bluuebunny/crossref_metadata_2025 huggingface dataset:
Continued Supervision for the Common Pediatric Subspecialty Entrustable Professional Activities May Be Needed Following Fellowship Graduation
Authors: Turner David A. , Schwartz Alan , Carraccio Carol , Herman Bruce , Weiss Pnina , Baffa Jeanne M. , Chess Patricia , Curran Megan , Dammann Christiane , High Pamela , Hsu Deborah , Pitts Sarah , Sauer Cary , Aye Tandy , Fussell Jill , Kesselheim Jennifer , Mahan John , McGann Kathleen , Myers Angie , Mink Richard
Published: June 2021

Purpose

Entrustable professional activities (EPAs) are one approach to competency-based medical education (CBME), and 7 EPAs have been developed that address content relevant for all pediatric subspecialties. However, it is not known what level of supervision fellowship program directors (FPDs) deem necessary for graduation. The Subspecialty Pediatrics Investigator Network (SPIN) investigated FPD perceptions of the minimum level of supervision required for a trainee to successfully graduate.

Method

In 2017, SPIN surveyed all FPDs of accredited fellowships for 14 subspecialties. For each EPA, the minimum supervision level for graduation (ranging from observation only to unsupervised practice) was set such that no more than 20% of FPDs would accept a lower level.

Results

The survey response rate was 82% (660/802). The minimum supervision level for graduation varied across the 7 EPAs from 2 (direct) to 4 (indirect for complex cases), with significant differences between EPAs. The percentage of FPDs desiring a lower minimum supervision level ranged from 3% to 17%. Compared with the 4 nonclinical EPAs (quality improvement, management, lead within the profession, scholarship), the 3 clinical EPAs (consultation, handover, lead a team) had higher minimum supervision graduation levels (P < .001), with less likelihood that an FPD would graduate a learner below their minimum level (P < .001)

Conclusions

Consensus among FPDs across all pediatric subspecialties demonstrates the potential need for ongoing supervision for graduates in all 7 common pediatric subspecialty EPAs after fellowship. As CBME programs are implemented, processes and infrastructure to support new graduates are important considerations for leaders.
Learner Levels of Supervision Across the Continuum of Pediatrics Training
Authors: Schwartz Alan , Borman-Shoap Emily , Carraccio Carol , Herman Bruce , Hobday Patricia M. , Kaul Paritosh , Long Michele , O’Connor Meghan , Mink Richard , Schumacher Daniel J. , Turner David A. , West Daniel C.
Published: June 2021

Purpose

To describe trajectories in level of supervision ratings for linked entrustable professional activities (EPAs) among pediatric learners in medical school, residency, fellowship.

Method

The authors performed secondary analyses of 3 linked datasets of level of supervision ratings for the Core EPAs for Entering Residency, the General Pediatrics EPAs, and the Subspecialty Pediatrics EPAs. After identifying 9 activities in common across training stages and aligning the level of entrustment-supervision scales across the datasets, piecewise ordinal and linear mixed effects models were fitted to characterize trajectories of supervision ratings.

Results

Within each training period, learners were rated as needing less supervision over time in each activity. When transitioning from medical school to residency or during the first year of residency, learners were rated as needing greater supervision in activities related to patient management, teamwork, emergent care, and public health/QI than in earlier periods. When transitioning from residency to fellowship, learners were always rated as needing greater supervision than they had been accorded at the end of residency and sometimes even more than they had been accorded at the start of residency.

Conclusions

Although development over training is often imagined as continuous and monotonically increasing competence, this study provides empirical evidence supporting the idea that entrustment is a set of discrete decisions. The relaxation of supervision in training is not a linear process. Even with a seamless curriculum, supervision is tightly bound to the training setting. Several explanations for these findings are discussed.
Entrustable Professional Activities and Entrustment Decision Making: A Development and Research Agenda for the Next Decade
Authors: ten Cate Olle , Balmer Dorene F. , Caretta-Weyer Holly , Hatala Rose , Hennus Marije P. , West Daniel C.
Published: June 2021

To establish a research and development agenda for Entrustable Professional Activities (EPAs) for the coming decade, the authors, all active in this area of investigation, reviewed recent research papers, seeking recommendations for future research. They pooled their knowledge and experience to identify 3 levels of potential research and development: the micro level of learning and teaching; the meso level of institutions, programs, and specialty domains; and the macro level of regional, national, and international dynamics. Within these levels, the authors categorized their recommendations for research and development.

The authors identified 14 discrete themes, each including multiple questions or issues for potential exploration, that range from foundational and conceptual to practical.

