Continuous Fetal Cardiac Monitoring during Fetoscopic Myelomeningocele Repair and Relationship to Spectral Doppler Changes.

INTRODUCTION: No evidence-based protocols exist for fetal cardiac monitoring during fetoscopic myelomeningocele (fMMC) repair and intraprocedural spectral Doppler data are limited. We determined the feasibility of continuous fetal echocardiography during fMMC repair and correlated Doppler changes with qualitative fetal cardiac function during each phase of fMMC repair. METHODS: Patients undergoing fMMC repair had continuous fetal echocardiography interpreted in real-time by pediatric cardiology. Fetal data included fetal heart rate (FHR), qualitative cardiac function, mitral and tricuspid valve inflow waveforms, and umbilical artery (UA), umbilical vein (UV), ductus arteriosus (DA), and ductus venosus (DV) Dopplers. RESULTS: UA abnormalities were noted in 14/25 patients, UV abnormalities were observed in 2 patients, and DV and DA abnormalities were each noted in 4 patients. Qualitative cardiac function was normal for all patients with the exception of one with isolated left ventricular dysfunction during myofascial flap creation, concurrent with an abnormal UA flow pattern. All abnormalities resolved by the first postoperative day. CONCLUSIONS: Continuous fetal echocardiography was feasible during all fMMC repairs. Spectral Doppler changes in the UA were common during fMMC procedures but qualitative cardiac dysfunction was rare. Abnormalities in the UV, DV, and DA Dopplers, FHR, and cardiac function were less common findings.

Superficial keratectomy for the treatment of spontaneous chronic corneal epithelial defects in dogs.

OBJECTIVE: To report the outcome of superficial keratectomy with bandage contact lens placement for the treatment of spontaneous chronic corneal epithelial defects (SCCEDs) in dogs. METHODS: Patients that underwent a superficial keratectomy with bandage lens placement for the treatment of one or more SCCEDs were retrospectively included in the study. Signalment, eye(s) affected, prior medical therapy and any procedures performed, post-operative medical therapy, healing rate, and any post-operative complications were recorded. Superficial keratectomy was performed to approximately one-fifth of corneal depth under operating microscope guidance and a bandage lens was placed immediately post-operatively. Corneas were considered healed when the fluorescein stain was negative. RESULTS: One hundred and seven dogs met the inclusion criteria with 121 SCCEDs. The mean age of patients was 8.34 ± 2.89 years (1-15). Ninety-nine percent (120/121) of SCCEDS healed with no additional treatment within 21 days of surgery. One eye had a diamond burr debridement performed on Day 14 post-operatively and healed 2 weeks following the additional procedure. No post-operative complications were noted. CONCLUSIONS: This study found superficial keratectomy with bandage lens placement to be an effective treatment for SCCEDs.

Free labial mucocutaneous graft for eyelid reconstruction in four dogs.

PURPOSE: To describe a technique for eyelid margin reconstruction following large mass resection utilizing a free labial mucocutaneous graft. METHODS: Four dogs (4 eyes) underwent en bloc eyelid mass excision under general anesthesia. Measurements were made of the mass followed by free labial mucocutaneous graft retrieval, resection of the mass, and then transplantation of retrieved region of labial mucocutaneous tissue into the resulting defect. RESULTS: Three patients underwent eyelid margin reconstruction with a free labial mucocutaneous graft. One patient received a pedicle advancement graft combined with a free labial mucocutaneous graft. In all cases, a length of 120%-150% of the eyelid defect was retrieved from the oral labia. Postoperative follow-up ranged from 6 weeks to 4 months. All cases had superficial graft necrosis and depigmentation of the donor tissue with total healing time taking up to 8 weeks. All cases had an esthetic and functional reconstruction. CONCLUSIONS: This technique allows reconstruction of the majority of the eyelid margin, greater than that which can be closed primarily. Due to tissue sloughing, the healing time can be extended but cosmetic outcomes are good. Eyelid reconstruction utilizing a free labial graft restored a mucocutaneous margin and recreated a functional eyelid, thus avoiding trichiasis or secondary keratitis.

Effect of dexmedetomidine added to retrobulbar blockade with lignocaine and bupivacaine in dogs undergoing enucleation surgery.

