Additional Episodes Research Articles

Reawakening of Voragine, the Oldest of Etna’s Summit Craters: Insights from a Recurrent Episodic Eruptive Behavior

Paroxysmal explosive activity at Etna volcano (Italy) has become quite frequent over the last three decades, raising concerns with the civil protection authorities due to its significant impact on the local population, infrastructures, viability and air traffic. Between 4 July and 15 August 2024, during the tourist season peak when the local population doubles, Etna volcano gave rise to a sequence of six paroxysmal explosive events from the summit crater named Voragine. This is the oldest and largest of Etna’s four summit craters and normally only produces degassing, with the previous explosive sequences occurring in December 2015 and May 2016. In this paper, we use thermal images recorded by the monitoring system maintained by the Istituto Nazionale di Geofisica e Vulcanologia, Osservatorio Etneo (INGV–OE), and an automatic procedure previously tested in order to automatically define the eruptive parameters of the six lava fountain episodes. These data allowed us to infer the eruptive processes and gain some insights on the evolution of the explosive sequences that are useful for hazard assessment. Specifically, our results lead to the hypothesis that the Voragine shallow storage has a capacity of ~12–15 Mm3, which was not completely emptied with the last two paroxysmal events. It is thus possible that one or two additional explosive paroxysmal events could occur in the future. It is noteworthy that an additional paroxysmal episode occurred at Voragine on 10 November 2024, after the submission of this paper, thus confirming our hypothesis.

Factors associated with the development of recurrent and contralateral Charcot neuroarthropathy in individuals with diabetes mellitus: A scoping review.

Charcot neuroarthropathy (CN) can result in fractures and dislocations of the foot and ankle in individuals with diabetes and neuropathy, leading to ulceration, amputation and a poor quality of life. Additional episodes of acute CN can lead to extended periods of physical and psychosocial distress. The aim of this scoping review was to identify and synthesise the evidence relating to factors associated with the development of recurrent and contralateral Charcot neuroarthropathy (CN) in individuals with diabetes. A systematic search of four electronic databases was conducted from inception to February 06, 2023. All relevant study designs, except single case studies, that had been published in full in peer-reviewed journals were included. Studies were excluded if they were not published in English and did not provide data on individuals with diabetes. The search identified two studies that investigated factors associated with the development of recurrent CN, but none that related to the development of contralateral CN. Ten factors were investigated for association with recurrent CN development: age, body mass index, diabetes type and duration, glycated haemoglobin, anatomical site affected, duration of offloading applied to treat the primary CN episode, use of pharmacological intervention, severity of neuropathy, and skin temperature. However, no significant associations were reported. There is an alarming lack of evidence-based findings in this research area to guide practice. Clearly, more research in the form of rigorous prospective studies is urgently required to identify risk factors for the development of recurrent and contralateral CN in individuals with diabetes.

A potential platform for future vaccine trials identifies high incidence of symptomatic and asymptomatic influenza infection among children aged 6-23 months in South Africa.

Approaches for determining whether influenza vaccination prevents infection, attenuates illness, or both, are important for developing improved vaccines. We estimated influenza infection incidence, and evaluated symptom ascertainment methodologies in children to inform future vaccine trial design. We conducted a prospective cohort study among children aged 6-23 months from May-October 2022. Study nurses collected symptom and temperature data and mid-turbinate nasal swabs twice-weekly irrespective of symptoms; caregivers entered symptom data daily and collected nasal swabs weekly. Samples were tested for influenza using PCR. Of 230 healthy, screened children, 93 were enrolled of whom 87 (94%) completed 6-months follow-up. 95% (4245/4476) of scheduled nurse, 90% (2045/2276) of caregiver swabs, 99% (92/93) of baseline blood collections and 67% (9245/13768) of scheduled symptom diaries were completed. PCR-confirmed influenza incidence was 65% (60/93) for ≥1 infection; 11 (18%) individuals had 2 and 1 (2%) had 3 episodes. Of 73 episodes, 55 (75%) had ≥1 symptom and 37 (51%) had fever (measured and/or reported). Median infection duration was 7 days (interquartile range 4-9). Human RNase P gene was detected in 99% (2032/2045) of caregiver-collected swabs, through which 5 additional episodes were identified. Per episode, caregiver's diaries of reported and measured fever were 19%(25/73,34%) and 11%(15/73,21%) higher than nurse-reported (11/73,15%) and -measured fevers (7/73,10%), respectively. The incidence of influenza infection was high and mainly symptomatic suggesting that this platform could be suitable for future trials of vaccine efficacy and correlates of protection against infection and illness in children.

