Self-Trephination in Cranial Excoriation Disorder.

BACKGROUND AND IMPORTANCE: Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION: Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION: Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.

Application of transcritical CO2 heat pumps to boiler replacement in low impact refurbishment projects.

80% of current UK housing stock is expected to still be in use in 2050. Difficult, intrusive and expensive, refurbishment measures are required to achieve the level of insulation required for current low temperature heat pumps. Transcritical CO2 heat pumps can achieve higher efficiencies, with higher output temperatures, than current, Carnot limited, synthetic gas heat pumps, with less environmental impact. Widely deployed in water heating and supermarket chilling systems, CO2 heat pumps need heating return temperatures of 30 °C or less to function effectively. This has impeded their adoption with hydronic heating systems which have high return temperatures. This study identified system modifications external to the refrigeration cycle that address return temperatures. It modelled a transcritical CO2 air source heat pump with a hydronic heating system in a solid wall semi-detached house. Full year system coefficients of performance over 3 were achieved in four UK locations by using space heating return fluids to defrost the air source heat exchanger and to pre-heat inlet water, recovering any remaining excess return fluid heat as a source for the heat pump. Solar panels boosted this to 5.1. The levelized cost of energy for the system was calculated (with heat pump grant) at 22p/kWh, lower than a gas boiler, with 9.45 tonnes CO2 emission savings over a fifteen-year life.

Effect of diet supplemented with functional amino acids and polyphenols on gut health in broilers subjected to a corticosterone-induced stress.

To address the overuse of antimicrobials in poultry production, new functional feed ingredients, i.e. ingredients with benefits beyond meeting basic nutritional requirements, can play a crucial role thanks to their prophylactic effects. This study evaluated the effects of the supplementation of arginine, threonine and glutamine together with grape polyphenols on the gut integrity and functionality of broilers facing a stress condition. 108 straight-run newly hatched Ross PM3 chicks were kept until 35 days and were allocated to 3 treatments. Broilers in the control group were raised in standard conditions. In experimental groups, birds were administered with corticosterone in drinking water (CORT groups) to impair the global health of the animal and were fed a well-balanced diet supplemented or not with a mix of functional amino acids together with grape extracts (1 g/kg of diet-CORT + MIX group). Gut permeability was significantly increased by corticosterone in non-supplemented birds. This corticosterone-induced stress effect was alleviated in the CORT + MIX group. MIX supplementation attenuated the reduction of crypt depth induced by corticosterone. Mucin 2 and TNF-α gene expression was up-regulated in the CORT + MIX group compared to the CORT group. Caecal microbiota remained similar between the groups. These findings indicate that a balanced diet supplemented with functional AA and polyphenols can help to restore broiler intestinal barrier after a stress exposure.

How to cope with potential malfeasance using artificial intelligence: Call to action.

Just as fire and electricity can be, and in many ways are, of great benefit to humanity, and as the contributions elsewhere in this issue of Clinics in Dermatology have shown, artificial intelligence (AI) can be used for the ill and help in medicine. We offer several suggestions to counter some of the more egregious and obvious ones: AI-generated material that purports to be caused by humans and AI-generated material that purports to show actual people doing things that these people would not normally do. Both suggestions rely on methods already in existence to ensure public safety.

Amino acid supplementation counteracts negative effects of low protein diets on tail biting in pigs more than extra environmental enrichment.

Low protein (LP) diets may increase the occurrence of damaging behaviours, like tail biting, in pigs. We investigated the effect of supplementing a LP diet with indispensable amino acids (IAA) or environmental enrichment on tail biting. Undocked pigs (n = 48 groups of 12) received either a normal protein diet (NP), a LP, LP with supplemented IAA (LP+), or LP diet with extra environmental enrichment (LP-E+) during the starter, grower, and finisher phase. Performance, activity, behaviour, and body damage were recorded. LP and LP-E+ had a lower feed intake, growth, and gain-to-feed ratio, and were more active than NP and LP+ pigs. LP-E+ pigs interacted most often with enrichment materials, followed by LP, LP+, and NP pigs. LP pigs showed more tail biting than all other groups during the starter phase and the finisher phase (tendency) compared to NP and LP+ pigs. Thus, LP-E+ only reduced tail biting in the starter phase, whereas LP+ tended to do so throughout. Tail damage was more severe in LP pigs than in NP and LP+, with LP-E+ in between. In conclusion, IAA supplementation was more effective than extra environmental enrichment in countering the negative effects of a low protein diet on tail biting in pigs.

