Rapid Improvement Research Articles

Tai Chi and Wellness Interventions for Veterans with Gulf War Illness: A Randomized Controlled Feasibility Trial.

Gulf War Illness (GWI) is a chronic multi-symptom illness that affects up to one-third of the 700,000 American military personnel deployed to the Persian Gulf region in 1990 and 1991. We conducted a randomized controlled trial to examine feasibility and the relative efficacy of two 12-week in-person group treatments (Tai Chi and Wellness) to address GWI symptoms of chronic pain, fatigue, and changes in mood and cognitive functioning. Male and female veterans were randomly assigned to Tai Chi (n = 27) or Wellness (n = 26) group interventions and assessed at four time points: baseline, post-treatment, 3-, and 9-month follow-up. Multilevel models with a treatment-by-time interaction term were utilized to evaluate treatment effects and changes in GWI-related outcomes over time. Satisfaction was high, there were no adverse events, and over half the participants attended 75% or more sessions with no significant differences between groups. For pain interference, analyses revealed a significant quadratic effect of time with no differences between treatment groups. For general fatigue and a cognitive test of trail making, no significant effects were detected. For depressed mood, linear and quadratic time effects and the group x linear time interaction were significant indicating greater reductions for Tai Chi participants. For a verbal learning test, linear and quadratic time and the group x quadratic time interaction significantly predicted total recall with Tai Chi participants demonstrating more rapid initial improvements. Findings indicate that both Tai Chi and Wellness are feasible and acceptable. Both interventions may have a salutary impact on pain interference, depression, and verbal learning with some advantages for Tai Chi.

Clinical Effects and Response Time of Biological Drugs in Chronic Rhinosinusitis with Nasal Polyps Patients: Real-life Experience.

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a challenging condition often managed with biologic therapies. This study compares the clinical effects and response times of dupilumab, omalizumab, and mepolizumab in Italian patients with severe uncontrolled CRSwNP. This bicentric, retrospective study included 33 patients treated at two Italian hospitals between April and December 2023. Inclusion criteria followed EPOS 2020 guidelines, focusing on adults with bilateral polyposis, history of endoscopic sinus surgery, and evidence of type 2 inflammation. Patients self-administered biologics according to AIFA protocols. Outcomes were assessed using SNOT-22 for quality of life, Nasal Polyp Score (NPS) for polyp size, and Sniffin' Sticks-12 for olfactory function at baseline, 4 weeks, 3, 6, and 9 months. All three treatment groups (dupilumab, omalizumab, mepolizumab) showed significant improvements in SNOT-22 scores from baseline to 9 months, with no significant differences between groups. Dupilumab showed the most rapid and sustained improvement in NPS, with significant reductions observed from 4 weeks onward. Both omalizumab and mepolizumab showed significant NPS reductions by 6 months. Olfactory function improved significantly in the dupilumab group, with a notable decrease in anosmic patients from 64.3% to 28.6% at 9 months. Asthma control, measured by Asthma Control Test (ACT) scores, improved across all groups. Dupilumab, omalizumab, and mepolizumab significantly improve quality of life and reduce nasal polyp size in CRSwNP patients, with dupilumab showing the fastest response. These findings support the effectiveness of biologics in real-world settings for managing severe CRSwNP. 3 Laryngoscope, 2024.

Students’ perception of the impact of AI generative tools in learning the English language

The advancement of AI techniques has presented several challenges for teachers and learners in language classrooms. Yet, students have demonstrated rapid improvements when given direct opportunities to experiment with advanced software. Despite AI’s substantial progress, the core of teacher-learner exchanges remains deeply anchored in human intelligence. As technology becomes more integrated into language classrooms, AI needs to imitate and complement human interactions effectively. This study aimed to investigate students' perceptions of generative tools’ impacts on their writing abilities. A quantitative design was employed, and the research was conducted at the National University of Cheasim Kamchaymear. The study involved 120 participants, consisting of 38 males and 82 females. Students’ writing capabilities using the generative tools were evaluated across different dimensions as part of a broader research framework. The findings emphasize the significance of AI advancements in enhancing students' writing skills while preserving key human-centered teaching dynamics. Future studies should be conducted with a bigger sample size with more universities using more advanced statistics. Qualitative and combined designs should also be taken into consideration.

