-methylbutyrate (MX). Gilts consumed an average of 2.171 kg/d over the 28-d trial. On d 26, fresh fecal samples were collected for determination of apparent total tract digestibility (ATTD) of gross energy (GE) and nitrogen (N), determination of fecal volatile fatty acids (VFA), and evaluation of microbial ecology. There was no interaction between diet type and isoacid addition, and no main effect of isoacid or diet type on alpha or Shannon microbial diversity measures (P > 0.05). There was no interaction between isoacid addition and diet type, and no main effect of isoacid addition on microbial beta diversity (P > 0.05), but differences were observed in microbial beta diversity due to diet type (P ≤ 0.05). There was no interaction between diet type and isoacid addition observed in fecal VFA concentrations (P > 0.05), with only minor differences in fecal VFA concentrations noted due to isoacid addition (P ≤ 0.05). The interaction between diet type and isoacid addition on ATTD of dietary GE and N (P ≤ 0.01) was largely because the addition of IB did not affect ATTD of GE or N in pigs fed the CSBM diet, but increased ATTD of GE and N in pigs fed diets containing DDGS and decreased the ATTD of GE and N in pigs fed diets containing SBP. In contrast, adding a blend of isoacids (i.e., MX) reduced the ATTD of GE and N, regardless of diet type. There was no interaction between diet type and isoacid addition, and no effect of isoacid addition was observed on pig performance (P > 0.05). Diet type did not affect ADG (P > 0.05), but pigs fed diets containing DDGS or SBP consumed less feed (P = 0.01) and exhibited greater GF ratios compared to pigs fed the low-fiber CSBM diet (P ≤ 0.05). In conclusion, there was little to no effect of isoacid addition on microbial ecology, fecal VFA concentrations, ATTD of GE or N, or pig performance, but the improvement in ATTD of GE and N in pigs fed diets containing DDGS when IB was added warrants further investigation.

Discovery, Multiparametric Optimization, and Solid-State Driven Identification of CHF-6550, a Novel Soft Dual Pharmacology Muscarinic Antagonist and ß2 Agonist (MABA) for the Inhaled Treatment of Respiratory Diseases.

Clinical guidelines for COPD and asthma recommend inhaled ß-adrenergic agonists, muscarinic antagonists, and, for frequent exacerbators, inhaled corticosteroids, with the challenge of combining them into a single device. The MABA (muscarinic antagonist and ß2 agonist) concept has the potential to simplify this complexity while increasing the efficacy of both pharmacologies. In this article, we report the outcome of our solid-state driven back-up program that led to the discovery of the MABA compound CHF-6550. A soft drug approach was applied, aiming at high plasma protein binding and high hepatic clearance, concurrently with an early stage assessment of crystallinity through a dedicated experimental workflow. A new chemotype was identified, the diphenyl hydroxyacetic esters, able to generate crystalline material. Among this class, CHF-6550 demonstrated in vivo efficacy, suitability for dry powder inhaler development, favorable pharmacokinetics, and safety in preclinical settings and was selected as a back-up candidate, fulfilling the desired pharmacological and solid-state profile.

Timing of Autologous Tissue Breast Reconstruction Does Not Affect Free Flap Failure.

ABSTRACT: This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival.

INTRODUCTION: A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates. METHODS: The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval. RESULTS: Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05). DISCUSSION: Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

Smoking cessation decreases arterial blood pressure in hypertensive smokers: A subgroup analysis of the randomized controlled trial GENTSMOKING.

INTRODUCTION: High blood pressure in hypertensive smokers is affected by nicotine consumption. This study aimed to evaluate the effect of smoking cessation treatments on blood pressure in hypertensive smokers. METHODS: A total of 113 hypertensive smokers on antihypertensives during smoking cessation treatment in the randomized controlled trial GENTSMOKING were considered for analysis. At Baseline (T0) and Week 12 (T12), systolic and diastolic blood pressure (SBP and DBP), and heart rate (HR) were measured using a semi-automated digital oscillometric device. Mean arterial pressure (MAP) and delta differences for SBP, DBP, HR, and MAP were calculated. Smoking cessation was confirmed by measuring carbon monoxide (CO) in exhaled air. RESULTS: After 12 weeks of treatment, 72 participants ceased smoking (cessation group) and 41 did not (no cessation group). At T0, there was no statistically meaningful difference between groups with respect to age, body mass index, CO, and daily cigarette consumption. At T12, daily cigarette consumption and CO had decreased in both groups (p<0.001). The cessation group showed decreased SBP (131 ± 2 vs 125 ± 2 mmHg, p=0.004), DBP (79 ± 1 vs 77 ± 1 mmHg, p=0.031), MAP (96 ± 1 vs 93 ± 1 mmHg, p=0.005), and HR (79 ± 1 vs 74 ± 1 beats/min, p=0.001), and increased body weight (77.4 ± 2.1 vs 79.2 ± 2.2 kg, p<0.001). No significant differences were seen for these variables in the no cessation group. Decrease in blood pressure was significantly higher among hypertensive participants with SBP ≥130 mmHg: SBP (145 ± 2 vs 132 ± 2 mmHg, p<0.001), DBP (85 ± 2 vs 80 ± 1 mmHg, p=0.002), MAP (105 ± 1 vs 97 ± 1 mmHg, p<0.001), and HR (81 ± 2 vs 74 ± 2 beats/min, p=0.002). A positive correlation was found between HR and CO (r=0.34; p=0.001). CONCLUSIONS: Smoking cessation treatment reduced blood pressure in hypertensive smokers, allowing them to reach therapeutic targets for hypertension management. Smoking cessation has a positive impact on hypertension treatment; therefore, it should be encouraged in clinical practice. CLINICALTRIALSGOV IDENTIFIER: NCT03362099.

