Influence of different stalks on the metallization degree of FeCl3-derived magnetic biochar through pyrolysis behavior and compositional differences.

To investigate the effect of stalk type on the metallization degrees in FeCl3-derived magnetic biochar (MBC), MBC was synthesized via an impregnation-pyrolysis method using six different stalks. The Fe0 content in MBC significantly influenced its magnetic properties and ostensibly governed its catalytic capabilities. Analysis of the interaction between stalks and FeCl3 revealed that the variation in metallization degrees, resulting from FeCl2 decomposition (6.1%) and stalk-mediated reduction (20.7%), was directly responsible for the observed differences in MBC metallization. The presence of oxygen-containing functional groups and fixed carbon appeared to promote metallization in MBC induced by reduction. A series of statistical analyses indicated that the cellulose, lignin, and hemicellulose content of the stalks were key factors contributing to differences in MBC metallization degrees. Further exploration revealed that hemicellulose and cellulose were more effective than lignin in enhancing metallization through FeCl2 decomposition and reduction. Constructing stalk models demonstrated that the variance in the content of these three biomass components across the six stalk types could lead to differences in the metallization degree attributable to reduction and FeCl2 decomposition, thereby affecting the overall metallization degree of MBC. A prediction model for MBC metallization degree was developed based on these findings. Moreover, the elevated Si content in some stalks facilitated the formation of Fe2(SiO4), which subsequently impeded the reduction process. This study provides a theoretical foundation for the informed selection of stalk feedstocks in the production of FeCl3-derived MBC.

Virtual parental presence with coaching for reducing preoperative anxiety in children: a feasibility and pilot randomized controlled trial.

BACKGROUND: Preoperative anxiety in children causes negative postoperative outcomes. Parental presence at induction is a non-pharmacological strategy for relieving anxiety; nevertheless, it is not always possible or effective, namely when parents are overly anxious. Parental presence via video has been demonstrated to be useful in other contexts (divorce, criminal court). This study reports the feasibility of a randomized controlled trial to investigate the effect of video parental presence and parental coaching at induction on preoperative anxiety. METHODS: The study was a randomized, 2 × 2 factorial design trial examining parental presence (virtual vs. physical) and coaching (provided vs. not provided). Feasibility was assessed by enrollment rate, attrition rate, compliance, and staff satisfaction with virtual method with the NASA-Task Load Index (NASA-TLX) and System Usability Scale (SUS). For the children's anxiety and postoperative outcomes, the modified Yale Preoperative Anxiety Scale (mYPAS) and Post-Hospitalization Behavioral Questionnaire (PHBQ) were used. Parental anxiety was evaluated with the State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS: A total of 41 parent/patient dyads were recruited. The enrollment rate was 32.2%, the attrition rate 25.5%. Compliance was 87.8% for parents and 85% for staff. The SUS was 67.5/100 and 63.5/100 and NASA-TLX was 29.2 (21.5-36.8) and 27.6 (8.2-3.7) for the anesthesiologists and induction nurses, respectively. No statistically significant difference was found in mYPAS, PHBQ and STAI. CONCLUSION: A randomized controlled trial to explore virtual parental presence effect on preoperative anxiety is feasible. Further studies are needed to investigate its role and the role of parent coaching in reducing preoperative anxiety.

Influence of soil composition and environmental factors on the adsorption of per- and polyfluoroalkyl substances: A review.

Per- and polyfluoroalkyl substances (PFASs) have garnered considerable scientific and regulatory scrutiny due to their widespread distribution across environments and their potential toxicological impacts on human health. The pedosphere serves as a vital reservoir for these chemicals, significantly determining their environmental trajectory and chemical transformations. This study offers a comprehensive synthesis of the current understanding regarding the adsorption mechanics of PFASs in soil matrices. Due to their unique molecular structure, PFASs predominantly engage in hydrophobic and electrostatic interactions during soil adsorption. This work thoroughly evaluates the influence of various factors on adsorption efficiency, including soil properties, molecular characteristics of PFASs, and the prevailing environmental conditions. The complex nature of soil environments complicates isolating individual impacts on PFAS behavior, necessitating an integrated approach to understanding their environmental destinies better. Through this exploration, we seek to clarify the complex interplay of factors that modulate the adsorption of PFASs in soils, highlighting the urgent need for future research to disentangle the intricate and combined effects that control the environmental behavior of PFAS compounds.

