Standard Course Research Articles

Facilitators, barriers, and changes in POCUS use: longitudinal follow-up after participation in a national point-of-care ultrasound training course in Japan

BackgroundPOCUS training courses are effective at improving knowledge and skills, but few studies have followed learners longitudinally post-course to understand facilitators, barriers, and changes in POCUS use in clinical practice. We conducted a prospective observational study of physicians who attended 11 standardized POCUS training courses between 2017 and 2019 in Japan. Physicians who attended a standardized POCUS course were surveyed about their current frequency of POCUS use of the heart, lung, abdomen, and lower extremity veins, and perceived barriers and facilitators to POCUS use in clinical practice.ResultsData were analyzed from 112 completed surveys (response rate = 20%). A majority of responding physicians were faculty (77%) in internal medicine (69%) affiliated with community hospitals (55%). The mean delay between course attendance and survey response was 50.3 months. A significant increase in POCUS use from < 1 to ≥ 1 time per week was seen for all organ systems after 50 months post-course (p < 0.01). Approximately half of course participants reported an increase in the frequency of cardiac (61%), lung (53%), vascular (44%), and abdominal (50%) ultrasound use. General facilitators of POCUS use were easy access to ultrasound machines (63%), having a colleague with whom to learn POCUS (47%), and adequate departmental support (46%). General barriers included lack of opportunities for POCUS training (47%), poor access to ultrasound machines (38%), and limited time for POCUS training (33%). In the group with increased POCUS usage, specific facilitators reported were enhanced POCUS knowledge, improved image acquisition skills, and greater self-confidence in performing POCUS. Conversely, the group without increased POCUS usage reported lack of supervising physicians, low confidence, and insufficient training opportunities as specific barriers.ConclusionsApproximately half of physicians reported an increase in cardiac, lung, vascular, and abdominal POCUS use > 4 years after attending a POCUS training course. In addition to improving access to ultrasound machines and training opportunities, a supportive local clinical environment, including colleagues to share experiences in learning POCUS and local experts to supervise scanning, is important to foster ongoing POCUS practice and implementation into clinical practice.

Why my doctor is a Kantian and my car mechanic is an Aristotelian: bringing marketplace ethics into the classroom

This article makes the case for bringing ethics more explicitly into the economics classroom. It outlines a theory of pluralist ethical institutions, explains how these may solve certain problems in markets and relates them to a model of human behaviour proposed by Adam Smith. Markets operate not only on the foundation of outcome incentives tied to contracts and property rights, but also on the basis of Kantian duty and Aristotelian virtue. These latter concepts explain the development of deeper trust, which reduces transaction costs and risks. Trust can be achieved through reputational effects in repeat trade and from sharing sentiments and principles. Smith’s moral sentiments model describes how individuals come to develop the self-control needed to obey social norms and laws relating to honesty and treating others with respect. The article provides examples of markets that are enhanced by non-consequentialist ethical institutions, as well as some of the constraints imposed by them. It thus provides a strong case for dealing with ethics in standard economics courses and it makes some suggestions for how this can be done simply and effectively.

Atypical Course of the Habenulo-Interpeduncular Tract in Chick Embryos.