OBJECTIVE: To investigate the effect of the addition of dexmedetomidine (BLD) to retrobulbar blockade with combined lignocaine and bupivacaine on nociception. ANIMALS: A total of 17 eyes from 15 dogs. METHODS: Prospective, randomized, masked clinical comparison study. Dogs undergoing unilateral enucleation were randomly assigned into two groups; a retrobulbar administration of lignocaine and bupivacaine in a 1:2 volume ratio combined with either BLD or 0.9% saline (BLS). The total volume of the intraconal injection was calculated at 0.1 mL/cm cranial length. Intraoperative parameters were recorded: heart rate (HR), respiratory rate (RR), end-tidal CO2 (EtCO2 ) arterial blood pressure (BP), and inspired isoflurane concentration (ISOinsp). Pain scores, heart rate and RR were recorded postoperatively. RESULTS: Dogs receiving BLD (n = 8) had significantly lower intraoperative RR (p = 0.007), and significantly lower ISOinsp (p = 0.037) than dogs in the BLS group (n = 9). Postoperatively heart rate was significantly lower in the BLD group at 1 min (p = 0.025) and 1 h (p = 0.022). There were no other significant differences in intraoperative or postoperative parameters, or in postoperative pain scores (p = 0.354). Dogs receiving BLD had a higher rate of anesthetic events of bradycardia and hypertension (p = 0.027). Analgesic rescue was not needed in either group. CONCLUSIONS: The addition of BLD to retrobulbar anesthesia did not result in a detectable difference in pain scores relative to blockade with lignocaine and bupivacaine alone. Dogs receiving retrobulbar BLD had a significantly lower intraoperative RR and isoflurane requirement and an increased incidence of intraoperative bradycardia and hypertension.

Integrated single-cell chromatin and transcriptomic analyses of human scalp identify gene-regulatory programs and critical cell types for hair and skin diseases.

Genome-wide association studies have identified many loci associated with hair and skin disease, but identification of causal variants requires deciphering of gene-regulatory networks in relevant cell types. We generated matched single-cell chromatin profiles and transcriptomes from scalp tissue from healthy controls and patients with alopecia areata, identifying diverse cell types of the hair follicle niche. By interrogating these datasets at multiple levels of cellular resolution, we infer 50-100% more enhancer-gene links than previous approaches and show that aggregate enhancer accessibility for highly regulated genes predicts expression. We use these gene-regulatory maps to prioritize cell types, genes and causal variants implicated in the pathobiology of androgenetic alopecia (AGA), eczema and other complex traits. AGA genome-wide association studies signals are enriched in dermal papilla regulatory regions, supporting the role of these cells as drivers of AGA pathogenesis. Finally, we train machine learning models to nominate single-nucleotide polymorphisms that affect gene expression through disruption of transcription factor binding, predicting candidate functional single-nucleotide polymorphism for AGA and eczema.

An investigation into the development of qualitative tear film disorders in dogs following cryoepilation for distichiasis.

OBJECTIVE: The aim of this prospective study was to compare tear film quality between dogs who have previously undergone cryoepilation for distichiasis to a reference population. ANIMALS STUDIED: Nine dogs (17 eyes) were recruited after surgery and were compared to a reference population of 21 dogs (42 eyes). PROCEDURES: Canine patients who had previously undergone cryoepilation for distichiasis for a minimum of 1 month prior to examination were recruited. A complete ophthalmic examination was performed by an ABVO resident (BDR), with additional tear tests, including tear film interferometry, infra-red meibography, and a tear film break-up time (TFBUT) performed. The tear test results were compared to a reference population obtained from client-owned dogs with no history of ophthalmic complaints, a normal ophthalmic examination performed by an ABVO resident (BDR) and a Schirmer Tear Test-1 > 15 mm/min. Statistical analysis was performed of the results obtained. RESULTS: The treated group was significantly more affected with meibomian gland dropout (MG-dropout) in 11/17 (64.7%) cases, compared to the reference population of 2/21 (9.5%) (p < .01). The treated group had an odds ratio of 23.8 to develop MG-dropout compared to the reference population (p < .01). Tear film breakup time (TFBUT) was significantly shorter in the treatment group (5.8 ± 2.6 s) compared to the reference population (10.1 ± 1.1 s) (p < .001). In the treatment group, 12/17 (70.5%) of treated eyes had a TFBUT < 5 s compared to 2/21 (9.5%) of the reference population. CONCLUSION: Cryoepilation for distichaiasis appears to be a risk factor for developing MG-dropout and qualitative tear film disorders post-operatively in canines.

Direct Instruction of Absolute Pitch Using the Theremin as a Musical Instrument and Experimental Apparatus.