Diffusely invasive supratentorial rosette-forming glioneuronal tumor: illustrative case.

BACKGROUND: Rosette-forming glioneuronal tumors (RGNTs) are rare tumors composed of mixed glial and neurocytic components. Most lesions are confined to the posterior fossa, especially in the region of the fourth ventricle, in young adults. In few instances, diffuse involvement of the supratentorial region is identified, thereby creating significant challenges in diagnosis, surgical intervention, and prognostication. OBSERVATIONS: The authors present a 23-year-old female with chronic headaches, papilledema, and hydrocephalus who underwent radiographic evaluation revealing obstructive hydrocephalus and diffuse supratentorial enhancing and nonenhancing cystic and nodular lesions. The patient underwent a right frontal craniotomy and septostomy. An exophytic nonenhancing right frontal horn lesion was resected, and an enhancing third-ventricular lesion was biopsied. Final pathology of both of the lesions sampled was consistent with RGNT. Next-generation sequencing demonstrated tumor alterations in the FGFR-1 and PIK3CA genes. Targeted therapy with the FGFR inhibitor erdafitinib demonstrated a partial remission. LESSONS: Diffuse supratentorial spread of RGNT is an extremely rare presentation of an already uncommon pathology. In some cases, gross-total resection may not be feasible. Goals of surgery include acquiring tissue for diagnosis, maximizing safe resection, and treating any associated hydrocephalus. FGFR inhibitors may be of benefit in cases of disease progression.

Three-dimensional ultrasound matrix imaging.

Matrix imaging paves the way towards a next revolution in wave physics. Based on the response matrix recorded between a set of sensors, it enables an optimized compensation of aberration phenomena and multiple scattering events that usually drastically hinder the focusing process in heterogeneous media. Although it gave rise to spectacular results in optical microscopy or seismic imaging, the success of matrix imaging has been so far relatively limited with ultrasonic waves because wave control is generally only performed with a linear array of transducers. In this paper, we extend ultrasound matrix imaging to a 3D geometry. Switching from a 1D to a 2D probe enables a much sharper estimation of the transmission matrix that links each transducer and each medium voxel. Here, we first present an experimental proof of concept on a tissue-mimicking phantom through ex-vivo tissues and then, show the potential of 3D matrix imaging for transcranial applications.

Remembering Edmund Klein: the Father of Immunotherapy

Edmund Klein’s seminal research in oncology transformed medicine. He would now be 100 years old. This extraordinary physician–scientist has been dubbed the Father of Immunotherapy and was honored with the highest American recognition in medicine, the Lasker Award, often a prelude to the Nobel Prize (AU)

Coccidiosis infection and growth performance of broilers in experimental trials: insights from a meta-analysis including modulating factors.

An infection by protozoa Eimeria spp. can cause coccidiosis, which negatively affects broiler chicken performance and causes economic and production losses. To understand the effect of coccidiosis on broilers' performance, we evaluated the independent variables and their interactions on the severity of coccidiosis in broilers that cause variation (Δ) of average daily feed intake (ADFI), average daily gain (ADG), and gain per feed (G:F) of broiler chicks using a meta-analysis approach. A database of 55 papers describing 63 experiments was gathered; broilers were challenged by Eimeria species (E. acervulina, E. maxima, E. tenella, and mixed) and at least 2 variables among ADFI, ADG, and feed conversion ratio (FCR) were studied. The variation induced by the challenge was calculated relative to the control group of each experiment. The indirect factors evaluated were days postinfection (DPI), Eimeria type and dose, infection age (IA), bird's mean age in the analyzed period, genetic line, sex, and whether they were raised in a cage or a pen. Graphical, correlation, and variance analyses were performed to evaluate the form of the responses. Then, a linear plateau model was adjusted for each response variable as a function of DPI to determine the consequences of the disease on the variation of performance over time after infection. The impact of the infection challenge on the variation of performance vs. nonchallenge broilers was only impacted by DPI (P < 0.05). The adjustment of the data with the linear plateau model allows us to determine the host response to the coccidiosis disease at different stages. At 5 DPI (acute phase), ΔADFI, ΔADG, ΔG:F were of -19.0; -39.8, and -25.5, respectively. After almost 13 DPI birds achieved the recovery phase for all variables with Δ varying from -19 to -3.75% for ADFI, from -39.8 to -10.5% for ADG, and from -25.5 to -7.24% for G:F. The Eimeria impact was higher in ADG than ADFI in all periods due to Eimeria aggressive action form causing lesions in gut epithelial reducing the use of nutrients and energy. The results can be used as a quantitative approach to determine the consequences of Eimeria spp. on broiler performance.