Effect of an early music intervention on emotional and neurodevelopmental outcomes of preterm infants at 12 and 24 months.

Few studies have found long-term effects of early musical environmental enrichment in the NICU on preterm infant's development. This study examines how early music enrichment affects emotional development and effortful control abilities in 12- and 24-month-old very preterm (VPT) infants. One hundred nineteen newborns were recruited, including 83 VPTs and 36 full-term (FT) infants. The VPT infants were randomly assigned to the music intervention (44 VPT-Music) or control (39 VPT-control) groups. VPT-Music infants listened specifically designed music intervention from the 33rd week of gestation until hospital discharge. At 12 and 24 months, children were clinically evaluated using the Bayley-III Scales of Infant and Toddler Development and the Laboratory Temperament Assessment Battery, and at 24 months, with 3 additional episodes of the Effortful Control Battery. Our analysis showed that during a fear eliciting task, the VPT-Music group expressed lower level of fear reactivity and higher positive motor actions than VPT-controls and FT infants. At 24 months, the VPT-music group had lower scores for negative motor actions in the joy task, compared to both VPT-control and FT groups. In addition, both FT and VPT-music had higher scores of sustained attention compared to VPT-controls, but the contrasts were not significant. No significant effects on mental, language and motor outcomes were identified and for all three dimensions of the ECBQ. The present study suggests that an early music intervention in the NICU might influence preterm children's emotional processing at 12 and 24 months. Limitations and suggestions for future research are highlighted.

Comparison of radiation exposure and fluoroscopy time between minimally invasive common bile duct exploration and endoscopic retrograde cholangiopancreatography for choledocholithiasis

BackgroundRadiation exposure (RE) causes dose-dependent deleterious effects, and efforts should be made to decrease patient exposure to ionizing radiation. Patients with choledocholithiasis are commonly exposed to ionizing radiation as fluoroscopy-guided interventions including minimally invasive common bile duct (CBD) exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for CBD stone clearance. However, RE and fluoroscopy times (FTs) have not been compared between these 2 treatment modalities. Thus, this study aimed to compare FT and RE between MICBDE and ERCP in patients with choledocholithiasis. MethodsThis is a retrospective analysis of a prospectively maintained database of a single surgeon performing MICBDE at an academic referral center between May 2021 and June 2023 compared with a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and postoperative outcomes were compared between the MICBDE and ERCP. The study was conducted as a single institution academic referral center located in the American Southwest. A total of 109 patients with choledocholithiasis were divided into 2 groups. A total of 53 (48.62%) patients underwent ERCP, and 56 (51.38%) patients underwent MICBDE. Inclusion criterion was all patients presenting with choledocholithiasis and subsequently undergoing ERCP or MICBDE. Patients who underwent ERCP for non–choledocholithiasis-related reasons were excluded. Primary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the CBD, complications, procedural time, and reinterventions. ResultsA significant difference (P < .001) between FTs was identified between ERCP (3.1 min) and MICBDE (1.54 min). Median RE doses between the ERCP group (38 mGy) and the MICBDE group (38.41 mGy) were not statistically different (P = .88). Technical success of CBD clearance was similar in both groups (91% in the MICBDE group vs 93% in ERCP group; P = .711). ConclusionAdvantages of MICBDE over ERCP include the treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and introduces the potential for shorter hospital length of stay. This study showed that MICDBE had lower FT than had ERCP, and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy.

