Residual biomasses at scale: Ensuring future bioeconomy uses outperform current baseline.

To shift towards low-fossil carbon economies, making more out of residual biomass is increasingly promoted. Yet, it remains unclear if implementing advanced technologies to reuse these streams really achieves net environmental benefits compared to current management practices. By integrating spatially-explicit resource flow analysis, consequential life cycle assessment (LCA), and uncertainty analysis, we propose a single framework to quantify the residual biomass environmental baseline of a territory, and apply it to the case of France. The output is the environmental threshold that a future large-scale territorial bioeconomy strategy should overpass. For France, we estimate the residual biomass baseline to generate 18.4 ± 2.7 MtCO2-eq·y-1 (climate change), 255 ± 35 ktN-eq·y-1 (marine eutrophication), and 12,300 ± 800 disease incidences per year (particulate matter formation). The current use of crop residues and livestock effluents, being essentially a return to arable lands, was found to represent more than 90 % of total environmental impacts and uncertainties, uncovering a need for more certain data. At present, utilizing residual streams as organic fertilizers fulfills over half of France's total phosphorus (P) and potassium (K) demands. However, it only meets 6 % of the nitrogen demand, primarily because nitrogen is lost through air and water. This, coupled with the overall territorial diagnosis, led us to revisit the idea of using the current situation (based on 2018 data) as a baseline for future bioeconomy trajectories. We suggest that these should rather be compared to a projected baseline accounting for ongoing basic mitigation efforts, estimated for France at 8.5 MtCO2-eq·y-1.

Bilateral Jaw Mycobacterium Abscessus Mimicking Actinomycosis: A Postoperative Complication of Wisdom Teeth Extraction.

The incidence of nontuberculous mycobacteria infections has surged over recent decades. Mycobacterium abscessus is one example that can present unique diagnostic challenges due to its variable antibiotic resistance profile and its clinical similarities to Actinomycoses israelii in postodontogenic infections. The authors report a case of a 22-year-old healthy female presenting with bilateral mandibular nodules following wisdom teeth extraction. After a presumptive diagnosis of actinomycosis, cultures revealed a Mycobacterium abscessus infection susceptible to macrolides. Magnetic resonance imaging depicted bilateral sinus tracts without osteomyelitis. The patient opted for dual antibiotic therapy, consisting of azithromycin and omadacycline, without surgical intervention. Given her clinical and radiographic improvement after three months, the patient elected to continue dual antibiotic therapy for 12 months with appropriate clinical and radiographic monitoring. This case underscores the importance of early microbial cultures to guide diagnosis and treatment, particularly considering Mycobacterium abscessus's similarities with other pathogens and its variable macrolide susceptibility due to genetic mutations. As highlighted in this case, clinicians must successfully differentiate between and appropriately treat various nontuberculous mycobacteria.

Virtual multi-institutional tumor board: a strategy for personalized diagnoses and management of rare CNS tumors.

PURPOSE: Multidisciplinary tumor boards (MTBs) integrate clinical, molecular, and radiological information and facilitate coordination of neuro-oncology care. During the COVID-19 pandemic, our MTB transitioned to a virtual and multi-institutional format. We hypothesized that this expansion would allow expert review of challenging neuro-oncology cases and contribute to the care of patients with limited access to specialized centers. METHODS: We retrospectively reviewed records from virtual MTBs held between 04/2020-03/2021. Data collected included measures of potential clinical impact, including referrals to observational or therapeutic studies, referrals for specialized neuropathology analysis, and whether molecular findings led to a change in diagnosis and/or guided management suggestions. RESULTS: During 25 meetings, 32 presenters discussed 44 cases. Approximately half (n = 20; 48%) involved a rare central nervous system (CNS) tumor. In 21% (n = 9) the diagnosis was changed or refined based on molecular profiling obtained at the NIH and in 36% (n = 15) molecular findings guided management. Clinical trial suggestions were offered to 31% (n = 13), enrollment in the observational NCI Natural History Study to 21% (n = 9), neuropathology review and molecular testing at the NIH to 17% (n = 7), and all received management suggestions. CONCLUSION: Virtual multi-institutional MTBs enable remote expert review of CNS tumors. We propose them as a strategy to facilitate expert opinions from specialized centers, especially for rare CNS tumors, helping mitigate geographic barriers to patient care and serving as a pre-screening tool for studies. Advanced molecular testing is key to obtaining a precise diagnosis, discovering potentially actionable targets, and guiding management.