Classical studies of the avian diencephalon hardly mention the habenulo-interpeduncular tract (a.k.a. retroflex tract), although both the habenula (HB) (its origin) and the interpeduncular nuclear complex (its target) are present. Retroflex tract fibers were described at early embryonic stages but seem absent in the adult in routine stains. However, this tract is a salient diencephalic landmark in all other vertebrate lineages. It typically emerges out of the caudal HB, courses dorsoventrally across thalamic alar and basal plates just in front of the thalamo-pretectal boundary, and then sharply bends 90° caudalwards at paramedian basal plate levels (this is the "retroflexion"), to approach longitudinally via paramedian pretectum and midbrain the rostralmost hindbrain, specifically the prepontine median interpeduncular complex across isthmus and rhombomere 1. We systematize this habenulo-interpeduncular course into four parts named subhabenular, retrothalamic, tegmental, and interpeduncular. We reexamined the chicken habenulo-interpeduncular fibers at stages HH30 and HH35 (6.5- and 9-day incubation) by mapping them specifically with immunoreaction for BEN protein, a well-known marker. We found that only a small fraction of the stained retroflex tract fibers approaches the basal plate by coursing along the standard dorsoventral pathway in front of the thalamo-pretectal boundary. Many other habenular fibers instead diverge into atypical dispersed courses across the thalamic cell mass (implying alteration of the first subhabenular part of the standard course) before reaching the basal plate; this dispersion explains their invisibility. A significant number of such transthalamic habenular fibers cross orthogonally the zona limitans (ZLI) (the rostral thalamic boundary) and invade the caudal alar prethalamus. Here, they immediately descend dorsoventrally, just rostrally to the ZLI, until reaching the prethalamic basal plate, where they bend (retroflex) caudalwards, entering the thalamic basal paramedian area. These atypical fibers gradually fasciculate with the other groups of habenular efferent fibers in their final longitudinal approach to the hindbrain interpeduncular complex. We conclude that the poor visibility of this tract in birds is due to its dispersion into a diversity of atypical alternative routes, though all components eventually reach the interpeduncular complex. This case merits further analysis of the diverse permissive versus nonpermissive guidance mechanisms called into action, which partially correlate distinctly with successive diencephalic, mesencephalic, and hindbrain neuromeric fields and their boundaries.

The Application of Geogebra in Teaching Open and Inner Sets in Metric Spaces

Topology of metric spaces is a standard and important course at the college level mathematics studied at University of Mumbai. As the course is abstract, students feel it as a difficult course and hence tend to develop a fear. In this paper, we will see how to use the open-source software GeoGebra to teach the concepts of this course effectively. We will concentrate on the topics of open set and interior set. GeoGebra applets are created for various examples in different metric spaces to teach these concepts efficiently.

15 to 5 weeks: Right-Sizing an Undergraduate Educational Technology Course

This design case describes the thought processes associated with redesigning an educational technology course for undergraduate preservice teachers from a 15-week hybrid course to a 5-week online course. The redesign is part of a push to create more flexible courses for working and rural students to remain competitive despite multiple alternative licensure paths now available to aspiring teachers. The designers face and overcome challenges regarding right-sizing the course content and assignments while maintaining student engagement. Additionally, the designers discuss how they streamlined the course without sacrificing standards or critical and relevant topics, like AI in education. The case details the development of the online course within the learning management system (LMS; Google Classroom) and the design questions that emerge during that process. The redesigned 5-week course was tested through two iterations in the 2023 summer semester: Summer 1 and Summer 2. The designers collected student feedback after both runs of the course using the standard course evaluation survey, their own Google Forms survey, and the instructor’s reflections. The feedback from Summer 1 informed the Summer 2 iteration. Finally, the designers observed that the experience of condensing the course from 15 weeks to 5 weeks required them to think critically about the course goals and how to make the content manageable for students. The redesign was so successful that the course instructor (also a design case author) determined to redesign the 15-week version of the course for Fall 2023 using the new 5-week design as an anchoring point.

Laparoscopy and thoracoscopy in small animal surgery: A 2020 survey of small animal diplomate and resident veterinary surgeons.

To document the utilization and training of laparoscopic and thoracoscopic minimally invasive surgery (MIS) techniques within the American, European, Australian and New Zealand Colleges of Small Animal Veterinary Surgeons (ACVS, ECVS, and ANZCVS) in 2020. Observational study. Diplomates and residents of the ACVS, ECVS, and FANZCVS. An electronic survey was sent using veterinary list servers. Questions were organized into categories evaluating (1) the demographics of the study population and the caseload, (2) comfort level with specific procedures, (3) motivating factors and limitations, and (4) surgical training and the role of the governing bodies. Respondents included 111 practicing surgeons and 28 residents. Respondents' soft-tissue MIS caseloads had increased since they first started performing MIS; however, most respondents were only comfortable performing basic laparoscopy. Over half of the respondents agreed on the patient benefits and high standard of care provided by MIS. Perceived adequate soft-tissue training in MIS during residency was strongly associated with perceived proficiency at the time of survey response. Most respondents agreed that the specialty colleges should take a more active role in developing standards for soft-tissue MIS, with residents agreeing that a required standardized course would be beneficial. Soft-tissue MIS is widely performed by diplomates and residents. Perceived adequate soft-tissue MIS training was strongly associated with perceived proficiency. There is substantial underutilization of advanced MIS techniques in veterinary specialty surgical practice, which might be improved by a stronger focus on MIS training during residency.