Much research to date has focused on a variety of issues regarding development and early implementation of EPAs. Future research should focus on large-scale implementation of EPAs to support competency-based medical education (CBME) and on its consequences at the 3 levels. In addition, emerging from the implementation phase, the authors call for rigorous studies focusing on conceptual issues. These issues include the nature of entrustment decisions and their relationship with education and learner progress and the use of EPAs across boundaries of training phases, disciplines and professions, including continuing professional development. International studies evaluating the value of EPAs across countries are another important consideration. Future studies should also remain alert for unintended consequences of the use of EPAs.

EPAs were conceptualized to support CBME in its endeavor to improve outcomes of education and patient care, prompting creation of this agenda.
Entrustment Unpacked: Aligning Purposes, Stakes, and Processes to Enhance Learner Assessment
Authors: Kinnear Benjamin , Warm Eric J. , Caretta-Weyer Holly , Holmboe Eric S. , Turner David A. , van der Vleuten Cees , Schumacher Daniel J.
Published: June 2021

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.
The Implementation of Entrustable Professional Activities in Postgraduate Medical Education in the Netherlands: Rationale, Process, and Current Status
Authors: de Graaf Jacqueline , Bolk Marieke , Dijkstra Auk , van der Horst Marieke , Hoff Reinier G. , ten Cate Olle
Published: June 2021

Postgraduate medical education in the Netherlands has adopted competency-based education since the turn of the century. In 2006, the CanMEDS competency framework was introduced.

A 2013 government plan to reduce the length and budgets of training programs led the Dutch Association of Medical Specialists (DAMS) to respond with a proposal to create more flexibility and individualization rather than a blunt cut in the length across all training programs. DAMS launched a government-funded, nation-wide, 4-year project (2014–2018) to blueprint the reform of postgraduate medical education in this direction.

To achieve competency-based individualization, the fixed duration of postgraduate programs was abandoned, and entrustable professional activities (EPAs) were introduced in all specialty programs. Implementation of this new generation of programs took place in 2017–2019 in all disciplines.

The project focused on EPA-based individualization of all programs, while addressing issues of the continuity of patient care in time-variable programs and the legal and regulatory consequences of individualization. About 30 specialty programs were revised at national, regional, local, and individual levels to incorporate EPAs; portfolio systems were adapted, clinical competency committees were installed for all programs, and procedures for summative entrustment decision making were elaborated.

This paper reports on the rationale and the process that led to a more time-variable postgraduate education landscape, and, on average, a shortening of training length by 3 months.
Constructing a Validity Map for a Workplace-Based Assessment System: Cross-Walking Messick and Kane
Authors: Kinnear Benjamin , Kelleher Matthew , May Brian , Sall Dana , Schauer Daniel P. , Schumacher Daniel J. , Warm Eric J.
Published: June 2021

Problem

Health professions education has shifted to a competency-based paradigm in which many programs rely heavily on workplace-based assessment (WBA) to produce data for summative decisions about learners. However, WBAs are complex and require validity evidence beyond psychometric analysis. Here, the authors describe their use of a rhetorical argumentation process to develop a map of validity evidence for summative decisions in an entrustment-based WBA system.

Approach

To organize evidence, the authors cross-walked 2 contemporary validity frameworks, one that emphasizes sources of evidence (Messick) and another that stresses inferences in an argument (Kane). They constructed a validity map using 4 steps: (1) Asking critical questions about the stated interpretation and use, (2) Seeking validity evidence as a response, (3) Categorizing evidence using both Messick’s and Kane’s frameworks, and (4) Building a visual representation of the collected and organized evidence. The authors used an iterative approach, adding new critical questions and evidence over time.

Outcomes

The first map draft produced 25 boxes of evidence that included all 5 sources of evidence detailed by Messick and spread across all 4 inferences described by Kane. The rhetorical question–response process allowed for structured critical appraisal of the WBA system, leading to the identification of evidentiary gaps.

Next Steps

Future map iterations will integrate evidence quality indicators and allow for deeper dives into the evidence. The authors intend to share their map with graduate medical education stakeholders (e.g., accreditors, institutional leaders, learners, patients) to understand if it adds value for evaluating their WBA programs’ validity arguments.
The role of CD8+ T-cell systemic lupus erythematosus pathogenesis: an update
Authors: Chen Ping-Min , Tsokos George C.
Published: June 2021

Purpose of review

Systemic lupus erythematosus (SLE) is a serious autoimmune disease with a wide range of organ involvement. In addition to aberrant B-cell responses leading to autoantibody production, T-cell abnormalities are important in the induction of autoimmunity and the ensuing downstream organ damage. In this article, we present an update on how subsets of CD8+ T cells contribute to SLE pathogenesis.