Nicolau Syndrome Following Glatiramer Injection in a Middle-Aged Woman.

Nicolau syndrome is a rare adverse reaction that can occur in the setting of intramuscular, intravenous, and subcutaneous injections. Proper diagnosis and management are critical to avoid complications including abscesses, muscular atrophy, and necrotizing fasciitis. Here, we report a 55-year-old female with multiple sclerosis who presented to our clinic following a subcutaneous injection of 40mg of glatiramer. She immediately noted a sharp pain and erythema, which developed into a purple discoloration, became purulent, and eventually necrosed. The patient's wound was debrided, and she was advised to clean the wound with soap and water, apply topical mupirocin, and change dressings twice daily. She continued to receive appropriate follow-up care with weekly to bi-weekly debridement with excellent resolution.

A multi-institutional phase I study of acetazolamide with temozolomide in adults with newly diagnosed MGMT-methylated malignant glioma.

Background: A significant unmet need exists for the treatment of glioblastoma, IDH-wildtype (GBM). Preclinical work shows that acetazolamide sensitizes GBM to temozolomide (TMZ) by overcoming TMZ resistance due to BCL-3-dependent upregulation of carbonic anhydrase. Acetazolamide is Food and Drug Administration-approved for the treatment of altitude sickness. Drug repurposing enables the application of drugs to diseases beyond initial indications. This multi-institutional, open-label, phase I trial examined a combination of acetazolamide and TMZ in patients with MGMT promoter-methylated high-grade glioma. Methods: A total of 24 patients (GBM, IDH-wildtype = 22; Grade 4 astrocytoma, IDH-mutant = 1; Grade 3 astrocytoma, IDH-mutant = 1) were accrued over 17 months. All patients received oral acetazolamide (250 mg BID for 7 days increased to 500 mg BID for Days 8-21 of each 28-day cycle) during the adjuvant phase of TMZ for up to 6 cycles. Results: No patient had a dose-limiting toxicity. Adverse events were consistent with known sequelae of acetazolamide and TMZ. In the 23 WHO Grade 4 patients, the median overall survival (OS) was 30.1 months and the median progression-free survival was 16.0 months. The 2-year OS was 60.9%. In total 37% of the study population had high BCL-3 staining and trended toward shorter OS (17.2 months vs N.R., P = .06). Conclusions: The addition of acetazolamide is safe and tolerable in GBM patients receiving standard TMZ. Survival results compare favorably to historical data from randomized trials in patients with MGMT promoter-methylated GBM and support examination of acetazolamide in a randomized trial. BCL-3 expression is a potential biomarker for prognosis in GBM or for patients more likely to benefit from TMZ.

ONC201 (Dordaviprone) in Recurrent H3 K27M-Mutant Diffuse Midline Glioma.

