bluuebunny/crossref_metadata_2025 huggingface dataset:
Characterization of magneto-convection in sunspots
Authors: Schmassmann M. , Rempel M. , Bello González N. , Schlichenmaier R. , Jurčák J.
Published: September 2021

Context. Observations have shown that in stable sunspots, the umbral boundary is outlined by a critical value of the vertical magnetic field component. However, the nature of the distinct magnetoconvection regimes in the umbra and penumbra is still unclear.

Aims. We analyse a sunspot simulation in an effort to understand the origin of the convective instabilities giving rise to the penumbral and umbral distinct regimes.

Methods. We applied the criterion from Gough & Tayler (1966, MNRAS, 133, 85), accounting for the stabilising effect of the vertical magnetic field, to investigate the convective instabilities in a MURaM sunspot simulation.

Results. We find: (1) a highly unstable shallow layer right beneath the surface extending all over the simulation box in which convection is triggered by radiative cooling in the photosphere; (2) a deep umbral core (beneath −5 Mm) stabilised against overturning convection that underlies a region with stable background values permeated by slender instabilities coupled to umbral dots; (3) filamentary instabilities below the penumbra nearly parallel to the surface and undulating instabilities coupled to the penumbra which originate in the deep layers. These deep-rooted instabilities result in the vigorous magneto-convection regime characteristic of the penumbra; (4) convective downdrafts in the granulation, penumbra, and umbra develop at about 2 km s−1, 1 km s−1, and 0.1 km s−1, respectively, indicating that the granular regime of convection is more vigorous than the penumbra convection regime, which, in turn, is more vigorous than the close-to-steady umbra; (5) the GT criterion outlines both the sunspot magnetopause and peripatopause, highlighting the tripartite nature of the sub-photospheric layers of magnetohydrodynamic (MHD) sunspot models; and, finally, (6) the Jurčák criterion is the photospheric counterpart of the GT criterion in deep layers.

Conclusions. The GT criterion as a diagnostic tool reveals the tripartite nature of sunspot structure with distinct regimes of magneto-convection in the umbra, penumbra, and granulation operating in realistic MHD simulations.
The Energy Consumption and CO2 emission impacts of Fuel and Electric Vehicles in China
Authors: Zheng Zhiqiang , Yang Ruoxi , Yicheng Hu
Published: September 2021

Vehicle electrification has been seriously considered as an industrial revolution to achieve sustainable transportation in China. With the development of the electric system, electric vehicles and railway systems are utilizing and generalizing. To accurately and adequately evaluate the energy consumption and CO2 emission effects of fuel and electric vehicles, this study focuses on these two kinds of vehicles, including buses and cars, and analyses their environmental impacts. Results show that electric vehicles consume less heat energy and release less CO2 emission than fuel vehicles do at the same distance. Public vehicles consume much less heat energy than private cars no matter which kind of fuel they use. In addition, the CO2 emission of fuel cars is larger than that of fuel buses. Moreover, electric energy is cheaper than gasoline and diesel. Therefore, the electric power will benefit the environment and society. The power should be recommended to substitute oil in the future. Although electric vehicles still have some limitations, such as prolonging the life of batteries, developing new energy, and green energy can guarantee energy security and benefit the environment and reduce the emission of CO2.
The Development of Si Anode Materials by Nanotechnology for Lithium-ion Battery
Authors: He Minghao , Li Mingzhao , Sun Zeyu
Published: September 2021

Nowadays, lithium-ion batteries (LIBs) are applied in many fields for their high energy density, low cost, and long cycle life, highly appreciated in a commercial application. Anode materials, a vital factor contributing to high specific capacity, have caught great attention in next-generation LIBs development. Silicon (Si) has been generally considered one of the best substitutes for the commercial carbon-based anodes of lithium-ion batteries due to its extremely high theoretical capacity, excellent charge-discharge performance, and low cost compared with other anode materials. In this review, various silicon-based materials, including nanostructured silicon and silicon composite materials, are summarized, and both advantages and challenges are analyzed. The article emphasizes the remarkable electrochemical characteristics and significant improvement of battery performance by applying nanostructure and silicon composites conjugates. Besides, the challenges and outlook on the nanostructure design of Si and silicon composites are presented.
The High-performance Separators in the Power Lithiumi-on Batteries
Authors: Fang Haoyu , Wang Ruixu , Yan Tongzhao , Yan Yiyang
Published: September 2021

In order to tackle different challenges related to the conventional energy consumptions in the near future, people need to dig more into the different types of green new energies, and the use of lithium-ion battery plays a very important role. It is necessary to enhance the performance of lithium-ion batteries via the improvement of separators. Lithium-ion batteries are now widely used in the electrical vehicles industries for their high power, long life circle, small weight and volume, large operating temperature range, and no memory effects. Separators are one of the important components of lithium-ion batteries since they can isolate the electrodes and prevent electrical short-circuits. The separator is a key element in all lithium-ion battery systems since it allows the control over the movement of ions between the anode and the cathode during the charge and discharge processes. Nowadays, to meet the safety demands of batteries, thermo-tolerant separators have become increasingly important for battery design and performances. As a result, some potential developments of the separators such as the inorganic coating and heat-resisting polymer methods are explained in this article. At the same time, the developments of those methods will also be discussed.
Corporate Social Responsibility and Idiosyncratic Risk The impact of CSR on the idiosyncratic risk of Chinese enterprises
Authors: Hu Yang , Shen Jiaxin , Chen Ruolin
Published: September 2021

