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Fournier gangrene (FG) is a necrotizing soft tissue infection (NSTI) of the perineum. Recent retrospective studies from quaternary centers suggest improved outcomes and a potentially less aggressive clinical course for FG than non-perineal NSTIs. However, comprehensive nationwide data remain limited.
Methods:
This retrospective cohort study analyzed the National Inpatient Sample (2016–2020) to compare outcomes between FG and non-perineal NSTIs. Adult patients undergoing surgical debridement with a diagnosis of FG or NSTI were identified using ICD-10 codes. Outcomes included in-hospital mortality, length of stay (LOS), hospital costs, and home discharge rates. Multivariable regression analyses adjusted for patient demographics, comorbidities, and hospital characteristics.
Results:
A total of 5,007 FG and 24,782 non-perineal NSTI patients were identified. Crude in-hospital mortality rates were 5.8% for FG and 5.4% for non-perineal NSTIs, with stable trends observed over five years. After adjustment, no significant difference in mortality was observed (adjusted odds ratio [aOR]: 1.04; 95% CI: 0.90–1.20). However, FG was associated with longer LOS (adjusted mean difference: 1.99 days; 95% CI: 1.53–2.46) and higher hospital costs ($37,809 higher; 95% CI: $29,540–$46,077). Home discharge rates were similar between groups (aOR: 0.97; 95% CI: 0.89–1.05).
Discussion:
Despite similar mortality rates, FG hospitalizations were associated with increased LOS and higher costs compared to non-perineal NSTIs. These findings may suggest potential nationwide disparities in FG care quality, particularly outside specialized referral centers. Further research is needed to understand if standardized care pathways tailored to FG may optimize management and reduce resource utilization.
Five discrete bismuth telluride compositions, characterised by high and variable degrees of Pb and Se substitutions, were observed at the Stall Lake VMS deposit in the Snow Lake area, Canada. The major cation substitutions are Pb (3.0 to 11.0 wt.%), Fe (0.2 to 1.4 wt.%), Cu (up to 0.9 wt.%) and Ag (up to 3.2 wt.%). The main anion substitution is Se (0.3 to 7.9 wt.%); S never exceeds 0.3 wt.%. These results were compared to a literature data compilation of all publicly available data for the pure bismuth tellurides tsumoite and tellurobismuthite, and the Pb-bearing rucklidgeite and kochkarite. On the basis of these new data and the literature compilation, a few generalisations about the substitutions in bismuth tellurides can be made. The major conclusion is that bismuth tellurides always contain at least some substitutional cations (Pb, Ag, Fe, Cu, Sb and Au), typically combining to ∼2 wt.% if Pb is excluded, and anions (mostly Se and some S, typically <1 wt.% combined). Another conclusion is that bismuth tellurides have highly variable compositions, which can be quite far from their theoretical ones, to the point of defining specific mineral varieties such as high-Pb tsumoite, low-Pb kochkarite, and high-Se rucklidgeite. Two high-Se bismuth telluride compositions were observed at Stall Lake (average Se ≈ 4.9 and ≈ 7.2 wt.%), which had never been documented before. This observation, in conjunction with the bismuth tellurides literature data, emphasises the high potential for both cation and anion substitutions in these minerals.
In 2022, highly pathogenic avian influenza (HPAI) A(H5N1) virus clade 2.3.4.4b became enzootic and caused mass mortality in Sandwich Tern Thalasseus sandvicensis and other seabird species across north-western Europe. We present data on the characteristics of the spread of the virus between and within breeding colonies and the number of dead adult Sandwich Terns recorded at breeding sites throughout north-western Europe. Within two months of the first reported mortalities, 20,531 adult Sandwich Terns were found dead, which is >17% of the total north-western European breeding population. This is probably an under-representation of total mortality, as many carcasses are likely to have gone unnoticed and unreported. Within affected colonies, almost all chicks died. After the peak of the outbreak, in a colony established by late breeders, 25.7% of tested adults showed immunity to HPAI subtype H5. Removal of carcasses was associated with lower levels of mortality at affected colonies. More research on the sources and modes of transmission, incubation times, effective containment, and immunity is urgently needed to combat this major threat for colonial seabirds.