PURPOSE: Histone 3 (H3) K27M-mutant diffuse midline glioma (DMG) has a dismal prognosis with no established effective therapy beyond radiation. This integrated analysis evaluated single-agent ONC201 (dordaviprone), a first-in-class imipridone, in recurrent H3 K27M-mutant DMG. METHODS: Fifty patients (pediatric, n = 4; adult, n = 46) with recurrent H3 K27M-mutant DMG who received oral ONC201 monotherapy in four clinical trials or one expanded access protocol were included. Eligible patients had measurable disease by Response Assessment in Neuro-Oncology (RANO) high-grade glioma (HGG) criteria and performance score (PS) ≥60 and were ≥90 days from radiation; pontine and spinal tumors were ineligible. The primary end point was overall response rate (ORR) by RANO-HGG criteria. Secondary end points included duration of response (DOR), time to response (TTR), corticosteroid response, PS response, and ORR by RANO low-grade glioma (LGG) criteria. Radiographic end points were assessed by dual-reader, blinded independent central review. RESULTS: The ORR (RANO-HGG) was 20.0% (95% CI, 10.0 to 33.7). The median TTR was 8.3 months (range, 1.9-15.9); the median DOR was 11.2 months (95% CI, 3.8 to not reached). The ORR by combined RANO-HGG/LGG criteria was 30.0% (95% CI, 17.9 to 44.6). A ≥50% corticosteroid dose reduction occurred in 7 of 15 evaluable patients (46.7% [95% CI, 21.3 to 73.4]); PS improvement occurred in 6 of 34 evaluable patients (20.6% [95% CI, 8.7 to 37.9]). Grade 3 treatment-related treatment-emergent adverse events (TR-TEAEs) occurred in 20.0% of patients; the most common was fatigue (n = 5; 10%); no grade 4 TR-TEAEs, deaths, or discontinuations occurred. CONCLUSION: ONC201 monotherapy was well tolerated and exhibited durable and clinically meaningful efficacy in recurrent H3 K27M-mutant DMG.

Assessment of a Unit-Level Acuity Tool in Inpatient Psychiatry.

Assessing acuity is deemed essential to staffing in intensive care nursing; however, it has not received sufficient attention in inpatient psychiatry, where acuity can fluctuate greatly within shifts. Staffing and admission decisions rely on the accuracy of this information. The current mixed methods study surveyed nurses from two hospitals within the same hospital system: one using an acuity tool and one naïve to acuity tools. The survey was followed by a focus group on the specific factors influencing acuity and nurses' assessment of needs. Results suggest that the current tool is not satisfactory for nurses who use it to help with staffing or admission decisions and it is not user-friendly. Most nurses from both hospitals indicated they would prefer an electronic version with automated features reflecting up-to-date patient and unit acuity that would assist in interprofessional collaborative admissions decisions and staffing. [Journal of Psychosocial Nursing and Mental Health Services, 62(1), 13-18.].

Differentiating Shoulder Pathology from Cervical Spine Pathology: An Algorithmic Approach.

Accurate and timely diagnosis of musculoskeletal conditions is an essential component of high-quality orthopaedic care. The proximity of the shoulder to the cervical spine leads to a multitude of pathologic conditions whose clinical presentations overlap, posing a diagnostic challenge to orthopaedic providers. Missed or delayed diagnosis of the etiology for patient-described 'shoulder pain' causes frustration among patients, incurs increased healthcare costs, and delays treatment. Moreover, patients with concurrent conditions of the cervical spine and shoulder require deliberate consideration for how each condition contributes to patients' symptoms. The purpose of this review was to describe a systematic approach for evaluating and differentiating pathologies of the shoulder and cervical spine.

Empowering law enforcement officers to engage effectively with individuals in crisis.

As first responders with a duty to protect the safety of civilians, law enforcement officers are required to carry firearms. Over the course of a career, officers are exposed to multiple traumatic events and are required to make rapid decisions regarding safety. In the last few years, the use of deadly force by law enforcement officers has become a public concern. Persons with untreated mental illness have a comparatively higher risk than most for deadly outcomes in crisis situations. The purpose of this manuscript is to describe policies and programs that have been developed and implemented by teams that include psychiatric mental health nurse practitioners to help law enforcement officers recognize and interact effectively with persons in crisis. The same programs help officers understand the effects of severe stress and trauma on emotional, behavioral, and cognitive functioning, and provide support, encouragement, and access for officers who need help.

Cutaneous larva migrans in the northeastern US.

