A Life Cycle Assessment of Reusable and Disposable Surgical Caps.

INTRODUCTION: Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps. METHODS: ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts. RESULTS: Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing. CONCLUSIONS: Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.

The Planetary Benefit of Suspending USMLE Step 2 CS: Estimating Carbon Emissions Associated with US Medical Students' Travel to Testing Centers.

Background: The discontinuation of the Step 2 Clinical Skills Exam (CS) by the United States Medical Licensing Examination (USMLE) eliminated the need for personal travel to testing centers. The carbon emissions associated with CS have not been previously quantified. Objective: To estimate the annual carbon emissions generated by travel to CS Testing Centers (CSTCs) and to explore differences across geographic regions. Methods: We conducted a cross-sectional, observational study by geocoding medical schools and CSTCs to calculate the distance between them. We obtained data from the 2017 matriculant databases of the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM). The independent variable was the location as defined by USMLE geographic regions. The dependent variables were distance traveled to CSTCs and estimated carbon emissions in metric tons CO2 (mtCO2) calculated using three models. In model 1 all students used single occupancy vehicles; in model 2, all carpooled; and in model 3, half traveled by train and half by single occupancy vehicle. Results: Our analysis included 197 medical schools. The mean out-of-town travel distance was 280.67 miles (IQR: 97.49-383.42). The mtCO2 associated with travel was 2,807.46 for model 1; 3,135.55 for model 2; and 635.34 for model 3. The Western region traveled the farthest, while the Northeast traveled significantly less than other regions. Conclusion: The annual estimated carbon emissions from travel to CSTCs was approximately 3,000 mtCO2. Northeastern students traveled the shortest distances; the average US medical student expended 0.13 mtCO2. Medical leaders must consider the environmental impact of medical curricula and pursue accordant reforms.

The Carbon Footprint of Residency Interview Travel.

BACKGROUND: Over the last decade, medical student residency applicants have shown a substantial increase in the number of interviews attended, which is associated with a significant increase in travel. The carbon footprint associated with residency interviews has not been well documented prior to this investigation, and is a critical issue related to climate health. OBJECTIVE: The purpose of this study is to document the carbon footprint associated with travel to residency interviews of the applicants from a single institution. METHODS: Graduating medical students from the University of Michigan Medical School were surveyed in 2020 to gather information regarding travel related to residency interviews. A validated carbon emissions calculator was used to determine the associated carbon footprint. RESULTS: Response rate was 103 of 174 (59%). Average interviews per student across all specialties was 14.39 interviews per student. The overall class average for total carbon footprint per student was calculated as 3.07 metric tons CO2, making the class average carbon footprint per interview 0.21 metric tons CO2. If we extrapolate the results of our study to all residents, the resulting CO2 emissions approach 51 665 metric tons CO2 per year, which is equivalent to the amount of CO2 produced by 11 162 passenger cars in 1 year. CONCLUSIONS: Medical education leaders could help reduce the carbon footprint by encouraging a reduction in number of in-person interviews attended by applicants.

A comparative carbon footprint analysis of disposable and reusable vaginal specula.

BACKGROUND: Healthcare systems in the United States have increasingly turned toward the use of disposable medical equipment in an attempt to save time, lower costs, and reduce the transmission of infections. However, the use of disposable instruments is associated with increased solid waste production and may have negative impacts on the environment, such as increased greenhouse gas emissions. OBJECTIVE: The purpose of this study was to inform this discussion; we applied life cycle assessment methods to evaluate the carbon footprints of 3 vaginal specula: a single-use acrylic model and 2 reusable stainless steel models. STUDY DESIGN: The functional unit of the study was defined as the completion of 20 gynecologic examinations by either type of speculum. The greenhouse gas emissions (eg, carbon dioxide, methane, nitrous oxide) across all life cycle stages, which includes material production and manufacturing, transportation, use and reprocessing, and end-of-life, were analyzed with the use of SimaPro life cycle assessment software and converted into carbon dioxide equivalents. RESULTS: The reusable stainless steel grade 304 speculum was found to have a lesser carbon footprint over multiple model scenarios (different reprocessing techniques, autoclave loading/efficiency, and number of uses) than either the reusable stainless steel grade 316 or the disposable acrylic specula. The material production and manufacturing phase contributed most heavily to the total life cycle carbon footprint of the acrylic speculum, whereas the use and reprocessing phase contributed most to the carbon footprints of both stainless steel specula. CONCLUSION: The use of disposable vaginal specula is associated with increased greenhouse gas equivalents compared with reusable alternatives with no significant difference in clinical utility. These findings can be used to inform decision-making by healthcare systems, because they weigh a wide range of considerations in making final purchase decisions; similar analytic methods can and should be applied to other components of health systems' waste streams.

Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.

OBJECTIVE: Childhood irritability is a common, impairing problem with changing age-related manifestations that predict long-term adverse outcomes. However, more investigation of overall and age-specific neural correlates is needed. Because youths with irritability exhibit exaggerated responses to frustrating stimuli, the authors used a frustration functional MRI (fMRI) paradigm to examine associations between irritability and neural activation and tested the moderating effect of age. METHOD: The authors studied a transdiagnostic sample of 195 youths with varying levels of irritability (disruptive mood dysregulation disorder, N=52; anxiety disorder, N=42; attention deficit hyperactivity disorder, N=40; and healthy volunteers, N=61). Irritability was measured by parent and child reports on the Affective Reactivity Index. The fMRI paradigm was a cued-attention task differentiating neural activity in response to frustration (rigged feedback) from activity during attention orienting in the trial following frustration. RESULTS: Whole-brain activation analyses revealed associations with irritability during attention orienting following frustration. Irritability was positively associated with frontal-striatal activation, specifically in the dorsolateral prefrontal cortex, inferior frontal gyrus, and caudate. Age moderated the association between irritability and activation in some frontal and posterior regions (the anterior cingulate cortex, medial frontal gyrus, cuneus, precuneus, and superior parietal lobule [F=19.04-28.51, df=1, 189, partial eta squared=0.09-0.13]). Specifically, higher irritability was more strongly related to increased activation in younger youths compared with older youths. CONCLUSIONS: Following frustration, levels of irritability correlated with activity in neural systems mediating attention orienting, top-down regulation of emotions, and motor execution. Although most associations were independent of age, dysfunction in the anterior cingulate cortex and posterior regions was more pronounced in young children with irritability.

Association of Irritability and Anxiety With the Neural Mechanisms of Implicit Face Emotion Processing in Youths With Psychopathology.

IMPORTANCE: Psychiatric comorbidity complicates clinical care and confounds efforts to elucidate the pathophysiology of commonly occurring symptoms in youths. To our knowledge, few studies have simultaneously assessed the effect of 2 continuously distributed traits on brain-behavior relationships in children with psychopathology. OBJECTIVE: To determine shared and unique effects of 2 major dimensions of child psychopathology, irritability and anxiety, on neural responses to facial emotions during functional magnetic resonance imaging. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional functional magnetic resonance imaging study in a large, well-characterized clinical sample at a research clinic at the National Institute of Mental Health. The referred sample included youths ages 8 to 17 years, 93 youths with anxiety, disruptive mood dysregulation, and/or attention-deficit/hyperactivity disorders and 22 healthy youths. MAIN OUTCOMES AND MEASURES: The child's irritability and anxiety were rated by both parent and child on the Affective Reactivity Index and Screen for Child Anxiety Related Disorders, respectively. Using functional magnetic resonance imaging, neural response was measured across the brain during gender labeling of varying intensities of angry, happy, or fearful face emotions. In mixed-effects analyses, the shared and unique effects of irritability and anxiety were tested on amygdala functional connectivity and activation to face emotions. RESULTS: The mean (SD) age of participants was 13.2 (2.6) years; of the 115 included, 64 were male. Irritability and/or anxiety influenced amygdala connectivity to the prefrontal and temporal cortex. Specifically, irritability and anxiety jointly influenced left amygdala to left medial prefrontal cortex connectivity during face emotion viewing (F4,888 = 9.20; P < .001 for mixed model term). During viewing of intensely angry faces, decreased connectivity was associated with high levels of both anxiety and irritability, whereas increased connectivity was associated with high levels of anxiety but low levels of irritability (Wald χ21 = 21.3; P < .001 for contrast). Irritability was associated with differences in neural response to face emotions in several areas (F2, 888 ≥ 13.45; all P < .001). This primarily occurred in the ventral visual areas, with a positive association to angry and happy faces relative to fearful faces. CONCLUSIONS AND RELEVANCE: These data extend prior work conducted in youths with irritability or anxiety alone and suggest that research may miss important findings if the pathophysiology of irritability and anxiety are studied in isolation. Decreased amygdala-medial prefrontal cortex connectivity may mediate emotion dysregulation when very anxious and irritable youth process threat-related faces. Activation in the ventral visual circuitry suggests a mechanism through which signals of social approach (ie, happy and angry expressions) may capture attention in irritable youth.