The Fragility Index of randomized controlled trials in pediatric anesthesiology.

PURPOSE: The P value is a widely used measure of statistical importance but has many drawbacks and limitations, one being that it does not reflect the robustness of the results of a clinical trial. The Fragility Index (FI) was developed as a measure of how many outcome events would need to change to nonevents to render a significant P value nonsignificant (P ≥ 0.05). The FI of trials from other medical specialties is typically < 5. We aimed to determine the FI of pediatric anesthesiology randomized controlled trials (RCT) and to test for association with various characteristics of the included trials. METHODS: We conducted a comprehensive systematic search of high-impact anesthesia, surgical, and medical journals from the last 25 years for trials comparing an intervention between two groups with a statistically significant P value (< 0.05) for a dichotomous outcome. We also compared FI values for variables that reflect the quality and importance of a trial. RESULTS: The median [interquartile range] FI was 3 [1-7] and correlated positively with the number of participants (rS = 0.41; P < 0.001) and events (rS = 0.42; P < 0.001), and negatively with the P value (rPB = -0.36; P < 0.001). Other measures of trial quality and impact or importance were not strongly associated with the FI. CONCLUSIONS: The FI of published trials in pediatric anesthesiology is similarly low as in other medical specialties. Larger trials with more events and P values ≤ 0.01 were associated with a higher FI.

RéSUMé: OBJECTIF: La valeur P est une mesure d'importance statistique largement utilisée, mais elle présente de nombreux inconvénients et limites, notamment parce qu'elle ne reflète pas la robustesse des résultats d'une étude clinique. L'indice de fragilité (IF) a été mis au point pour mesurer le nombre d'événements du critère d'évaluation qui devraient se transformer en non-événements pour obtenir une valeur P non significative (P ≥ 0,05). L'IF des études d'autres spécialités médicales est généralement < 5. Notre objectif était de déterminer l'IF des études randomisées contrôlées (ERC) en anesthésiologie pédiatrique et de tester l'association avec diverses caractéristiques des études incluses. MéTHODE: Nous avons réalisé une recherche systématique exhaustive dans les revues d'anesthésie, de chirurgie et médicales à fort impact des 25 dernières années pour trouver des études comparant une intervention entre deux groupes avec une valeur P significative d'un point de vue statistique (< 0,05) pour un résultat dichotomique. Nous avons également comparé les valeurs d'IF pour les variables qui reflètent la qualité et l'importance d'une étude. RéSULTATS: L'IF médian [écart interquartile] était de 3 [1 à 7] et était positivement corrélé avec le nombre de participant·es (rS = 0,41; P < 0,001) et d'événements (rS = 0,42; P < 0,001), et négativement avec la valeur P (rPB = -0,36; P < 0,001). D'autres mesures de la qualité et de l'impact ou de l'importance des études n'étaient pas fortement associées à l'IF. CONCLUSION: L'IF des études publiées en anesthésiologie pédiatrique est tout aussi faible que dans d'autres spécialités médicales. Des études plus importantes avec plus d'événements et des valeurs P ≤ 0,01 étaient associées à un IF plus élevé.

Investigation and molecular identification of Anisakis infection in marine fish sold in Fuxin, Liaoning Province / 中国热带医学

@#Abstract: Objective　To investigate the infection of Anisakis in marine fish sold in Fuxin, and conduct molecular identification and evolutionary tracing of third-stage larvae to determine Anisakis species. Methods　From 2018 to 2021, marine fish sold in the market were collected randomly, and the third stage larvae of Anisakis were detected in marine fish sold in the market by direct dissection, and the morphological characteristics were used to preliminarily identify species by microscopy; the total DNA was extracted, the internal transcribed spacer sequence of the ribosomal DNA of Anisakis was amplified, and the sequence alignment and evolution analysis were carried out. Results　A total of 289 market-sold sea fish samples of marine fish sold in the market were dissected and 84 samples of Anisakis were detected with a detection rate of 29.1%, of which the infection rates of hairtail and small yellow croaker were higher, at 41.4% and 41.2%, respectively. BLAST comparison of 28 sequences revealed eight species of anisakids, including Anisakis pegreffii, Anisakis simplex, Anisakis typical, Raphidascaris trichiurid, Contracaecum muraenesoxi, Hysterothylcaium zhoushanensis, Hysterothylacium amoyense and Hysterothylcaium fabri,belonging to the genera Anisakis and Hysterothylacium. The phylogenetic tree constructed from 28 sequences generally formed two topological branches, with Anisakis pegreffii, Anisakis simplex, and Anisakis typical forming three separate clusters as the topology branch of Anisakis genus. However, meanwhile, Hysterothylacium, Contracaecum, and Raphidascaris formed a separate topological branch. Conclusions　The marine fish sold in Fuxin City have severe anisakid infection, with a wide variety of anisakid species, the dominant species being Anisakis pegreffii.