Late Pleistocene to Holocene alluvial deposits of the Inaouène Valley and their paleoenvironmental significance (north Morocco)

This study investigates the paleoenvironmental changes and fluvial dynamics in the Inaouène River Valley of central northern Morocco over the last 22,000 years. Through comprehensive field study and radiocarbon dating of Upper Pleistocene and Holocene alluvial deposits, the research identifies six main alluvial units reflecting distinct phases of fluvial activity and environmental conditions. These phases include coarse gravel aggradation between ∼22 and 15 cal kaBP, indicating a braided channel system, followed by multiple fine-dominated alluviation phases occurring at ∼13, ∼10, ∼6–5, ∼3, ∼0.7–0.3, and ∼0.1-0 cal kaBP. The trunk channel evolved from a low-sinuosity wandering style in the Early-Middle Holocene to a high-sinuosity pattern in the Late Holocene. Periods of landscape stability, evidenced by soil formation, were dated around 0.3 and 0.8 cal kaBP, with additional episodes estimated just after ∼12 cal kaBP and around 3.8 cal kaBP. Notably, the study also uncovered evidence of significant human intervention during the Middle Holocene.A comparison with other archives enabled us to reconstruct late Pleistocene and Holocene palaeoenvironmental conditions on both regional and supraregional scales, linking specific stages of floodplain development to prevalent influencing factors. Emphasizing the fluvial system response, we present a cause-effect model that focuses on long-lasting climatic phases (e.g., Last Glacial Maximum, MIS2-MIS1 transition, African Humid Period) as well as sub-millennial to centennial Rapid Climate Changes, North Atlantic cooling events, and solar activity minima. Human intervention played a key role in the Inaouène's evolution during the Middle Holocene, as evidenced by clear anthropogenic markers found in the associated deposits. These findings not only contribute to our understanding of the area's geomorphological history but also highlight its significant archaeological potential, opening new avenues for interdisciplinary research in this understudied region.The study offers new insights into central northern Morocco's late Quaternary alluvial geochronology and paleoenvironmental evolution, aligning with regional findings and contributing to a broader understanding of climate-driven landscape changes and human-environment interactions across North Africa and the Mediterranean.

Atlas-based structural analysis of prefrontal cortex atrophy in major depressive disorder: Correlations with severity and episode frequency

BackgroundCurrent models of major depressive disorder (MDD) primarily focus on the structural and functional changes in key prefrontal areas responsible for emotional regulation. Among these regions some sections such as the dorsal prefrontal area, has received limited attention regarding its structural abnormalities in MDD. This study aims to evaluate volumetric abnormalities in brain regions associated with markers of depression severity and episode frequency. MethodsThe study included 33 MDD patients and 33 healthy subjects. Using an atlas-based method, we measured the volumes of several key brain regions based on MRI data. The regions of interest included prefrontal and posterior sections of the middle frontal gyrus (MFG) and superior frontal gyrus (SFG). Additionally, we evaluated the volumes of the dorsal anterior cingulate cortex (dACC), perigenual (rostral) anterior cingulate cortex (pgACC), subgenual cingulate cortex (sgACC), posterior cingulate cortex (PCC), hippocampus (HPC), and parahippocampus (paraHPC). Hamilton Depression Scale (HAM-D) scores and count of the depressive episodes of patients were also obtained. A regression analysis with sex as the confounding factor has been made. ResultsAnalysis of covariances, controlling for sex, showed significant atrophy in the sgACC in the depression group: F(1, 63) = 4.013, p = 0.049 (left) and F(1, 63) = 8.786, p < 0.004 (right). Poisson regression, also controlling for sex, found that each additional depressive episode was associated with a significant reduction in left posterior MFG volume (0.952 times, 95 % CI, 0.906 to 1.000; p = 0.049). ConclusionsFindings in this study highlight the structural abnormalities in MDD patients in correlation to either current depression severity or chronicity of the disease.

Once-weekly insulin icodec compared with daily basal insulin analogues in type 2 diabetes: Participant-level meta-analysis of the ONWARDS 1-5 trials.