Orthoamphibole, clinoamphibole and magnetite are common minerals in altered rocks associated spatially with Palaeoproterozoic volcanogenic massive sulfide (VMS) deposits in Colorado, USA and metamorphosed to the amphibolite facies. These altered rocks are dominated by the assemblage orthoamphibole (anthophyllite/gedrite)–cordierite–magnetite±gahnite±sulfides. Magnetite also occurs in granitoids, banded iron formations, quartz garnetite, and in metallic mineralisation consisting of semi-massive pyrite, pyrrhotite, chalcopyrite, and sphalerite with subordinate galena, gahnite and magnetite; amphibole also occurs in amphibolite. The precursor to the anthophyllite/gedrite–cordierite assemblages was probably the assemblage quartz–chlorite formed from hydrothermal ore-bearing fluids (~250° to 400°C) associated with the formation of metallic minerals in the massive sulfide deposits.
Element–element variation diagrams for amphibole, magnetite and ilmenite based on LA-ICP-MS data and Principal Component Analysis (PCA) for orthoamphiboles and magnetite show a broad range of compositions which are primarily dependent upon the nature of the host rock associated spatially with the deposits. Although discrimination plots of Al/(Zn+Ca) vs Cu/(Si+Ca) and Sn/Ga vs Al/Co for magnetite do not indicate a VMS origin, the concentration of Al+Mn together with Ti+V and Sn vs Ti support a hydrothermal rather than a magmatic origin for magnetite. Principal Component Analyses also show that magnetite and orthoamphibole in metamorphosed altered rocks and sulfide zones have distinctive eigenvalues that allow them to be used as prospective pathfinders for VMS deposits in Colorado. This, in conjunction with the contents of Zn and Al in magnetite, Zn and Pb in amphibole, ilmenite and magnetite, the Cu content of orthoamphibole and ilmenite, and possibly the Ga and Sn concentrations of magnetite constitute effective exploration vectors.
A high-grade ore sample from the Cu–Zn–Au Photo Lake volcanogenic massive sulfide deposit (Flin Flon–Snow Lake greenstone belt, Manitoba, Canada) contains a Bi–Ag sulfo-selenide with a composition situated approximately in the middle of the S–Se substitution range (Se ≈ 0.86 apfu and S ≈ 1.05 apfu). These new data, combined with a literature compilation of all publicly available matildite and bohdanowiczite compositional data, reveal a nearly complete range of S–Se substitution between these two minerals, with only the section between BiAgSe0.78S1.18 and BiAgSe0.25S1.75 – about a quarter of the complete S–Se range – not yet documented. These observations suggest that a complete solid-solution series between matildite and bohdanowiczite, as previously suspected, might exist and in a manner similar to the galena–clausthalite complete solid-solution series.
Response to lithium in patients with bipolar disorder is associated with clinical and transdiagnostic genetic factors. The predictive combination of these variables might help clinicians better predict which patients will respond to lithium treatment.
Aims
To use a combination of transdiagnostic genetic and clinical factors to predict lithium response in patients with bipolar disorder.
Method
This study utilised genetic and clinical data (n = 1034) collected as part of the International Consortium on Lithium Genetics (ConLi+Gen) project. Polygenic risk scores (PRS) were computed for schizophrenia and major depressive disorder, and then combined with clinical variables using a cross-validated machine-learning regression approach. Unimodal, multimodal and genetically stratified models were trained and validated using ridge, elastic net and random forest regression on 692 patients with bipolar disorder from ten study sites using leave-site-out cross-validation. All models were then tested on an independent test set of 342 patients. The best performing models were then tested in a classification framework.
Results
The best performing linear model explained 5.1% (P = 0.0001) of variance in lithium response and was composed of clinical variables, PRS variables and interaction terms between them. The best performing non-linear model used only clinical variables and explained 8.1% (P = 0.0001) of variance in lithium response. A priori genomic stratification improved non-linear model performance to 13.7% (P = 0.0001) and improved the binary classification of lithium response. This model stratified patients based on their meta-polygenic loadings for major depressive disorder and schizophrenia and was then trained using clinical data.