Simultaneous CAS9 editing of cpSRP43, LHCA6, and LHCA7 in Picochlorum celeri lowers chlorophyll levels and improves biomass productivity.

High cellular pigment levels in dense microalgal cultures contribute to excess light absorption. To improve photosynthetic yields in the marine microalga Picochlorum celeri, CAS9 gene editing was used to target the molecular chaperone cpSRP43. Depigmented strains (>50% lower chlorophyll) were generated, with proteomics showing attenuated levels of most light harvesting complex (LHC) proteins. Gene editing generated two types of cpSRP43 transformants with distinct lower pigment phenotypes: (i) a transformant (Δsrp43) with both cpSRP43 diploid alleles modified to encode non-functional polypeptides and (ii) a transformant (STR30309) with a 3 nt in-frame insertion in one allele at the CAS9 cut site (non-functional second allele), leading to expression of a modified cpSRP43. STR30309 has more chlorophyll than Δsrp43 but substantially less than wild type. To further decrease light absorption by photosystem I in STR30309, CAS9 editing was used to stack in disruptions of both LHCA6 and LHCA7 to generate STR30843, which has higher (5-24%) productivities relative to wild type in solar-simulating bioreactors. Maximal productivities required frequent partial harvests throughout the day. For STR30843, exemplary diel bioreactor yields of ~50 g m-2 day-1 were attained. Our results demonstrate diel productivity gains in P. celeri by lowering pigment levels.

Telemedicine Utilization in an Outpatient Pediatric Neurosurgical Clinic: A Prospective Survey of Patient and Family Preferences.

OBJECTIVE: After becoming widespread during the COVID-19 pandemic, telemedicine continues to play an important role in outpatient neurosurgical care. Nevertheless, the factors that influence individual decisions to choose telemedicine versus in-person appointments remain understudied. Here, we performed a prospective survey of pediatric neurosurgical patients and caregivers presenting for telemedicine or in-person outpatient visits, to identify factors associated with appointment choice. METHODS: All patients and caregivers with an outpatient pediatric neurosurgical encounter at Connecticut Children's between January 31st and May 20th, 2022, were invited to participate in this survey. Data related to demographics, socioeconomics, technological access, COVID-19 vaccination status, and appointment preferences were collected. RESULTS: During the study period, there were 858 unique pediatric neurosurgical outpatient encounters (86.1% in-person and 13.9% telemedicine). A total of 212 (24.7%) respondents completed the survey. Those with a telemedicine appointment were more likely to be white (P = 0.005), not Hispanic or Latino (P = 0.020), have private insurance (P = 0.003), be established patients (P < 0.001), have a household income >$80,000 (P = 0.005), and have caregivers who completed a 4-year college degree (P < 0.001). Those who were seen in-person cited the patient's condition, quality of care, and communication as important factors, whereas those who were seen via telemedicine cited time, travel, and convenience. CONCLUSIONS: While convenience influences some to choose telemedicine, concerns regarding the quality of care persist among those who prefer in-person encounters. Recognizing these factors will minimize barriers to care, better define the appropriate populations/contexts for each encounter type, and improve the integration of telemedicine within an outpatient neurosurgical setting.

Recruitment into Academic Neurosurgery Using a Model for Successful Cross-Campus Research Collaboration: A Premedical Student Survey.

OBJECTIVE: Recruitment of diverse and talented students to the field of neurosurgery is key to its continued growth and scientific advancement. Barriers, including poor perceptions and lack of early exposure, can impact recruitment and have been compounded by the ongoing COVID-19 pandemic. This study examines the impact of an inaugural Neurosurgery Research Consortium meeting on premedical students, assessing whether this exposure generated interest and improved perceptions of a career in neurosurgery. METHODS: Premedical students were recruited to virtually attend an inaugural Neurosurgery Research Consortium developed by the affiliated medical school's American Association of Neurological Surgeons (AANS) Student Chapter. Questionnaires were distributed to students before and after the meeting to assess student demographics and perceptions of neurosurgery. RESULTS: A total of 54 students attended the meeting, with general interest in neurosurgery, medicine, and research opportunities being the primary factors for attendance. Following the research meeting, we found that students perceived neurosurgeons to be friendlier and more approachable, with a more positive quality of life (QoL). Overall perceptions of neurosurgery improved after the meeting, but perceptions among racial and ethnic minority students did not significantly change in the areas of diversity, inclusion, and equity. CONCLUSIONS: These results suggest recruitment strategies targeting undergraduate students may improve their perception of neurosurgery as a career, and may mitigate some barriers to entry. These strategies are cost effective and easily replicable, making an easily implementable approach to provide direct insight into neurosurgery for future medical students while also promoting academic efforts in the field of neurosurgery.