Improving medical students recognizing surgery of glioblastoma removal/decompressive craniectomy via physical lifelike brain simulator training

BackgroundThis study aims to investigate the benefits of employing a Physical Lifelike Brain (PLB) simulator for training medical students in performing craniotomy for glioblastoma removal and decompressive craniectomy.MethodsThis prospective study included 30 medical clerks (fifth and sixth years in medical school) at a medical university. Before participating in the innovative lesson, all students had completed a standard gross anatomy course as part of their curriculum. The innovative lesson involved PLB Simulator training, after which participants completed the Learning Satisfaction/Confidence Perception Questionnaire and some received qualitative interviews.ResultsThe average score of students’ overall satisfaction with the innovative lesson was 4.71 out of a maximum of 5 (SD = 0.34). After the lesson, students’ confidence perception level improved significantly (t = 9.38, p < 0.001, effect size = 1.48), and the average score improved from 2,15 (SD = 1.02) to 3.59 (SD = 0.93). 60% of the students thought that the innovative lesson extremely helped them understand the knowledge of surgical neuroanatomy more, 70% believed it extremely helped them improve their skills in burr hole, and 63% thought it was extremely helpful in improving the patient complications of craniotomy with the removal of glioblastoma and decompressive craniectomy after completing the gross anatomy course.ConclusionThis innovative lesson with the PLB simulator successfully improved students’ craniotomy knowledge and skills.

Twenty-four Month Outcomes of Extended- Versus Standard-course Antibiotic Therapy in Children Hospitalized With Pneumonia in High-risk Settings: A Randomized Controlled Trial.

Pediatric community-acquired pneumonia (CAP) can lead to long-term respiratory sequelae, including bronchiectasis. We determined if an extended (13-14 days) versus standard (5-6 days) antibiotic course improves long-term outcomes in children hospitalized with CAP from populations at high risk of chronic respiratory disease. We undertook a multicenter, double-blind, superiority, randomized controlled trial involving 7 Australian, New Zealand, and Malaysian hospitals. Children aged 3 months to ≤5 years hospitalized with radiographic-confirmed CAP who received 1-3 days of intravenous antibiotics, then 3 days of oral amoxicillin-clavulanate, were randomized to either extended-course (8-day oral amoxicillin-clavulanate) or standard-course (8-day oral placebo) arms. Children were reviewed at 12 and 24 months. The primary outcome was children with the composite endpoint of chronic respiratory symptoms/signs (chronic cough at 12 and 24 months; ≥1 subsequent hospitalized acute lower respiratory infection by 24 months; or persistent and/or new chest radiographic signs at 12-months) at 24-months postdischarge, analyzed by intention-to-treat, where children with incomplete follow-up were assumed to have chronic respiratory symptoms/signs ("worst-case" scenario). A total of 324 children were randomized [extended-course (n = 163), standard-course (n = 161)]. For our primary outcome, chronic respiratory symptoms/signs occurred in 97/163 (60%) and 94/161 (58%) children in the extended-courses and standard-courses, respectively [relative risk (RR) = 1.02, 95% confidence interval (CI): 0.85-1.22]. Among children where all sub-composite outcomes were known, chronic respiratory symptoms/signs between groups, RR = 1.10, 95% CI: 0.69-1.76 [extended-course = 27/93 (29%) and standard-course = 24/91 (26%)]. Additional sensitivity analyses also revealed no between-group differences. Among children from high-risk populations hospitalized with CAP, 13-14 days of antibiotics (versus 5-6 days), did not improve long-term respiratory outcomes.