Recent findings

Reduced cytolytic function of CD8+ T cells not only promotes systemic autoimmunity but also accounts for the increased risk of infections. Additional information suggests that effector functions of tissue CD8+ T cells contribute to organ damage. The phenotypic changes in tissue CD8+ T cells likely arise from exposure to tissue microenvironment and crosstalk with tissue resident cells. Research on pathogenic IL-17-producing double negative T cells also suggests their origin from autoreactive CD8+ T cells, which also contribute to the induction and maintenance of systemic autoimmunity.

Reduced CD8+ T-cell effector function illustrates their role in peripheral tolerance in the control of autoimmunity and to the increased risk of infections. Inflammatory cytokine producing double negative T cells and functional defects of regulatory CD8+ T cell both contribute to SLE pathogenesis. Further in depth research on these phenotypic changes are warranted for the development of new therapeutics for people with SLE.
Lenvatinib treatment for thyroid cancer in COVID era: safety in a patient with lung metastases and SARS-CoV-2 infection
Authors: Locantore Pietro , Del Gatto Valeria , Corsello Andrea , Pontecorvi Alfredo
Published: June 2021

During the coronavirus disease 2019 (COVID-19) pandemic, clinicians are required to manage patient care for pre-existing conditions. Currently, there are no clear indications regarding the management of lenvatinib-treated patients for radioiodine-refractory thyroid cancer and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 74-year-old male patient was treated with lenvatinib since March 2019, with disease recurrence in the thyroid bed and bilateral multiple lung metastases. The patient partially responded to treatment, with reduction in lung metastases. In September 2019, the patient tested positive for SARS-CoV-2 and isolated at home. Initially asymptomatic, the patient developed mild symptoms. Lenvatinib treatment continued with daily monitoring of vital signs. After telemedicine consultation of patient’s clinical condition, severity of symptoms was low. He tested negative for SARS-CoV-2 21 days after testing positive. The patient received the full course of lenvatinib treatment. This is the first reported case of a lenvatinib-treated patient who developed COVID-19 and could continue treatment. Despite concerns over COVID-19, clinicians should not overlook treatment of pre-existing diseases or discontinue treatment, particularly for cancer. Clinicians should evaluate a patient’s history and clinical presentation, monitoring the patient to reduce the development of complications in high-risk settings, avoiding treatment discontinuation.
Searching for essential genes and drug discovery in breast cancer and periodontitis via text mining and bioinformatics analysis
Authors: Luo Lan , Zheng Weijie , Chen Chuang , Sun Shengrong
Published: June 2021

The primary purpose of the study was (1) to search for the essential genes associated with breast cancer and periodontitis, and (2) to identify candidate drugs targeted to these genes for expanding the potential drug indications. The genes related to both breast cancer and periodontitis were determined by text mining. Gene ontology and Kyoto Encyclopedia of Genes and Genomes analysis were performed on these genes, and protein–protein interaction analysis was carried out to export significant module genes. Drug–gene interaction database was employed for potential drug discovery. We identified 221 genes common to both breast cancer and periodontitis. The top six significant enrichment terms and 15 enriched signal pathways were selected. Among 24 significant genes demonstrated as a gene cluster, we found SERPINA1 and TF were significantly related to poor overall survival between the relatively high and low groups in patients. Using the final two genes, 12 drugs were identified that had potential therapeutic effects. SERPINA1 and TF were screened out as essential genes related to both breast cancer and periodontitis, targeting 12 candidate drugs that may expand drug indications. Drug discovery using text mining and analysis of different databases can promote the identification of existing drugs that have the potential of administration to improve treatment in breast cancer.
Comorbidities and mortality risk among extensive-stage small-cell lung cancer patients in mainland China: impacts of hypertension, type 2 diabetes mellitus, and chronic hepatitis B virus infection
Authors: Xiu Weigang , Huang Yin , Li Yanying , Yu Min , Gong Youling
Published: June 2021

The present study investigated the impact of major comorbidities, including hypertension, type 2 diabetes mellitus (T2DM), and chronic hepatitis B virus (HBV) infection, on the progression-free survival (PFS) and overall survival (OS) of extensive-stage small-cell lung cancer (ES-SCLC) patients in China. Patients having a pathologic diagnosis of ES-SCLC between 2009 and 2017 were enrolled and grouped according to their specific comorbidities. The PFS and OS for each group were evaluated using the Kaplan–Meier method and Cox proportional hazard models. In total, 632 patients were analyzed. The median PFS (mPFS) of these patients was 9 months [95% confidence interval (CI), 6–12 months]. The mPFS of patients without hypertension or T2DM was 9 months; conversely, it was significantly reduced for patients with hypertension [7 months (P < 0.0001)] or T2DM [5 months (P < 0.0001)]. However, mPFS was not significantly different between patients with and without HBV infection (P = 0.2936). A similar trend was observed for OS as well. Further multivariate analyses showed that the OS of patients with hypertension [hazard ratio (HR), 1.344; 95% CI, 1.073–1.683; P = 0.010] or T2DM (HR, 1.455; 95% CI, 1.134–1.868; P = 0.003) was significantly shorter than that of patients without these comorbidities. Accordingly, mortality risk was the highest in patients with concurrent hypertension and T2DM (HR, 1.665; 95% CI, 1.037–2.672; P = 0.00058). Our study found that hypertension and T2DM may be associated with a worse prognosis in ES-SCLC patients. Considerable attention should be paid to the accompanying anti-comorbidity therapies available for patients with ES-SCLC.
Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization
Authors: Zadek Francesco , Rubin Jonah , Grassi Luigi , Van Den Kroonenberg Daniel , Larson Grant , Capriles Martin , De Santis Santiago Roberta , Florio Gaetano , Imber David A. , Bittner Edward A , Hibbert Kathryn A. , Legassey Alex , LaRocque Jeliene , Cudemus-Deseda Gaston , Bagchi Aranya , Crowley Jerome , Shelton Kenneth , Kacmarek Robert , Berra Lorenzo
Published: June 2021