Clinical metrics and tools for provider assessment and tracking of trigonocephaly.

OBJECTIVE: Quantitative measurements of trigonocephaly can be used to characterize and track this phenotype, which is associated with metopic craniosynostosis. Traditionally, trigonocephaly metrics were extracted from CT scans; however, this method exposes patients to ionizing radiation. Three-dimensional optical scans are another option but are not routinely available in most outpatient settings. Recently, the authors developed semiautomated artificial intelligence algorithms that extract craniometric data from orthogonal 2D photographs. Although 2D photographs are safe, inexpensive, and straightforward to obtain, the accuracy of photograph-based craniometrics in comparison to CT and 3D optical scan correlates has not been established. In this study the authors compared the classification power of 2D photograph-based metrics of trigonocephaly with four CT-based metrics and one 3D optical scan-based metric in a heterogeneous series of patients who presented to an outpatient craniofacial clinic. METHODS: In this study the authors performed retrospective craniometric analyses of patient 2D photographs, 3D optical scans, and CT scans. Imaging-derived craniometrics include the 2D photograph-based anterior arc angle (AAA2D-photo), anterior-posterior ratio (APR2D-photo), and anterior-middle ratio (AMR2D-photo); the CT-based anterior arc angle (AAACT), metopic index (MICT), endocranial-bifrontal angle (eBFACT), and interfrontal angle (IFACT); and the 3D optical scan-based anterior arc angle (AAA3D-optical). Receiver operating characteristics (ROCs) were used to identify craniometrics strongly descriptive of trigonocephaly. Interrater comparisons were made between paired trigonocephaly measurements obtained from photographs and either CT scans or 3D optical scans. RESULTS: There were 13 photograph-based and CT-based pairs and 22 paired measurements from 2D photographs and 3D optical scans. AAA displayed the strongest classification capacity across all three imaging modalities. Significant agreement was observed between AAACT and AAA2D-photo (intraclass correlation coefficient [ICC] = 0.68 [95% CI 0.24-0.89], p = 0.0035), and AAA3D-optical and AAA2D-photo (ICC = 0.70 [95% CI 0.41-0.87], p < 0.0001). There was no significant correlation between APR2D-photo or AMR2D-photo and conventional CT-based metrics describing longitudinal width ratios (MICT). CONCLUSIONS: Photograph-based craniometrics are powerful tools that can be used to quantify the severity of trigonocephaly and exhibit high concordance with standard measurements derived from CT scans and 3D optical scans. The authors developed and freely share a research-use application to calculate trigonocephaly metrics from 2D photographs. Given the availability of digital photography, lack of ionizing radiation, and low cost of photograph-based craniometric derivation, this technique may be useful to supplement routine ambulatory care and objectively track outcomes following treatment.

Remembering Edmund Klein: the Father of Immunotherapy.

Edmund Klein's seminal research in oncology transformed medicine. He would now be 100 years old. This extraordinary physician-scientist has been dubbed the Father of Immunotherapy and was honored with the highest American recognition in medicine, the Lasker Award, often a prelude to the Nobel Prize.

Research Note: Impact of Eimeria on apparent retention of components and metabolizable energy in broiler chickens fed single or mixture of feed ingredients-based diets.

The effect of Eimeria on apparent retention (AR) of components and metabolizable energy corrected for nitrogen (AMEn) content in corn, wheat, soybean meal (SBM), and pork meal (PM) was investigated in broiler chickens. A total of 840 male d-old Ross 708 chicks were placed in 84 cages (10 birds/cage) and allocated either a nitrogen-free diet (NFD), or 1 of 6 test cornstarch-based semipurified diets: 1) corn, 2) wheat, 3) SBM, 4) PM, 5) corn, SBM, and PM (CSP) mixture, and 6) wheat, SBM, and PM (WSP) mixture (n = 12). Diets contained 0.3% titanium dioxide and nutrient digestibility was determined by difference method using NFD. On d 10, birds in half of replicates per diet were orally challenge with 1 mL of E. acervulina and E. maxima culture and the other half equal volume of saline. Excreta samples were collected from d 12 to 14. With exception of AR of Ca and P, there was no interaction (P > 0.05) between Eimeria and diet on AR of dry matter, crude fat (CF), crude protein and gross energy and AMEn of ingredients. Eimeria reduced AR of CF (P = 0.01) and had a tendency to reduce AR of DM (P = 0.09) and AMEn (P = 0.063) of ingredients. The data demonstrated exposure to Eimeria impacted nutrient retention and energy utilization irrespective to diet composition.