Perfluoroalkyl Substances (PFASs) in Rivers and Drinking Waters from Qingdao, China.

Perfluoroalkyl substances (PFASs) in rivers; drinking water sources (reservoirs and groundwater); and various types of drinking waters (tap waters, barreled pure waters, and bottled mineral waters) in Qingdao, Eastern China were quantified by high-performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS). The total concentrations of PFASs (ΣPFASs) in the river waters ranged from 28.3 to 292.2 ng/L, averaging 108 ± 70.7 ng/L. PFBS was the most abundant compound, with a maximum concentration of 256.8 ng/L, followed by PFOA (maximum concentration: 72.4 ng/L) and PFBA (maximum concentration: 41.6 ng/L). High levels of PFASs were found in rivers in the suburban and rural areas. The estimated annual mass loading of the total PFASs to Jiaozhou Bay (JZB) was 5.9 tons. The PFASs in the drinking water reservoirs were relatively low. The ΣPFASs in the tap water ranged from 20.5 ng/L to 29.9 ng/L. Differences in the PFAS levels and composition profiles were found among barreled water at different market sites and for different brands of mineral water products. The sequence of the contamination levels of the waters related to drinking water was reservoir water > tap water > barrel water > groundwater > bottled mineral water. The PFASs in drinking water may not pose a serious risk to the drinking water consumers of Qingdao City.

Effect of Protein Genotypes on Physicochemical Properties and Protein Functionality of Bovine Milk: A Review.

Milk protein comprises caseins (CNs) and whey proteins, each of which has different genetic variants. Several studies have reported the frequencies of these genetic variants and the effects of variants on milk physicochemical properties and functionality. For example, the C variant and the BC haplotype of αS1-casein (αS1-CN), ß-casein (ß-CN) B and A1 variants, and κ-casein (κ-CN) B variant, are favourable for rennet coagulation, as well as the B variant of ß-lactoglobulin (ß-lg). κ-CN is reported to be the only protein influencing acid gel formation, with the AA variant contributing to a firmer acid curd. For heat stability, κ-CN B variant improves the heat resistance of milk at natural pH, and the order of heat stability between phenotypes is BB > AB > AA. The A2 variant of ß-CN is more efficient in emulsion formation, but the emulsion stability is lower than the A1 and B variants. Foaming properties of milk with ß-lg variant B are better than A, but the differences between ß-CN A1 and A2 variants are controversial. Genetic variants of milk proteins also influence milk yield, composition, quality and processability; thus, study of such relationships offers guidance for the selection of targeted genetic variants.

Dissemination of Anesthesia Information During the Coronavirus Disease 2019 Pandemic Through Twitter: An Infodemiology Study.