Direct Instruction (DI) is a method of education that has historically been applied to improve academic behaviors. Though DI has a modest history of teaching musical literacy skills, its application in teaching music performance skills has been limited. This article presents two methods derived from DI principles to teach the advanced musical skill of absolute pitch using the theremin as a unique musical instrument and experimental apparatus. The two methods are optimized for either fast learning of the new skill or assessment of the skill in a general sample of participants, and both are shown to significantly improve posttraining performance. Instructors recruited 53 college aged participants with a variety of music education histories across two studies (16 participants in Study 1; 37 participants in Study 2) for participation in either of the novel DI protocols for teaching absolute pitch using prompt fading. All participants showed significantly improved absolute pitch accuracy above baseline following 1 hr or less of DI with either method. Implications and suggestions for educators and researchers are discussed.

Electropolymerized Molecularly Imprinted Polymer Synthesis Guided by an Integrated Data-Driven Framework for Cortisol Detection.

Molecularly imprinted polymers (MIPs), often called "synthetic antibodies", are highly attractive as artificial receptors with tailored biomolecular recognition to construct biosensors. Electropolymerization is a fast and facile method to directly synthesize MIP sensing elements in situ on the working electrode, enabling ultra-low-cost and easy-to-manufacture electrochemical biosensors. However, due to the high dimensional design space of electropolymerized MIPs (e-MIPs), the development of e-MIPs is challenging and lengthy based on trial and error without proper guidelines. Leveraging machine learning techniques in building the quantitative relationship between synthesis parameters and corresponding sensing performance, e-MIPs' development and optimization can be facilitated. We herein demonstrate a case study on the synthesis of cortisol-imprinted polypyrrole for cortisol detection, where e-MIPs are fabricated with 72 sets of synthesis parameters with replicates. Their sensing performances are measured using a 12-channel potentiostat to construct the subsequent data-driven framework. The Gaussian process (GP) is employed as the mainstay of the integrated framework, which can account for various uncertainties in the synthesis and measurements. The Sobol index-based global sensitivity is then performed upon the GP surrogate model to elucidate the impact of e-MIPs' synthesis parameters on sensing performance and interrelations among parameters. Based on the prediction of the established GP model and local sensitivity analysis, synthesis parameters are optimized and validated by experiment, which leads to remarkable sensing performance enhancement (1.5-fold increase in sensitivity). The proposed framework is novel in biosensor development, which is expandable and also generally applicable to the development of other sensing materials.

NEAT-seq: simultaneous profiling of intra-nuclear proteins, chromatin accessibility and gene expression in single cells.

In this work, we describe NEAT-seq (sequencing of nuclear protein epitope abundance, chromatin accessibility and the transcriptome in single cells), enabling interrogation of regulatory mechanisms spanning the central dogma. We apply this technique to profile CD4 memory T cells using a panel of master transcription factors (TFs) that drive T cell subsets and identify examples of TFs with regulatory activity gated by transcription, translation and regulation of chromatin binding. We also link a noncoding genome-wide association study single-nucleotide polymorphism (SNP) within a GATA motif to a putative target gene, using NEAT-seq data to internally validate SNP impact on GATA3 regulation.

High-throughput biochemical profiling reveals functional adaptation of a bacterial Argonaute.

Argonautes are nucleic acid-guided proteins that perform numerous cellular functions across all domains of life. Little is known about how distinct evolutionary pressures have shaped each Argonaute's biophysical properties. We applied high-throughput biochemistry to characterize how Thermus thermophilus Argonaute (TtAgo), a DNA-guided DNA endonuclease, finds, binds, and cleaves its targets. We found that TtAgo uses biophysical adaptations similar to those of eukaryotic Argonautes for rapid association but requires more extensive complementarity to achieve high-affinity target binding. Using these data, we constructed models for TtAgo association rates and equilibrium binding affinities that estimate the nucleic acid- and protein-mediated components of the target interaction energies. Finally, we showed that TtAgo cleavage rates vary widely based on the DNA guide, suggesting that only a subset of guides cleaves targets on physiologically relevant timescales.

Use of subdermal hyaluronic acid injections and a free labial mucocutaneous graft for the repair of feline eyelid agenesis.

OBJECTIVE: To describe a technique to repair feline eyelid agenesis using a hyaluronic acid (HA) subdermal filler injection to allow for acute soft tissue expansion, followed by a free labial mucocutaneous graft. MATERIALS AND METHODS: Thirty-nine colobomatous eyelids in 24 feline patients with secondary keratitis were recruited to the study group. RESULTS: Keratitis and trichiasis were markedly resolved in 27/39 (69.2%) eyelids after a single procedure. Post-operative HA subdermal filler injections were required to resolve 5/39 (12.8%) eyelids that had mild post-operative trichiasis, and 1/39 (2.5%) eyelids that had post-operative lateral canthal collapse. Complications occurred in 6/39 (15.4%) cases, consisting of distal graft necrosis (n = 2 eyes), suture rubbing the cornea (n = 2 eyes), moderate trichiasis (n = 1 eye) and graft adherence to the episclera (n = 1 eye). CONCLUSION: The technique was successful in enhancing corneal protection, cosmesis and eyelid function and should be considered as a surgical option for any degree of eyelid agenesis in feline patients.