OBJECTIVE:

To investigate whether individualized optimization of mechanical ventilation through the implementation of a lung rescue team could reduce the need for venovenous extracorporeal membrane oxygenation in patients with obesity and acute respiratory distress syndrome and decrease ICU and hospital length of stay and mortality.

DESIGN:

Single-center, retrospective study at the Massachusetts General Hospital from June 2015 to June 2019.

PATIENTS:

All patients with obesity and acute respiratory distress syndrome who were referred for venovenous extracorporeal membrane oxygenation evaluation due to hypoxemic respiratory failure.

INTERVENTION:

Evaluation and individualized optimization of mechanical ventilation by the lung rescue team before the decision to proceed with venovenous extracorporeal membrane oxygenation. The control group was those patients managed according to hospital standard of care without lung rescue team evaluation.

MEASUREMENT AND MAIN RESULTS:

All 20 patients (100%) allocated in the control group received venovenous extracorporeal membrane oxygenation, whereas 10 of 13 patients (77%) evaluated by the lung rescue team did not receive venovenous extracorporeal membrane oxygenation. Patients who underwent lung rescue team evaluation had a shorter duration of mechanical ventilation (p = 0.03) and shorter ICU length of stay (p = 0.03). There were no differences between groups in in-hospital, 30-day, or 1–year mortality.

CONCLUSIONS:

In this hypothesis-generating study, individualized optimization of mechanical ventilation of patients with acute respiratory distress syndrome and obesity by a lung rescue team was associated with a decrease in the utilization of venovenous extracorporeal membrane oxygenation, duration of mechanical ventilation, and ICU length of stay. Mortality was not modified by the lung rescue team intervention.
Challenges adopting next-generation sequencing in community oncology practice
Authors: Ashbury Fredrick D. , Thompson Keith , Williams Casey , Williams Kirstin
Published: June 2021

Purpose of review

We are in an exhilarating time in which innovations exist to help reduce the impact of cancer for individuals, practitioners and society. Innovative tools in cancer genomics can optimize decision-making concerning appropriate drugs (alone or in combination) to cure or prolong life. The genomic characterization of tumours can also give direction to the development of novel drugs. Next-generation tumour sequencing is increasingly becoming an essential part of clinical decision-making, and, as such, will require appropriate coordination for effective adoption and delivery.

Recent findings

There are several challenges that will need to be addressed if we are to facilitate cancer genomics as part of routine community oncology practice. Recent research into this novel testing paradigm has demonstrated the barriers are at the individual level, while others are at the institution and societal levels.

This article, based on the authors’ experience in community oncology practice and summary of literature, describes these challenges so strategies can be developed to address these challenges to improve patient outcomes.
The role of multiparity and maternal age at first pregnancy in the association between early menarche and metabolic syndrome among middle-aged and older women
Authors: Rocha Tiago Novais , Macêdo Pedro Rafael de Souza , Vafaei Afshin , Guedes Dimitri Taurino , Azevedo Ingrid Guerra , Maciel Álvaro Campos Cavalcanti , Câmara Saionara Maria Aires da
Published: June 2021

Objective:

To analyze whether maternal age at first pregnancy and parity are mediators of the association between early menarche and metabolic syndrome in a sample of middle-aged and older women.

Methods:

Cross-sectional study of 428 women (40 to 80 y), who had experienced a pregnancy in their lifetime, was performed between 2014 and 2016. Age at first pregnancy, parity, and early menarche were self-reported. Metabolic syndrome was assessed using the criteria described by the National Cholesterol Education Program's Adult Treatment Panel III. The association between metabolic syndrome and early menarche was assessed by logistic regression analysis. The mediating role of age at first pregnancy and multiparity in the relationship between early menarche and metabolic syndrome was assessed through mediation analysis, adjusted for covariates.