This paper investigates the impact of corporate social responsibility on the idiosyncratic risk of enterprises. We find that corporate social responsibility is negatively associated with the idiosyncratic risk of enterprises. This association is robust to a series of robustness checks, including the use of alternative indicators, exclusion of the effect of multicollinearity, and the addition of missing variables to address endogeneity concerns. Further analyses show that the impact of corporate social responsibility on idiosyncratic risk is more significant in state-owned enterprises, firms with poor corporate governance or low growth. Our findings support the notion that corporate social responsibility appears to improve corporate performance.
The Application of Green Ecological Concept in the Architectural Design of Kindergartens in Coastal Cities of Korea - Busan as an Example
Authors: ShuWen Zhao , HuiMin Yang , Chool-Soo Kim
Published: September 2021

Korea has accelerated its economic development with advanced science and technology and has been ranked among the developed countries. However, resource scarcity and environmental pollution problems in the country are becoming increasingly stressful, and energy conservation and environmental protection have become important issues in Korea. The development of green building design in most kindergarten buildings is lagging, and most kindergartens do not have the green design. In this paper, we take the representative green kindergarten buildings in Korea and Japan as examples and explore and study the green ecological design of kindergarten buildings in Busan, a city surrounded by the sea on three sides of Korea. This paper proposes improvement strategies and gives guidance for the future design of kindergartens in coastal areas.
The Pathology of Poliomyelitis and the Vaccines and Nonvaccine Therapy
Authors: Chen Yushuo , Yue Tianrui , Zhang Zixiao
Published: September 2021

Poliomyelitis is an exclusively human disease that mainly affects children. Clinical features of poliomyelitis can be varied, from mild illness to the most severe paralysis, and the factor why poliomyelitis has different performances in individuals has been proved strongly correlated with membrane protein CD155. The nervous system shows a special protecting phenomenon against the invasion of poliovirus, and the mechanism is not very clear at present. Vaccines are the main means of preventing and controlling polio, and many different vaccines have been invented in the process of fighting polio. Inactivated polio vaccine (IPV) and oral polio vaccine (OPV) are the two main vaccines. IPV is known for its safety while OPV is widely used in developing countries because of its relatively low cost. This usage also leads to some side effects: vaccine-associated paralytic polio (VAPP) and vaccine-derived poliovirus (VDPV). Now, for polio eradication, the elimination of these two diseases has become particularly important. Thus, a new type of vaccine was created: sequential IPV-OPV with the safety of IPV and the low cost of OPV. This paper will talk about the different polio vaccines and their effects. An enormous difference between people who have gotten the vaccine and people who have not got the vaccine. Comparing the two kinds of people, people who get normal poliovirus, and people who get poliovirus after taking a vaccine, known as VAPP (vaccine-associated paralytic poliomyelitis), the former cannot get full recovery whole life and the latter has a very low possibility. In conclusion, people should take vaccines if it is affordable for them.
Three Typical Mental Disorders Associated With Behavioral Genetics And Environment
Authors: Hu Dongbin , Yang Jiewen , Zhang Jiankai
Published: September 2021

The purpose of the paper is to review the studies on family and identify the major factor contribute to these psychiatric problems. The basic psychiatric problem was range from bipolar disorder to antisocial personality disorder with the addition of reading disability. In the study of using the principle of animal behavior to research three different types of the psychiatric problem were being used to find out the influence of genetic and environment on both the history and current condition of the family and the impact on people’s future behavior with the experiment of how family study and twin study. This is a common psychiatric disease among current society due to the heavy pressure around people after reviewing different types of articles related to this psychiatric problem. The study was based on several datasets from the previous study, including 3 family studies and 6 twin studies with several different types of DSM questionnaires and interview information from thousands of twins with various in the category. With an analysis of all the statistical information, we conclude that the psychiatric problem is closely related. Both genetic and environmental are differentiated in the percentage of effect to the cause of the related problem.
The Comparison and Contrast on NAFLD between the East and the West: Metabolic Mechanism, Dietary Habits, and Policies
Authors: Guo Mingshan , Pan Qianyu , Shi Xiaojin
Published: September 2021