To perform a participant-level post hoc meta-analysis of Phase 3a trials in type 2 diabetes (T2D) to characterize the hypoglycaemia safety and glycaemic efficacy of once-weekly insulin icodec (icodec). All ONWARDS 1-5 randomized participants were pooled as overall T2D, insulin-naive, an insulin-experienced subgroups, and by once-daily trial comparator (degludec or glargine U100). The main outcomes included incidence and rates of clinically significant and severe hypoglycaemia. Additional endpoints included change in glycated haemoglobin (HbA1c) from baseline and HbA1c target achievement without clinically significant or severe hypoglycaemia. The meta-analysis comprised 3765 participants (1882 icodec vs. 1883 comparators). In the overall T2D pool, clinically significant hypoglycaemia incidence was similar in the icodec group versus the comparator group (17.9% vs. 16.2%, odds ratio [OR] 1.14, 95% confidence interval [CI] 0.94, 1.38); however, rates were low but significantly higher in the icodec group (1.15 vs. 1.00 episodes/participant-year of exposure, estimated rate ratio 1.51 [95% CI 1.24, 1.85]). Fewer severe hypoglycaemic episodes occurred with icodec than with comparators (8 vs. 18). A greater reduction in HbA1c occurred with icodec versus comparators, irrespective of subgroup (estimated treatment difference range [-0.10 to -0.29%]; all p < 0.05). Across subgroups, except for the insulin-experienced subgroup, the odds of achieving HbA1c <53 mmol/mol (7.0%) without clinically significant or severe hypoglycaemia were greater with icodec than with comparators (OR range 1.30-1.55; all p < 0.05). Icodec was associated with a similar incidence but higher rates of clinically significant hypoglycaemia (equating to one additional hypoglycaemic episode every 6 years) and fewer severe hypoglycaemic episodes versus comparators. Our findings also confirmed the greater efficacy of icodec that was demonstrated in the ONWARDS trial programme.

Letermovir as secondary prophylaxis of cytomegalovirus infection after allogeneic hematopoietic cell transplantation: A single center experience.

Letermovir, a novel anti-cytomegalovirus (CMV) agent acts by inhibiting the viral terminase complex and is approved for primary prophylaxis in CMV seropositive patients post allogeneic hematopoietic cell transplantation (HCT). The favorable efficacy and safety profile make it an attractive option for use as secondary prophylaxis in patients at high-risk for CMV reactivation. In this study, we report the efficacy and safety of letermovir secondary prophylaxis after at least one treated episode of CMV reactivation in a cohort of 39 high-risk patients. Thirty two (82%) patients received anti-thymocyte globulin (ATG), 27 (69%) received a combination of ATG and post-transplant cyclophosphamide for graft-versus-host disease (GVHD) prophylaxis. Twenty one patients (54%) received CMV seronegative grafts. In addition, 18 (46%) patients had HLA mismatched unrelated or haploidentical donors while 18 (46%) had active GVHD requiring immunosuppression at the time of commencing secondary prophylaxis. Letermovir was initiated at a median of 47 days (range, 41-56) after HCT and was administered for a median duration of 77 days (range, 46-90). A single breakthrough CMV reactivation was noted in this high-risk cohort. Four additional episodes of CMV reactivation occurred at a median of 28 days (range, 23-59 days) after discontinuation of secondary prophylaxis. The drug was well tolerated and 77% of the cohort completed the planned duration of secondary prophylaxis. None of the patients discontinued treatment due to treatment-related adverse effects. In conclusion, letermovir is effective and well tolerated and may be considered for secondary prophylaxis in patients at high risk for CMV reactivation. Prospective studies are required to validate these findings.

Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study

ObjectivesTo determine the strength and nature of the association between delirium and incident dementia in a population of older adult patients without dementia at baseline.DesignRetrospective cohort study using large scale...

Reducing exercise-related hypoglycemia in automated insulin delivery with reinforcement learning

Exercise is an important component for glucose management in type 1 diabetes, but remains challenging for automated insulin delivery systems as altered glucose dynamics are difficult to model explicitly. Glucose monitoring data might enable data-driven approaches for learning these dynamics implicitly. We propose combining model predictive control with a reinforcement learning component to adjust basal insulin infusion rates for exercise. We train our model on a variety of exercise scenarios and demonstrate improved glucose control using a generically trained model. We further improve performance by personalizing the model with a small number of additional individual-specific training episodes.

