Sex influences how attendings evaluate surgical residents in the operating room.

BACKGROUND: The aim of this study was to evaluate the influence of sex on facultys' perception of resident autonomy and performance. METHODS: Autonomy/performance/complexity evaluations performed by faculty of categorical general surgery residents (2015-2021) were analyzed. Comparisons of scores by faculty and resident sex were performed. RESULTS: A total of 10967 paper/electronic evaluations were collected. Female attendings rated female residents significantly lower in autonomy when compared to males (2.75 vs 2.91, p â€‹= â€‹0.0037). There was no significant difference in autonomy ratings for male versus female residents when evaluated by a male attending (2.93 vs 2.96, p â€‹= â€‹0.054) but male attendings did rate female residents significantly lower in autonomy at the highest complexities (2.37 vs 2.50, p â€‹= â€‹0.012). CONCLUSION: The data suggests a unique interaction between attending and resident sex. A periodic evaluation of evaluations within one's program may provide invaluable implicit bias insight and should be considered.

Heterogeneity and Gaps in Reporting Primary Outcomes From Neonatal Trials.

OBJECTIVES: Clear outcome reporting in clinical trials facilitates accurate interpretation and application of findings and improves evidence-informed decision-making. Standardized core outcomes for reporting neonatal trials have been developed, but little is known about how primary outcomes are reported in neonatal trials. Our aim was to identify strengths and weaknesses of primary outcome reporting in recent neonatal trials. METHODS: Neonatal trials including ≥100 participants/arm published between 2015 and 2020 with at least 1 primary outcome from a neonatal core outcome set were eligible. Raters recruited from Cochrane Neonatal were trained to evaluate the trials' primary outcome reporting completeness using relevant items from Consolidated Standards of Reporting Trials 2010 and Consolidated Standards of Reporting Trials-Outcomes 2022 pertaining to the reporting of the definition, selection, measurement, analysis, and interpretation of primary trial outcomes. All trial reports were assessed by 3 raters. Assessments and discrepancies between raters were analyzed. RESULTS: Outcome-reporting evaluations were completed for 36 included neonatal trials by 39 raters. Levels of outcome reporting completeness were highly variable. All trials fully reported the primary outcome measurement domain, statistical methods used to compare treatment groups, and participant flow. Yet, only 28% of trials fully reported on minimal important difference, 24% on outcome data missingness, 66% on blinding of the outcome assessor, and 42% on handling of outcome multiplicity. CONCLUSIONS: Primary outcome reporting in neonatal trials often lacks key information needed for interpretability of results, knowledge synthesis, and evidence-informed decision-making in neonatology. Use of existing outcome-reporting guidelines by trialists, journals, and peer reviewers will enhance transparent reporting of neonatal trials.

Strengthening Reporting of Neonatal Trials.

BACKGROUND AND OBJECTIVES: There is variability in the selection and reporting of outcomes in neonatal trials with key information frequently omitted. This can impact applicability of trial findings to clinicians, families, and caregivers, and impair evidence synthesis. The Neonatal Core Outcomes Set describes outcomes agreed as clinically important that should be assessed in all neonatal trials, and Consolidated Standards of Reporting Trials (CONSORT)-Outcomes 2022 is a new, harmonized, evidence-based reporting guideline for trial outcomes. We reviewed published trials using CONSORT-Outcomes 2022 guidance to identify exemplars of neonatal core outcome reporting to strengthen description of outcomes in future trial publications. METHODS: Neonatal trials including >100 participants per arm published between 2015 to 2020 with a primary outcome included in the Neonatal Core Outcome Set were identified. Primary outcome reporting was reviewed using CONSORT 2010 and CONSORT-Outcomes 2022 guidelines by assessors recruited from Cochrane Neonatal. Examples of clear and complete outcome reporting were identified with verbatim text extracted from trial reports. RESULTS: Thirty-six trials were reviewed by 39 assessors. Examples of good reporting for CONSORT 2010 and CONSORT-Outcomes 2022 criteria were identified and subdivided into 3 outcome categories: "survival," "short-term neonatal complications," and "long-term developmental outcomes" depending on the core outcomes to which they relate. These examples are presented to strengthen future research reporting. CONCLUSIONS: We have identified examples of good trial outcome reporting. These illustrate how important neonatal outcomes should be reported to meet the CONSORT 2010 and CONSORT-Outcomes 2022 guidelines. Emulating these examples will improve the transmission of information relating to outcomes and reduce associated research waste.