Random forest identifies predictors of discharge destination following total shoulder arthroplasty.

Background: Machine learning algorithms are finding increasing use in prediction of surgical outcomes in orthopedics. Random forest is one of such algorithms popular for its relative ease of application and high predictability. In the process of sample classification, algorithms also generate a list of variables most crucial in the sorting process. Total shoulder arthroplasty (TSA) is a common orthopedic procedure after which most patients are discharged home. The authors hypothesized that random forest algorithm would be able to determine most important variables in prediction of nonhome discharge. Methods: Authors filtered the National Surgical Quality iImprovement Program database for patients undergoing elective TSA (Current Procedural Terminology 23472) between 2008 and 2018. Applied exclusion criteria included avascular necrosis, trauma, rheumatoid arthritis, and other inflammatory arthropathies to only include surgeries performed for primary osteoarthritis. Using Python and the scikit-learn package, various machine learning algorithms including random forest were trained based on the sample patients to predict patients who had nonhome discharge (to facility, nursing home, etc.). List of applied variables were then organized in order of feature importance. The algorithms were evaluated based on area under the curve of the receiver operating characteristic, accuracy, recall, and the F-1 score. Results: Application of inclusion and exclusion criteria yielded 18,883 patients undergoing elective TSA, of whom 1813 patients had nonhome discharge. Random forest outperformed other machine learning algorithms and logistic regression based on American Society of Anesthesiologists (ASA) classification. Random forest ranked age, sex, ASA classification, and functional status as the most important variables with feature importance of 0.340, 0.130, 0.126, and 0.120, respectively. Average age of patients going to facility was 76 years, while average age of patients going home was 68 years. 78.1% of patients going to facility were women, while 52.7% of patients going home were. Among patients with nonhome discharge, 80.3% had ASA scores of 3 or 4, while patients going home had 54% of patients with ASA scores 3 or 4. 10.5% of patients going to facility were considered of partially/totally dependent functional status, whereas 1.3% of patients going home were considered partially or totally dependent (P value < .05 for all). Conclusion: Of various algorithms, random forest best predicted discharge destination following TSA. When using random forest to predict nonhome discharge after TSA, age, gender, ASA scores, and functional status were the most important variables. Two patient groups (home discharge, nonhome discharge) were significantly different when it came to age, gender distribution, ASA scores, and functional status.

Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up.

Purpose: To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up. Methods: A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound. Results: We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores. Conclusions: SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months. Level of Evidence: Level IV, therapeutic case series.

Reduced Access to Acute Hand Care and Potential Role of Telemedicine in Tennessee During the COVID Pandemic.

INTRODUCTION: Previous studies have identified that there is limited, although expanding, access to acute hand care in Tennessee. Because of the rapid changes that occurred in health delivery and access during the coronavirus disease pandemic, we reassessed access to acute hand care, with particular interest in the utilization of telemedicine to assess if this increased access. METHOD: We surveyed Tennessee hospitals listed by the Tennessee Hospital Association on their management of hand trauma and availability of telemedicine programs. Census data including population demographics such as race, age, income, and county size were merged with the survey data. Descriptive analysis was performed comparing the 2021 cohort with the historic 2018 cohort and between counties that had hand care versus counties that had no hand care. RESULT: Survey response rate was 71.4% (n = 80 of 112). Telemedicine was used in 80% of the hospitals for other specialties but was not used for hand care. Overall, counties that offered hand trauma care reduced from 60% to 26% from 2018 to 2021 ( P < 0.001). This change was associated with a significant reduction of acute hand care among counties that were classified micropolitan (from 56.3% to 6.7%, P < 0.01). Percentage of hand specialists on staff and 24/7 specialists availability remained low and were similar to the availability in 2018. CONCLUSIONS: There was a decrease of acute hand care access in Tennessee during the coronavirus disease pandemic despite widespread utilization of telemedicine for other specialty consults. Expansion of telemedicine in acute hand care, targeted to micropolitan areas, may help to reduce variability in access to care.