Revive the Dennie-Morgan Fold: A Forgotten Sign of Atopic Dermatitis in Children.

In 1980, Hanifin and Rajka (1) proposed major and minor diagnostic criteria for atopic dermatitis (AD). Major associations included pruritus, dry skin, and history of atopy. One minor feature included Dennie-Morgan Folds (DMFs), which manifest as secondary creases in the skin underneath the inferior eyelid, usually found in infants (2). In an attempt to refine these criteria, a study evaluating 210 patients with an existing AD diagnosis observed DMF in 84% of AD cases. A pediatric study in Bijapur, India on 174 children under 16 years of age with AD identified DMF to be the most prevalent minor criterion. DMFs were found in 71.8% of the study's population and was followed by palmar hyperlinearity and xerosis in prevalence (2). Although DMF pathophysiology remains unclear, we suggest a theory stemming from nocturnal pruritus (NP). The two leading causes of NP are AD and psoriasis, both of which interfere with the patient's sleep quality. Children with increased NP have greater sleep fragmentation and difficulty waking up in the morning (3). A lack of melatonin rhythmic secretions resulting in circadian misalignment may serve as an intermediary for DMF onset. As more blood perfuses the skin under the eyes, edematous fluid enhances dysregulation of the collagen fibers under the eyelids. NP also manifests as facial touching and rubbing or scratching the eyelids during sleep, which can aggravate tissue surrounding the eye (3). AD affects 15-20% of the pediatric population, whereas food allergies, some life-threatening, are found in up to 30% of children with AD, compared with 0.1-0.6% of children in the general population (2). Identifying DMF in children can facilitate the diagnosis of AD and thus lead to the necessary tests to determine whether conditions associated with AD exist, such as food allergy. DMFs are indicative of an AD diagnosis and can be especially critical for children who have life-threatening food allergies associated with their AD (3). One challenge in using DMF as a marker for AD are its different manifestations across ethnic and racial groups. In a study of 160 children aged 3-11 years in London, England, DMFs were present in 34/69 children classified as "black", regardless of whether the child presented with AD. In children classified as "white", only 11/44 had DMFs regardless of AD diagnosis. When cases of AD were excluded, 25% of the white children and 49% of black children had DMFs (4). In a separate study evaluating the differences in prevalence of AD minor characteristics between African Americans and European Americans, African Americans were more likely to have extensor involvement along with diffuse xerosis, palmar hyperlinearity, and DMFs (5). Furthermore, in individuals with darker skin tones, DMFs may be of greater importance, as other characteristics such as erythema may be harder to recognize (5). Life-threatening food allergies are rare, but represent serious sequelae associated with AD. DMFs can serve as a critically simple, easy-to-identify marker for AD and perhaps identify the condition before the presence of serious sequelae. DMFs may guide the clinician towards inquiring further about other AD-related symptoms, thus improving clinical assessment of a significant pediatric condition.

Early experience with targeted therapy as a first-line adjuvant treatment for pediatric low-grade glioma.

OBJECTIVE: Pediatric low-grade gliomas (pLGGs) frequently exhibit dysregulation of the mitogen-activated protein kinase (MAPK) pathway. Targeted therapies, including mutant BRAF inhibitors (dabrafenib) and MEK inhibitors (trametinib), have shown promise in patients in whom conventional chemotherapy has failed. However, few studies have investigated the use of targeted therapy as a first-line treatment for pLGG. Here, the authors reviewed their institutional experience with using a personalized medicine approach to patients with newly diagnosed pLGGs. METHODS: All pediatric patients at the authors' institution who had been treated with dabrafenib or trametinib for pLGG without first receiving conventional chemotherapy or radiation were retrospectively reviewed. Demographic, clinical, and radiological data were collected. RESULTS: Eight patients underwent targeted therapy as a first-line treatment for pLGG. Five patients had a BRAF alteration (1 with a BRAFV600E mutation, 4 with a KIAA1549:BRAF fusion), and 3 patients had an NF1 mutation. One of the 8 patients was initially treated with dabrafenib, and trametinib was added later. Seven patients were initially treated with trametinib; of these, 2 later transitioned to dual therapy, whereas 5 continued with trametinib monotherapy. Six patients (75%) demonstrated a partial response to therapy during their treatment course, whereas stable disease was identified in the remaining 2 patients (25%). One patient experienced mild disease progression after completing a course of trametinib monotherapy, but ultimately stabilized after a period of close observation. Another patient experienced tumor progression while on dabrafenib, but subsequently responded to dual therapy with dabrafenib and trametinib. The most common adverse reactions to targeted therapy were cutaneous toxicity (100%) and diarrhea (50%). CONCLUSIONS: Targeted therapies have the potential to become a standard treatment option for pLGG due to their favorable toxicity profile and oral route of administration. This case series provides preliminary evidence that targeted therapies can induce an early disease response as a first-line adjuvant treatment; however, large-scale studies are required to assess long-term durability and safety.