Computers and chess masters: The role of AI intransforming elite human performance.

Advances in Artificial Intelligence (AI) have made significant strides in recent years, often supplementing rather than replacing human performance. The extent of their assistance at the highest levels of human performance remains unclear. We analyse over 11.6 million decisions of elite chess players, a domain commonly used as a testbed for AI and psychology due to its complexity and objective assessment. We investigated the impact of two AI chess revolutions: the first in the late 1990s with the rise of powerful PCs and internet access and the second in the late 2010s with deep learning-powered chess engines. The rate of human improvement mirrored AI advancements, but contrary to expectations, the quality of decisions mostly improved steadily over four decades, irrespective of age, with no distinct periods of rapid improvement. Only the youngest top players saw marked gains in the late 1990s, likely due to better access to knowledge and computers. Surprisingly, the recent wave of neural network-powered engines has not significantly impacted the best players - at least, not yet. Our research highlights AI's potential to enhance human capability in complex tasks, given the right conditions, even among the most elite performers.

Mobile phone based laser scanning as a low-cost alternative for multidisciplinary data collection

Airborne and terrestrial laser scanners have traditionally been used as specialised toolsets for three-dimensional scene capture in engineering, providing highly accurate measurements with increasingly minimal human interaction. However, commercial or engineering-grade scanning instruments remain expensive and sensitive, requiring costly routine calibrations to ensure their optimum functionality. The recent inclusion of laser scanning sensors by mobile phone corporations such as Apple Computer Inc. is now analogous to the integration of Global Navigation Satellite Systems (GNSS) and cameras into smartphones as seen decades ago. Likely, these initial efforts to include the scanning sensor in mobile phones will see rapid improvements in the application and accuracy of the sensor to serve the growing need for scanning applications for transdisciplinary users. However, there is a limited amount of literature that benchmarks the emerging and low-cost scanning sensors to existing commercial ones to inform practice, thus prompting a need for researchers to evaluate and provide scientific evidence that can inform multidisciplinary scanning. It was noted that there was some absolute positional shift and scan drift in the iPhone Light Detection and Ranging (LiDAR) data. The researchers therefore investigated the extent to which the accuracy of laser scanning tools available within the iPhone 12 Pro compared to engineering-grade laser scanners. Outcomes from the study showed that iPhone scanners can deliver the required models, despite being unstable in dynamic environments when pitched against engineering-grade LiDAR scanners. The research recommends that stabilisers, such as stabilising gimbals or enhanced GNSS receivers, be used in practice to achieve improved accuracy from the mobile phone LiDAR.

Immune Checkpoint Inhibitor-Associated Celiac Disease: A Retrospective Analysis and Literature Review