Systematic Review and Meta-Analysis of Global Neuroma Incidence in Upper Extremity Amputees.

BACKGROUND: Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees. METHODS: A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review. RESULTS: Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment. CONCLUSIONS: The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.

Effect of a Perioperative Educational Video in Patients Undergoing Mohs Reconstruction: A Randomized Clinical Trial.

BACKGROUND: Skin cancer is the most common type of cancer in the United States, and most are treated with Mohs micrographic surgery (MMS) by fellowship-trained dermatologic surgeons. Complex reconstruction in cosmetically and functionally sensitive areas often requires a plastic surgery consult. The uncertainty regarding reconstructive options and cosmetic appearance is difficult emotionally and cognitively for patients. OBJECTIVES: To improve patient understanding about MMS reconstruction with plastic surgeons, we investigated the utility of a multimedia presentation during perioperative education. METHODS: A randomized clinical trial was conducted at a hospital-affiliated outpatient MMS clinic and surgery center in the United States. Patients in the intervention arm were given a tablet or Web site link to watch a multimedia presentation about reconstruction after MMS. All patients were given a questionnaire about their understanding of MMS reconstruction and satisfaction with the reconstructive care they received. RESULTS: A total of 46 patients were recruited for the study and completed the questionnaire. Of these patients, 22 were randomized to the test intervention arm, and the remaining 24 were in the control group. Among participants in the test intervention arm, feedback regarding the platform was positive with more than 90% of patients reporting that the video was engaging, useful, and easy to understand. Patient understanding and satisfaction scores in the test intervention arm ranked higher across all domains than those of the control group. CONCLUSIONS: This randomized clinical trial showed increases in patient understanding and satisfaction among patients undergoing MMS reconstruction with the implementation of a perioperative educational video.

Mapping Single-Molecule Protein Complexes in 3D with DNA Nanoswitch Calipers.

The ability to accurately map the 3D geometry of single-molecule complexes in trace samples is a challenging goal that would lead to new insights into molecular mechanics and provide an approach for single-molecule structural proteomics. To enable this, we have developed a high-resolution force spectroscopy method capable of measuring multiple distances between labeled sites in natively folded protein complexes. Our approach combines reconfigurable nanoscale devices, we call DNA nanoswitch calipers, with a force-based barcoding system to distinguish each measurement location. We demonstrate our approach by reconstructing the tetrahedral geometry of biotin-binding sites in natively folded streptavidin, with 1.5-2.5 Å agreement with previously reported structures.

Deeply jaundiced: Not so surgical after all.

Leptospirosis is an under-recognised disease in sub-Saharan Africa and the diagnosis requires a high index of suspicion. This case report highlights the protean manifestations of leptospirosis. Leptospirosis should be considered in any patient presenting with fever and jaundice, especially when there has been a history of occupational or recreational exposure to water, soil or rodents. Contribution: This case report describes a typical case of leptospirosis, which often presents as a diagnostic dilemma.

Health literacy in rotator cuff repair: a quantitative assessment of the understandability of online patient education material.

Background: The American Medical Association and National Institutes of Health recommend online health information be written at a 6th grade or lower reading level for clear understanding. While syntax reading grade level has previously been utilized, those analyses do not determine whether readers are processing key information (understandability) or identifying available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a method to measure the understandability and actionability of online patient education materials. The purpose of this study was to evaluate online resources regarding rotator cuff repair utilizing measures of readability, understandability, and actionability. Methods: The search term "rotator cuff surgery" was used in two independent online searches to obtain the top 50 search results. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level, Simple Measure of Gobbledygook grade, Coleman-Liau Index, and Gunning Fog Index. The PEMAT-P form was used to assess actionability and understandability. Results: A total of 49 unique websites were identified to meet our inclusion criteria and were included in our analysis. The mean Flesch-Kincaid Grade Level graded materials at a 10.6 (approximately a 10th grade reading level), with only two websites offering materials at a 6th grade reading level or below. The remaining readability studies graded the mean reading level at high school or greater, with the Gunning Fog Index scoring at a collegiate reading level. Mean understandability and actionability scores were 64.6% and 29.5%, respectively, falling below the 70% PEMAT score threshold for both scales. Fourteen (28.6%) websites were above the threshold for understandability, while no website (0%) scored above the 70% threshold for actionability. When comparing source categories, commercial health publishers provided websites that scored higher in understandability (P < .05), while private practice materials scored higher in actionability (P < .05). Resources published by academic institutions or organizations scored lower in both understandability and actionability than private practice and commercial health publishers (P < .05). No readability, understandability, or actionability score was significantly associated with search result rank. Conclusion: Overall, online patient education materials related to rotator cuff surgery scored poorly with respect to readability, understandability, and actionability. Only two (4.1%) of the patient education websites scored at the American Medical Association and National Institutes of Health recommended reading level. Fourteen (28.6%) scored above the 70% PEMAT score for understandability; however, no website met the threshold for actionability.