Anti-inflammatory and Antioxidant Effects of Plant Components in Complex Therapy for Acute Female Cystitis

It is well known that phytotherapy as a method of treatment and prevention of diseases with the use of medicinal plants and their extracts has a positive effect not only on the organ, but also on the whole body as a whole. The objective: to analyze the anti-inflammatory and antioxidant effects of a combined herbal remedy, which includes such active ingredients as castor oil (Castor oil), α-pinene, peppermint oil (Mentha piperita oil), extract of common nettle grass (Leonuri cardiacae), juniper berry oil (Juniperus oil), Ammi dental extract (Ammi visnaga), chamomile flower extract (Matricaria chamomilla), in young women with acute cystitis (AC). Materials and methods. 50 outpatient women with AC aged 18 to 35 years (average age – 25.9±6.1 years) took part in the study. The diagnosis was established on the basis of complaints, the results of the acute cystitis symptom score (ACSS), anamnesis data, physical examination and was confirmed by laboratory tests, clinical and biochemical blood tests were performed, and indicators of immune status were determined. The patients were divided into two groups of 25 people each. The groups were comparable in terms of age, severity of clinical symptoms, and laboratory parameters. Patients of the control group received a standard course of antibacterial therapy for 7 days. Women in the main group additionally took the combined herbal preparation at a dose of 1 capsule twice a day for 30 days and then for another 60 days at a dose of 1 capsule once a day. Follow-up visits were in 7 days after the first and 1 and 3 months after the start of therapy. During the study, the dynamics of complaints, the results of the ACSS questionnaire and laboratory analyzes of urine and blood were evaluated, and indicators of immune status and parameters of the oxidative stress-antioxidant status system were determined. Results. After a course of etiotropic treatment it was determined that the average duration of AC symptoms in patients of the control group was 1.67 times longer than in women of the main group (p&lt;0.05). After a month of using the combined herbal preparation, stabilization of the antioxidant protection system was observed, namely: indicators of oxidative stress in the main group were significantly more positive than in the control group (p&lt;0.01); indicators of the antioxidant system reached the norm and had significant differences compared to the control group (p&lt;0.05). In the main group, an increase in the functional reserve of phagocytic cells was observed, a pronounced increase in the number of cells capable of phagocytosis was determined, and the absorptive activity of neutrophils was also significantly greater than in the control group (p&lt;0.05). During the 3-month prophylactic course of treatment with the herbal preparation, the absence of recurrent disease was found in 96% of patients in the main group, in contrast to women in the control group, where the absence of reinfection was determined in only 72% of patients (p&lt;0.05). Conclusions. The use of a combined herbal preparation in a dose of 1 capsule 2 times a day in addition to the standard therapy of acute cystitis (AC) in women reliably shortens the duration of clinical symptoms and promotes faster clinical and laboratory recovery. After 30 days of use there is a normalization of indicators of oxidative stress, antioxidant protection and phagocytic activity of neutrophils. Complex therapy of AC with the inclusion of herbal medicine for 3 months is associated with significantly fewer cases of reinfection of the urinary tract compared to treatment without herbal therapy.

Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation

The health-care industry is a substantial contributor to global greenhouse gas emissions, yet the specific environmental impact of radiotherapy, a cornerstone of cancer treatment, remains under-explored. We aimed to quantify the emissions associated with the delivery of radiotherapy in the USA and propose a framework for reducing the environmental impact of oncology care. In this multi-institutional retrospective analysis and simulation study, we conducted a lifecycle assessment of external beam radiotherapy (EBRT) for ten anatomical disease sites, adhering to the International Organization for Standardization's standards ISO 14040 and ISO 14044. We analysed retrospective data from Jan 1, 2017, to Oct 1, 2023, encompassing patient and staff travel, medical supplies, and equipment and building energy use associated with the use of EBRT at four academic institutions in the USA. The primary objective was to measure the environmental impacts across ten categories: greenhouse gases (expressed as kg of carbon dioxide equivalents [CO2e]), ozone depletion, smog formation, acidification, eutrophication, carcinogenic and non-carcinogenic potential, respiratory effects, fossil fuel depletion, and ecotoxicity. Human health effects secondary to these environmental impacts were also estimated as disability-adjusted life years. We also assessed the potential benefits of hypofractionated regimens for breast and genitourinary (ie, prostate and bladder) cancers on US greenhouse gas emissions using an analytic model based on the 2014 US National Cancer Database for fractionation patterns and patient commute distances. We estimated that the mean greenhouse gas emissions associated with a standard 25-fraction EBRT course were 4310 kg CO2e (SD 2910), which corresponded to 0·0035 disability-adjusted life years per treatment course. Transit and building energy usage accounted for 25·73% (1110 kg CO2e) and 73·95% of (3190 kg CO2e) of total greenhouse gas emissions, respectively, whereas supplies contributed only 0·32% (14 kg CO2e). Across the other environmental impact categories, most of the environmental impact also stemmed from patient transit and energy use within facilities, with little environmental impact contributed by supplies used. Hypofractionated treatment simulations suggested a substantial reduction in greenhouse gas emissions-by up to 42% for breast and 77% for genitourinary cancer-and environmental impacts more broadly. This comprehensive lifecycle assessment of EBRT delineates the environmental and secondary health impacts of radiotherapy, and underscores the urgent need for sustainable practices in oncology. The findings serve as a reference for future decarbonisation efforts in cancer care and show the potential environmental benefits of modifying treatment protocols (when clinical equipoise exists). They also highlight strategic opportunities to mitigate the ecological footprint in an era of escalating climate change and increasing cancer prevalence. Mount Zion Health Fund.

The Expression of TP63 as a Biomarker of Early Recurrence in Resected Esophageal Squamous Cell Carcinoma after Neoadjuvant Chemoradiotherapy.

Esophageal cancer ranks among the ten most common cancers worldwide. Despite the adoption of neoadjuvant concurrent chemoradiotherapy (nCCRT) followed by surgery as the standard treatment approach in recent years, the local recurrence rate remains high. In this study, we employed RNA-seq to investigate distinctive gene expression profiles in esophageal squamous cell carcinoma (ESCC) with or without recurrence following a standard treatment course. Our findings indicate that recurrent ESCC exhibits heightened keratinizing and epidermis development activity compared to non-recurrent ESCC. We identified TP63 as a potential candidate for distinguishing clinical outcomes. Furthermore, immunohistochemistry confirmed the trend of TP63 overexpression in ESCC recurrence. Patients with elevated TP63 expression had poorer overall survival and lower 3-year recurrence-free survival. This study underscores the potential of TP63 as a biomarker for detecting cancer recurrence and suggests its role in guiding future treatment options.

Establishing a Material Description Table to Optimize Mandarin Proficiency for Indonesian Learners: An Applied Contrastive Analysis Perspective

Abstract. This study aims to elucidate the most contrasting differences between Mandarin and Indonesian language rules. Based on the analysis results, it is hoped that this can serve as a foundation for creating a learning media, namely a descriptive material table. The study reveals that the most contrasting rule lies in the Indonesian language auxiliary number words, which have no more than 30 auxiliary number words, whereas in Mandarin, or known as 量, there are over 200 such words. Additionally, there is a rule for constructing past tense sentences. In Indonesian, a word meaning “finished” is used to indicate the past, contrasting with Mandarin, which employs the particle “了”, which can also have different meanings according to different rules. Furthermore, there is a Numeral system rule where Indonesian simply translates numbers into letters, while Mandarin has specific and detailed rules; this clearly presents a contrasting difference. There is also a rule on reduplication, or in Mandarin termed 重叠, where the quantity of rules between the two languages is almost balanced, yet the functions of usage are vastly contrasting. Lastly, there is the rule of “离合词”, a Mandarin language rule that has no equivalent in Indonesian. The method employed is a mixed-method approach, along with a narrative elaboration model based on quantitative differences in the amount of data between Mandarin and Indonesian languages, which are then expounded upon qualitatively. The data source used is the Confucius Institute (孔子学院) recommended books: 标准教程 Standard Course HSK (Hanyu Shuping Kaoshi / Chinese Proficiency Tes) 1 - 6 下 (Part 2). Data analysis techniques include identification, classification, and presentation of the results of data analysis. The results of the research and presentation show that there is a big gap between Mandarin and Bahasa Indonesia linguistic tools, with each of the rules that bind it. Therefore, it is necessary to develop a learning media to reduce this gap.Keywords: Material description table, Applied Contrastive Analysis, Mandarin, Indonesian Learners.