Introduction: Immune checkpoint inhibitors (ICI) are used to treat various malignancies. They block the inhibitory signals of tumor cells and enhance the inflammatory cascade, which results in tumor killing. However, this can lead to unchecked inflammation throughout the body, leading to various adverse effects. A rare gastrointestinal adverse effect of ICI therapy is the development of immune-mediated celiac disease. This entity has a similar clinical presentation to the more common ICI-induced enterocolitis. Our study aims to determine the clinical characteristics and optimal treatment strategies for this rare ICI toxicity and differentiate it from ICI-induced enterocolitis. Methods and Material: We conducted a retrospective analysis of eight cases of ICI-induced celiac disease and 24 cases of ICI-induced enterocolitis from the literature. Data on patient demographics, clinical history, therapeutic interventions and outcomes were collected. A comparative analysis was performed to identify the key differences between the two groups. Results: Patients with ICI-induced celiac disease were more likely to have a pre-existing autoimmune condition and HLA-DQ2 positivity. Significant differences in clinical manifestations, histological findings, and treatment outcomes were observed. Notably, weight loss, nutritional deficiencies and electrolyte abnormalities were more commonly associated with ICI-induced celiac disease. Regarding pathology, duodenal villous blunting was noted more commonly with ICI-induced celiac disease. Initiating a gluten-free diet led to a rapid improvement in patients with ICI-induced celiac disease, while immunosuppressive therapy did not have an impact. Conclusion: ICI-induced celiac disease is a rare and underrecognized gastrointestinal adverse effect of ICI therapy, often misdiagnosed as ICI-induced enterocolitis. Early recognition and treatment with a gluten-free diet can lead to rapid symptom resolution, sparing patients from unnecessary systemic immunosuppression and the discontinuation of antineoplastic immunotherapy.

Zenker’s Per-Oral Endoscopic Myotomy (Z-POEM): The Ideal First Line Therapy for Treatment of Zenker’s Diverticulum

Zenker's diverticulum is a mucosal herniation at the pharyngoesophageal junction. While open surgical myotomy is the conventional treatment, robust evidence on third-space flexible endoscopic myotomy is lacking. We assessed safety, effectiveness and patient-reported outcomes of per-oral endoscopic myotomy (Z-POEM) in the largest reported single-centre experience with this technique. Retrospective cohort study was performed of consecutive patients undergoing Z-POEM in a tertiary hospital thoracic surgery practice from 2018-2024. Data collected included demographics, comorbidities, clinical and radiographic (pre/post-operative esophagram) outcomes, and validated patient-reported quality-of-life outcomes (Dakkak and Eckardt scores). Descriptive analyses were used to describe the population, outcomes, and complications. Aggregate and individual-patient symptom trajectories were charted over time. Fifty-seven patients (57.9% female, n=33) with a mean age of 74 years underwent Z-POEM. Median diverticulum size was 2 cm (IQR 2-3). All patients reported subjective symptom improvement and showed complete resolution of obstructed barium flow on postoperative esophagrams. At median follow-up of 9 months, all Z-POEM patients reported clinically-important improvements in objective symptom scores, with symptom trajectories showing rapid and durable improvement up to 5 years postoperatively. Four patients (7%) experienced complications. Majority of the cohort (66.7%) was unsuitable for rigid stapled myotomy, mainly due to short diverticulum or limited neck/mouth movement. No patients required repeat myotomy. We demonstrate significant and sustained relief of patient-reported outcomes/symptoms following Z-POEM, including for small diverticuli, with low complication rates. Its safety and versatility has made it the new standard of care locally; Z-POEM can be adopted by third-space endoscopy-trained thoracic surgeons.

Equine granulocytic anaplasmosis (EGA): Case description and overview of the epidemiological situation with focus on Germany

Equine granulocytic anaplasmosis (EGA) is a tick-borne disease caused by Anaplasma (A.) phagocytophilum. In Central, Northern, Western, and Eastern Europe, ticks of the Ixodes (I.) ricinus/I. persulcatus complex, in Germany mainly I. ricinus, are considered as vectors. Ixodes ricinus ticks show peaks of activity during the spring and summer months, particularly April to July. Changing climatic conditions, however, have meanwhile led to a year-round risk of tick exposure and thus infections with A. phagocytophilum. The presented case report underlines the seasonal peak phase of the infection risk in that the presentation of the horse to the veterinarian occurred in June. Additionally, clinical signs - including fever - are mostly unspecific and thrombocytopenia represents the most significant hematological abnormality. Direct and indirect detection methods are available for the diagnosis of an infection or contact with the pathogen. A positive PCR confirms an acute infection, as in the presented case, while positive antibody levels indicate contact with the pathogen in the (recent) past. Additionally, inclusion bodies, so called morulae, may be detected rapidly and inexpensively in smears derived from the peripheral blood and are predominantly found in neutrophilic granulocytes, less frequently in eosinophilic granulocytes. However, microscopy has a lower sensitivity compared to PCR-testing. In the presented case, morulae could not be detected in EDTA blood despite positive PCR. Antibiotics with intracellular activity, such as oxytetracycline and/or doxycycline are the treatment of choice and, as in the described case, often result in rapid clinical improvement in horses suffering from EGA. The elimination of the pathogen should be confirmed by PCR-testing 5-8 days after the completion of the antibiotic therapy. Whether and how long antibodies against A. phagocytophilum could possibly be protective against reinfection remains unknown. In humans, A. phagocytophilum is classified as an emerging pathogen of increasing clinical importance in the northern hemisphere.