Neonatal Near Fatal Flecainide Toxicity

Background: Flecainide is an anti-arrhythmic medication with a narrow therapeutic index and a high mortality rate, when overdosed. Few cases of flecainide toxicity in neonates and children due to medication error have been reported in the literature. A case of an accidental flecainide overdose in a neonate in Oman was presented. Case Presentation: A 19-day-old newborn girl developed persistent supra ventricular tachycardia (SVT) after receiving nebulized albuterol for acute bronchitis. After unsuccessful treatment with adenosine, she was given flecainide 5.6 mg orally every 24 hours for resolution of the SVT. On day four of admission, the child inadvertently received 100 mg of flecainide orally due to a dose calculation error. The child developed wide complex tachyarrhythmia followed by pulseless ventricular tachycardia (VT) requiring cardiopulmonary resuscitation. Sodium bicarbonate IV bolus followed by an infusion was administered. The patient developed two additional episodes of pulseless VT that coincided temporally with two interruptions of the sodium bicarbonate infusion, and required high dose of inotropic support. The patient developed convulsions but her brain ultrasound was normal. Her condition stabilized on day three after the toxicity occurred. Repeated echo showed a normal EF. The patient was discharged on propranolol and levetiracetam and was doing well on outpatient follow up. Conclusion: Flecainide is a potentially lethal medication in overdose due to its sodium channel blocking properties. Sodium bicarbonate remains an essential component of treatment.

Gastrointestinal bleeding following Heartmate 3 left ventricular assist device implantation: The Michigan Bleeding Risk Model

BackgroundGastrointestinal bleeding (GIB) results in frequent hospitalizations and impairs quality of life in durable left ventricular assist device (LVAD) recipients. Anticipation of these events before implantation could have important implications for patient selection and management. MethodsThe study population included all adult HeartMate 3 (HM3) primary LVAD recipients enrolled in the STS-Intermacs registry from January 2017-December 2020. Using multivariable modeling methodologies, we investigated the relationships between preimplantation characteristics and postimplant bleeding, bleeding and death, and additional bleeding episodes on subsequent bleeding episodes, and created a risk score to predict the likelihood of post-LVAD GIB based solely on pre-implantation factors. ResultsOf 6425 patients who received a HM3 LVAD, 1010 (15.7%) patients experienced GIB. Thirteen pre-implantation factors were independent predictors of post-LVAD GIB. A risk score was created from these factors and calculated for each patient. By 3-years postimplant, GIB occurred in 11%, 26%,and 43% of low-, medium- and high-risk patients. Experiencing one post-LVAD GIB event was associated with an increased risk for further GIB events, with 33.9% of patients experiencing at least one recurrence. While post-LVAD GIB was associated with mortality, there was no relationship between number of GIB events and death. ConclusionThe Michigan Bleeding Risk Model is a simple tool which facilitates the prediction of post-LVAD GIB in HM3 recipients, by using 13 pre-implant variables. The implementation of this tool may help in the risk stratification process and may have therapeutic and clinical implications in HM3 LVAD recipients.

Assessing the Impact of Blood Cancer Talks, a Novel ‘how I Treat’ Style Podcast on Hematologic Malignancies: A Survey-Based Analysis

Introduction: The advent of podcasts has revolutionized the field of medical education. Podcasts offer a portable and convenient format that accommodates the busy schedule of healthcare professionals and students alike. Initially popularized particularly in the field of critical care medicine and emergency medicine (Cadogan M et.al 2014), educational podcasts are now available across a wide range of medical specialties. We launched a new, independent, and free podcast dedicated to hematologic malignancies, named “ Blood Cancer Talks” in July 2022. The vision of our podcast is to deliver high quality educational content in a unique “ How I Treat” format, where we interview subspecialty experts in order to provide listeners clinically-relevant insights from world-leading content experts at the forefront of their respective areas across hematologic malignancies. We further seek to assess relevant recent updates, especially clinical trials, and incorporate critical appraisal of recent data and literature into our episodes. Methods: To gather honest and unbiased feedback from our listeners and to continue to refine our content and format for maximum impact and engagement, we deployed an anonymous survey using SurveyMonkey. The survey was distributed via Twitter and email. The survey had a total of 13 questions, of which 6 used a 5-point Likert scale (1, “strongly disagree” to 5, “strongly agree”; or 1, “poor” to 5, “excellent”). Results: The survey was open for 30 days (6/25-7/25/2023), and received a total of 36 responses. A majority of respondents were Attending Physicians (50%), and treated only patients with hematologic malignances (91.3%). Categories and locations of all respondents are shown in Figure 1. A majority of respondents (79%) learnt about the podcast on Twitter, followed by word of mouth (21%), followed by MashupMD (6%). The mean length of our episode was 51 minutes (range, 32-64). 92% of respondents perceived the length as “about right”, and 8% as “too long”. The overall quality of podcast was described as “excellent” by 21 (58%), “very good” by 11 (31%), “good” by 3 (8%), and “fair” by 1 (3%) respondents (mean score 4.44/5). Most of the respondents felt that the podcast provided access to content experts they otherwise wouldn't have access to (mean score 4.28/5), improved their critical appraisal skills (mean score 4.42/5), helped them stay updated on the latest data in hematologic malignancies (mean score 4.56/5), and improved their knowledge in clinically relevant areas (mean score 4.47/5). The three most common additional episode formats that respondents expressed interest in were pro-con debate (77%), evidence-based medicine (69%), and roundtable discussions (57%). Conclusion: In summary, “ Blood Cancer Talks” has distinguished itself as a pioneering medical podcast with a broad, global listenership. Its specialized focus on hematologic malignancies resonates with an engaged audience of clinicians. An encouraging 94% of respondents either agree or strongly agree that this resource has been instrumental in keeping them informed about the latest research and advancements in hematologic malignancies. We hope to continue to develop clinically relevant, expert-focused episodes across the breadth of hematologic malignancies, including new episode formats that incorporate listener feedback.