BACKGROUND: Twitter is a web-based social media platform that allows instantaneous sharing of user-generated messages (tweets). We performed an infodemiology study of the coronavirus disease 2019 (COVID-19) Twitter conversation related to anesthesiology to describe how Twitter has been used during the pandemic and ways to optimize Twitter use by anesthesiologists. METHODS: This was a cross-sectional study of tweets related to the specialty of anesthesiology and COVID-19 tweeted between January 21 and October 13, 2020. A publicly available COVID-19 Twitter dataset was filtered for tweets meeting inclusion criteria (tweets including anesthesiology keywords). Using descriptive statistics, tweets were reviewed for tweet and account characteristics. Tweets were filtered for specific topics of interest likely to be impactful or informative to anesthesiologists of COVID-19 practice (airway management, personal protective equipment, ventilators, COVID testing, and pain management). Tweet activity was also summarized descriptively to show temporal profiles over the pandemic. RESULTS: Between January 21 and October 13, 2020, 23,270 of 241,732,881 tweets (0.01%) met inclusion criteria and were generated by 15,770 accounts. The majority (51.9%) of accounts were from the United States. Seven hundred forty-nine (4.8%) of all users self-reported as anesthesiologists. 33.8% of all tweets included at least one word or phrase preceded by the # symbol (hashtag), which functions as a label to search for all tweets including a specific hashtag, with the most frequently used being #anesthesia. About half (52.2%) of all tweets included at least one hyperlink, most frequently linked to other social media, news organizations, medical organizations, or scientific publications. The majority of tweets (67%) were not retweeted. COVID-19 anesthesia tweet activity started before the pandemic was declared. The trend of daily tweet activity was similar to, and preceded, the US daily death count by about 2 weeks. CONCLUSIONS: The toll of the pandemic has been reflected in the anesthesiology conversation on Twitter, representing 0.01% of all COVID-19 tweets. Daily tweet activity showed how the Twitter community used the platform to learn about important topics impacting anesthesiology practice during a global pandemic. Twitter is a relevant platform through which to communicate about anesthesiology topics, but further research is required to delineate its effectiveness, benefits, and limitations for anesthesiology discussions.

General medical publications during COVID-19 show increased dissemination despite lower validation.

BACKGROUND: The COVID-19 pandemic has yielded an unprecedented quantity of new publications, contributing to an overwhelming quantity of information and leading to the rapid dissemination of less stringently validated information. Yet, a formal analysis of how the medical literature has changed during the pandemic is lacking. In this analysis, we aimed to quantify how scientific publications changed at the outset of the COVID-19 pandemic. METHODS: We performed a cross-sectional bibliometric study of published studies in four high-impact medical journals to identify differences in the characteristics of COVID-19 related publications compared to non-pandemic studies. Original investigations related to SARS-CoV-2 and COVID-19 published in March and April 2020 were identified and compared to non-COVID-19 research publications over the same two-month period in 2019 and 2020. Extracted data included publication characteristics, study characteristics, author characteristics, and impact metrics. Our primary measure was principal component analysis (PCA) of publication characteristics and impact metrics across groups. RESULTS: We identified 402 publications that met inclusion criteria: 76 were related to COVID-19; 154 and 172 were non-COVID publications over the same period in 2020 and 2019, respectively. PCA utilizing the collected bibliometric data revealed segregation of the COVID-19 literature subset from both groups of non-COVID literature (2019 and 2020). COVID-19 publications were more likely to describe prospective observational (31.6%) or case series (41.8%) studies without industry funding as compared with non-COVID articles, which were represented primarily by randomized controlled trials (32.5% and 36.6% in the non-COVID literature from 2020 and 2019, respectively). CONCLUSIONS: In this cross-sectional study of publications in four general medical journals, COVID-related articles were significantly different from non-COVID articles based on article characteristics and impact metrics. COVID-related studies were generally shorter articles reporting observational studies with less literature cited and fewer study sites, suggestive of more limited scientific support. They nevertheless had much higher dissemination.

Risk prediction models for emergence delirium in paediatric general anaesthesia: a systematic review.

OBJECTIVES: Emergence delirium (ED) occurs in approximately 25% of paediatric general anaesthetics and has significant adverse effects. The goal of the current systematic review was to identify the existing literature investigating performance of predictive models for the development of paediatric ED following general anaesthesia and to determine their usability. DESIGN: Systematic review using the Prediction model study Risk Of Bias Assessment Tool (PROBAST) framework. DATA SOURCES: Medline (Ovid), PubMed, Embase (Ovid), Cochrane Database of Systematic Reviews (Ovid), Cochrane CENTRAL (Ovid), PsycINFO (Ovid), Scopus (Elsevier) and Web of Science (Clarivate Analytics), ClinicalTrials.gov, International Clinical Trials Registry Platform and ProQuest Digital Dissertations and Theses International through 17 November 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: All randomised controlled trials and cohort studies investigating predictive models for the development of ED in children undergoing general anaesthesia. DATA EXTRACTION AND SYNTHESIS: Following title, abstract and full-text screening by two reviewers, data were extracted from all eligible studies, including demographic parameters, details of anaesthetics and performance characteristics of the predictive scores for ED. Evidence quality and predictive score usability were assessed according to the PROBAST framework. RESULTS: The current systematic review yielded 9242 abstracts, of which only one study detailing the development and validation of the Emergence Agitation Risk Scale (EARS) met the inclusion criteria. EARS had good discrimination with c-index of 0.81 (95% CI 0.72 to 0.89). Calibration showed a non-significant Homer-Lemeshow goodness-of-fit test (p=0.97). Although the EARS demonstrated low concern of applicability, the high risk of bias compromised the overall usability of this model. CONCLUSIONS: The current systematic review concluded that EARS has good discrimination performance but low usability to predict ED in a paediatric population. Further research is warranted to develop novel models for the prediction of ED in paediatric anaesthesia. PROSPERO REGISTRATION NUMBER: CRD42019141950.