Parameters of Spinal Cord Stimulation in Complex Regional Pain Syndrome: Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Complex Regional Pain Syndrome (CRPS) is a chronic debilitating neuropathic pain condition characterized by autonomic and inflammatory features that typically occurs after a traumatic event. Spinal cord stimulation (SCS) has been shown to be effective in the treatment of chronic CRPS refractory to conventional treatment modalities. The collective evidence of novel parameters of SCS for treating CRPS has not been characterized extensively. OBJECTIVE: To provide evidence for the use of SCS to treat CRPS and characterize the additional benefits of various SCS waveforms. STUDY DESIGN: Systematic Review and Meta-analysis. METHODS: PubMed, Embase and CINHLA were screened for all randomized controlled trials (RCT) comparing SCS parameters for the treatment of CRPS. RESULTS: Four RCTs were identified that included SCS as a treatment arm for CRPS. Of these, one study compared low frequency tonic SCS (LF-SCS) versus conventional physical therapy, 2 studies compared placebo/sham SCS with LF-SCS and a multitude of waveforms, and one study compared LF-SCS with high-frequency SCS (HF-SCS). Two of the studies were rated as having a low risk of bias, one study was rated as having some concerns for bias, while the final study was rated as having a high risk of bias. A meta-analysis of 4 studies comparing conventional therapy/placebo SCS stimulation against LF-SCS revealed increased benefit of LF-SCS in pain reduction up to a month (mean difference [MD] = -1.17 points; 95% CI = -1.61 to -0.73; P < 0.001, I2 = 42%). Another meta-analysis of 2 studies showed that LF-SCS results in higher global perceived effect scores relative to conventional therapy/placebo SCS stimulation (MD = 1.58; 95% CI = 1.00 to 2.15; P < 0.001, I2 = 0%). LIMITATIONS: A pooled analysis using different designs for RCTs was conducted. Some studies folded in multiple neuropathic pain pathologies in addition to CRPS. One study was at a high risk for bias in at least one domain. CONCLUSION: LF-SCS is superior to conventional therapy/placebo SCS stimulation. However, more evidence is required to demonstrate that novel SCS parameters are superior to LF-SCS in improving pain scores and functional outcomes.

Dissecting Optical Response and Molecular Structure of Fluorescent Proteins With Non-canonical Chromophores.

Tracking the structural dynamics of fluorescent protein chromophores holds the key to unlocking the fluorescence mechanisms in real time and enabling rational design principles of these powerful and versatile bioimaging probes. By combining recent chemical biology and ultrafast spectroscopy advances, we prepared the superfolder green fluorescent protein (sfGFP) and its non-canonical amino acid (ncAA) derivatives with a single chlorine, bromine, and nitro substituent at the ortho site to the phenolate oxygen of the embedded chromophore, and characterized them using an integrated toolset of femtosecond transient absorption and tunable femtosecond stimulated Raman spectroscopy (FSRS), aided by quantum calculations of the vibrational normal modes. A dominant vibrational cooling time constant of ~4 and 11 ps is revealed in Cl-GFP and Br-GFP, respectively, facilitating a ~30 and 12% increase of the fluorescent quantum yield vs. the parent sfGFP. Similar time constants were also retrieved from the transient absorption spectra, substantiating the correlated electronic and vibrational motions on the intrinsic molecular timescales. Key carbon-halogen stretching motions coupled with phenolate ring motions of the deprotonated chromophores at ca. 908 and 890 cm-1 in Cl-GFP and Br-GFP exhibit enhanced activities in the electronic excited state and blue-shift during a distinct vibrational cooling process on the ps timescale. The retrieved structural dynamics change due to targeted site-specific halogenation of the chromophore thus provides an effective means to design new GFP derivatives and enrich the bioimaging probe toolset for life and medical sciences.