Conclusions
Using PRS to first stratify patients genetically and then train machine-learning models with clinical predictors led to large improvements in lithium response prediction. When used with other PRS and biological markers in the future this approach may help inform which patients are most likely to respond to lithium treatment.
Background: COVID-19 in hospitalized patients may be the result of community acquisition or in-hospital transmission. Molecular epidemiology can help confirm hospital COVID-19 transmission and outbreaks. We describe large COVID-19 clusters identified in our hospital and apply molecular epidemiology to confirm outbreaks. Methods: The University of Iowa Hospitals and Clinics is an 811-bed academic medical center. We identified large clusters involving patients with hospital onset COVID-19 detected during March–October 2020. Large clusters included ≥10 individuals (patients, visitors, or HCWs) with a laboratory confirmed COVID-19 diagnosis (RT-PCR) and an epidemiologic link. Epidemiologic links were defined as hospitalization, work, or visiting in the same unit during the incubation or infectious period for the index case. Hospital onset was defined as a COVID-19 diagnosis ≥14 days from admission date. Admission screening has been conducted since May 2020 and serial testing (every 5 days) since July 2020. Nasopharyngeal swab specimens were retrieved for viral whole-genome sequencing (WGS). Cluster patients with a pairwise difference in ≤5 mutations were considered part of an outbreak. WGS was performed using Oxford Nanopore Technology and protocols from the ARTIC network. Results: We identified 2 large clusters involving patients with hospital-onset COVID-19. Cluster 1: 2 hospital-onset cases were identified in a medical-surgical unit in June 2020. Source and contact tracing revealed 4 additional patients, 1 visitor, and 13 employees with COVID-19. Median age for patients was 62 (range, 38–79), and all were male. In total, 17 samples (6 patients, 1 visitor, and 10 HCWs) were available for WGS. Cluster 2: A hospital-onset case was identified via serial testing in a non–COVID-19 intensive care unit in September 2020. Source investigation, contact tracing, and serial testing revealed 3 additional patients, and 8 HCWs. One HCW also had a community exposure. Patient median age was 60 years (range, 48–68) and all were male. In total, 11 samples (4 patients and 7 HCWs) were sequenced. Using WGS, cluster 1 was confirmed to be an outbreak: WGS showed 0–5 mutations in between samples. Cluster 2 was also an outbreak: WGS showed less diversity (0–3 mutations) and ruled out the HCW with a community exposure (20 mutations of difference). Conclusion: Whole-genome sequencing confirmed the outbreaks identified using classic epidemiologic methods. Serial testing allowed for early outbreak detection. Early outbreak detection and implementation of control measures may decrease outbreak size and genetic diversity.
Background: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 RNA can be detected by real-time reverse-transcription polymerase chain reaction (RT-PCR) for several weeks after infection. Discerning persistent RT-PCR positivity versus reinfection is challenging and the frequency of COVID-19 reinfections is unknown. We aimed to determine the frequency of clinically suspected reinfection in our center and confirm reinfection using viral whole-genome sequencing (WGS). Methods: The University of Iowa Hospitals and Clinics (UIHC) is an 811-bed academic medical center. Patients with respiratory complaints undergo COVID-19 RT-PCR using nasopharyngeal swabs. The RT-PCR (TaqPath COVID-19 Combo kit) uses 3 targets (ORF1ab, S gene, and N gene). We identified patients with previous laboratory-confirmed COVID-19 who sought care for new respiratory complaints and underwent a repeated SARS-CoV-2 test at least 45 days from their first positive test. We then identified patients with median RT-PCR cycle threshold (Ct) values. Results: During the study period, 13,603 patients had a SARS-CoV-2– positive RT-PCR. Of these, 296 (2.2%) had a clinical visit for new onset of symptoms and a repeated RT-PCR assay >45 days from the first test. Moreover, 29 patients (9.8%) had a positive RT-PCR assay in the repeated testing. Ct values were available for samples from 25 patients; 7 (28%) had Ct values. Conclusions: In patients with a recent history of COVID-19 infection, repeated testing for respiratory symptoms was infrequent. Some had a SARS-CoV-2–positive RT-PCR assay on repeated testing, but only 1 in 4 had Ct values suggestive of a reinfection. We confirmed 1 case of reinfection using WGS.