Unique challenges in pediatric anesthesia created by COVID-19.

Coronavirus disease 2019 (COVID-19) has affected anesthetic care worldwide, including the provision of anesthesia for pediatric patients. Hospitals have balanced the risks associated with the potential surges of resource-intensive COVID-19 patients against the probable morbidity of delaying elective surgical procedures. These decisions are complicated by the unclear influence that COVID-19 has on the perioperative risk for disease-positive pediatric patients. We conducted a comprehensive literature search on MEDLINE for publications involving pediatric patients with COVID-19 who underwent general anesthesia. A total of eight publications met inclusion criteria, and together described 20 patients. Nine patients had documented preoperative COVID-19 symptoms and one perioperative death was reported. Overall, further studies are needed to increase patient numbers and properly assess the perioperative risk. As we continue to provide care without clear guiding data, we present a discussion of modified anesthetic techniques for pediatric patients with suspected or confirmed COVID-19.

Per- and Polyfluoroalkyl Substances in the Air Particles of Asia: Levels, Seasonality, and Size-Dependent Distribution.

Information regarding the size-dependent distribution of per- and polyfluoroalkyl substances (PFAS) in atmospheric particulate matter (PM) is very limited. In this study, 248 size-specific PM samples were collected from 9 Asian cities using a portable 4-stage cascade impactor for the analysis of PFAS. Of the 34 investigated PFAS, perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS) were the major compounds. In particular, the emerging PFAS, hexafluoropropylene oxide dimer acid, was quantified in the PM for the first time, with concentrations ranging from <0.086 to 21.5 pg/m3. Spatially, PFOA and PFOS were the predominant compounds in China, while precursors, emerging PFAS, and short-chain PFAS dominated in India, Japan, and South Korea, respectively. Seasonal variations of PFAS may be controlled by regional climate, local or seasonal emission sources, and long-range transport of air masses. Size-dependent distribution was investigated, showing that the majority of PFAS predominantly affiliated in fine particles, while PFOS and its alternatives tended to attach on coarser particles. Moreover, PFOS distributed on specific sizes exhibited seasonal and regional dependency, while no such patterns were observed for PFOA. These findings will provide useful information on the geographical and size-dependent distribution of PFAS in the atmospheric PM.

A practical guide to acute pain management in children.

In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact the management of pain in children. The purpose of this review is to provide a practical clinical approach to the management of acute pain in the pediatric inpatient population. This will include an overview of commonly used pain management modalities and their potential pitfalls. For institutions that have a pediatric acute pain service or are considering initiating one, it is our hope to provide a useful tool to aid clinicians in the safe and effective treatment of pain in children.

Source Tracking and Risk Assessment of Pharmaceutical and Personal Care Products in Surface Waters of Qingdao, China, with Emphasis on Influence of Animal Farming in Rural Areas.

The occurrence and potential sources of pharmaceuticals and personal care products (PPCPs) in surface waters from a large coastal city Qingdao, North China, were investigated. Forty-five compounds were analyzed by high-performance liquid chromatography-tandem mass spectrometry. The results showed that 28 compounds of PPCPs were detected. The most frequently detected compounds were atrazine, clarithromycin, nonylphenol, and bisphenol A with the detection rates > 90%. Paracetamol showed the highest concentration up to 4400 ng/L (mean 152.5 ng/L), followed by ampicillin (max. 2980 ng/L) with the highest mean concentration (229.3 ng/L), iopromide (max. 1744 ng/L, mean 74.5 ng/L), atrazine (max. 1612 ng/L, mean 96.1 ng/L), and bisphenol A (max. 1384 ng/L, mean 78.3 ng/L). The contamination levels and composition profiles of PPCPs along the rivers flowing through rural and urban areas and in seawater showed large spatial variability. Typical source markers and principle component analysis were used to track and differentiate the potential PPCP sources. The emphases of the study were the influence of animal farming in rural areas on PPCP composition profiles and the ecological risk. The results indicated that PPCPs in Qingdao surface water mainly came from three potential sources, i.e., treated wastewater (effluents from WWTPs), untreated wastewater, and nonpoint sources in agricultural areas.