Retinal cone photoreceptor distribution in the American black bear (Ursus americanus).

The distribution of cone photoreceptor subtypes (important for color vision and vision quality) varies widely in different carnivore species, but there have been limited studies on bear (ursid) cone distribution. A previous behavioral study suggests that American black bears (Ursus americanus) are dichromatic, indicating that they possess two cone subtypes, although the retinal distribution of cones is unknown. The purpose of this study was to examine the subtype and topography of cones in American black bear retinas to further predict the nature of their color vision and image resolution. We studied 10 eyes from seven individual legally hunted black bears in northeastern North Carolina. Cryosections and retinal wholemounts were labeled using antibodies targeting two cone opsin subtypes: long/medium (L/M) wavelength sensitive and short (S) wavelength sensitive. Cones in fluorescent microscopy images were counted and density maps were created for retinal wholemounts. The black bear retina contains both cone subtypes and L/M cones outnumber S cones by at least 3:1, a finding confirmed in retinal frozen sections. There are higher concentrations of S cones present than typically seen in other carnivores with some evidence for co-expression of L/M and S cones. A cone-dense area centralis is present dorsotemporal to the optic nerve, similar to other carnivores. These results confirm that American black bears are predicted to have a dichromatic vision with high acuity indicated by the presence of a dorsotemporally located area centralis.

Design for Implementation of a System-Level ICU Pandemic Surge Staffing Plan.

BACKGROUND: The current coronavirus disease 2019 pandemic is causing significant strain on ICUs worldwide. Initial and subsequent regional surges are expected to persist for months and potentially beyond. As a result of this, as well as the fact that ICU provider staffing throughout the United States currently operate at or near capacity, the risk for severe and augmented disruption in delivery of care is very real. Thus, there is a pressing need for proactive planning for ICU staffing augmentation, which can be implemented in response to a local surge in ICU volumes. METHODS: We provide a description of the design, dissemination, and implementation of an ICU surge provider staffing algorithm, focusing on physicians, advanced practice providers, and certified registered nurse anesthetists at a system-wide level. RESULTS: The protocol was designed and implemented by the University of Pittsburgh Medical Center's Integrated ICU Service Center and was rolled out to the entire health system, a 40-hospital system spanning Pennsylvania, New York, and Maryland. Surge staffing models were developed using this framework to assure that local needs were balanced with system resource supply, with rapid enhancement and expansion of tele-ICU capabilities. CONCLUSIONS: The ICU pandemic surge staffing algorithm, using a tiered-provider strategy, was able to be used by hospitals ranging from rural community to tertiary/quaternary academic medical centers and adapted to meet specific needs rapidly. The concepts and general steps described herein may serve as a framework for hospital and other hospital systems to maintain staffing preparedness in the face of any form of acute patient volume surge.

Use of a chronic soft tissue expansion device to facilitate blepharoplasty in a horse with lower-lid cicatricial ectropion with a 14-year follow-up.

A 3-year-old Thoroughbred filly presented to a referral equine hospital for surgical correction of a severe cicatricial lateral lower eyelid ectropion OD, with secondary exposure keratitis. The severity of the ectropion deemed that conventional ectropion repairs would be unsuccessful. Therefore, a soft tissue expansion device was used to create sufficient local tissue for a rotational graft with tension-relieving horizontal incisions to be performed to facilitate closure and acceptable eyelid apposition. The keratitis had resolved by two months postoperatively. There were no long-term complications and only mild recurrence of the keratitis observed 14-years postoperatively.

Misalignment of specialty nurse practitioners and the Consensus Model.

Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.

Microsporidial stromal keratitis in a cat.

A 12 year-old female spayed felid presented after a 35 day history of right eye pain. On examination, a sub-epithelial opacity was identified in the cornea. A lamellar keratectomy was performed and histopathological analysis revealed low numbers of 2x4um, Gram, Hamatoxylin-eosin and Gomori methanamine-silver positive spores. Transmission electron microscopy found ultrastructural findings consistent with the phylum Microspora. To the author's knowledge, this is only the second case of microsporidial stromal keratitis reported in a felid.

High-Throughput Analysis Reveals Rules for Target RNA Binding and Cleavage by AGO2.