The Snails: A Simple Technique for Reduction of Frontal Bossing in Children With Scaphocephaly

Objective: Scaphocephaly represents the most frequent single-suture craniosynostosis, with a male prevalence. In many cases, prominent frontal bossing (sphenocephaly) is the major aesthetic concern, typically in school-aged children. This aspect is also usually found in patients with late presentation (after 1 year of age). Several techniques have been described for the correction of frontal bossing in these patients, most involving wide frontal bone exposure and reconstruction. The authors describe a different, less invasive technique, useful in severe sphenocephalic patients, independently from age. Methods: Thirteen children aged from 3.5 to 22 months were operated on in our institution between 2016 and 2023 using the snails technique, in addition to the treatment for the craniosynostosis itself. The technique is described, consisting in spiral frontal impacted craniotomies. Transfusional rate and duration of surgery are reported and compared with 15 randomly selected patients treated at the same time without Snails technique. Postoperative follow-up is almost 1 year. Results: Cosmetic postoperative results, based on parental and clinician’s satisfaction as well as on radiographic and photographic assessment, showed rapid improvement of frontal bossing, which remains stable during years. Transfusion rate during scaphocephaly repair with Snails technique is not different from control, even if time of procedure is longer. Conclusion: Among several techniques described to directly correct frontal bossing, the snail technique is more simple and less invasive, avoiding further craniotomies over the superior sagittal sinus, and does not imply consistent blood loss.

Longitudinal markers of cognitive procedural learning in fronto-striatal circuits and putative effects of a BDNF plasticity-related variant

Procedural learning and automatization have widely been studied in behavioral psychology and typically involves a rapid improvement, followed by a plateau in performance throughout repeated training. More recently, brain imaging studies have implicated frontal-striatal brain circuits in skill learning. However, it is largely unknown whether frontal-striatal activation during skill learning and behavioral changes follow a similar learning curve pattern. To address this gap in knowledge, we performed a longitudinal brain imaging study using a procedural working memory (pWM) task with repeated measurements across two weeks to map the temporal dynamics of skill learning. We additionally explored the effect of the BDNF Val66Met polymorphism, a common genetic polymorphism impacting neural plasticity, to further inform the relevance of the identified neural markers. We used linear and exponential modeling to characterize procedural learning by means of learning curves on the behavioral and brain functional level. We show that repeated training led to an exponential decay in a distributed set of brain regions including fronto-striatal circuits, which paralleled the exponential improvement in task performance. In addition, we show that both behavioral and neurofunctional readouts were sensitive to the BDNF Val66Met polymorphism, suggesting less efficient learning in 66Met-allele carriers along with protracted signal decay in frontal and striatal brain regions. Our results extend existing literature by showing the temporal relationship between procedural learning and frontal-striatal brain function and suggest a role of BDNF in mediating neural plasticity for establishing automatized behavior.

Orbital Inflammatory Manifestations in a Patient With VEXAS (Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic) Syndrome.