Results:

According to adjusted logistic regression models, early menarche was associated with higher odds of prevalent metabolic syndrome (OR: 2.26; 95% CI: 1.15-4.46). Mediation analysis showed a significant direct effect of early menarche on metabolic syndrome (β: 0.808; 95% CI: 0.107-1.508). Of the two mediators tested, age at first pregnancy was significant (β: 0.065; 95% CI: 0.004-0.221), ie, participants with and without early menarche differ, on average, by 0.879 SDs in the log odds of MetS (total effect), of which 0.065 SDs (8%), on average, would be attributable to the effect of early menarche on age at first pregnancy (indirect effect), which, in turn, affects MetS.

Conclusions:

Age at first pregnancy may partially contribute to the association between early menarche and metabolic syndrome among middle-aged and older women who had experienced a pregnancy over their lifetime.
Overcoming Nuclear Winter: The Cutting-edge Science of Bone Healing and Regeneration in Irradiated Fields
Authors: Daniel Melissa , Luby Alexandra O. , Buchman Lauren , Buchman Steven R.
Published: June 2021

Background:

The incidence of cancer worldwide is expected to be more than 22 million annually by 2030. Approximately half of these patients will likely require radiation therapy. Although radiotherapy has been shown to improve disease control and increase survivorship, it also results in damage to adjacent healthy tissues, including the bone, which can lead to devastating skeletal complications, such as nonunion, pathologic fractures, and osteoradionecrosis. Pathologic fractures and osteoradionecrosis are ominous complications that can result in large bone and soft tissue defects requiring complex reconstruction. Current clinical management strategies for these conditions are suboptimal and dubious at best. The gold standard in treatment of severe radiation injury is free tissue transfer; however, this requires a large operation that is limited to select candidates.

Methods:

With the goal to expand current treatment options and to assuage the devastating sequelae of radiation injury on surrounding normal tissue, our laboratory has performed years of translational studies aimed at remediating bone healing and regeneration in irradiated fields. Three therapeutics (amifostine, deferoxamine, and adipose-derived stem cells) have demonstrated great promise in promoting healing and regeneration of irradiated bone.

Results:

Amifostine confers prophylactic protection, whereas deferoxamine and adipose-derived stem cells function to remediate postradiation associated injury.

Conclusions:

These prospective therapeutics exploit a mechanism attributed to increasing angiogenesis and ultimately function to protect or restore cellularity, normal cellular function, osteogenesis, and bone healing to nonirradiated metrics. These discoveries may offer innovative treatment alternatives to free tissue transfer with the added benefit of potentially preventing and treating osteoradionecrosis and pathologic fractures
Rotating the Tip in Long Noses: A Strategy rather than a Single Technique
Authors: Abdelkader Rasha , El-Noamany Sameh , Makarem Kyrillos
Published: June 2021

Background:

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery, the incidence of which has increased up to approximately 1 million cases in 2016 according to the recent International Society of Aesthetic Plastic Surgery survey. This study aimed at defining the importance of each sequential procedure within the same surgery, the extent to which a procedure can be performed, and those that can be omitted.

Methods:

In this descriptive study, 27 candidates (18 women; nine men; age range, 20–48 years) for primary rhinoplasty between September 2016 and September 2019 were included. All had long noses, their main concern was reduction of nasal tip projection and all were seeking cranial tip rotation to enhance their tip aesthetics. Those who required revision rhinoplasty or who had nasal deformities due to congenital defects, and those older than 60 or younger than 18 years of age, were excluded.

Results:

The average nasolabial angle in women preoperatively was 88.2 ± 6.6 and postoperatively 102.8 ± 5.6. In men, the average average nasolabial angle preoperatively was 79.6 ± 5.4 and postoperatively 92.3 ± 2.3. In both men and women, the P value was <0.001, which indicates high significance. Tip rotation was achieved in all patients, with 81% achieving ideal rotation, and 19% exceeding the ideal range.

Conclusions:

Rotating the tip in long noses is a complex procedure. It can be achieved by many described techniques, but not all are required. A general strategy should be followed during which variable techniques, with varying efficacy, can be utilized.
Reconstructive Microsurgery in the COVID-19 Environment
Authors: Shachar Tal , Yaacobi Dafna (Shilo) , Cohen Keren , Olshinka Asaf , Ad-El Dean D.
Published: June 2021