Diurnal cycles drive rhythmic physiology and promote survival in facultative phototrophic bacteria

Bacteria have evolved many strategies to spare energy when nutrients become scarce. One widespread such strategy is facultative phototrophy, which helps heterotrophs supplement their energy supply using light. Our knowledge of the impact that such behaviors have on bacterial fitness and physiology is, however, still limited. Here, we study how a representative of the genus Porphyrobacter, in which aerobic anoxygenic phototrophy is ancestral, responds to different light regimes under nutrient limitation. We show that bacterial survival in stationary phase relies on functional reaction centers and varies depending on the light regime. Under dark-light alternance, our bacterial model presents a diphasic life history dependent on phototrophy: during dark phases, the cells inhibit DNA replication and part of the population lyses and releases nutrients, while subsequent light phases allow for the recovery and renewed growth of the surviving cells. We correlate these cyclic variations with a pervasive pattern of rhythmic transcription which reflects global changes in diurnal metabolic activity. Finally, we demonstrate that, compared to either a phototrophy mutant or a bacteriochlorophyll a overproducer, the wild type strain is better adapted to natural environments, where regular dark-light cycles are interspersed with additional accidental dark episodes. Overall, our results highlight the importance of light-induced biological rhythms in a new model of aerobic anoxygenic phototroph representative of an ecologically important group of environmental bacteria.

Alteration of carbon and nitrogen allocation in winter wheat under elevated ozone

Tropospheric ozone accelerates senescence and shortens grain filling, consequently affecting the remobilization and allocation efficiency of aboveground biomass and nutrients into grains in cereal crops. This study investigated carbon (C) and nitrogen (N) concentrations repeatedly in shoot biomass during the growth period and in grain after the harvest in eighteen wheat genotypes under control and ozone treatments in open-top chambers. Season-long ozone fumigation was conducted at an average ozone concentration of 70 ppb with three additional acute ozone episodes of around 150 ppb. Although there were no significant differences in straw C and N concentrations between the two treatments, the straw C:N ratio was significantly increased after long-term ozone fumigation, and the grain C:N ratio decreased under elevated ozone without significance. Grain N concentrations increased significantly under ozone stress, whereas N yield declined significantly due to grain yield losses induced by ozone. Moreover, different indicators of N use efficiency were significantly reduced with the exception of N utilization efficiency (NUtE), indicating that elevated ozone exposure reduced the N absorption from soil and allocation from vegetative to reproductive organs. The linear regression between straw C:N ratio and productivity indicated that straw C:N was not a suitable trait for predicting wheat productivity due to the low coefficient of determination (R2). Nitrogen harvest index (NHI) was not significantly affected by ozone stress among all genotypes. However, elevated ozone concentration changed the relationship between harvest index (HI) and NHI, and the reduced regression slope between them indicated that ozone exposure significantly affected the relationship of N and biomass allocation into wheat grains. The cultivar “Jenga” showed optimal ozone tolerance due to less yield reduction and higher NUE after ozone exposure. The genotypes with higher nutrient use efficiencies are promising to cope with ozone-induced changes in nitrogen partitioning.

