Comparison of "IN-REC-SUR-E" and LISA in preterm neonates with respiratory distress syndrome: a randomized controlled trial (IN-REC-LISA trial).

BACKGROUND: Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. METHODS: In this study, 382 infants born at 24+0-27+6 weeks' gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks' postmenstrual age. The secondary outcomes are BPD at 36 weeks' postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24+0 to 25+6 weeks or 26+0 to 27+6 weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). DISCUSSION: This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24+0-27+6 weeks' gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks' postmenstrual age of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT05711966. Registered on February 3, 2023.

Seized drug reporting of NPS helps to guide regional toxicological practice: A 17 month review between 2022 and 2023.

Novel psychoactive substances (NPS) are everchanging and plague forensic laboratories who must identify an unending variety of emerging substances and evolve current methodologies to detect these substances. Identifying potential regional NPS targets and timely examining trends in seized drug data could help mitigate the burden laboratories face. Over 17 months, NPS seized drug data were processed and categorized from three laboratories located across the United States to determine any NPS regional similarities and prevalent NPS drug categories: the South Carolina Law Enforcement Division (SLED), the Sedgwick County Regional Forensic Science Center (SCRFSC), and the Orange County Crime Laboratory (OCCL). Seized drug materials, including pills, powders, and plant material, were primarily analyzed for NPS via gas chromatography-mass spectrometry and Fourier transform infrared spectroscopy. From June 2022 to October 2023, 1940 NPS seized drug identifications were reported by these laboratories with 63 different NPS reported. Novel synthetic opioids (NSO) were the most prevalent NPS class across all three laboratories (55%), with fluorofentanyl accounting for 74% of NSO identifications. This is unsurprising given the fentanyl epidemic in the United States. Furthermore, these data highlighted varying regional NPS seized drug trends: eutylone, a synthetic cathinone, was one of the most frequently identified NPS in SLED, SCRFSC observed the most diverse set of synthetic cannabinoids, and OCCL observed an increased prevalence in the designer benzodiazepine, bromazolam. NPS scope recommendations are a valuable resource for forensic laboratories; however, most focus on a national perspective. Timely analysis and reporting of NPS seized drug data may help to develop regional NPS scope recommendations laboratories may employ.

The impact of fentanyl on DUIDs and traffic fatalities: Blood and oral fluid data.

Fentanyl has emerged as the most prolific drug in the ongoing opioid epidemic and has greatly impacted traffic safety in recent years. This study aimed to evaluate fentanyl prevalence and concentrations in blood and oral fluid in driving under the influence of drugs (DUID) cases in three different regions (i.e., Alabama, Orange County, CA, and Houston, TX) from 2017 to 2022. Furthermore, traffic fatalities were evaluated for Alabama and Orange County, CA. Fentanyl positivity in DUID and traffic fatalities increased for most years in this study. In Alabama, the prevalence of fentanyl DUID cases increased 4-fold in 2022 compared to 2017. Orange County's increase from 2017 to 2022 was 14-fold. In Houston, the increase was approximately 2-fold from 2019 to 2022. The greatest increase for all laboratories coincided with the start of the COVID-19 pandemic. In 2022, the median fentanyl DUID blood concentrations were 4.7, 11, and 4.7 ng/mL in Alabama, Orange County, and Houston, respectively. Most fentanyl cases were polydrug cases (≥90%). Methamphetamine, THC, and alprazolam were the most frequently detected drugs in combination with fentanyl. Alabama has collected oral fluid and blood in DUID cases since 2018. The detection of fentanyl in oral fluid was comparable to blood. However, 59% and 8.7% of fentanyl-positive cases had concentrations of >20 ng/mL in oral fluid and blood, respectively. Therefore, oral fluid as an alternative or supplemental specimen to blood is an attractive approach for fentanyl in DUID cases. This study contributes to understanding recent fentanyl trends and their impact on traffic safety.

Amniotic Band Syndrome: Head-to-Toe Manifestations and Clinical Management Guidelines.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand and describe the basic principles underlying the intrinsic versus extrinsic proposed mechanisms for the development of amniotic band syndrome (ABS). 2. Discuss risk factors and conditions that are associated with the development of ABS. 3. Understand the various presentations and associated clinical implications of ABS by anatomic location. 4. Describe the basic tenets underlying various repair technique options for ABS of the extremities. 5. Discuss the common manifestations of ABS in the face and trunk. 6. Understand clinical implications of fetoscopic surgery as it relates to ABS treatment as a novel method for limb salvage in utero. SUMMARY: Amniotic band syndrome (ABS) refers to the development of constrictive bands of fibrotic tissue in utero. It can lead to a variety of clinical manifestations after delivery. There is much debate in the plastic surgery community regarding the exact pathophysiologic mechanism for the development of ABS, and the most appropriate management. This CME article aims to provide an overview of ABS manifestations throughout the body, and to expound on the most recent advances in anticipatory and definitive management of the condition.