The COVID-19 pandemic has presented unique challenges to the plastic surgery field. Substantial changes have been incorporated in hospital and practice protocols in all branches of medicine. Organic medical teams were placed on scheduled shifts to prevent cross-infection, and some working teams were discontinued. Remote technology consultations and deliberations were instituted in hospitals and community medical services to maintain the flow of information on patient status. Several mitigation strategies were implemented during these times throughout medical facilities. We present those implemented in our facility to ensure adequate labor, resources, and facilities along with proper protocols for patient selection and management according to predetermined risk assessment criteria with the hope to assist the healthcare staff to minimize mortality risks.
Perception of Cosmetic Procedures among Saudis during COVID-19 Pandemic
Authors: Alhujayri Abdulaziz K. , Alyousef Loujain A. , Alharthi Sawsan A. , Aldekhayel Salah
Published: June 2021

Background:

A novel coronavirus disease (COVID-19) was first reported in December 2019 in Wuhan, China. The fast spread of the virus has led to a significant reduction in the numbers of elective procedures especially cosmetic interventions. Although many measures have been carried out to offload the health care system, it is unclear whether these changes had an effect on general population perception toward undergoing cosmetic procedures. The aim of this study was to assess the perception of Saudis toward undergoing a cosmetic surgery during the COVID-19 pandemic.

Method:

An online survey consisting of two parts was used, with a series of questions about cosmetic procedures, in general, and cosmetic procedures during the COVID-19 pandemic, in particular. The survey included Saudis (age 18 to 60 years) with access to social media.

Results:

A total of 563 respondents participated in this survey. The vast majority were women (86.9%) and were between 18 and 24 years old (38.7%). Some 27.4% considered a cosmetic procedure during the COVID-19 pandemic; however, only 11.9% underwent any. In the majority of the participants (86%), the pandemic did not change their minds about having a cosmetic procedure. About 49.7% agreed that fear of contracting the virus would be a factor for not undergoing a cosmetic procedure during the pandemic.

Conclusions:

Clear differences in the engagement and perception of cosmetic procedures during the COVID-19 pandemic exist among Saudis. More studies are needed to explore the effects of pandemics on aesthetic practice and to find ways to perform elective procedures in a safe way.
Acute Liver Injury Among Pediatric Liver Transplantation Recipients With Coronavirus Disease 2019: An International Collaborative Study
Authors: Sin Priscila , Díaz Luis Antonio , Martínez Mercedes , Vizcaya Cecilia , D’Agostino Daniel , Gana Juan Cristóbal
Published: June 2021

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic. The occurrence of acute liver injury (ALI) has been reported in liver transplant (LT) recipients; however, the findings on children remain controversial. This is the first extensive, worldwide report on the impact of COVID-19 on pediatric LT recipients. Our online survey reported 110 pediatric LT recipients with severe acute respiratory syndrome coronavirus 2 infection. Of these, 37 were symptomatic and 20 out of them (54%) had complicated COVID-19, which included ALI and acute liver graft rejection. No mortality was reported. Pediatric LT recipients who had undergone transplantation less than 6 months before contracting COVID-19 had a greater number of hospital admissions and a higher ALI frequency (P = 0.013 and P = 0.033, respectively) than those who had undergone transplantation more than 6 months prior. Our study found that COVID-19 cases among pediatric LT recipients demonstrated a high complication rate. We propose that these patients must be followed up strictly.
Providing Palliative Care to Neonates With Anencephaly in the Home Setting
Authors: Berry Shandeigh N.
Published: June 2021

Parents who choose to carry a pregnancy complicated by a life-limiting congenital anomaly such as anencephaly may give birth to a live neonate and be discharged home. Very little guidance is available to health care professionals providing palliative care in the home setting to this population. This article is a secondary analysis that discusses the concerns and complications that parents experienced after bringing home a neonate with anencephaly. Each parental experience is a qualitative descriptive summary extracted from a larger study on the impact of anencephaly on parents. Parents reported feeling alone in their grief and struggled with their partners' differing style of grief. Parents' primary concerns after hospital discharge included transporting their neonate home, feeding their neonate, changing cranial defect dressings, managing pain and seizures, addressing uncertainty, and facilitating a good death. All parents received hospice services from health care professionals without perinatal bereavement training or experience. Only 1 woman received follow-up care after the death of her son. Preparing and educating health care professionals providing hospice and palliative services with perinatal bereavement training may be beneficial. Identifying and allocating local and online perinatal bereavement resources may provide parents with the tools and support necessary to facilitate healing after perinatal loss.
PD-L1 Tumor Cell Expression in Upper Tract Urothelial Carcinomas is Associated With Higher Pathologic Stage
Authors: Ward Michael , Albertson Daniel , Furtado Larissa V. , Deftereos Georgios
Published: June 2021

Background:

Upper tract urothelial carcinomas (UTUCs) are a rare and unique subset of urothelial carcinoma (UC). Patients with UTUC may qualify for treatment with immune checkpoint inhibitors if their tumor cells express programmed death ligand-1 (PD-L1). While several large studies have looked at PD-L1 expression in UC, most have not investigated UTUC as a separate group, and most have not used Food and Drug Administration approved PD-L1 stains and scoring systems. Moreover, comparison between studies of PD-L1 expression is challenging as a wide variety of different PD-L1 antibody clones, testing platforms, and cutoff values have been used in the literature.