As non-alcoholic fatty liver disease (NAFLD) is becoming prevailing in both western and eastern countries, it affects people’s liver health and causing more severe diseases such as cancer, cardiovascular diseases, and type II diabetes worldwide. In this case, exploring NAFLD itself further and studying the difference between western and eastern countries from various perspectives is important for decreasing NAFLD cases. In this article, we aimed to investigate the metabolic mechanism of NAFLD, how the difference in dietary habits influenced the incidence of NAFLD worldwide, and the similarities and disparities between NAFLD policies from the East and those from the West. To reach this goal, we reviewed literature in English and Chinese that discussed NAFLD and non-alcoholic steatohepatitis (NASH) and visited official websites related to liver health. As a result, we concluded that most of the drugs designed based on fatty acid sources and metabolism had deficiencies, and lifestyle change was the best treatment. Western countries consume more meat, fewer vegetables, and a relatively similar number of fruits as eastern countries. The East and the West have relatively similar incidences of NAFLD. The high consumption of olive oil, vegetables, fruits, and whole grains and a low intake of meat in the Mediterranean diet led to a lower incidence of NAFLD in the Mediterranean area than in other places. There was overall a lack of policies on NAFLD. Still, while exploring the ones we currently had, there were some agreements and disagreements on NAFLD policies about lifestyle, diagnosis, treatment, research, organization, social problems, patient-centered care, and coalition between western and eastern countries. There were also diverse suggestions and different potential suggestions from these perspectives between the East and the West.
Veränderungen des Alveolarknochens nach Gaumennahterweiterung
und Therapie mit festsitzenden Apparaturen
Authors: Jung Britta A.
Published: September 2021

Material und Methoden

Im Rahmen einer retrospektiven Kohortenstudie wurden die DVT-Datensätze
von 45 Patienten (durchschnittliches Alter: 13,01 Jahre) mit klassischer
Gaumennahterweiterung und Edgewise-Therapie analysiert. Die Studie untersuchte
die Fragestellung, ob die Variablen Patientenalter, Expansionsweite,
Behandlungsdauer sowie die initiale Knochendicke Einfluss auf die bukkale
Knochendicke nach Therapie haben. Es wurden die Null-Hypothesen untersucht: (a)
es gibt keine Unterschiede zwischen der Knochendicke und anatomischen Defekten
im Bereich des bukkalen Alveolarknochens vor und nach der Therapie, (b) die
Dicken des bukkalen Alveolarknochens und anatomischen Defekte korrelieren nicht
mit dem Alter der Patienten, der Expansionsmenge, dem Behandlungszeitpunkt und
der initialen Knochendicke. Es wurden bei allen Patienten DVTs vor der
Behandlung (T1) und nach der Behandlung (T2) ausgewertet.
A 5,000-year vegetation and fire history for
tierra firme
forests in the Medio Putumayo-Algodón watersheds, northeastern Peru
Authors: Piperno Dolores R. , McMichael Crystal H. , Pitman Nigel C. A. , Andino Juan Ernesto Guevara , Ríos Paredes Marcos , Heijink Britte M. , Torres-Montenegro Luis A.
Published: September 2021

Significance

The extent to which pre-Columbian societies in Amazonia occupied and significantly altered the
tierra firme
(nonflooded, nonriverine) forest environment is an enduring question and the subject of a current debate. Our research addresses these issues in
tierra firme
forests of northeastern Peru. We present phytolith and charcoal data indicating the forests were not cleared, farmed, or otherwise significantly altered in prehistory. Frequencies of hyperdominant palm species did not increase through time, indicating prehistoric human exploitation contributed little to the species’ disproportionate abundance in the modern flora. Our data indicate that forest resurgence and fire decrease upon the tragic consequences of European contact were not so widespread as to have been principal contributors to the onset of the “Little Ice Age.”
Predicting voice choice in symmetrical voice languages
Authors: Riesberg Sonja , Bardají i Farré Maria , Malcher Kurt , Himmelmann Nikolaus P.
Published: September 2021

Western Austronesian symmetrical voice languages exhibit at least two basic transitive constructions. This paper investigates what factors influence speakers’ choice of one voice over another in natural spoken discourse. It provides a thorough assessment of all factors that have been proposed to be relevant for voice choice in the literature on symmetrical voice systems. Using the Indonesian language Totoli as a case study, we show that unlike in languages with asymmetrical voice alternations, argument-related properties such as topicality, activation state, animacy, etc. do not play a major role in voice choice in symmetrical voice languages. We argue that for symmetrical voice alternations other factor groups are relevant than for asymmetrical voice alternations and that the clear structural differences between the two alternation types are mirrored in functional differences.
Biomechanical responses to landing strategies of female artistic gymnasts
Authors: Straker Rebecca , Exell Timothy A. , Farana Roman , Hamill Joseph , Irwin Gareth
Published: September 2021

Inconsistencies between sexes in the landing criteria provided by the international gymnastics governing body (FIG) may predispose female gymnasts to lower extremity injury. This study aimed to investigate lower extremity biomechanics when performing the male and female landing strategy. Seven collegiate, female gymnasts (age: 20.5 ± 1.2 years, height: 1.64 ± 0.06 m, mass: 60.4 ± 10.2 kg) performed drop landings using the prescribed women's and men's landing strategy. Kinematic and kinetic data from 10 trials of each landing strategy were collected. Differences between landing strategy at individual and group level for key injury risk variables of the lower limb were explored. Group differences (p ≤ .05) were reported in the sagittal range of motion (ROM) at the knees and hips, with the men's landing strategy eliciting a larger ROM decelerating the body upon impact. Large inter and intra‐individual variation was apparent with different movement responses shown across individuals and demonstrating degeneracy as gymnasts satisfied the overall landing objective. These results indicate an individually favoured landing strategy to fulfil the informational constraints and hence supporting the use of a single‐subject design. The current study emphasises the potential injury risk associated with the different informational constraints placed on females’ landing strategy by the FIG, whilst recognising the individual gymnasts’ task response.