The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.
We report an idealized numerical study of a melting and freezing solid adjacent to a turbulent, buoyancy-affected shear flow, in order to improve our understanding of topography generation by phase changes in the environment. We use the phase-field method to dynamically couple the heat equation for the solid with the Navier–Stokes equations for the fluid. We investigate the evolution of an initially flat and horizontal solid boundary overlying a pressure-driven turbulent flow. We assume a linear equation of state for the fluid and change the sign of the thermal expansion coefficient, such that the background density stratification is either stable, neutral or unstable. We find that channels aligned with the direction of the mean flow are generated spontaneously by phase changes at the fluid–solid interface. Streamwise vortices in the fluid, the interface topography and the temperature field in the solid influence each other and adjust until a statistical steady state is obtained. The crest-to-trough amplitude of the channels is larger than approximately 10$\delta _{\nu }$ in all cases, with $\delta _{\nu }$ the viscous length scale, but is much larger and more persistent for an unstable stratification than for a neutral or stable stratification. This happens because a stable stratification makes the cool melt fluid buoyant such that it shields the channel from further melting, whereas an unstable stratification makes the cool melt fluid sink, inducing further melting by rising hot plumes. The statistics of flow velocities and melt rates are investigated, and we find that channels and keels emerging in our simulations do not significantly change the mean drag coefficient.
Individuals diagnosed with borderline personality disorder (BPD) often describe their lives as stressful and unpredictable. However, it is unclear whether the adversity faced by those with BPD is a product of stress reactivity or stress generation. Here, we examined the dynamic, prospective associations between BPD and stressful life events over 3 years. Given the heterogeneity present in BPD, we sought to understand which empirically derived dimensions of this heterogeneous disorder explain stress reactivity v. stress generation.
Methods
Participants included 355 individuals diagnosed with BPD and followed longitudinally at three annual assessments. Auto-regressive cross-lagged panel models were used to examine prospective associations between stressful life events and three latent dimensions implicated in BPD: negative affect, disinhibition, and antagonism.
Results
Antagonism and disinhibition, but not negative affect, prospectively predicted dependent stressful life events (events the individual may have some role in). Evidence for decompensation under stress was more tenuous, with independent stressful life events (those presumably outside the individual's control) predicting increases in negative affect.
Conclusions
Our longitudinal study of a well-characterized clinical sample found more evidence for stress generation than for stress-induced decompensation in BPD. Stress generation in BPD is driven by externalizing dimensions: antagonism and disinhibition. These results highlight the utility of empirically derived dimensions for parsing heterogeneity present in BPD, leading to improvements in diagnostic evaluation, clinical prediction, and individualized approaches to treatment planning.
This paper provides an up-to-date review of the problems related to the generation, detection and mitigation of strong electromagnetic pulses created in the interaction of high-power, high-energy laser pulses with different types of solid targets. It includes new experimental data obtained independently at several international laboratories. The mechanisms of electromagnetic field generation are analyzed and considered as a function of the intensity and the spectral range of emissions they produce. The major emphasis is put on the GHz frequency domain, which is the most damaging for electronics and may have important applications. The physics of electromagnetic emissions in other spectral domains, in particular THz and MHz, is also discussed. The theoretical models and numerical simulations are compared with the results of experimental measurements, with special attention to the methodology of measurements and complementary diagnostics. Understanding the underlying physical processes is the basis for developing techniques to mitigate the electromagnetic threat and to harness electromagnetic emissions, which may have promising applications.
The aim of the article is to provide a characterization of the Haagerup property for locally compact, second countable groups in terms of actions on $\unicode[STIX]{x1D70E}$-finite measure spaces. It is inspired by the very first definition of amenability, namely the existence of an invariant mean on the algebra of essentially bounded, measurable functions on the group.