The Outer Membrane Cytochrome OmcA Is Essential for Infection of Shewanella oneidensis by a Zebrafish-Associated Bacteriophage.

The microbiota-the mixture of microorganisms in the intestinal tract of animals-plays an important role in host biology. Bacteriophages are a prominent, though often overlooked, component of the microbiota. The mechanisms that phage use to infect susceptible cells associated with animal hosts, and the broader role they could play in determining the substituents of the microbiota, are poorly understood. In this study, we isolated a zebrafish-associated bacteriophage, which we named Shewanella phage FishSpeaker. This phage infects Shewanella oneidensis strain MR-1, which cannot colonize zebrafish, but it is unable to infect Shewanella xiamenensis strain FH-1, a strain isolated from the zebrafish gut. Our data suggest that FishSpeaker uses the outer membrane decaheme cytochrome OmcA, which is an accessory component of the extracellular electron transfer (EET) pathway in S. oneidensis, as well as the flagellum to recognize and infect susceptible cells. In a zebrafish colony that lacks detectable FishSpeaker, we found that most Shewanella spp. are sensitive to infection and that some strains are resistant to infection. Our results suggest that phage could act as a selectivity filter for zebrafish-associated Shewanella and show that the EET machinery can be targeted by phage in the environment. IMPORTANCE Phage exert selective pressure on bacteria that influences and shapes the composition of microbial populations. However, there is a lack of native, experimentally tractable systems for studying how phage influence microbial population dynamics in complex communities. Here, we show that a zebrafish-associated phage requires both the outer membrane-associated extracellular electron transfer protein OmcA and the flagellum to infect Shewanella oneidensis strain MR-1. Our results suggest that the newly discovered phage-FishSpeaker-could exert selective pressure that restricts which Shewanella spp. colonize zebrafish. Moreover, the requirement of OmcA for infection by FishSpeaker suggests that the phage preferentially infects cells that are oxygen limited, a condition required for OmcA expression and an ecological feature of the zebrafish gut.

Postmortem Mitragynine Distribution in a Single Drug Fatality Case.

A 32-year-old Caucasian male was found unconscious at his sober-living home and pronounced dead after transportation to the emergency room. The decedent had a documented history of substance-use disorder and past suicide attempts, but according to his family, he was sober for the past year. Significant autopsy findings were cardiomegaly, hepatomegaly, congested lungs, cerebral edema, and obesity. The toxicology examination of blood and tissues using liquid chromatography tandem mass spectrometry detected only mitragynine in the central blood (7.5 mg/L), peripheral blood (3.3 mg/L), liver (42.2 mg/kg), and gastric contents (33.1 mg). The qualitative identification of 7-hydroxymitragynine was performed only on the central blood. The pathologist ruled the cause of death acute mitragynine intoxication combined with cardiomegaly with left ventricular hypertrophy, with severe hepatomegaly and obesity listed as other significant conditions. The mode, or manner, of death was determined to be an accidental overdose. To the authors' knowledge, this is the first reported case where mitragynine was the only drug detected. This case study will contribute to the understanding of mitragynine-only death investigation and provide valuable toxicology information for medical examiners and pathologists.

Post-traumatic stress symptoms and burnout in healthcare professionals working in neonatal intensive care units: Results from the STRONG study.