Highlights

An increase in the range of motion at the knee and hip may support the recommendation of the men's landing style.

Gymnasts appear to utilise individual landing strategies to complete the landing objective, supporting the use of a single‐subject design.
Genomic organization of the autonomous regulatory domain of eyeless locus in Drosophila melanogaster
Authors: Verma Shreekant , Pathak Rashmi U , Mishra Rakesh K
Published: September 2021

In Drosophila, expression of eyeless (ey) gene is restricted to the developing eyes and central nervous system. However, the flanking genes, myoglianin (myo), and bent (bt) have different temporal and spatial expression patterns as compared to the ey. How distinct regulation of ey is maintained is mostly unknown. Earlier, we have identified a boundary element intervening myo and ey genes (ME boundary) that prevents the crosstalk between the cis-regulatory elements of myo and ey genes. In the present study, we further searched for the cis-elements that define the domain of ey and maintain its expression pattern. We identify another boundary element between ey and bt, the EB boundary. The EB boundary separates the regulatory landscapes of ey and bt genes. The two boundaries, ME and EB, show a long-range interaction as well as interact with the nuclear architecture. This suggests functional autonomy of the ey locus and its insulation from differentially regulated flanking regions. We also identify a new Polycomb Response Element, the ey-PRE, within the ey domain. The expression state of the ey gene, once established during early development is likely to be maintained with the help of ey-PRE. Our study proposes a general regulatory mechanism by which a gene can be maintained in a functionally independent chromatin domain in gene-rich euchromatin.
Objectively Measured Patterns of Daily Physical Activity and Phenotypic Frailty
Authors: Wanigatunga Amal A , Cai Yurun , Urbanek Jacek K , Mitchell Christine M , Roth David L , Miller Edgar R , Michos Erin D , Juraschek Stephen P , Walston Jeremy , Xue Qian-Li , Appel Lawrence J , Schrack Jennifer A
Published: September 2021

Background

Self-reported low physical activity is a defining feature of phenotypic frailty but does not adequately capture physical activity performed throughout the day. This study examined associations between accelerometer-derived patterns of routine daily physical activity and frailty.

Methods

Wrist accelerometer and frailty data from 638 participants (mean age 77 [SD = 5.5] years; 44% women) were used to derive 5 physical activity metrics: active minutes/day, sedentary minutes/day, total activity counts/day, activity fragmentation (reciprocal of the average active bout length), and sedentary fragmentation (reciprocal of the average sedentary bout length). Robust, prefrail, and frail statuses were identified using the physical frailty phenotype defined as having 0, 1–2, or ≥3 of the following criterion: weight loss, exhaustion, slowness, self-reported low activity, and weakness. Frailty was collapsed into not frail (robust and prefrail) and frail, and each frailty criteria was dichotomized. Multiple logistic regression was used to model each accelerometer metric. Separate frailty criteria and interactions with age and sex were also examined.

Results

With higher amounts and intensity of daily activity (more active minutes, fewer sedentary minutes, higher activity counts) and lower activity fragmentation, the odds of frailty were lower compared to robust/prefrail states (p < .02 for all). For interactions, only an age by sedentary fragmentation interaction on the odds of frailty was observed (p = .01). For each separate criteria, accelerometer metrics were associated with odds of slowness, low activity, and weakness.

Conclusion

Less favorable patterns of objectively measured daily physical activity are associated with frailty and the components of slowness, low self-reported activity, and weakness.
Effects of Spinal Anesthesia in Geriatric Hip Fracture: A Propensity-Matched Study
Authors: Rodkey Daniel L. , Pezzi Alexandra , Hymes Robert
Published: September 2021

Objectives:

To identify whether anesthesia type is associated with surgical outcomes in geriatric patients undergoing operative treatment for a hip fracture.

Design:

Retrospective database review of prospectively collected data.

Patients:

Patients included in the American College of Surgeons National Surgical Quality Improvement Program database. All included patients were 65–89 years of age and had a hip fracture treated with internal fixation, arthroplasty, or intramedullary device. Patients were excluded for open, pathologic, stress-related, or periprosthetic hip fractures.

Intervention:

Use of spinal anesthesia (SA) or general anesthesia (GA).

Main Outcome Measurements:

Complications, mortality, and discharge destination.