Giant Liver Hemangiomas: A Plea for Early Surgical Referral and Resection.

Hepatic hemangiomas are the most common benign hepatic tumor. Current guidelines recommend surveillance imaging and reserving surgical intervention for symptomatic patients with giant liver hemangiomas (>5 cm). We present the case of a patient with a rapidly enlarging giant hepatic hemangioma initially managed by surveillance. During her observation period, she developed weight loss, constipation, and pancytopenia concerning for Kasabach-Merritt Syndrome. Resection of the hemangioma was complicated by its large size (28.0 × 18.0 × 11.4 cm). Patients with rapidly growing giant liver hemangiomas, even when asymptomatic, should be promptly referred to specialized surgical centers for evaluation and management.

A Compelling Virtual Tour of the Dunhuang Cave With an Immersive Head-Mounted Display.

The Dunhuang Caves are the home to the largest Buddhist art sites in the world and are listed as a UNESCO World Heritage Site. Over time, the murals have been damaged by both humans and nature. In this article, we present an immersive virtual reality system for exploring spatial cultural heritage, which utilizes the digitized data from the Dunhuang Research Academy to represent the virtual environment of the cave. In this system, the interaction techniques that allow users to flexibly experience any of the artifacts or displays contribute to their understanding of the cultural heritage. Additionally, we evaluated the system by conducting a user study to examine the extent of user acquaintance after the entire experience. Our result has shown what participants learn from the spatial context and augmented information in the VR. This can be used as design considerations for developing other spatial heritages.

On the unusual amber coloration of nanoporous sol-gel processed Al-doped silica glass: An experimental study.

Silica is the most abundant component on the earth's surface. It plays an important role in many natural processes. Silica is also a critical material for a wide range of technical applications such as in optics and electronics. In this work, we discuss our recent experimental observation of the unusual amber coloration of aluminum doped sol-gel glass that has not been reported in the past. We characterized Al-doped sol-gel glasses, prepared at different sintering temperature, using a plethora of techniques to investigate the origin of this unusual coloration and to understand their structural and chemical properties. We used these experimental results to test a number of possible coloring mechanisms. The results suggested this coloring is likely caused by temperature-dependent aluminum-associated defect centers associated with different amorphous-to-crystalline ratios of the annealed sol-gel silica glass structures.

Singapore Neonatal Resuscitation Guidelines 2016.

We present the revised Neonatal Resuscitation Guidelines for Singapore. The 2015 International Liaison Committee on Resuscitation Neonatal Task Force's consensus on science and treatment recommendations (2015), and guidelines from the American Heart Association and European Resuscitation Council were debated and discussed. The final recommendations of the National Resuscitation Council, Singapore, were derived after the task force had carefully reviewed the current available evidence in the literature and addressed their relevance to local clinical practice.

Large-scale Generation of Patterned Bubble Arrays on Printed Bi-functional Boiling Surfaces.

Bubble nucleation control, growth and departure dynamics is important in understanding boiling phenomena and enhancing nucleate boiling heat transfer performance. We report a novel bi-functional heterogeneous surface structure that is capable of tuning bubble nucleation, growth and departure dynamics. For the fabrication of the surface, hydrophobic polymer dot arrays are first printed on a substrate, followed by hydrophilic ZnO nanostructure deposition via microreactor-assisted nanomaterial deposition (MAND) processing. Wettability contrast between the hydrophobic polymer dot arrays and aqueous ZnO solution allows for the fabrication of heterogeneous surfaces with distinct wettability regions. Heterogeneous surfaces with various configurations were fabricated and their bubble dynamics were examined at elevated heat flux, revealing various nucleate boiling phenomena. In particular, aligned and patterned bubbles with a tunable departure frequency and diameter were demonstrated in a boiling experiment for the first time. Taking advantage of our fabrication method, a 6 inch wafer size heterogeneous surface was prepared. Pool boiling experiments were also performed to demonstrate a heat flux enhancement up to 3X at the same surface superheat using bi-functional surfaces, compared to a bare stainless steel surface.