A simple construction of finitely generated infinite torsion groups

The goal of this note is to provide yet another proof of the following theorem of Golod: there exists an infinite finitely generated group G such that every element of G has finite order. Our proof is based on the Nielsen–Schreier index formula and is simple enough to be included in a standard group theory course.

A brief mindfulness-based intervention for stress, pain, emotion and attention regulation in military service members with mild traumatic brain injury.

The primary aim of this study was to conduct an open pilot clinical trial of a brief mindfulness-based intervention for persistent postconcussion symptoms that occur after mild traumatic brain injury in military service members. For many service members, operational tempo and other time constraints may prevent them from completing a standard mindfulness-based stress reduction course. Thus, this study sought to examine the effectiveness of a five-session intervention called mindfulness-based stress, pain, emotion, and attention regulation (MSPEAR). Participants were active duty service members with a history of mild traumatic brain injury (TBI) and persisting postconcussion symptoms, all of whom were recruited from an outpatient TBI rehabilitation program at a military treatment facility. Of the 38 service members that were initially enrolled, 25 completed the 5-session MSPEAR intervention, and 20 returned for a 5-week follow-up evaluation. Questionnaires assessing perceived stress, positive affect, pain interference and catastrophizing, sleep disturbances, perceived behavioral and attention regulation, self-efficacy and satisfaction with life were administered at preintervention, postintervention, and at 5-week follow-up intervals. Neuropsychological testing at preintervention and 5-week follow-up included performance validity measures, attention, working memory, and executive function measures. T-tests were run to compare for questionnaire measures at preintervention (Time 1) to postintervention (Time 2). Repeated analysis of variances were conducted to compare questionnaire and neuropsychological measures at Time 1, Time 2, and at Time 3 which is the 5-week follow-up. Improvements in perceived stress, positive affect, behavioral regulation, metacognition, sleep disturbance, self-efficacy, and satisfaction with life were found immediately after the MSPEAR intervention and were maintained at the 5-week follow-up. Magnification and helplessness aspects of pain catastrophizing improved when comparing preintervention to the 5-week follow-up. Pain interference was not significantly different across study assessment times. Neuropsychological testing revealed improvements in sustained attention, working memory, cognitive flexibility, and inhibitory control when comparing preintervention to the 5-week follow-up assessment. The MSPEAR intervention appears to show promise as a brief and effective therapy for specific postconcussion symptoms after mild traumatic brain injury in military service members. Each of the components of MSPEAR including stress, pain catastrophizing, emotion and attention regulation showed improvements in this study, and bears further investigation in a larger scale, preferably randomized controlled trial in those active duty military service members who experience persisting symptoms after a mild traumatic brain injury.

Abstract PO4-14-11: Findings of clinically significant variants (Tier IA) with OmniSeq INSIGHT ® in a breast cancer cohort of 987 patients