Results:

A total of 23,649 cases met inclusion and exclusion criteria and were successfully matched using propensity score matching: 15,766 GA and 7883 SA. The odds of sustaining a complication were 21% lower in the SA group compared with those in the GA group (odds ratio SA/GA 0.791; 95% confidence interval, 0.747–0.838). The 30-day mortality rate was not correlated with SA or GA choice. Patients who underwent SA were significantly more likely to be discharged to home (odds ratio SA/GA 1.65; 95% confidence interval, 1.531–1.773).

Conclusions:

No mortality difference exists between patients undergoing SA and those undergoing GA for hip fracture surgery. For patients undergoing hip fracture surgery with SA, there is lower 30-day complication profile and higher discharge to home rate compared with those undergoing GA. Both anesthesia modalities may be acceptable.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
NurseVR
Authors: Girão Ana Lívia Araújo , dos Santos Maria Naila Oliveira , Chaves Edna Maria Camelo , Gomes Emiliana Bezerra , de Oliveira Sherida Karanini Paz , de Carvalho Rhanna Emanuela Fontenele Lima
Published: September 2021

The use of simulation for nursing education has several advantages. The present study aimed to develop and validate a serious virtual reality game for medication preparation and administration training. This is a methodological study in which a serious virtual reality game named NurseVR was developed and evaluated by teachers and students of a nursing course. In NurseVR, the player presents himself or herself in a simulated hospital environment to prepare and administer a medication. From then on, all the steps to be taken are the player's free choice according to what was learned in the classroom, making the game the closest to reality. High levels of positive agreement to statements concerning the validity of the game were found between students and teachers. The virtual immersion proposal was an innovative tool, and the validation results of the final version of NurseVR allow its use for nursing training.
Brazilian Mobile Phone Applications Related to Hand Hygiene and Their Applicability for Healthcare Professionals
Authors: Baggio Érica , Cadore Weis Margani , da Silva Santos Bruno , Mccabe Catherine , Neill Freda , Duarte Valim Marília
Published: September 2021

The objective of this study was to identify available mobile applications regarding education for hand hygiene and their applicability as a resource for nurses and other healthcare professionals. The aim was to assess the quality of the mobile apps for education on hand hygiene for health professionals. A review of mobile apps available from Apple App Store and Google Play Store in Brazil was conducted. The World Health Organization recommendations and the Mobile Application Rating Scale for evaluating quality were used. Six applications were selected, only three presented gamification elements incorporated into the learning method and only two of them—SureWash Pocket and Give Me 5—used the international recommendations to improve hand hygiene compliance in a more substantial and interactive way. The mean quality total score for the five rated apps was 3.41, indicating poor to acceptable quality. SureWash Pocket was the only application that reached Mobile Application Rating Scale ≥4 in all dimensions. These mobile applications can be used as complementary alternatives in addition to other available education strategies to improve the standards of hand hygiene and change the behavior of health professionals.
Accounting for Preinvasive Conditions in Analysis of Invasive Cancer Risk
Authors: Kim Jung In , Fine Jason P. , Sandler Dale P. , Zhao Shanshan
Published: September 2021

Background:

Preinvasive cancer conditions are often actively treated to minimize progression to life-threatening invasive cancers, but this creates challenges for analysis of invasive cancer risk. Conventional methods of treating preinvasive conditions as censoring events or targeting at the composite outcome could both lead to bias.

Methods:

We propose two solutions: one that provides exact estimates of risk based on distributional assumptions about progression, and one that provides risk bounds corresponding to extreme cases of no or complete progression. We compare these approaches through simulations and an analysis of the Sister Study data in the context of ductal carcinoma in situ (DCIS) and invasive breast cancer.

Results:

Simulations suggested important biases with conventional approaches, whereas the proposed estimate is consistent when progression parameters are correctly specified, and the risk bounds are robust in all scenarios. With Sister Study, the estimated lifetime risks for invasive breast cancer are 0.220 and 0.269 with DCIS censored or combined. Without detailed progression information, a sensitivity analysis suggested lifetime risk falls between the bounds of 0.214 and 0.269 across assumptions of 10%–95% of DCIS patients progressing to invasive cancer in an average of 1–10 years.

Conclusions:

When estimating invasive cancer risk while preinvasive conditions are actively treated, it is important to consider the implied assumptions and potential biases of conventional approaches. Although still not perfect, we proposed two practical solutions that provide improved understanding of the underlying mechanism of invasive cancer.
The Association Between Concussion History and Increased Symptom Severity Reporting Is Independent of Common Medical Comorbidities, Personality Factors, and Sleep Quality in Collegiate Athletes
Authors: Brett Benjamin L. , Nelson Lindsay D. , Meier Timothy B.
Published: September 2021

Objective:

We investigated the degree to which the association between history of concussion with psychological distress and general symptom severity is independent of several factors commonly associated with elevated symptom severity. We also examined whether symptom severity endorsement was associated with concussion injury specifically or response to injury in general.

Setting:

Academic medical center.

Participants:

Collegiate athletes (N = 106; age: M = 21.37 ± 1.69 years; 33 female) were enrolled on the basis of strict medical/psychiatric exclusion criteria.