Specialist teams for neonatal transport to neonatal intensive care units for prevention of morbidity and mortality.

BACKGROUND: Maternal antenatal transfers provide better neonatal outcomes. However, there will inevitably be some infants who require acute transport to a neonatal intensive care unit (NICU). Because of this, many institutions develop services to provide neonatal transport by specially trained health personnel. However, few studies report on relevant clinical outcomes in infants requiring transport to NICU. OBJECTIVES: To determine the effects of specialist transport teams compared with non-specialist transport teams on the risk of neonatal mortality and morbidity among high-risk newborn infants requiring transport to neonatal intensive care. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE (1966 to 31 July 2015), EMBASE (1980 to 31 July 2015), CINAHL (1982 to 31 July 2015), conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. STUDY DESIGN: randomised, quasi-randomised or cluster randomised controlled trials. POPULATION: neonates requiring transport to a neonatal intensive care unit. INTERVENTION: transport by a specialist team compared to a non-specialist team. OUTCOMES: any of the following outcomes - death; adverse events during transport leading to respiratory compromise; and condition on admission to the neonatal intensive care unit. DATA COLLECTION AND ANALYSIS: The methodological quality of the trials was assessed using the information provided in the studies and by personal communication with the author. Data on relevant outcomes were extracted and the effect size estimated and reported as risk ratio (RR), risk difference (RD), number needed to treat for an additional beneficial outcome (NNTB) or number needed to treat for an additional harmful outcome (NNTH) and mean difference (MD) for continuous outcomes. Data from cluster randomised trials were not combined for analysis. MAIN RESULTS: One trial met the inclusion criteria of this review but was considered ineligible owing to serious bias in the reporting of the results. AUTHORS' CONCLUSIONS: There is no reliable evidence from randomised trials to support or refute the effects of specialist neonatal transport teams for neonatal retrieval on infant morbidity and mortality. Cluster randomised trial study designs may be best suited to provide us with answers on effectiveness and clinical outcomes.

FLT1 signaling in metastasis-associated macrophages activates an inflammatory signature that promotes breast cancer metastasis.

Although the link between inflammation and cancer initiation is well established, its role in metastatic diseases, the primary cause of cancer deaths, has been poorly explored. Our previous studies identified a population of metastasis-associated macrophages (MAMs) recruited to the lung that promote tumor cell seeding and growth. Here we show that FMS-like tyrosine kinase 1 (Flt1, also known as VEGFR1) labels a subset of macrophages in human breast cancers that are significantly enriched in metastatic sites. In mouse models of breast cancer pulmonary metastasis, MAMs uniquely express FLT1. Using several genetic models, we show that macrophage FLT1 signaling is critical for metastasis. FLT1 inhibition does not affect MAM recruitment to metastatic lesions but regulates a set of inflammatory response genes, including colony-stimulating factor 1 (CSF1), a central regulator of macrophage biology. Using a gain-of-function approach, we show that CSF1-mediated autocrine signaling in MAMs is downstream of FLT1 and can restore the tumor-promoting activity of FLT1-inhibited MAMs. Thus, CSF1 is epistatic to FLT1, establishing a link between FLT1 and inflammatory responses within breast tumor metastases. Importantly, FLT1 inhibition reduces tumor metastatic efficiency even after initial seeding, suggesting that these pathways represent therapeutic targets in metastatic disease.

Nonimmune hydrops fetalis in a children's hospital: a six-year series.