Twitter Hashtags for Anesthesiologists: Building Global Communities.

Twitter is a social media platform that has been encouraged for use among anesthesiologists as a way to stimulate conversation, distribute research, enhance conference experiences, and expand journal club sessions. We aimed to establish the typical baseline use of hashtags that are not related to events such as conferences. Systematic searches were performed on Twitter, as well as through hashtag-tracking services, to identify actively used anesthesia-related hashtags. The most frequently used general anesthesia hashtags were #anesthesia and #anaesthesia. The most popular and relevant hashtags within anesthesia subspecialties or interest groups include #pedsanes, #anesJC, #OBanes, #intubation, #regionalanesthesia, #neuroanesthesia, and #cardiacanesthesia. We have identified the most popular anesthesia-related hashtags on Twitter to help anesthesiologists increase the reach and degree of discussions in anesthesia-related social media or twitter verse.

Pharmaceutical and Personal Care Products in Surface Waters from the Inner City of Beijing, China: Influence of Hospitals and Reclaimed Water Irrigation.

Surface waters from five districts in the inner city of Beijing were collected for analysis of 43 target compounds of pharmaceuticals and personal care products (PPCPs) to understand the spatial distribution patterns of different groups of PPCPs in the central urban area of a metropolitan city characterized by many hospitals and public parks. The total concentrations of PPCPs showed large spatial variability, ranging from 71.1 to 2400 ng/L. The x-ray contrast medium iopromide was the compound with the highest concentrations. Pharmaceuticals showed similar spatial distributional patterns with large hospitals. Positive correlations between iopromide and pharmaceuticals were observed. In contrast, in general there is no correlation between iopromide and personal care products. The concentrations of PPCPs in the landscape waters were not high but were characterized by high proportions of acidic, nonsteroidal anti-inflammatory drugs with low or even negative removal efficiencies in the WWTP in Beijing, suggesting that the reclaimed water irrigation can be another source of PPCPs in surface waters in the inner city of Beijing.

The use of point-of-care ultrasound to diagnose patent foramen ovale in elective hip and knee arthroplasty patients and its association with postoperative delirium.

PURPOSE: Hip and knee arthroplasty surgeries are associated with embolism of materials such as air, cement, and fat. Patent foramen ovale (PFO) is a common congenital cardiac condition that has been reported to lead to paradoxical embolism. This observational study aimed to investigate if the presence of a PFO was associated with an increased risk of postoperative delirium in patients undergoing primary elective hip or knee arthroplasties. METHOD: This was a prospective cohort study at a tertiary teaching hospital. We enrolled patients undergoing primary elective hip or knee arthroplasty who did not have any risk factors for embolism or delirium. Bedside transthoracic echocardiography (TTE) with a bubble study was performed on all patients to detect the presence of PFO. The primary outcome was postoperative delirium as assessed by the standardized Confusion Assessment Method. Secondary outcomes included the ease of performing a TTE bubble study in the perioperative setting, the quality of the TTE images, length of stay, major cardiovascular and neurologic complications, and effects of anesthetic or analgesic management techniques on delirium. RESULTS: Two hundred two patients completed the study. The median [interquartile range] duration of stay was 2 [2-3] days. Only 16 patients (8%) had a positive bubble study. Postoperative delirium was observed in only one patient. Major adverse events were not seen. The inter-rater reliability for the TTE image quality scores was fair (kappa statistic = 0.22). CONCLUSION: Given the very low incidence of PFO and postoperative delirium in this study, we could not form any conclusions regarding the impact of a PFO on important outcomes including delirium or other major adverse events. No recommendation can be made regarding screening for PFO in patients scheduled for lower extremity arthroplasty surgery. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02400892). Registered 27 March 2015.