Design:

Cross-sectional single-visit study. Comprehensive assessment, including semistructured interviews to retrospectively diagnose the number of previous concussions, was completed. Single-predictor and stepwise regression models were fit to examine the predictive value of prior concussion and orthopedic injuries on symptom severity, both individually and controlling for confounding factors.

Main Outcome Measures:

Psychological distress was operationalized as Brief Symptom Inventory-18 Global Severity Index (BSI-GSI) ratings; concussion-related symptom severity was measured using the Sport Concussion Assessment Tool.

Results:

Controlling for baseline factors associated with the symptom outcomes (agreeableness, neuroticism, negative emotionality, and sleep quality), concussion history was significantly associated with psychological distress (B = 1.25 [0.55]; P = .025, ΔR
2 = 0.034) and concussion-like symptom severity (B = 0.22 [0.08]; P = .005, ΔR
2 = 0.064) and accounted for a statistically significant amount of unique variance in symptom outcomes. Orthopedic injury history was not individually predictive of psychological distress (B = −0.06 [0.53]; P = .905) or general symptom severity (B = 0.06 [0.08]; P = .427) and did not explain the relationship between concussion history and symptom outcomes.

Conclusions:

Concussion history is associated with subtle elevations in symptom severity in collegiate-aged athletes; this relationship is independent of medical, lifestyle (ie, sleep), and personality factors. Furthermore, this relationship is associated with brain injury (ie, concussion) and is not a general response to injury history.
Adolescent and Parent Perceptions of the Impact of Concussion/mTBI on Family Functioning and Activity Levels in Recovery
Authors: Quatman-Yates Catherine C. , Miley Aimee E. , Morrison Paige , Hugentobler Jason , Wade Shari L. , Rhine Tara D. , Kurowski Brad G.
Published: September 2021

Objective:

To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery.

Setting:

Outpatient research setting.

Participants:

Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study.

Design:

Prospective ecological study with qualitative, semistructured interviews.

Main Measures:

Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures.

Results:

Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies.

Conclusions:

Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions.
Management of Pediatric Thoracic Empyema in the North Queensland Region of Australia and Impact of a Local Evidence-based Treatment Guideline
Authors: Gautam Anil , Wiseman Gregory , Legg Robert , Lindsay Daniel , Puvvadi Ramaa , Rathnamma Bhanu Mariyappa , Stalewski Harry , Norton Robert , White Andrew Vernon
Published: September 2021

Aim:

The North Queensland region of Australia has a high incidence of pediatric thoracic empyema (pTE). We describe the management of empyema at the Townsville University Hospital which is the regional referral center for these children. The impact of a newly developed institutional guideline is also discussed.

Methods:

This retrospective audit included children under the age of 16 years treated for empyema between 1 Jan 2007 and 31 December 2018. Demographic and management-related variables were correlated to outcomes. A local guideline was introduced at the beginning of 2017 and patient outcomes characteristics pre, and post introduction of this guideline are compared.

Results:

There were 153 children with pTE (123 before and 30 after the introduction of a local guideline). Nonsurgical management was associated with a higher treatment failure rate. Median length of stay (LOS) was 11.8 (IQR 9.3–16) days. Longer hospital LOS was associated with younger age (r2 −0.16, P = 0.04), Aboriginal and/or Torres Strait (ATSI) ancestry (13.8 vs. 10.5 days, P = 0.002) and concomitant respiratory viral infections (14.4 vs. 10.9 days, P = 0.003). The introduction of local guideline was associated with significant decrease in the use of empirical chest CT scans (54.4% before vs. 6.7% after, P < 0.001) and duration of intravenous antibiotics (14 days before vs. 10 days after, P = 0.02). There was no significant change in the hospital LOS (12.1 days pre and 11.7 post, P = 0.8).

Conclusions:

Younger age, concomitant viral respiratory infections and ATSI ancestry were identified as potential risk factors for increase LOS. Hospital LOS following the adoption of an institutional guideline was unchanged. However, such a guideline may identify populations at risk for an unfavorable course and avoid unnecessary antibiotic treatment and radiation exposure.
A New Surgical Technique for Postoperative Trachomatous Trichiasis
Authors: Merbs Shannath L. , Talero Sandra L. , Tadesse Demissie , Sisay Alemayehu , Bayissasse Belay , Weaver Jerusha U. , Gower Emily W.
Published: September 2021

Introduction:

The World Health Organization has identified management of postoperative trichiasis (PTT) as one of the key remaining areas of focus needed to eliminate blinding trachoma as a public health problem. We developed the Bevel-Rotation Advancement Procedure (B-RAP) to treat individuals who need repeat trichiasis surgery.

Methods:

Scarring caused by trichiasis surgery can cause the eyelid to become thick and distorted, making repeat surgery more difficult. To minimize eyelid thickness following B-RAP, a beveled incision of the tarsus is made allowing a marginal rotation of the eyelash fragment. Dissection between the anterior and posterior lamellae above the beveled incision and removal of scar tissue allows the marginal rotation to be combined with a posterior lamellar advancement to treat severely scarred eyelids with PTT and eyelid contour abnormalities (ECAs).