Modeling the impact of a long-term horizon and multiple treatment episodes on estimates of the cost-effectiveness of alcohol treatment in the United States.

Most clinical studies of alcohol use disorder (AUD) treatment have short follow-up periods, underestimating the full benefits of alcohol treatment. Furthermore, clinical studies only consider one treatment cycle and do not account for the need for multiple episodes to treat a chronic recurrent condition. A validated microsimulation model of the long-term drinking patterns of people with AUD in the United States simulated 10,000 individuals resembling those from a large clinical trial. The model was used to assess the impact of (1) 1-year, 5-year, and lifetime horizon on alcohol treatment cost-effectiveness estimates and (2) no, one, two, four, and unlimited additional treatment episodes on alcohol treatment cost-effectiveness estimates. Model outcomes included healthcare costs, crime costs, labor market productivity, life expectancy, quality-adjusted life years (QALYs), alcohol-related hospitalizations, and deaths. Cost-effectiveness analyses were conducted for two perspectives: a healthcare perspective that included costs from hospitalization and AUD treatment, and a broader societal perspective that also included crime costs and productivity. The incremental cost per additional QALY gained for alcohol treatment compared with no treatment decreased from $55,590 after 1 year to $78 when healthcare costs and QALYs were tracked over the lifetime, that is, treatment became more cost effective. Treatment was cost saving for any time frame when the impacts on crime and labor productivity were also accounted for in a societal perspective. Access to multiple treatment episodes dominated (i.e., it was more effective and less costly) than no-treatment and one-episode scenarios. From a healthcare perspective, incremental costs per additional QALY for increasing from a maximum of two to four treatment episodes was $499 and from four to unlimited episodes was $5049. The unlimited treatment scenario dominated all others from a societal perspective. Results were robust in sensitivity analyses. A long-term perspective and multiple episodes of alcohol treatment improve cost-effectiveness estimates. When societal impacts are included, alcohol treatment is cost saving. Results support the value of alcohol treatment.

Association of Instability History and Off-Track Hill-Sachs Lesions in Anterior Shoulder Instability.

The glenoid track concept is now widely accepted, and its evaluation is considered essential for making decisions about surgery. To define preoperative descriptive data and clinical and functional features in patients with anterior glenohumeral instability according to glenoid track status and to analyze the influence of off-track Hill-Sachs (HS) lesions on preoperative shoulder function. Case-control study; Level of evidence, 3. Preoperative magnetic resonance imaging or computed tomography scans were used to measure the glenoid track. Descriptive data and preoperative objective and subjective clinical and functional features were compared between patients with on-track HS lesions versus off-track HS lesions. Multivariate regression analysis was conducted to identify potential risk factors for off-track HS lesion development. A total of 235 patients (201 men, 34 women; mean age, 29.6 ± 8.6 years) were included- 134 shoulders (57%) with on-track HS lesions and 101 shoulders (43%) with off-track HS lesions. Age <20 years at first dislocation, number of dislocations, and ≥2 years between first dislocation and surgery were significantly different between the study groups (P = .005, P = .0001, and P = .01, respectively). Regarding these characteristics, the odds ratios for the risk of developing an off-track lesion were 2.67 (95% CI, 1.2-5.99)-1.2 times higher for each additional instability episode (95% CI, 1.025-1.14) and 2.42 times higher (95% CI, 1.176-4.608) for patients whose first dislocation was ≥2 years before surgery, respectively. Patients with off-track HS lesions had a significantly greater degree of instability (P = .04), worse Rowe scores (48.8 ± 15.3 vs 54.8 ± 28.3 for on-track HS lesions; P = .04), and lower Western Ontario Shoulder Instability scores (975 ± 454 vs 1179 ± 428 for on-track HS lesions; P = .01). Characteristics related to a history of instability (age <20 years at first instability episode, larger number of dislocations, ≥2 years between first dislocation and surgery) were found to be risk factors for the development of an off-track HS lesion in this study. Off-track lesions led to a higher degree of instability and worse objective and subjective preoperative shoulder function versus on-track HS lesions.