The aviation industry relies on accurate models. These models are used to predict an aircraft system’s outputs, and thus allow an understanding of the parameters involved, which could lead to system improvements. This study focuses on the engine modelling of an aircraft, and on its experimental validation using the Cessna Citation X Research Aircraft Simulator designed by CAE Inc., equipped with a level D Flight Dynamics toolbox. Level D is the highest rank attributed by the Federal Aviation Administration FAA certification authorities for flight dynamics. The proposed model aims to predict the thrust and the fuel consumption for various altitudes, Mach numbers and throttle lever angles (TLA). Different generic static models, which correspond to their steady state, from the literature, were used in this study; however, most of them were validated under restricted hypotheses. An optimisation algorithm was used in order to tune the static model parameters with the set of identification flight test data. Another set of data was then used in order to validate the identified model. Furthermore, a dynamic model corresponding to the transient operations was identified. TLA steps, impulses and ramp perturbations were performed in order to identify the system response, and to validate system dynamic model with other flight tests than the identification tests.
Recent therapeutic advances in the management of multiple sclerosis (MS) have raised questions about the selection of appropriate patient candidates for various treatments and, if the plan is to move from one treatment to another, the appropriate sequencing of these therapies. The selected approach should provide optimal disease management without limiting future therapeutic options based on safety concerns, and recognize potential future treatments and the possibility of combination therapies. Additional challenges include incorporation of patient needs and preferences into the overall therapeutic approach, in order to ensure optimal outcomes in the short and long term. The objective of this manuscript is to provide an overview of what is currently known regarding the impact of various therapies for MS on future therapeutic choices (sequencing). In this context, we reviewed the available evidence in support of various treatments and, based on the presence of disease activity, suggested a scheme for switching or escalating therapy with the main focus on sequencing of therapeutic approaches.
The illegal killing and taking of wild birds remains a major threat on a global scale. However, there are few quantitative data on the species affected and countries involved. We quantified the scale and scope of this issue in Northern and Central Europe and the Caucasus, using a diverse range of data sources and incorporating expert knowledge. The issue was reported to be widespread across the region and affects almost all countries/territories assessed. We estimated that 0.4–2.1 million birds per year may be killed/taken illegally in the region. The highest estimate of illegal killing in the region was for Azerbaijan (0.2-1.0 million birds per year). Out of the 20 worst locations identified, 13 were located in the Caucasus. Birds were reported to be illegally killed/taken primarily for sport and food in the Caucasus and for sport and predator/pest control in both Northern and Central Europe. All of the 28 countries assessed are parties to the Bern Convention and 19 are also European Union Member States. There are specific initiatives under both these policy instruments to tackle this threat, yet our data showed that illegal killing and taking is still occurring and is not restricted to Mediterranean European countries. Markedly increased effort is required to ensure that existing legislation is adequately implemented and complied with/enforced on the ground. Our study also highlighted the paucity of data on illegal killing and taking of birds in the region. It is a priority, identified by relevant initiatives under the Bern Convention and the European Union, to implement systematic monitoring of illegal killing and taking and to collate robust data, allowing stakeholders to set priorities, track trends and monitor the effectiveness of responses.
The mechanical behavior of superconductor lamellar-like BaFe2As2 single crystals was investigated at nanoscale by instrumented indentation. The unique responses of the ab- and a(b)c-crystallographic planes were discussed based on their influence in hardness (H) and elastic modulus (E). The results allowed two main conclusions. (i) The choice of testing parameters strongly affected the scaling of mechanical properties on the lamellar surfaces. Lamellar cracking was the leading mechanism of deformation, featuring a brittle-like behavior and affecting considerably H and E. However, the plastic deformation history allowed different elastic–plastic responses on the ab-plane owing to the compaction of the material. Threshold loads for cracking depended on both loading rate and penetration velocity, pointing out to time-dependent plastic deformation mechanisms. (ii) Proper estimates were achieved for H in multiple loading tests [3.4 GPa for ab- and ∼1 GPa for a(b)c-planes], and for E under loads less than 3 mN (∼55 GPa for both planes).