INTRODUCTION: We aimed to study the profile of nonimmune hydrops fetalis (NIHF) in the local population and identify its outcomes and causes. METHODS: We carried out a retrospective review of the medical records in KK Women's and Children's hospital, a single tertiary referral centre, for pregnancies with an antenatal diagnosis of NIHF in the six-year period from 1 January 2005 to 31 December 2010. RESULTS: A total of 29 cases of NIHF were identified; 19 (66%) cases underwent karyotype evaluation, 17 (59%) underwent intrauterine infection screening, and all underwent antenatal thalassaemia screening. The median gestational age at diagnosis was 27 (range 12-37) weeks, median gestational age at birth was 33 (range 27-37) weeks, and median birth weight of live births was 2,480 (range 1,230-3,900) g. The aetiologies for NIHF were identified in 20 (69%) cases, which included cardiac anomalies (n = 5), haematological problems (n = 4), congenital tumours (n = 4), genetic/metabolic disorders (n = 4) and cystic hygromas (n = 3). The cause of NIHF was not identified in the remaining 9 (31%) cases. There were 19 live births - 8 (42%) survived and 11 (58%) died in the neonatal period - and one stillbirth. Nine women opted for medical termination of pregnancy following the diagnosis of NIHF. CONCLUSION: It is important to thoroughly investigate all cases of NIHF and identify its causes in order to provide appropriate antenatal and postnatal counselling. In our series, almost one-third of NIHF cases had no identified aetiology. The neonatal mortality rate was approximately 58%.

Changes in the process of care and outcome over a 10-year period in a neonatal nursery in a developing country.

BACKGROUND: Over a 10-year period there was increasing involvement by clinicians in the generation and implementation of evidence-based practices in the neonatal intensive care unit (NICU). For two cohorts of very low birth weight (VLBW) babies admitted 10 years apart to a developing country, NICU were compared and changes occurring in process of care that might have contributed to any change in outcome were documented. METHODS: Prospective data were collected on characteristics, management and complications of all VLBW infants admitted over the same 6-month period in 1993 and 2003 and examined for changes in evidence-based practices and outcome. RESULTS: Compared to the first cohort of 69 babies, 60 babies in the second cohort were significantly more likely to have been inborn (p < 0.001), born by Caesarean section (p = 0.035), to have received antenatal corticosteroids (p < 0.001), to be intubated at birth (p < 0.001) and have a 5 min Apgar score above 6 (p = 0.034). They were also significantly lighter and of lower gestation (p = 0.005). They were significantly more likely to have received surfactant (p < 0.001), to have been ventilated and to have had double prong nasal continuous positive pressure either as a mode of ventilation or for weaning (p < 0.001). Hypothermia on admission was more common in the second cohort (p < 0.001). Survival increased from 62.3% to 81.6% (p = 0.015). CONCLUSIONS: Although causality cannot be established, an increase in the use of evidence-based practices was associated with a significant improvement in outcomes. In spite of greater barriers to implementation there are evidence-based strategies that can be put into neonatal practice in developing countries.

Infection-induced modulation of m1 and m2 phenotypes in circulating monocytes: role in immune monitoring and early prognosis of sepsis.

To monitor and better understand the immunoinflammatory sequelae in sepsis and septic shock, systemic and monocyte-related cytokine responses were evaluated in baboons with experimental peritonitis induced by an E. coli-laden fibrin clot. Despite similar bacterial inocula, considerable interindividual variability in clinical manifestation and outcome of infection was observed. Because monocytes and macrophages are a key component of innate immunity, we hypothesized that early polarization of distinct activation programs in circulating monocytes that culminates in the emergence of either classically (M1) or alternatively (M2) activated monocytes may underlie the observed susceptibility or resistance to infection. To test our hypothesis, we analyzed infection-induced expression of cytokine mRNAs in monocytes isolated from surviving and dead animals. Our data show that resistance to E. coli sepsis may well be associated with a mixed M1/M2 activation state of circulating monocytes, whereas M1 phenotype appeared to be prevailing in monocytes from animals that died. Together with data on systemic cytokine responses, the latter findings indicate that morbidity and mortality of animals with gram-negative sepsis may well result from an overwhelming proinflammatory response. Collectively, our data contribute to a better understanding of cytokine networking in the immunoinflammatory response to microbial infection and suggest M1/M2 immunophenotypic profiling of readily available circulatory monocytes for early prognosis of severe infections.