A Qualitative Review of Barriers and Facilitators Identified While Implementing the Native Students Together Against Negative Decisions Curriculum in a Multisite Dissemination and Implementation Study.

Culturally-adapted evidence-based programs (EBPs) are needed to promote healthy behaviors among Native teens and young adults. Little is known about the facilitators and barriers of implementing and sustaining EBPs in Native communities. This paper aims to identify those factors described by educators who implemented the Native Students Together Against Negative Decisions (STAND) curriculum. METHODS: We conducted qualitative, semi-structured interviews with 44 Native STAND educators from 48 sites throughout the United States. We used a modified grounded theory approach to explore barriers, facilitators, and sustainability factors related to implementing Native STAND. RESULTS: We learned that disruptions to staffing, coordination, and organizational factors were the most common barriers. Factors that improved implementation success included: tailoring the program to local needs/constraints, having a supportive Project Manager, improved fidelity due to check-in calls, and participation in summer training. Factors that improved sustainability included: access to needed infrastructure, administrative support, community support, and student interest. DISCUSSION: The delivery of Native STAND was further improved by person-to-person communication and resource sharing across sites. Sustaining EBPs in AI/AN settings requires culturally-tailored technical assistance, sufficient implementation funds for materials and staffing, and a community of peer educators to inspire forward progress. CONCLUSION: EBPs that reflect the needs and experiences of American Indian and Alaska Native (AI/AN) youth are necessary to address systemic inequities in adolescent health outcomes. The Native STAND Dissemination and Implementation study is among the first to assess facilitators and barriers to program delivery in diverse AI/AN settings.

Family-acquired photographs for the evaluation of pediatric head shape via telemedicine: an analysis of photograph quality.

OBJECTIVE: Telemedicine can be an effective tool for the evaluation of the pediatric patient with a cranial deformity, but it increases the reliance of neurosurgical providers on data provided by patients and families. Family-acquired photographs, in particular, can be used to augment the evaluation of pediatric head shape abnormalities via telemedicine, but photographs of sufficient quality are necessary. Here, the authors systematically reviewed the quality and utility of family-acquired photographs for patients referred to their pediatric neurosurgery clinic for telemedicine-based head shape evaluations. METHODS: All telemedicine encounters that were completed for head shape abnormalities at the authors' institution between May 2020 and December 2021 were retrospectively reviewed. Instructions were sent to families prior to each visit with examples of ideal photographs. Three orthogonal views of the patient's head-frontal, lateral, and vertex-were requested. Data were collected regarding demographics, diagnosis, follow-up, and photograph quality. Quality variables included orthogonality of each requested view, appropriate distance, appropriate lighting, presence of distracting elements, and whether hair obscured the head shape. RESULTS: Overall, 565 patients had 892 visits during the study period. A total of 1846 photograph requests were made, and 3335 photographs were received for 829 visits. Of 2676 requested orthogonal views, 1875 (70%) were received. Of these, 1826 (97%) had adequate lighting, 1801 (96%) had appropriate distance, and 1826 (97%) had no distracting features. Hair did not obscure the head shape on the vertex view in 557 visits with orthogonal vertex views (82%). In-person follow-up was requested for further medical evaluation in 40 visits (5%). CONCLUSIONS: The family-acquired photographs in this series demonstrated high rates of adequate lighting and distance, without distracting features. Lack of orthogonality and obscuration of the head shape by hair, however, were more common issues. Family education prior to the visit may improve the quality of family-acquired photographs but requires an investment of time by medical staff. Efforts to further improve photographic quality will facilitate efforts to perform craniometric evaluations through telemedicine visits.