Background: Newborns' deaths and life-threatening conditions represent extremely stressful events for parents and professionals working in NICUs, facilitating the onset of secondary traumatic stress symptoms. The STRONG study aims to better understand the psychological impact on Italian NICUs staff of bereavement care. Methods: The STRONG (STress afteR lOss in NeonatoloGy) study is a cross-sectional study based on a web survey consisted of four sections: sociodemographic, CommuniCARE-Newborn questionnaire, the Maslach Burnout Inventory and the Impact of Event Scale-Revised. Results: 227 NICU workers (42.7% nurses, 23.3% midwives, 22.2% physicians, 11.8% other HCPs) answered the survey. The hardest tasks were "communicating baby's death" and "informing on autopsy results"; 44.7% of HCPs did not receive formal training in communicating bad news, 44.2% 'learned from the field' by watching other colleagues; 41.2% declared that they do not have any communication strategy. More than 90% of professionals thought that training on bereavement care is necessary. The majority of HCPs showed some degree of post-traumatic stress symptoms: 34% medium and 35.3% severe. Professionals with training in bereavement care and/or in communication had less probability to develop stress symptoms. A multivariate analysis showed that higher levels of burnout were associated with 4 or more monthly losses and medium or severe stress symptoms. Having a well-defined communication strategy for breaking bad news was independently associated with a better personal accomplishment. Conclusion: Dealing with newborns' deaths is a highly stressful task; professionals should receive proper support such as debriefing, psychological support and training in order to prevent post-traumatic stress symptoms and reduce professional burnout.

A Two-Year Evaluation of Flualprazolam Concentrations in Orange County Drivers: Effects on Driving and Field Sobriety Test Performance.

Starting in early 2017, flualprazolam was detected in toxicology and seized drug cases across the USA. Due to the addition of fluorine to alprazolam, flualprazolam's chemistry was enough to bypass targeted toxicology confirmations, and it has become increasingly available for purchase both on the dark web and in counterfeit pills. Flualprazolam was added to the exact mass screening regiment of the Orange County forensic laboratory in December 2018. Through data mining of previously analyzed cases, data were evaluated beginning from August 2018. Flualprazolam was subsequently added to the laboratory's validated quantitative liquid chromatography dual mass spectrometry method in the summer of 2020, and all driving cases from August 2018 to June 2020 were re-analyzed to obtain concentrations. The police and drug recognition evaluation (if available) reports were collected and reviewed for all cases where flualprazolam was detected. Of the 203 cases containing quantifiable drug, the average flualprazolam concentration (median, range) was 22.8 ng/mL (15.4 ng/mL, 4.0-133.3 ng/mL). Only two cases had flualprazolam detected with no other drugs. The other most common drugs detected were cannabinoids (62%), ethanol (20%) and cocaine and/or methamphetamine (32%). The most common reason for the police investigation was an accident/collision (50%), and the most common time of officer contact was evening (18:00 to 23:59). The field sobriety test (FST) results were evaluated and showed a higher frequency of impaired performance in cases of flualprazolam in combination with other drugs. No conclusion could be made regarding the effect of flualprazolam alone on FST performance.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations.

OBJECTIVE: The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. METHODS: Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. RESULTS: TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. CONCLUSIONS: TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Dorsal Fixation of Coronal Hamate and Fifth Metacarpal Base Fractures: An Anatomic Evaluation of the Ulnar Nerve.

PURPOSE: Traumatic drill overshoot during dorsal fixation of coronal hamate and fifth metacarpal base fractures risks iatrogenic ulnar nerve injury. This study describes the anatomic relationships between exiting volar drill tips and ulnar nerve branches. METHODS: Dorsal drilling of hamate bones and fifth metacarpal bases was performed on cadavers. Dorsal hamate bodies were subdivided into 4 quadrants: (1) distal-ulnar, (2) distal-radial, (3) proximal-ulnar, and (4) proximal-radial. Screws measuring 5 mm more than the dorsal-to-volar bone depths were placed in each quadrant to represent drill exit trajectories with consistent overshoot. A single screw was similarly placed 5 mm distal to the midline articular surface of the dorsal fifth metacarpal base. Distances between estimated drill tips and ulnar nerve branches were measured. RESULTS: Ten cadaver hands were examined. The fifth metacarpal base screw tips directly abutted the ulnar motor branch in 6 hands, and were within 1 mm in 4 hands (mean, 0.4 ± 0.5 mm). Distances from the tips to the ulnar motor and sensory branches were largest in the distal-radial quadrant (11.8 ± 0.8 mm and 9.2 ± 1.9 mm, respectively) and smallest in the proximal-ulnar quadrant (7.3 ± 1.5 mm and 4.3 ± 1.1 mm, respectively). Distances to the ulnar motor and sensory branches were similar between the proximal-ulnar and distal-ulnar quadrants, and between the proximal-radial and distal-radial quadrants. CONCLUSIONS: Dorsal drilling of coronal hamate fractures appears to be safe, as volar drill tips are well away from ulnar nerve motor and sensory branches. Distances to ulnar nerve branches are largest, and theoretically safest, with dorsal drilling in the distal-radial hamate. Dorsal drilling of fifth metacarpal base fractures appears to carry a high risk for potential ulnar motor nerve injury. CLINICAL RELEVANCE: These findings may help minimize potential risks for iatrogenic ulnar nerve injury with dorsal drilling of hamate and fifth metacarpal base fractures.