Complexity measure based on sensitivity analysis applied to an intensive care unit system.

This work proposes a system complexity metric and its application to Intensive Care Unit (ICU) system. The methodology for applying said complexity metric comprises: (i) parameters sensitivity indices calculation, (ii) mapping connections dynamics between system components, and (iii) system's complexity calculation. After simulating the ICU computer model and using the proposed methodology, we obtained results regarding: number of admissions, number of patients in the queue, length of stay, beds in use, ICU performance, and system complexity values (in regular or overloaded operation). As the number of patients in the queue increased, the ICU system complexity also increased, indicating a need for policies to promote system robustness.

A non-enzymatic test for SARS-CoV-2 RNA using DNA nanoswitches.

The emergence of a highly contagious novel coronavirus in 2019 led to an unprecedented need for large scale diagnostic testing. The associated challenges including reagent shortages, cost, deployment delays, and turnaround time have all highlighted the need for an alternative suite of low-cost tests. Here, we demonstrate a diagnostic test for SARS-CoV-2 RNA that provides direct detection of viral RNA and eliminates the need for costly enzymes. We employ DNA nanoswitches that respond to segments of the viral RNA by a change in shape that is readable by gel electrophoresis. A new multi-targeting approach samples 120 different viral regions to improve the limit of detection and provide robust detection of viral variants. We apply our approach to a cohort of clinical samples, positively identifying a subset of samples with high viral loads. Since our method directly detects multiple regions of viral RNA without amplification, it eliminates the risk of amplicon contamination and renders the method less susceptible to false positives. This new tool can benefit the COVID-19 pandemic and future emerging outbreaks, providing a third option between amplification-based RNA detection and protein antigen detection. Ultimately, we believe this tool can be adapted both for low-resource onsite testing as well as for monitoring viral loads in recovering patients.

Mapping Single-molecule Protein Complexes in 3D with DNA Nanoswitch Calipers.

The ability to accurately map the 3D geometry of single-molecule complexes in trace samples would lead to new insights into molecular mechanics and provide an approach for single-molecule structural proteomics. To enable this, we have developed a high-resolution force-spectroscopy method capable of measuring multiple distances between labeled sites in natively folded protein complexes. Our approach combines reconfigurable nanoscale devices we call DNA Nanoswitch Calipers, which we have previously introduced, with a force-based barcoding system to distinguish each measurement location. We demonstrate our approach by reconstructing the tetrahedral geometry of biotin-binding sites in natively folded streptavidin, with 1.5-2.5 Å agreement to previously reported structures.

Delayed Versus Immediate Breast Reconstruction in the Ambulatory Surgery Setting: A Cross-Sectional Analysis of the Nationwide Ambulatory Surgery Sample.

BACKGROUND: Breast reconstruction remains an important part of a patient's journey after the diagnosis of breast carcinoma and treatment with mastectomy. Although inpatient immediate breast reconstruction has been described, there is a paucity information about whether similar procedures are performed in the ambulatory setting. OBJECTIVE: The authors sought to investigate rates and patterns for delayed and immediate breast reconstruction in the ambulatory surgery setting using nationally representative data from 2016 to 2019. METHODS: Using the Nationwide Ambulatory Surgery Sample database, we identified patients with an International Statistical Classification of Disease and Related Health Problems, Tenth Revision, procedure code for breast reconstruction. Demographic and clinical characteristics were recorded for each encounter of breast reconstruction, and linear regression and logistic regression were used to assess for trends and disparities. RESULTS: National weighted estimates for ambulatory breast reconstruction increased by 15.6% from 89 237 in 2016 to 103 134 in 2019, resulting in 377 109 procedures during the study period. Inflation-adjusted total charges for ambulatory breast reconstruction were $14 billion between 2016 and 2019, or 1.7% of overall charges for ambulatory surgery. Immediate reconstruction was performed in 34.7% (95% CI, 33.4%-36.1%) of cases and increased by 46.9% from 26 930 in 2016 to 39 559 in 2019. Racial disparities were observed in access, comorbidities, and spending. CONCLUSIONS: Our findings indicate a moderate increase in ambulatory breast reconstruction with a substantial growth in the performance of immediate breast reconstruction in the ambulatory setting.