An 84-year-old man with a genetically confirmed diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome treated with tocilizumab reported with a 3-day history of left eye pain, conjunctival chemosis and injection, and horizontal binocular diplopia. Examination revealed restriction of left eye ductions in all directions with mild unilateral proptosis. MRI of his brain and orbits demonstrated abnormal enhancement of the left posterior sclera and intraorbital optic nerve sheath, without involvement of the extraocular muscles, cavernous sinus, or optic nerve parenchyma. B-scan ultrasonography heralded a positive "T-sign." Empiric treatment with high-dose intravenous methylprednisolone led to rapid clinical improvement. Workup for alternative causes was unremarkable. Oral prednisone dose and tocilizumab ultimately resulted in complete resolution after 4 weeks. The final diagnosis was consistent with orbital inflammatory manifestations of VEXAS syndrome.

A Review of YOLO-Based Target Detection Methods

Target detection is now a popular topic in computer vision. With the development and iteration of technology, deep learning is constantly emerging. The integration of deep learning in the target detection task has led to rapid improvement in accuracy and speed, among which the You Only Look Once (YOLO) series of methods have the most rapid and varied improvements and upgrades, which have been widely used in the fields of navigation, video surveillance, face detection, text detection, and aerospace, etc. This paper initially provides an overview of the research context, importance, and challenges associated with this domain, compares and analyzes the network structure and implementation of the single-phase target detection method represented by the YOLO series with the two-phase and other improved algorithms, and then introduces the research progress of the target detection algorithms of deep learning, the characteristics of the commonly used datasets, and the key parameters of the evaluation of performance indicators, and then presents a compilation of experimental outcomes associated with several widely recognized algorithms applied to prominent datasets. Subsequently, it enumerates the experimental findings of diverse algorithms on these established datasets. Ultimately, this paper anticipates future research trajectories and developmental trends pertaining to target detection algorithms.

Recalcitrant Scalp Psoriasis Successfully Treated with Once-Daily Roflumilast Cream 0.3%

Scalp psoriasis is a chronic, immune-mediated skin disease with varying phenotypes and is estimated to affect up to 80% of individuals suffering from psoriasis [1]. The physical symptoms, along with social and emotional impacts of scalp psoriasis can significantly reduce quality of life, necessitating long-term treatment for most patients [3]. Numerous topical and systemic treatments are available for scalp psoriasis, yet the condition remains challenging to manage, underscoring a persistent unmet need for safe and effective therapies [2]. Treatment of the scalp and other hair bearing areas is challenging and can affect the ability to apply topical products and hinder their efficacy [2, 3]. Roflumilast cream 0.3% is a highly selective, non-steroidal and potent topical phosphodiesterase 4 (PDE4) inhibitor approved in 2022 by the FDA for the treatment of psoriasis, including intertriginous disease; in 2023 as a foam for the treatment of seborrheic dermatitis and in 2024, roflumilast cream 0.15% was approved for the treatment of atopic dermatitis. Roflumilast has demonstrated a higher affinity for binding to PDE4 relative to other approved PDE4 inhibitors resulting in greater potency [4, 5]. The results of a phase 3 study investigating roflumilast foam 0.3% in patients with scalp and body psoriasis showed that once daily treatment produced significant clearance of affected areas, rapid improvement in pruritus, and was well-tolerated [6]. Here we report a case involving a 28-year-old female with recalcitrant scalp psoriasis following 10 years of unsuccessful treatment with topical products. Due to the severity of adverse effects experienced with prior therapies, the patient was reluctant to initiate systemic therapy and a trial of once daily topical roflumilast cream 0.3% was initiated. The patient demonstrated rapid improvement after 3 days and clearance of the scalp lesion following daily application for 5 days without any reported adverse effects. Lesions on the patient’s torso also cleared. Upon clearance of lesions, the patient discontinued application of roflumilast cream, and lesions remained clear for several weeks and applies only as needed with any recurrence. Our patient’s case demonstrates the significant potential of roflumilast cream 0.3% in addressing the inflammatory etiology of scalp psoriasis.