Simultaneous quantitative analysis of 39 common toxicological drugs for increased efficiency in an ante- and postmortem laboratory.

BACKGROUND: A novel forensic method was developed to quantitate 39 drugs of toxicological interest for ante-mortem and postmortem analysis. This method was created to combine and replace four existing quantitation methods as well as add three additional compounds of interest and serves to drastically increase the efficiency of the criminalists and reduce the case backlog. The method is currently applied to ante-mortem blood, postmortem blood, urine, liver, brain, and gastric contents. METHODS: The extraction was performed by using a protein precipitation and DPX WAX-S tips with analysis on a Waters® i-class Acquity ultra-performance liquid chromatography with a Phenomenex Kinetex® Column (1.7 µm Biphenyl Å, 2.1 ×100 mm) followed by a Waters® XeVo-TQS tandem mass spectrometer using positive electrospray ionization in multiple reaction monitor mode. The sample volume required for analysis was 0.5 mL, or 0.5 g, an improvement from 4 mL when performing previous methods utilized in the laboratory. RESULTS: The improved method incorporated the 2017 recommended cut-offs for toxicological investigation of driving under the influence of drugs and was validated following the SWGTOX and ANSI/ASB guidelines of method validation. The advantages of analyzing low volume cases and/or detecting drugs previously outside the laboratory's scope of analysis, (such as gabapentin, pregabalin and baclofen) will be presented in two case studies. CONCLUSION: The multi-drug quantitation method allowed for the analysis of 39 drugs including a hydrolysis step, if needed, with only 0.5 mL or 0.5 g of sample. The method condensed two previously un-validated quantitative methods and two additional qualitative methods, which detected many commonly seen drugs, all into a single method. Three additional analytes of interest, gabapentin, pregabalin and baclofen, which it had previously been unable to detect, were added to the new method. The added benefit of these new drugs added both the coroner's investigators in cause of death determination and driving under the influence of drugs investigation especially with the high prevalence of gabapentin.

Hand and Upper Extremity Trauma in the Undocumented Immigrant Population in the United States.

Undocumented immigrants in the United States are at risk for upper extremity trauma due to occupational exposure, and decreased access to healthcare can worsen outcomes. The purpose of this study was to compare documented versus undocumented patients in a large cohort of patients in New York City's most diverse neighborhood in order to characterize upper extremity trauma in this population. METHODS: The Elmhurst Hospital trauma database was examined for patients admitted with upper extremity trauma from April 2016 to December 2019. Charts were examined for demographic information, documentation status, injury mechanism, and outcomes. RESULTS: Of the 1041 patients included, 865 (83.1%) were documented and 176 (16.9%) were undocumented. Undocumented immigrants were younger (40.5 versus 62.4 years, P < 0.0001) and predominantly men (83.5% versus 57.1%, P < 0.0001) with fewer comorbidities (42.6% versus 64.6%, P < 0.0001). Occupational injury was three times as likely in undocumented immigrants (13.6% versus 4.6%, P < 0.0001) and these patients were nearly twice as likely to be harmed from violence (19.9% versus 10.2%, P = 0.0003). Increased rates of injury during bicycle/motorcycle accidents (8.0% versus 3.0%, P = 0.0017) or being struck as a pedestrian (21.6% versus 14.3%, P = 0.0149) were found in the undocumented cohort, with falls (39.8% versus 59.3%, P < 0.0001) or vehicle collisions (0.6% versus 3.5%, P = 0.0402). CONCLUSIONS: Undocumented patients with upper extremity trauma represent a younger/healthier cohort, but are more likely to be injured at work or by violence. Documentation status plays a role in injury characteristics.

Prevalence of Five Commonly Analyzed Cannabinoids in Forensic Toxicology Casework from Orange County CA, USA, from 2016 to 2019.