Argonaute proteins loaded with microRNAs (miRNAs) or small interfering RNAs (siRNAs) form the RNA-induced silencing complex (RISC), which represses target RNA expression. Predicting the biological targets, specificity, and efficiency of both miRNAs and siRNAs has been hamstrung by an incomplete understanding of the sequence determinants of RISC binding and cleavage. We applied high-throughput methods to measure the association kinetics, equilibrium binding energies, and single-turnover cleavage rates of mouse AGO2 RISC. We find that RISC readily tolerates insertions of up to 7 nt in its target opposite the central region of the guide. Our data uncover specific guide:target mismatches that enhance the rate of target cleavage, suggesting novel siRNA design strategies. Using these data, we derive quantitative models for RISC binding and target cleavage and show that our in vitro measurements and models predict knockdown in an engineered cellular system.

Patient and tumour factors influencing canine mast cell tumour histological grade and mitotic index.

The aim of this study was to identify patient and tumour factors most frequently associated with high histological grades of canine mast cell tumours (MCTs). Search criteria in a shared database of multiple Animal Referral Hospital locations within Australia generated 400 canine MCTs in 286 patients. Patient and tumour data were extrapolated and the association between a tumour being histologically high grade and patient and tumour factors, including: patient breed, patient gender and neuter status, patient age at MCT excision, tumour location and tumour size was assessed using univariate analysis. The study consisted of 90 (21.9%) tumours meeting histological high-grade criteria. Shar peis were the most likely breed to have high grade MCTs, whereas the Pug and the Golden Retriever were the least likely breeds to develop high-grade MCTs. No significant difference in risks could be established between the age at which the tumour was excised, or the gender and neuter status of patients. MCTs of the inguinal region were the most likely single location to be high grade. Tumour size did not influence the likelihood of a tumour being high grade or low grade. The results of this study suggest that patient and tumour factors may play a role in the histological grades of canine MCTs.

Chronic exposure to complex metal oxide nanoparticles elicits rapid resistance in Shewanella oneidensis MR-1.

Engineered nanoparticles are incorporated into numerous emerging technologies because of their unique physical and chemical properties. Many of these properties facilitate novel interactions, including both intentional and accidental effects on biological systems. Silver-containing particles are widely used as antimicrobial agents and recent evidence indicates that bacteria rapidly become resistant to these nanoparticles. Much less studied is the chronic exposure of bacteria to particles that were not designed to interact with microorganisms. For example, previous work has demonstrated that the lithium intercalated battery cathode nanosheet, nickel manganese cobalt oxide (NMC), is cytotoxic and causes a significant delay in growth of Shewanella oneidensis MR-1 upon acute exposure. Here, we report that S. oneidensis MR-1 rapidly adapts to chronic NMC exposure and is subsequently able to survive in much higher concentrations of these particles, providing the first evidence of permanent bacterial resistance following exposure to nanoparticles that were not intended as antibacterial agents. We also found that when NMC-adapted bacteria were subjected to only the metal ions released from this material, their specific growth rates were higher than when exposed to the nanoparticle. As such, we provide here the first demonstration of bacterial resistance to complex metal oxide nanoparticles with an adaptation mechanism that cannot be fully explained by multi-metal adaptation. Importantly, this adaptation persists even after the organism has been grown in pristine media for multiple generations, indicating that S. oneidensis MR-1 has developed permanent resistance to NMC.

Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma, and nearly 40% of prehospital deaths can be attributed to blood loss. The Stop the Bleed program provides a structured curriculum for teaching hemorrhage control and the use of bleeding control kits. To overcome implementation barriers and to achieve the goal of making education on bleeding control as common as cardiopulmonary resuscitation, widespread implementation with outreach to the public and law enforcement is necessary. METHODS: We provide a description and analysis of the implementation of a regional Stop the Bleed program, which includes a step-by-step guide to the design of this program provided as a template to guide attempts at large-scale Stop the Bleed program development. RESULTS: Combining the efforts of regional trauma and nontrauma centers as a hub-and-spoke design, a region covering four states, 72 counties, and 30,000 square miles was targeted. A total of 27,291 individuals were trained in a 21-month period including 3,172 trainers, 19,310 lay public, and 4,809 law enforcement officers. A total of 436 bleeding control kits were distributed to 102 public schools, and tourniquets were provided to 4,809 law enforcement officers. Program development and community outreach resulted in official recognition of the program by the Pennsylvania State Senate. CONCLUSIONS: With the use of a multicenter outreach program design with emphasis on law enforcement and public education while developing a train-the-trainer program, widespread and rapid dissemination of Stop the Bleed teaching is feasible. The general steps described in this manuscript may serve as a template for new or developing programs in other areas to increase the national exposure to Stop the Bleed. LEVEL OF EVIDENCE: Economic/Decision study, level IV.