Pityriasis Rubra Pilaris, Refractory to IL-17A Inhibition, with Rapid Improvement Following IL-17A/IL-17F Blockade by Bimekizumab

Introduction: Pityriasis rubra pilaris (PRP) is a rare inflammatory skin disorder which can severely affect patient quality of life. While there are no FDA-approved therapies for PRP, methotrexate and acitretin are often used as first line treatments. Recent analyses have implicated dysregulation of the IL23/IL17 axis in PRP pathogenesis and the use of biologics for severe cases have been reported in the literature. Case Report: We report the case of a male in his thirties who presented with PRP refractory to a second course of secukinumab. Physical exam revealed diffuse salmon-colored hyperkeratotic patches coalescing to cover his entire body (BSA >95%). The patient was started on combination therapy with acitretin and bimekizumab. The patient recovered rapidly, with near total resolution of his skin findings four weeks after beginning treatment. Discussion: Unlike earlier biologics targeting IL-17, bimekizumab has activity on IL-17F in addition to IL-17AF and IL-17A. The efficacy of bimekizumab in this case may signify an important role for IL-17F in PRP pathogenesis. Bimekizumab may offer improved efficacy for the treatment of pityriasis rubra pilaris (PRP) in patients who do not respond to other therapies.

Effects of dietary cellulose on clinical and gut microbiota recovery in dogs with uncomplicated acute diarrhea: a randomized prospective clinical trial.

To assess the impact of dietary fiber supplementation with cellulose on clinical course, fecal consistency, and intestinal microbiota composition in dogs with uncomplicated acute diarrhea (AD). From September 2022 to November 2023, a total of 19 dogs presenting with uncomplicated AD were included in this prospective, randomized, and double-blinded clinical trial. The time to resolution of diarrhea was evaluated via owner surveys and a fecal scoring chart. The client-owned dogs were randomly assigned to a cellulose group (CG) or control group. The intestinal microbiota was analyzed via quantitative PCR. A marginally significant, faster improvement in stool consistency on day 1 was observed in the CG (P = .09). All dogs improved clinically, with a median recovery time of 3.0 days in the CG and 3.2 days in the control group (range, 1 to 6 days in both groups). There was no significant difference regarding the Canine Acute Diarrhea Severity index or composition of the intestinal microbiota during the study. All dogs with uncomplicated AD exhibited rapid clinical improvement and recovery of the core intestinal microbiota within the first few days. Cellulose improved the fecal consistency in a subset of dogs, and intestinal dysbiosis was mild and self-limiting. The administration of dietary cellulose has the potential to accelerate improvements of stool consistency. Mild changes in pathobionts, such as an increased amount of Clostridium perfringens, are self-limiting; thus, antibiotic intervention is not warranted.

Urinary Retention After GreenLight Laser Photoselective Vaporization of the Prostate (GLL.PVP) Surgery for Benign Prostatic Hyperplasia (BPH): A 3-6 Month Retrospective Follow-Up Study.