CD2-associated protein (CD2AP) enhances casitas B lineage lymphoma-3/c (Cbl-3/c)-mediated Ret isoform-specific ubiquitination and degradation via its amino-terminal Src homology 3 domains.

Ret is the receptor tyrosine kinase for the glial cell line-derived neurotrophic factor (GDNF) family of neuronal growth factors. Upon activation by GDNF, Ret is rapidly polyubiquitinated and degraded. This degradation process is isoform-selective, with the longer Ret51 isoform exhibiting different degradation kinetics than the shorter isoform, Ret9. In sympathetic neurons, Ret degradation is induced, at least in part, by a complex consisting of the adaptor protein CD2AP and the E3-ligase Cbl-3/c. Knockdown of Cbl-3/c using siRNA reduced the GDNF-induced ubiquitination and degradation of Ret51 in neurons and podocytes, suggesting that Cbl-3/c was a predominant E3 ligase for Ret. Coexpression of CD2AP with Cbl-3/c augmented the ubiquitination of Ret51 as compared with the expression of Cbl-3/c alone. Ret51 ubiquitination by the CD2AP·Cbl-3/c complex required a functional ring finger and TKB domain in Cbl-3/c. The SH3 domains of CD2AP were sufficient to drive the Cbl-3/c-dependent ubiquitination of Ret51, whereas the carboxyl-terminal coiled-coil domain of CD2AP was dispensable. Interestingly, activated Ret induced the degradation of CD2AP, but not Cbl-3/c, suggesting a potential inhibitory feedback mechanism. There were only two major ubiquitination sites in Ret51, Lys(1060) and Lys(1107), and the combined mutation of these lysines almost completely eliminated both the ubiquitination and degradation of Ret51. Ret9 was not ubiquitinated by the CD2AP·Cbl-3/c complex, suggesting that Ret9 was down-regulated by a fundamentally different mechanism. Taken together, these results suggest that only the SH3 domains of CD2AP were necessary to enhance the E3 ligase activity of Cbl-3/c toward Ret51.

Management of acute anemia in a Jehovah's Witness patient with acute lymphoblastic leukemia with polymerized bovine hemoglobin-based oxygen carrier: a case report and review of literature.

BACKGROUND: Management of severe symptomatic anemia is exceptionally challenging when blood transfusions cannot be administered. Use of hemoglobin (Hb)-based oxygen carriers as "bridging treatment" can be an option. CASE REPORT: This is a report of a 36-year-old Jehovah's Witness diagnosed with acute lymphoblastic leukemia (ALL) who developed severe symptomatic anemia (Hb as low as 3.1 g/dL) during induction chemotherapy and refused allogeneic blood transfusions. Fifteen units of Hemopure (Biopure Corp.), an investigational polymerized bovine Hb-derived artificial oxygen carrier, were administered over a 12-day period after informed consent was obtained. The patient's condition improved. RESULTS: Chart review was performed to identify relevant information about the patient's clinical status during Hemopure treatment. With the use of Hemopure the patient's total Hb level was maintained between 3.6 and 5.3 g/dL, over a 12-day period, without any evidence of ischemia or organ dysfunction indicating that Hemopure was providing adequate tissue oxygen supply until marrow red blood cell recovery. The patient completed the chemotherapy regimen and was discharged in stable condition and has been in remission for 28 months. CONCLUSION: This report documents the successful management of profound anemia in an acute leukemia patient who refused blood transfusion, with the use of Hemopure, to save the patient from the devastating effects of ischemia associated with severe anemia. Hemopure may represent a life-saving intervention in patients with severe symptomatic anemia when blood transfusion is not an option.

Spontaneous intestinal perforation.

So much is unknown about SIP-its etiology, pathophysiology, best treatment modality, and outcome. Yet the incidence of SIP is increasing as more VLBW infants are surviving and since SIP has been identified as a separate disease from NEC. Because many cases present with an insidious onset, it is imperative that practitioners review all x-rays with SIP in mind. Although SIP is a relatively rare occurrence in the NICU, its potential to increase morbidity and mortality in premature infants warrants further research to improve outcomes.

Hyperparathyroidism accompanying multiple myeloma.

Hypercalcemia is a manifestation of a variety of both benign and malignant diseases. These conditions are not mutually exclusive, and we present a case report of a patient first diagnosed with the classic findings of multiple myeloma who, after appropriate therapy, demonstrated persistent hypercalcemia and was found on further testing to have an elevated parathormone level (PTH) and scintigraphic evidence of a benign parathyroid adenoma. Hypercalcemia responded to excision of the parathyroid adenoma. There are only 18 similar cases reported in the medical literature.