Over the last 25 years, marijuana laws have been changing throughout the USA. California started legalizing medicinal marijuana in 1996 and has since continued to relax laws. Compared to Washington and Colorado, there are little data on how the changing laws have affected the cannabinoid detection rate in California. This paper looks at the prevalence of five cannabinoids (Δ9-tetrahydrocannabinol (THC), 11-hydroxy-tetrahydrocannabinol (hydroxy-THC), 11-nor-9-carboxy-tetrahydrocannabinol (carboxy-THC), cannabinol and cannabidiol) in Orange County, CA, from 2016 to 2019. From 2016 to 2017, after legalizing recreational marijuana, there was an increase in the presence of THC, carboxy-THC and hydroxy-THC in postmortem and major crime cases, consisting mostly of sexual assaults. However, driving under the influence of drugs (DUID) saw a slight decrease. In 2018, when shops could be licensed to sell marijuana to anyone over 21 years old, there was an increase seen in all five cannabinoids for DUID and postmortem cases. The age group from 21 to 30 years showed the most prevalent cannabinoid use in all case types for all years except in major crime cases in 2019, where <21 year-old age group was the most prevalent. Surprisingly, the >50-year-old group in death investigation cases was a close second in prevalence in all years, which differs from DUID and major crime cases.

Flualprazolam distribution in postmortem samples.

The constant emergence of novel psychoactive substances is troubling to both public health officials and legislators. Additionally, sufficient data collection for each new compound can take months up to years. Flualprazolam, a triazolobenzodiazepine, quickly garnered attention as a sedative drug that likely expresses adverse reactions similarly to alprazolam. This study focuses on the distribution of flualprazolam in multiple common postmortem matrices. Central blood, vitreous humor, liver homogenate, brain homogenate, gastric contents, and urine samples from death investigation cases were quantitated when available. Samples were screened with liquid chromatography quadrupole time-of-flight with limit of detection set at 4 ng/ml and quantitated on liquid chromatography tandem mass spectrometry, with concentration range from 4 to 256 ng/ml. From August 2018 to September 2020, 24 central blood samples were quantitated for flualprazolam. Central bloods of 22 cases had concentrations above the limit of quantitation. The average flualprazolam central blood concentration was 16.3 ng/ml with a median of 9.95 ng/ml (4.24-48.0). Additional analyses for unconjugated flualprazolam were performed on at a total of 15 urine samples ( x ¯  = 14.4, 4.07-36.1 ng/ml), 23 brain homogenates ( x ¯  = 23.2, 3.99-69.3 ng/g), 23 liver homogenates ( x ¯  = 50.7, 13.6-156 ng/g), five vitreous humor samples ( x ¯  = 7.70, 4.03-12 ng/ml), and 12 gastric contents samples ( x ¯  = 0.36, 0.02-2.51 mg). The cause of death for 13 of the 24 cases listed flualprazolam as a contributing factor of death.

Exergame training-induced neuroplasticity and cognitive improvement in institutionalized older adults: A preliminary investigation.

BACKGROUND: Prior research has reported cognitive improvements in elderly individuals when mental and physical exercise are practiced simultaneously, as in exergaming. However, the molecular mechanisms driving this beneficial response remain unclear. Moreover, there is robust evidence that regular exercise increases neurotrophic factors and promotes neuroplasticity, contributing to cognitive improvement. This research aimed to assess the impact of a 6-week Xbox 360 Kinect exergame protocol on cognitive function and brain-derived neurotrophic factor (BDNF) levels in institutionalized older individuals. METHODS: Participants living in a long-term care facility were included. The intervention (Xbox 360 Kinect exergame protocol) was conducted individually and consisted of two sessions per week (40 min each) over 6 weeks. Participants' cognitive function (Montreal Cognitive Assessment, MoCA) was evaluated before and after the intervention. Blood samples (15 ml) were collected at the same time to measure BDNF levels. RESULTS: Although there were no changes in total MoCA scores, exergame training improved the "language" domain and demonstrated a tendency toward an improvement in the "abstraction" and "memory/delayed recall" domains. Furthermore, BDNF levels were significantly increased after the intervention. CONCLUSION: BDNF enhancement might mediate, at least in part, the cognitive changes induced by a 6-week Xbox 360 Kinect exergame protocol in institutionalized older adults.

Evaluation of National Resident Matching Program and Electronic Residency Application Service Data in the Integrated Plastic Surgery Match.