Methods:

This is a retrospective study of 37 cases of resected UTUC. Representative tissue from each case was compiled into tissue microarrays and immunohistochemical stains for PD-L1 (Dako antibody clones 22C3 and 28-8) were performed. PD-L1 staining was evaluated using several established Food and Drug Administration approved scoring systems: tumor proportion score (TPS), combined positive score, and immune cell score. Associations between PD-L1 expression and clinicopathologic features were investigated.

Results:

Overall expression of PD-L1 in UTUC was 29.7% when using a TPS cutoff of ≥1%. Total of, 55.6% of cases with higher pathologic stage (pT3 or pT4) were positive for PD-L1, compared with only 5.3% of cases with lower pathologic stage (pTis, pT1, or pT2; P=0.0011). When using a combined positive score cutoff of ≥10, there was no significant association between tumor stage and PD-L1 expression. There was no association between PD-L1 positivity and tumor grade, tumor location, sex, or age. There was 100% concordance between 22C3 and 28-8 in terms of positivity rate.

Conclusions:

Our study using approved testing methods shows that PD-L1 expression in UTUC is more often associated with high pathologic stage, which may reflect an immune response evasion mechanism that UC cells acquire later in disease progression. In addition we show that 29.7% of UTUCs are positive for PD-L1 TPS expression, comparable to the 20% to 30% reported in UC literature. Finally, PD-L1 22C3 and 28-8 clones show similar overall patterns of staining in this setting.
A Review of PROM Implementation in Surgical Practice
Authors: Sokas Claire , Hu Frances , Edelen Maria , Sisodia Rachel , Pusic Andrea , Cooper Zara
Published: June 2021

Objective:

To synthesize the current state of PROM implementation and collection in routine surgical practice through a review of the literature.

Summary of Background Data:

Patient-reported outcomes (PROs) are increasingly relevant in the delivery of high quality, individualized patient care. For surgeons, PROMs can provide valuable insight into changes in patient quality of life before and after surgical interventions. Despite consensus within the surgical community regarding the promise of PROMs, little is known about their real-world implementation.

Methods:

The literature search was conducted in MEDLINE and Embase for studies published after 2012. We conducted a scoping review to synthesize the current state of implementation of PROs across all sizes and types of surgical practices. Studies were included if they met the following inclusion criteria: (1) patients ≥18 years 2) routine surgical practice, (3) use of a validated PRO instrument in the peri-operative period to report on general or disease-specific health-related quality of life, (4) primary or secondary outcome was implementation. Two independent reviewers screened 1524 titles and abstracts.

Findings:

16 studies were identified that reported on the implementation of PROMs for surgical patients. Sample size ranged from 41 patients in a single-center pilot study to 1324 patients in a study across 17 institutions. PROs were collected pre-operatively in 3 studies, post-operatively in 10, and at unspecified times in 4. The most commonly reported implementation outcomes were fidelity (12) and feasibility (11). Less than half of studies analyzed nonrespondents. All studies concluded that collection of PROMs was successful based on outcomes measured.

Conclusions:

The identified studies suggest that implementation metrics including minimum standards of collection pre- and postintervention, reporting for response rates in the context of patient eligibility and analysis of respondents and nonrespondents, in addition to transparency regarding the resources utilized and cost, can facilitate adoption of PROMs in clinical care and accountability for surgical outcomes.
Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study)
Authors: Mora-López Laura , Ruiz-Edo Neus , Estrada-Ferrer Oscar , Piñana-Campón Maria Luisa , Labró-Ciurans Meritxell , Escuder-Perez Jordi , Sales-Mallafré Ricard , Rebasa-Cladera Pere , Navarro-Soto Salvador , Serra-Aracil Xavier
Published: June 2021

Objective:

Mild AD can be treated safely and effectively on an outpatient basis without antibiotics.

Summary of Background Data:

In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective.

Methods:

A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.

The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.

The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms.

Results:

Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18).

Conclusions:

Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment.

Trial registration:

ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75)
The Effect of Electrical Stimulation Therapy With Pelvic Floor Muscle Exercise on Stress Urinary Incontinence in Middle-Aged Women
Authors: Lim Heeyoung , Kang Jung A. , Park Hyojung
Published: June 2021

PURPOSE:

The purpose of this study was to evaluate the effects of combined pelvic floor muscle exercises (PFMEs) and a novel electrical stimulation (ES) device versus PFMEs alone on lower urinary tract symptoms, urinary incontinence–related quality of life, and pelvic floor muscle contractions (PFMCs).