Results:

Two surgeons performed B-RAP on 44 eyelids of 30 patients with PTT. The number of prior trachomatous trichiasis (TT) surgeries ranged from 2 to more than 4. At the 3–6 months postoperative visit, 37 eyelids (84%) had no recurrence of PTT. Three eyelids had central lashes touching; the remaining eyelids with recurrent PTT had nasal and temporal lashes touching. Fifteen eyelids (34%) had ECAs, but only 1 was severe.

Conclusions:

B-RAP was developed considering the altered eyelid anatomy found in the postsurgical eyelid with TT. Thinning of the eyelash fragment and removal of postoperative scar tissue improves the ability to advance and stabilize the eyelash fragment after external rotation. B-RAP shows promise as a procedure for improving outcomes of repeat trichiasis surgery.
Left Ventricular Assist Device as a Bridge to Recovery: Single Center Experience of Successful Device Explantation
Authors: Zhang Robert S. , Hanff Thomas C. , Peters Carli J. , Evans Peter T. , Marble Judy , Rame J. Eduardo , Atluri Pavan , Urgo Kimberly , Tanna Monique S. , Mazurek Jeremy A. , Acker Michael A. , Cevasco Marisa , Birati Edo Y. , Wald Joyce W.
Published: September 2021

Continuous-flow left ventricular assist devices (CF-LVAD) have been shown to enhance reverse remodeling and myocardial recovery in certain patients allowing for device removal. We sought to analyze the characteristics and describe outcomes of patients who underwent CF-LVAD explantation at a large academic center. We retrospectively identified all patients who underwent CF-LVAD explants due to recovery from 2006 to 2019. Patient baseline characteristics and data on pre- and postexplant evaluation were collected and analyzed. Of 421 patients who underwent CF-LVAD implantation, 13 underwent explantation (3.1%). Twelve HeartMate II and one HeartWare LVAD were explanted. All patients had nonischemic cardiomyopathy. Median time from heart failure diagnosis to LVAD implant was 12 months (interquartile range [IQR], 2–44) and the median time supported on LVAD was 22 months (IQR, 11–28). Two patients died within 30 days of explant. Three additional patients died during the follow-up period and all were noted to be nonadherent to medical therapy. After a mean follow-up duration of 5 years, overall survival was 52%. Mean pre-explant ejection fraction was 49%, which decreased at most recent follow-up to 32%. Mean pre-explant left ventricular internal diameter in diastole (LVIDD) was 4.37 cm and increased to 5.52 cm at most recent follow-up. Continuous-flow left ventricular assist device explantation is feasible and safe in select patients.
Use of apheresis in the age of new therapies for familial hypercholesterolaemia
Authors: Thompson Gilbert R.
Published: September 2021

Purpose of review

Lipoprotein apheresis has been first line therapy for homozygous familial hypercholesterolaemia (FH) and other severe and refractory forms of dyslpidaemia for over 40 years but the recent advent of novel and potent LDL-lowering compounds necessitates a reappraisal of its role.

Recent findings

During the past decade a substantial amount of evidence has accumulated describing the effect of LDL-lowering with apheresis and conventional drug therapy upon the cardiovascular outcomes associated with homozygous and statin-refractory heterozygous FH. This has necessitated re-defining the target levels of LDL cholesterol needed to arrest progression of atherosclerosis in these situations. At the same time, evidence has accrued regarding the pathogenicity of raised levels of lipoprotein (a) and the promising role of apheresis in mitigating the adverse effects of the latter. The latest advance in treatment has been the introduction of three classes of novel and potent LDL-lowering compounds in the shape of inhibitors of Propertin convertase subtilisin kexin 9 (PCSK9), microsomal triglyceride transfer protein and angiopoietin-like 3.

These recent developments raise the question of whether these compounds will be used as adjuvants to bolster lipoprotein apheresis in FH homozygotes or whether they will render it obsolete, as is already occurring with PCSK9 inhibitors in FH heterozygotes.
Indirect Effects of COVID on Oncology Patients
Authors: Lyvannak Sam , Sreynich Korb , Khauv Phara , Qaddoumi Ibrahim , Heng Sing , Camitta Bruce
Published: September 2021

The interaction of coronavirus disease-2019 (COVID-19) and chemotherapy may result in worse outcomes. However, there may be more indirect effects of COVID. We report 3 cases in which treatment was delayed because of COVID-related inability or reluctance to travel. Oncology programs should consider such indirect effects when devising treatments.
Data on Safety of Intravaginal Boric Acid Use in Pregnant and Nonpregnant Women: A Narrative Review
Authors: Mittelstaedt Rachel , Kretz Alyssa , Levine Michael , Handa Victoria L. , Ghanem Khalil G. , Sobel Jack D. , Powell Anna , Tuddenham Susan
Published: September 2021