Patellar Dislocation in Adolescent Patients: Influence on Cartilage Properties Based on T1ρ Relaxation Times

Background: Adolescents who experience a patellar dislocation have an elevated risk of patellofemoral posttraumatic osteoarthritis. Magnetic resonance imaging (MRI)–based T1ρ relaxation times were measured for adolescents to evaluate patellofemoral cartilage after patellar dislocation. Long T1ρ relaxation times are an indicator of cartilage degradation. Hypothesis: The primary hypothesis is that patellofemoral cartilage T1ρ relaxation times will be elevated in the acute phase after patellar dislocation. The secondary hypothesis is that T1ρ relaxation times will be higher for knees with multiple rather than single dislocations due to repeated traumatic injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: In total, 23 adolescents being treated for a recent patellar dislocation, 13 for a first-time dislocation (47 ± 38 days since most recent dislocation) and 10 for multiple dislocations (55 ± 24 days since most recent dislocation), and 10 healthy controls participated in MRI-based T1ρ relaxation time mapping. For multiple regions of the patellofemoral joint, mean T1ρ values were compared between the 3 groups with multiple group comparisons and post hoc tests. T1ρ relaxation times were also correlated against measures of patellofemoral anatomy and alignment for single and multiple dislocations. Statistical significance was set at P < .05. Results: T1ρ relaxation times were significantly longer for injured knees (single and multiple dislocations) than controls at the medial and central patella and central trochlear groove. For the regions on the patella, significant differences between injured and control knees exceeded 15%. No significant differences were identified between single and multiple dislocations. For the initial dislocation group, T1ρ relaxation times within multiple regions of the patellofemoral joint were significantly correlated with lateral patellar alignment or patellar height. Conclusion: Elevated patellofemoral cartilage T1ρ relaxation times are consistent with a high risk of long-term patellofemoral osteoarthritis for adolescents who experience patellar dislocations. T1ρ relaxation times were elevated for multiple regions of patellofemoral cartilage. T1ρ relaxation times were expected to increase with additional dislocation episodes, but relaxation times after single and multiple dislocations were similar. After a first dislocation, parameters related to patellar maltracking were correlated with cartilage degradation.

Pharmacy stewardship to reduce recurrent hypoglycemia

BackgroundInpatient hypoglycemia is associated with increased morbidity and mortality. After a hypoglycemic event, the likelihood of additional episodes increases. The Joint Commission recommends evaluating all episodes of hypoglycemia for root-cause analysis. Studies have shown that pharmacists’ involvement with glycemic control protocols can prevent hypoglycemia. ObjectivesThis study aimed to assess whether the implementation of pharmacists’ real-time assessment of hypoglycemic events using an electronic alert messaging system contributes to the reduction of the number of recurrent hypoglycemia during hospitalization. Practice descriptionA community hospital that provides a wide range of health care services. The pharmacy department provides fully decentralized clinical services and team-based specialist services. Practice innovationThe pharmacist-led hypoglycemia stewardship initiative included a comprehensive review of hypoglycemic alerts received via an automated message. The alerts generated in the electronic health record (EHR) every time a patient’s blood glucose resulted in less than 70 mg/dL if there was a documented administration of a hypoglycemic agent 48 hours before the hypoglycemia event. Once the alert was received by the pharmacists via an EHR in-basket, a real-time review was conducted to identify the potential causes of the event and opportunities for therapy modification. Evaluation methodsA single-center retrospective observational study including a pre- and post-implementation phase from January 1 to June 3, 2020, and January 1 to June 30, 2021, respectively. Continuous data were analyzed using paired and equal variance t test. Noncontinuous data were analyzed using Fisher exact and chi-square test. Descriptive statistics were used to describe distribution and frequency of data. ResultsThere was a 5.1% absolute reduction in recurrent hypoglycemic events (P < 0.001) and a 0.6% reduction of severe hypoglycemic days (P = 0.269) in the postimplementation group. The average time to pharmacist intervention was 4 (± 3.5) hours with a 92% acceptance rate. ConclusionThis study demonstrated the utility of pharmacist-led hypoglycemia reviews in the reduction of recurrent hypoglycemic events in the inpatient setting.