DESIGN:

Nonrandomized comparison cohort study.

SUBJECTS AND SETTING:

The sample comprised 54 community-dwelling middle-aged women with stress urinary incontinence recruited from churches and cultural centers in Gyeonggi Province, South Korea. Comparisons of demographic and pertinent clinical characteristics revealed no significant differences between the experimental and comparison groups.

METHODS:

Participants allocated to the combined intervention group (n = 27) performed self-exercises of the pelvic floor muscles 3 times a day under weekly telephone coaching, and they used the ES device twice daily for 8 weeks. Participants in the comparison group (n = 27) received the PFMEs alone without telephone coaching. The 3 main outcomes including lower urinary tract symptoms, urinary incontinence–related quality of life, and PFMCs were measured using the Bristol Female Lower Urinary Tract Symptom instrument (BFLUTS), King's Health Questionnaire (KHQ), and a perineometer, respectively. Study outcomes were measured at baseline and at the end of the 8-week period.

RESULTS:

Participants in the experimental group achieved significantly greater reductions in lower urinary tract symptoms (t = −4.07, P < .001) and improvement in urinary incontinence–related quality of life (P = .006), peak PFMC pressure (P = .004), mean pelvic muscle contraction (PMC) pressure (P < .001), and duration of PFMCs (P < .001) when compared to participants undergoing PFMEs alone.

CONCLUSIONS:

Combined ES and pelvic floor exercise was more effective in reducing severity of lower urinary tract symptoms, enhancing health-related quality of life, and increasing PMC pressure in middle-aged women with stress urinary incontinence than PFMEs alone.
GPS collars have an apparent positive effect on the survival of a large carnivore
Authors: Milleret Cyril , Bischof Richard , Dupont Pierre , Brøseth Henrik , Odden John , Mattisson Jenny
Published: June 2021

Are instrumented animals representative of the population, given the potential bias caused by selective sampling and the influence of capture, handling and wearing bio-loggers? The answer is elusive owing to the challenges of obtaining comparable data from individuals with and without bio-loggers. Using non-invasive genetic data of a large carnivore, the wolverine (Gulo gulo) in Scandinavia, and an open-population spatial capture–recapture model, we found a 16 (credible interval: 4–30) percentage points lower mortality probability for GPS-collared individuals compared with individuals without GPS collars. While the risk of dying from legal culling was comparable for collared and non-collared wolverines, the former experienced lower probability of mortality due to causes other than legal culling. The aforementioned effect was pronounced despite a potentially lower age—and therefore likely higher natural mortality—of collared individuals. Reports of positive effects of bio-loggers on the survival of individuals are uncommon and we argue that GPS collars could shield animals from poaching. Our results highlight the challenges of drawing population-level inferences for populations subjected to poaching when using data from instrumented individuals.
The confounding effects of sub-thermoneutral housing temperatures on aerobic exercise-induced adaptations in mouse subcutaneous white adipose tissue
Authors: McKie Greg L. , Wright David C.
Published: June 2021

Mice are the most commonly used model organism for human biology, and failure to acknowledge fundamental differences in thermal biology between these species has confounded the study of adipose tissue metabolism in mice and its translational relevance to humans. Here, using exercise biochemistry as an example, we highlight the subtle yet detrimental effects sub-thermoneutral housing temperatures can have on the study of adipose tissue metabolism in mice. We encourage academics and publishers to consider ambient housing temperature as a key determinant in the methodological conception and reporting of all research on rodent white adipose tissue metabolism.
The earliest Asian bats (Mammalia: Chiroptera) address major gaps in bat evolution
Authors: Jones Matthew F. , Li Qiang , Ni Xijun , Beard K. Christopher
Published: June 2021

Bats dispersed widely after evolving the capacity for powered flight, and fossil bats are known from the early Eocene of most continents. Until now, however, bats have been conspicuously absent from the early Eocene of mainland Asia. Here, we report two teeth from the Junggar Basin of northern Xinjiang, China belonging to the first known early Eocene bats from Asia, representing arguably the most plesiomorphic bat molars currently recognized. These teeth combine certain bat synapomorphies with primitive traits found in other placental mammals, thereby potentially illuminating dental evolution among stem bats. The Junggar Basin teeth suggest that the dentition of the stem chiropteran family Onychonycteridae is surprisingly derived, although their postcranial anatomy is more primitive than that of any other Eocene bats. Additional comparisons with stem bat families Icaronycteridae and Archaeonycteridae fail to identify unambiguous synapomorphies for the latter taxa, raising the possibility that neither is monophyletic as currently recognized. The presence of highly plesiomorphic bats in the early Eocene of central Asia suggests that this region was an important locus for the earliest, transitional phases of bat evolution, as has been demonstrated for other placental mammal orders including Lagomorpha and Rodentia.