Abstract Background: There were an estimated 2.3 million new breast cancer cases worldwide in 2020, with breast cancer now the most diagnosed type of cancer representing 25% of cancer cases and 17% of cancer deaths (1). The GLOBOCAN Cancer Tomorrow prediction tool estimates that incidence will increase by &amp;gt; 45% by 2040 (2). Optimal treatment for breast cancer is increasingly dependent upon knowing a patient’s somatic and germline genomic alteration status. To highlight the importance of these genomic alterations, we provide an overview of the genomic findings in 987 consecutive breast cancer patients tested in the course of routine clinical care. Methods: Comprehensive Genomic and Immune Profiling (CGIP) was performed on 987 qualified breast cancer samples at a CAP/CLIA and NYS CLEP certified reference laboratory with the OmniSeq INSIGHT ® test (3). OmniSeq INSIGHT ® is a next generation sequencing-based laboratory developed test for the detection of genomic variants, signatures, HLA Class I genotypes, and immune gene expression in formalin-fixed paraffin-embedded (FFPE) tumor tissue. DNA is sequenced to detect small variants in the full exonic coding region of 523 genes, copy number alterations in 59 genes (gains and losses), as well as analysis of microsatellite instability (MSI) and tumor mutational burden (TMB). RNA is sequenced to detect fusions and splice variants in 55 genes, in addition to mRNA expression in 64 immune genes. The resultant information, along with PD-L1 protein expression by immunohistochemistry (IHC), is intended for use by qualified health care professionals in accordance with professional guidelines in oncology for management of patients with solid neoplasms. Tier IA variants include variants with strong clinical significance as per AMP–ASCO–CAP recommendations (4). Results: There were 384 Tier IA variants detected in 370 of 987 breast cancer patients (~37.5%) with 251 in PIK3CA (65.3%), 60 in ERBB2 (15.6%), 46 in BRCA2 (11.9%), 19 in BRCA1 (4.9%), 4 in NTRK3 (1.0%), 1 in NTRK1 (0.26%) and 1 in PALB2 (0.26%) including copy number variations (CNV), gene fusion and single nucleotide variants (SNV). At the individual gene level for Tier IA variants, PIK3CA had 251 SNVs detected, ERBB2 had 55 CNVs, 1 gene fusion and 4 SNVs detected, BRCA2 had 39 SNVs and 8 CNVs detected, BRCA1 had 19 SNVs, NTRK3 had 4 gene fusions, NTRK1 had 1 gene fusion and PALB2 had 1 SNV detected. At the variant class level, there were 63 CNVs, 6 gene fusions and 315 SNVs observed. Conclusions: CGIP for breast cancer patients identified one or more clinically significant Tier IA genomic alterations that directs targeted therapy in ~ 37.5% of patients in a cohort of real world patients tested during the standard course of clinical care. This highlights the need for comprehensive genomic testing in breast cancer patients to drive therapeutic decision making.

The Born rule: Axiom or result?

The Born rule is part of the collapse axioms in the standard version of quantum theory, as presented by most textbooks on the subject. We show here that its signature quadratic dependence on the initial wavefunction's projection onto the measured outcome state follows from a single additional assumption beyond the other axioms. We give two examples of such an assumption, with a separate derivation for each, and we discuss their relationship with existing derivations. Our presentation is suitable for advanced undergraduates or graduate students who have taken a standard course in quantum theory. It does not depend on any particular interpretation of the theory.

Clinical Outcomes in T4 and/or N2 Rectal Cancer Treated With Neoadjuvant Chemoradiotherapy: A Retrospective Study

IntroductionTotal neoadjuvant therapy (TNT) in the management of locally advanced rectal cancer (LARC) did not show survival benefit over the standard long course chemoradiotherapy. Trials of TNT did not address the impact of each risk feature in isolation from other high-risk features. MethodologyIn this retrospective study, we describe the clinical outcomes of patients with T4 and/or N2 rectal adenocarcinoma who were treated with chemoradiotherapy followed by total mesorectal excision (TME). After obtaining the local regulatory approvals, demographic and clinical data were collected for patients in Manitoba between January 2007 and December 2019. ResultsThe cohort included 331 patients. 61 patients had T4-only disease and 218 had N2-only disease. Mean age was 59.65 years. 74.3% received adjuvant chemotherapy (ACT), but only 56.5% completed the planned course. R0 resection was achieved in 93.4% of patients (78.7% and 97.2% in T4 and N2, respectively). Median follow up was 4.93 years. 3-year overall recurrence rate was 29%. 3-year locoregional recurrence (LRR) rate was 8% (16% and 6% in T4 and N2, respectively). 3-year overall survival (OS) rate was 84% in the whole cohort (72.6% and 87.1% in T4 and N2, respectively). Incomplete surgical resection was a poor prognostic factor for both OS and LRR. ACT was associated with a survival benefit in the whole cohort (P = .001) and in the N2 sub-cohort (P = 003) but there was no survival benefit observed in T4 sub-cohort. ACT did not have an impact on LRR. ConclusionsAchieving R0 resection in LARC with neoadjuvant therapy improves recurrence and survival rates. T4 disease carries a worse clinical outcome than N2 and consideration should be given to upstage T4 to stage III. Different high-risk features in LARC predict different clinical outcomes. In the era of TNT, personalization of treatment strategy based on these factors could potentially improve outcomes.