Objective Our study was designed to evaluate the postoperative urinary retention (UR) and success rate of the GreenLight Laser (Boston Scientific, Marlborough, MA, USA) photoselective vaporization of the prostate (GLL.PVP) procedure for Benign Prostatic Hyperplasia (BPH) patients, both with and without high-risk factors. Methodology We conducted a retrospective follow-up study of postoperative patients who underwent GLL.PVP for BPH. We collected data from clinical health records, including notes from the lower urinary tract symptoms (LUTS) clinic, trial without catheter (TWOC) clinic, and emergency department presentations with UR. The analysis examined several parameters, including the patient's age, high-risk factors, prostate volume, and both preoperative and postoperative objective voiding parameters. These voiding parameters included post-void residual (PVR) and maximum flow rate (Qmax). Additionally, the analysis looked into whether the patient had a catheter or experienced urinary retention prior to the surgery. Results A total of 50 GreenLight Laser PVP surgeries were performed over a 14-month period from May 2023 to July 2024 at West Middlesex University Hospital in London. Most of the patients were between the ages of 60 and 80. Prior to the surgery, data indicated that 17 patients (34%) were using long-term catheters, whereas 33 patients (66%) were not. Additionally, 25 patients (50%) were identified as having high-risk factors, which included being on anticoagulation therapy, a history of urinary retention, and a prostate volume exceeding 100 cc.Notably, the patient without h/o urinary retention had an average preoperative PVR of 150 mL and an averageQmaxof 7 mL/second In our 3-6 month retrospective postoperative follow-up study, we found that eight cases (16%) developed urinary retention, while 42 cases (84%) did not, with an average PVR volume of 105 mL and an average Qmax of 13.5 mL/second. In patients with preoperative urinary retention, 13 cases (76%) did not develop UR postoperatively whereas four cases (24%) developed. Conclusion Our study conclusively found that 42 cases (84%) of patients did not experience urinary retention (UR) in the follow-up after undergoing the GLL PVP operation, irrespective of any history of urinary retention or other high-risk factors. This unequivocally demonstrates the operation's efficacy. Furthermore, our findings revealed that three-quarters of patients with a preoperative history of urinary retention also did not develop UR post-surgery. The GLL.PVP procedure is safe and effective, leading to rapid improvements in voiding parameters.

Need for national guidance regarding proactive care of infants born at 22-23 weeks' gestation.

With recent rapid improvements in neonatal intensive care, the limit of viability has shifted downward to 22-23 weeks' gestation. The younger the gestational age of preterm infants, the higher the risk of survival despite severe neurodevelopmental impairments. For infants born at 22-23 weeks' gestation, the limit of viability, neurodevelopmental outcomes, and survival rates may be determined by the quality of proactive care. Owing to the high risk of severe neurodevelopmental impairment in 22-23 weeks' gestation, proactive care is sometimes withheld according to ethical or legal considerations, and there are significant differences in the provision of proactive care and survival rates across countries or institutions. Additionally, there are differing or even lacking guidelines regarding the care of these infants across countries and institutions. Japan and Sweden are countries with well-established national guidance and proactive care for infants born at 22-23 weeks' gestation, resulting in higher survival rates among them. In Korea, where there is an extreme shortage of neonatologists, maternal transfer before delivery at 22-23 weeks' gestation to high-activity regions with appropriate neonatal intensive care unit resources, such as adequate personnel and facilities similar to the centralized care model seen in Sweden, is crucial for improving the survival rates of infants born at 22-23 weeks' gestation. The survival of these infants largely depends on the quality of proactive care provided. This rate is not static and can be improved through proactive case management based on national guidance and the implementation of enhanced neonatal intensive care practices, including centralization of care.

Optimising school leadership development for 21st-century learning: An in-depth analysis of South African private secondary schools in KwaZulu-Natal

There have been significant and rapid improvements in information and communication technology (ICT) since the early 1990s. Subsequent global changes have increased with the onset of the Fourth Industrial Revolution and have dictated pedagogical transformation. Many countries have moved from traditional approaches of education to 21st-century Learning (21CL). 21CL is ICT-aligned, inquiry-based, and includes the development of affective abilities. School leadership influences all structures and individuals directly in a school. It has the potential to be one of the cornerstones of the paradigm shift to 21CL. I investigated how school leadership is developed to facilitate 21CL and how it can be improved. I required quantitative and qualitative data to achieve the research objectives. Therefore, I adopted a mixed methods research approach that is underpinned by the positivist and interpretivist paradigms. I used a case study design. The data collection methods I employed were questionnaires, semi-structured interviews, and focus group interviews. Phase one of the research involved the quantitative data collection from twenty-five schools, of which five schools were purposely sampled for the second qualitative phase. The use of transformational leadership, strategic leadership, system leadership, and ecological leadership in enacting 21CL featured prominently in the reviewed literature. However, the research findings show that, largely, these four leadership theories were not incorporated in leadership development in South Africa. The results also show that school leadership development specifically designed for 21CL, was limited. The leadership training that is available focused more on administrative tasks instead of on leadership theories and skills to facilitate 21CL. I recommend that further research be conducted in both private and public schools in other South African provinces.