INTRODUCTION: The National Resident Matching Program and Electronic Residency Application Service provide data for tracking trends among applicants in each specialty over the past 5 years. The purpose of this study was to examine this information and determine sex and race/ethnicity distribution over the past 5 years. METHODS: The National Resident Matching Program and Electronic Residency Application Service databases were surveyed for trends in the following categories: number of positions, number of applicants, percent of applicants per position, and number of applicants by sex and self-identified race/ethnicity. This information was analyzed graphically for visual representation of the changes in the field. RESULTS: While there has been a steady increase in number of positions offered, there has also been a significant decrease in number of applicants, resulting in an increase in number of positions offered per applicant. While female and Asian applicants have increased in number, rates of applications from other diverse groups have remained stagnant. CONCLUSIONS: The number of plastic surgery positions offered has increased, whereas the number of applicants has decreased, resulting in a reduction in the number of applicants per position. Lack of racial diversity remains a significant issue in the applicant pool.

Unusually High Concentration of Fentanyl in a Driver: A Case Report.

A case of driving under the influence of drugs with an extremely high blood fentanyl concentration and concomitant use of methamphetamine is presented. As the increase of the appearance of fentanyl in drug seizures continues, the likelihood of tolerant users increases as well. Data presented on fentanyl in antemortem cases over time from several regions of North America show geographic differences on whether fentanyl concentrations are increasing. This case is an example of a blood concentration that could have been assumed to be fatal if presented on its own, a reminder that concentrations, especially those of opioids, must be interpreted with care.

Trends in Peripheral Nerve Epidemiology and Reconstruction: A State Database Study of Direct Repairs, Grafts, and Conduits.

BACKGROUND: Peripheral nerve injuries (PNIs) are most commonly treated with direct nerve repair procedures or nerve autografts. However, recent advancements in synthetic and vein conduits have led to their increased utilization. The present study quantifies the incidence of these procedures over time and geography and identifies differences in complication rates, illustrating the current epidemiologic climate regarding conduit use for PNI repair. METHODS: A query was conducted using the State Ambulatory Surgery and Services Databases data from 2006 to 2011 in both Florida and California for patients undergoing nerve repair, nerve grafting, synthetic conduits, and vein conduits. Patient zip code data were analyzed to determine the geographic distribution of various types of repair. In addition, text-mining algorithms were used to identify trends in PNI-related publications. RESULTS: In the 6-year period investigated, direct nerve repair was the most frequently used procedure for PNIs. However, the utilization of direct repairs declined significantly from 2006 to 2011. Synthetic and vein conduits demonstrated a significant increase over the same period. There were significantly higher rates of complications for autologous grafts (3.3%), vein conduits (3.5%), and synthetic conduits (2.4%), as compared with direct nerve repairs (1.4%). There was a nonsignificant difference in infection rates between these types of nerve repair. CONCLUSIONS: From an epidemiologic perspective, both graft and synthetic conduit-based PNI repairs are increasing in prevalence both in clinical practice and in the academic literature. This will likely continue in the future with the development of advancements in biologic and synthetic nerve conduit PNI repair options.

Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon.

Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.

Longitudinal change in ventricular volume is accelerated in astronauts undergoing long-duration spaceflight.

An 11-25% increase in total ventricular volume has been documented in astronauts following spaceflight on the ISS. Given the approximately 2-year time interval between pre- and post-flight MRI, it is unknown if ventricular enlargement simply reflects normal aging or is unique to spaceflight exposure. Therefore, we compared percent ventricular volume change per year (PVVC/yr) documented on pre- to post-flight MRI in a group of NASA ISS astronauts (n = 18, 16.7% women, mean age (SD) 48.43 (4.35) years) with two groups who underwent longitudinal MRI: (1.) healthy age- and sex-matched adults (n = 18, 16.7% women, mean age (SD) 51.26 (3.88) years), and (2.) healthy older adults (n = 79, 16.5% women, mean age (SD) 73.26 (5.34) years). The astronauts, who underwent a mean (SD) 173.4 (51.3) days in spaceflight, showed a greater increase in PVVC/yr than the control (6.86 vs 2.23%, respectively, p < .001) and older adult (4.18%, p = 0.04) groups. These results highlight that on top of physiologically ventricular volume changes due to normal aging, NASA astronauts undergoing ISS missions experience an additional 4.63% PVVC/yr and underscore the need to perform post-flight follow-up scans to determine the time course of PVVC in astronauts over time back on Earth along with monitoring to determine if the PVVC is ultimately clinically relevant. One sentence summary: NASA astronauts who were exposed to prolonged spaceflight experienced an annual rate of ventricular expansion more than three times that expected from normal aging.