Intravaginal boric acid (IBA) represents one of the only options available to treat azole-resistant vulvovaginal candidiasis (VVC) and is included as part of multiple national guidelines (including the United Kingdom and the United States) for the treatment of VVC or recurrent bacterial vaginosis. Novel products using IBA are under development for treatment and suppression of VVC and bacterial vaginosis. Use of over-the-counter or clinician-prescribed IBA in reproductive-aged women is already widespread and may increase further if drug resistance in VVC rises. However, IBA is not a Food and Drug Administration–approved drug, and safety data are sparse. Given these factors, it is important to understand the currently available data on the safety of IBA use. Herein, we set out to synthesize human and animal data (converting, where appropriate, dose and serum values to standard units to facilitate comparison) to answer 2 key questions: (1) What are the data on the safety of IBA use for women? and (2) What are the data on the safety of IBA use in pregnancy? We find that, despite gaps, available data suggest IBA use is safe, at least when used in doses commonly described in the literature as being prescribed by clinicians. Information on harms in pregnancy is limited, and data remain insufficient to change current guidelines, which recommend IBA avoidance in pregnancy.
Malignant Gonadal Germ Cell Tumors (Other Than Pure Germinoma) in Patients With Disorders of Sex Development
Authors: Segura Sheila E. , Young Robert H. , Oliva Esther , Ulbright Thomas M.
Published: September 2021

We describe 21 nonpure germinomatous gonadal germ cell tumors (9 with a germinoma component), all but 1 associated with gonadoblastoma, in patients with disorders of sex development who ranged from 7 to 36 years old (average, 20 y). Twenty patients were clinically described as phenotypic females with ambiguous genitalia/virilization and primary amenorrhea. The most common documented peripheral karyotype was 46,XY (10/12; 83%). Fifteen of 16 tumors with available clinicopathologic data were unilateral. They ranged from 7 to 30 cm (mean, 15.5 cm) and were solid and cystic with frequent necrosis and hemorrhage. Gonadoblastoma, in its classic (70%), dissecting (5%), or combined (25%) forms, was identified in all but 1. The malignant germ cell tumors were typically mixed except for 5 pure yolk sac tumors and 1 expansile gonadoblastoma with syncytiotrophoblast cells. When admixed, the most common component was yolk sac tumor (n=10), followed by germinoma (n=9), embryonal carcinoma (n=5), choriocarcinoma (n=4), immature teratoma (n=3), and teratoma (n=2). Typical morphologic patterns of yolk sac neoplasia, including reticular/microcystic, solid (including blastema-like), and endodermal sinus (Schiller-Duval bodies), were seen, as well as glandular (n=10) and hepatoid (n=6) differentiation, with cystically dilated glands and diffuse hepatoid morphology in 3 and 2 tumors, respectively. Two yolk sac tumors showed a sarcomatoid pattern. Somatic-type malignancies (alveolar rhabdomyosarcoma and low-grade spindle cell sarcoma, not otherwise specified) were identified in 1 case each. This is the first large series of germ cell tumors other than typical pure germinoma associated with gonadoblastoma. The high frequency of yolk sac tumor with glandular (especially cystic glandular) and hepatoid morphologies is noteworthy, and their presence should prompt further evaluation for an associated gonadoblastoma and possible disorder of sex development.
Prediction Model Performance With Different Imputation Strategies: A Simulation Study Using a North American ICU Registry
Authors: Steif Jonathan , Brant Rollin , Sreepada Rama Syamala , West Nicholas , Murthy Srinivas , Görges Matthias
Published: September 2021

OBJECTIVES:

To evaluate the performance of pragmatic imputation approaches when estimating model coefficients using datasets with varying degrees of data missingness.

DESIGN:

Performance in predicting observed mortality in a registry dataset was evaluated using simulations of two simple logistic regression models with age-specific criteria for abnormal vital signs (mentation, systolic blood pressure, respiratory rate, WBC count, heart rate, and temperature). Starting with a dataset with complete information, increasing degrees of biased missingness of WBC and mentation were introduced, depending on the values of temperature and systolic blood pressure, respectively. Missing data approaches evaluated included analysis of complete cases only, assuming missing data are normal, and multiple imputation by chained equations. Percent bias and root mean square error, in relation to parameter estimates obtained from the original data, were evaluated as performance indicators.

SETTING:

Data were obtained from the Virtual Pediatric Systems, LLC, database (Los Angeles, CA), which provides clinical markers and outcomes in prospectively collected records from 117 PICUs in the United States and Canada.

PATIENTS:

Children admitted to a participating PICU in 2017, for whom all required data were available.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Simulations demonstrated that multiple imputation by chained equations is an effective strategy and that even a naive implementation of multiple imputation by chained equations significantly outperforms traditional approaches: the root mean square error for model coefficients was lower using multiple imputation by chained equations in 90 of 99 of all simulations (91%) compared with discarding cases with missing data and lower in 97 of 99 (98%) compared with models assuming missing values are in the normal range. Assuming missing data to be abnormal was inferior to all other approaches.

CONCLUSIONS:

Analyses of large observational studies are likely to encounter the issue of missing data, which are likely not missing at random. Researchers should always consider multiple imputation by chained equations (or similar imputation approaches) when encountering even only small proportions of missing data in their work.