Cutaneous larva migrans (CLM) is a dermo-epidermal parasitic infection with a disproportionate incidence in developing countries, particularly in, and near tropical areas. It is characterized by erythematous, twisting, and linear plaques that can migrate to adjacent skin. Herein, we present an otherwise healthy 45-year-old woman who acquired a pruritic, erythematous, and serpiginous rash localized to her right medial ankle during a trip to New England. Oral ivermectin, the preferred first-line treatment for cutaneous larva migrans, was administered in combination with triamcinolone. This was followed by removal of the papular area via punch biopsy; treatment was successful with a one-week recovery. Although cutaneous larva migrans has traditionally been considered a tropical disease, clinicians should be cognizant of its expanding geographic spread.

Usage Trends and Safety Profile of Recombinant Human Bone Morphogenetic Protein-2 for Spinal Column Tumor Surgery: A National Matched Cohort Analysis.

STUDY DESIGN: Retrospective Cohort Analysis. OBJECTIVE: The purpose of this study is to investigate national rates of rhBMP-2 utilization in spinal tumor surgery and examine its association with postoperative complications, revisions, and carcinogenicity. METHODS: All patients diagnosed with primary or metastatic spinal tumors with subsequent surgical intervention involving a spinal fusion procedure were identified in PearlDiver. Patients were 1:1 matched into 2 cohorts according to rhBMP-2 usage. Postoperative complications and revisions were examined at 1 month, 3 months, 6 months, and 1 year after fusion. New cancer incidence following spinal tumor surgery was assessed until 5 years postoperatively. RESULTS: A total of 11,198 patients underwent fusion surgery after resection of spinal tumors between 2005 and 2020, with 909 cases reporting the use of rhBMP-2 (8.1%). An annualized analysis revealed that the proportion of spine tumor fusion procedures utilizing rhBMP-2 has been significantly decreasing (R2 = .859, P < .001), with the most recent annual utilization rate at 1.1%. At least 3 months after surgery, significantly increased incidences of surgical site (11.4% vs 3.3%, P = .03) and systemic infections (8.1% vs 1.6%, P = .02) were observed in patients who underwent fusion with rhBMP-2. Across all time points, no significant differences were observed in survival, implant removal, revision rates, or new cancer diagnoses. CONCLUSION: This analysis demonstrated significantly declining national utilization rates. Spinal tumor cases utilizing rhBMP-2 sustained greater rates of surgical site and systemic infections. rhBMP-2 usage did not significantly reduce the risk of mortality, implant failure, or reoperation.

Strokes in Patients With Injection Drug Use and Tricuspid Valve Endocarditis - A Case Series.

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients.

Characterizing thoracic morphology variation to develop representative 3D models for applications in chest trauma.

BACKGROUND: Rib fracture(s) occurs in 85% of blunt chest trauma cases. Increasing evidence supports that surgical intervention, particularly for multiple fractures, may improve outcomes. Thoracic morphology diversity across ages and sexes is important to consider in the design and use of surgical intervention devices in chest trauma. However, research on non-average thoracic morphology is lacking. METHODS: The rib cage was segmented from patient computed tomography (CT) scans to create 3D point clouds. These point clouds were uniformly oriented and chest height, width, and depth were measured. Size categorization was determined by grouping each dimension into small, medium, and large tertiles. From small and large size combinations, subgroups were extracted to develop thoracic 3D models of the rib cage and surrounding soft tissue. RESULTS: The study population included 141 subjects (48% male) ranging from age 10-80 with ∼20 subjects/age decade. Mean chest volume increased with age by 26% from the age groups 10-20 to 60-70, with 11% of this increase occurring between the youngest groups of 10-20 and 20-30. Across all ages, chest dimensions were ∼10% smaller in females and chest volume was highly variable (SD: ±3936.5 cm3). Representative thoracic models of four males (ages 16, 24, 44, 48) and three females (ages 19, 50, 53) were developed to characterize morphology associated with combinations of small and large chest dimensions. CONCLUSIONS: The seven models developed cover a broad range of non-average thoracic morphologies and can serve as a basis for informing device design, surgical planning, and injury risk assessments.

Caring for a "Blue" Population: Addressing Priorities of the Officer Safety and Wellness Group in Nurse Practitioner Practice.