Prone positioning is associated with increased insulin requirements in mechanically ventilated patients with COVID-19

Stress hyperglycaemia is common in critical illness. We have previously observed that increasing severity of respiratory failure in patients with severe COVID-19 is associated with increased insulin demand. Given previously reported direct effects of hypoxia on insulin action, we reasoned that rapid improvements in oxygenation following prone positioning may improve insulin sensitivity and increase risk of hypoglycaemia. A retrospective multi-centre service evaluation comparing blood glucose and insulin administration in patients with COVID-19 pneumonitis receiving prone mechanical ventilation, comparing the 16 h pre-prone and 16 h post-prone time periods. 155 patients were included in this analysis. Oxygenation improved significantly following prone positioning (change in SpO2/FIO2 per hour prone: 3.01 ± 0.14, P < 0.0001). Glycaemic control was similar during the supine and prone study periods, and there were no hypoglycaemic events in the prone study period. Prone positioning was associated with an unexpected modest but significant increase in insulin requirements (mean difference in total insulin dose (IU): 8.32 ± 2.14, P < 0.001) that was robust to several sensitivity analyses, and could not be explained by changes in carbohydrate intake. We did not observe an increased rate of hypoglycaemia during prone ventilation and the adequacy of glycaemic control was comparable during the supine and prone study periods. Unexpectedly, prone ventilation was associated with an increase in insulin requirements despite significant improvement in hypoxaemia. Our findings support the safety of prone ventilation with respect to glycaemic control and identify a novel relationship between ventilation position and insulin requirements in critical illness.

Abstract 4121816: Viral Venture: A Case of Myocarditis and IgA Vasculitis from Adenovirus Infection

Case Description: A 19-year-old man presented to the emergency department for 3 days of shortness of breath, progressive bilateral lower extremity rash, generalized fatigue, and diffuse joint following an earlier visit to urgent care for pharyngitis symptoms. Physical exam was notable for tachycardia, pain with active wrist and ankle range of motion, pharyngeal erythema, cervical adenopathy, and confluent erythematous palpable purpura and petechiae noted on bilateral lower extremities with scattered lesions on his thighs, arms, and back. Laboratory workup notable for markedly elevated high-sensitivity troponin to 3398 ng/L, and elevated CRP. Further workup was notable for normal urinalysis, negative streptococcus antigen, negative ANCA antibodies, ANA, Hepatitis B and C, and cryoglobulins. Imaging and cardiac workup were notable for normal left ventricular function and cardiac MRI notable for late gadolinium enhancement in the anteroapical mid-myocardial region suggestive of myocarditis. Skin biopsy ultimately revealed immunodeposition of IgA on superficial capillaries compatible with a diagnosis of IgA vasculitis. The patient was started on steroids for IgA vasculitis with rapid improvement in his symptoms and he was discharged home in good condition. Discussion: Recognizing the severe complications of viral infection can lead to prompt treatment and prevention of progression to severe end organ damage. Our case highlights rarely reported cardiac involvement of IgA vasculitis secondary to adenovirus infection based on laboratory and imaging diagnosis with cardiac MRI. To date, only 16 cases of cardiac involvement in IgA vasculitis have been reported. This case adds to the limited body of published cases describing this presentation of IgA vasculitis and is also consistent with the results of prior cases suggesting that an immunosuppressive regimen including glucocorticoids may help to prevent disease progression and induce remission in cases with cardiac involvement without the need for endomyocardial biopsy.