Implementation of a Global Pediatric Trauma Course in an Upper Middle–Income Country: A Pilot Study

IntroductionOver 90% of pediatric trauma deaths occur in low- and middle-income countries (LMICs), yet pediatric trauma-focused training remains unstandardized and inaccessible, especially in LMICs. In Brazil, where trauma is the leading cause of death for children over age 1, we piloted the first global adaptation of the Trauma Resuscitation in Kids (TRIK) course and assessed its feasibility. MethodsA 2-day simulation-based global TRIK course was hosted in Belo Horizonte in October 2022, led by one Brazilian and four Canadian instructors. The enrollment fee was $200 USD, and course registration sold out in 4 d. We administered a knowledge test before and after the course and a postcourse self-evaluation. We recorded each simulation to assess participants’ performance, reflected in a team performance score. Groups received numerical scores for these three areas, which were equally weighted to calculate a final performance score. The scores given by the two evaluators were then averaged. As groups performed the specific simulations in varying orders, the simulations were grouped into four time blocks for analysis of performance over time. Statistical analysis utilized a combination of descriptive analysis, Wilcoxon signed-rank tests, Kruskal–Wallis tests, and Wilcoxon rank-sum tests. ResultsTwenty-one surgeons (19 pediatric, one trauma, one general) representing four of five regions in Brazil consented to study participation. Women comprised 76% (16/21) of participants. Overall, participants scored higher on the knowledge assessment after the course (68% versus 76%; z = 3.046, P < 0.001). Participants reported improved knowledge for all tested components of trauma management (P < 0.001). The average simulation performance score increased from 66% on day 1% to 73% on day 2, although this increase was not statistically significant. All participants reported they were more confident managing pediatric trauma after the course and would recommend the course to others. ConclusionsCompletion of global TRIK improved surgeons’ confidence, knowledge, and clinical decision-making skills in managing pediatric trauma, suggesting a standardized course may improve pediatric trauma care and outcomes in LMICs. We plan to more closely address cost, language, and resource barriers to implementing protocolized trauma training in LMICs with the aim to improve patient outcomes and equity in trauma care globally.

Medical Student and Faculty Attitudes Toward Translanguaging with Spanish-Speaking Patients

Background: Spanish is the second most common US language, and Spanish speakers commonly translanguage—spontaneously integrate multiple languages. Medical language courses have proliferated, yet learner and faculty attitudes about translanguaging with patients remain unexplored. Also, it is unclear whether medical Spanish courses address real-world patient linguistic practices, such as translanguaging. Methods: We applied a community cultural wealth framework to identify translanguaging practices relevant to patient-physician communication: regionalisms, Spanglish, and non-standard language usage. From January 2020 to May 2021, we surveyed students (n=355) and faculty (n=14) in a standardized medical Spanish course at 14 sites on their attitudes toward translanguaging practices. Results: Regionalisms were the most widely accepted translanguaging practice by both students and faculty, and this opinion was reinforced by the course (94% pre vs. 95% post-course agreement; p=0.045). Student agreement with Spanglish was moderate and declined post-course (58% vs. 55%; p&lt;0.001). Faculty were likelier than students to be accepting of non-standard language usage (57% faculty vs. 5% students; p&lt;0.001). Conclusion: Medical students and faculty reported mixed attitudes about translanguaging practices in healthcare, and taking a medical Spanish course had variable effects on student responses. Future work should focus on developing and evaluating medical Spanish educational pedagogies that explicitly incorporate real-world patient perspectives and promote flexible language use that prioritizes mutual respect and understanding.

Bleeding Control Protections Within US Good Samaritan Laws.

In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.