Increased public concern over policing and the psychological impact of trauma-associated events by first responders have highlighted a critical need to improve the availability of mental health and wellness resources for law enforcement officers. The national Officer Safety and Wellness Group prioritized mental health, alcohol use, fatigue, and body weight/poor nutrition as targets for safety and wellness initiatives. Departmental culture will need to change from silence and fear-driven hesitancy to a culture of openness and support. Increased education, openness, and support for mental health will likely reduce stigma and improve access to care. Psychiatric-mental health nurse practitioners and other advanced practice nurses who wish to work with law enforcement officers should be aware of the specific health risks and standards of care that are summarized in this article. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 13-18.].

From the ER to the OR: Initial Evaluation of Primary Central Nervous System Lymphoma.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) is a rare, often curable neoplasm, often initially presenting in acute care settings by nonneuroscience specialized physicians. Delays in the recognition of specific imaging findings, lack of appropriate specialist consultation, and urgent incorrect medication administration can delay necessary diagnosis and treatment. REVIEW SUMMARY: In this paper, the reader is moved quickly from the initial presentation to the diagnostic surgical intervention for PCNSL in a manner analogous to the experience of clinicians in the frontline setting. We review the clinical presentation of PCNSL, its radiographic features, the effect of prebiopsy steroids, and the role of a biopsy in the diagnosis. In addition, this paper revisits the role of surgical resection for PCNSL and investigational diagnostic studies for PCNSL. CONCLUSION: PCNSL is a rare tumor that is associated with high morbidity and mortality. However, with appropriate identification of clinical signs, symptoms, and key radiographic findings, the early suspicion of PCNSL can lead to steroid avoidance and timely biopsy for rapid administration of the potentially curative chemoimmunotherapy. Surgical resection presents the potential for improving outcomes for patients with PCNSL, however, this remains controversial. Further research into PCNSL presents the opportunity for better outcomes and longer livelihoods for patients.

Enabling Technologies and the Development of Single Position Lateral Spine Surgery.

Technological advances have paved the way for surgical innovation in spine surgery. These advances have allowed for the creation of more accurate and less invasive surgical techniques. Spine surgeons play a critical role in the integration of new technology into the surgical workflow with the goal of improving safety, efficiency, and clinical outcomes. Navigation and robotic techniques are emerging technologies that have begun to revolutionize spine surgery. One particular advancement these technologies have recently enabled is single position prone lateral surgery. This review provides a history and brief overview of the different applications of new technologies in spine surgery. It will also discuss their enablement of single position prone lateral surgery in order to more critically evaluate their utilization.

Effect of Active Muscles on Astronaut Kinematics and Injury Risk for Piloted Lunar Landing and Launch While Standing.

While astronauts may pilot future lunar landers in a standing posture, the response of the human body under lunar launch and landing-related dynamic loading conditions is not well understood. It is important to consider the effects of active muscles under these loading conditions as muscles stabilize posture while standing. In the present study, astronaut response for a piloted lunar mission in a standing posture was simulated using an active human body model (HBM) with a closed-loop joint-angle based proportional integral derivative controller muscle activation strategy and compared with a passive HBM to understand the effects of active muscles on astronaut body kinematics and injury risk. While head, neck, and lumbar spine injury risk were relatively unaffected by active muscles, the lower extremity injury risk and the head and arm kinematics were significantly changed. Active muscle prevented knee-buckling and spinal slouching and lowered tibia injury risk in the active vs. passive model (revised tibia index: 0.02-0.40 vs. 0.01-0.58; acceptable tolerance: 0.43). Head displacement was higher in the active vs. passive model (11.6 vs. 9.0 cm forward, 6.3 vs. 7.0 cm backward, 7.9 vs. 7.3 cm downward, 3.7 vs. 2.4 cm lateral). Lower arm movement was seen with the active vs. passive model (23 vs. 35 cm backward, 12 vs. 20 cm downward). Overall simulations suggest that the passive model may overpredict injury risk in astronauts for spaceflight loading conditions, which can be improved using the model with active musculature.