Richmond VA Medical Center

This manuscript summarizes the first part of the proceedings of the 2023 Dublin ISUP Consensus Conference encompassing the best practice recommendations on the pathology of neoplasms of urachal origin. The rationale for convening this consensus conference was the lack of structured and consented histopathologic recommendations in these rare tumors. Consensus among the meeting participants (n=80) was reached on the following statements: (1) combination of gross, histologic, clinical and imaging findings with exclusion of secondary tumor metastasis are to be used in the diagnosis of urachal carcinoma; (2) the 2022 World Health Organization (WHO) separate criteria for the diagnosis of urachal adenocarcinoma and for nonglandular carcinoma should be applied; (3) specific elements are to be evaluated and recorded in the gross examination of resection specimens containing urachal tumors; (4) sampling considerations for resection specimens containing urachal tumors are advised; (5) participants are against using 5% or 10% cutoff for the extent of intraepithelial carcinoma in urachal mucinous cystic tumor of low malignant potential; (6) use of immunohistochemical markers for the differential diagnosis of urachal adenocarcinomas in transurethral resection (TUR) specimen is considered optional; (7) similar tumor classificatory (nosology) rules for carcinomas arising from bladder mucosa (eg, urothelial carcinoma, squamous cell carcinoma, and neuroendocrine carcinoma) should be applied for nonglandular urachal carcinomas; (8) a new staging approach other than the previously proposed systems should be designed for urachal carcinoma; (9) a system modifying the current Tumor-Node-Metastasis (TNM)/American Joint Committee on Cancer (AJCC) staging system for urinary bladder cancer is considered appropriate for a study in urachal carcinoma; and (10) several histologic elements are to be reported when diagnosing urachal carcinoma in TUR and resection specimens. This report from the Dublin ISUP consensus conference will serve as a practice recommendation for pathologists and as a guide for future standardized reporting protocols and research regarding urachal tumors. In addition, an international database for urachal cancers under the guidance of ISUP is being planned to be established to address pertinent issues in the pathology of urachal cancers.

Study Design: Pilot randomized clinical trial. Objective: To examine the effect of electrically evoked muscle hypertrophy on indices of spasticity, as measured by Biodex after spinal cord injury (SCI). Setting: Medical research center. Methods: Thirteen males with chronic SCI were randomized into sixteen weeks of either surface neuromuscular resistance training (NMES-RT) + testosterone treatment (TT) (n = 7) or a TT-only group (n = 6). A Biodex isokinetic dynamometer was used to measure knee extensor and flexor muscle spasticity at the beginning (baseline; BL) and at the end (post-intervention; PI) of 16 weeks. The passive tension of the right knee extensor and flexor muscle groups were evaluated at angles of 5°, 30°, 60°, 90°, 180°, and 270° per second (sec). Dual energy X-ray absorptiometry and magnetic resonance imaging were used to measure leg lean mass and thigh muscle cross-sectional areas (CSAs). Results: Robust muscle hypertrophy was noted in leg lean mass [11%, p = 0.023] as well as whole thigh [17%, p = 0.001] and knee extensor muscle [28%, p = 0.001] CSAs in the NMES-RT+TT compared to the TT-only group. There was no difference in extensor or flexor spasticity between the NMES-RT+TT or TT-only groups at different angular velocities following 16 weeks of intervention. Collapsing the extensor passive torques indicated an (24–28%) increase (p < 0.004) in response to angular velocities at BL and following PI measurements [180 deg/sec (23%; p = 0.03) and 270 deg/sec (32%; p = 0.009)] compared to 5 deg/sec. The extensor slope showed a non-significant (p > 0.05) decrease of 15–28% across all angular velocities. The catch-AB slopes were non-significantly lower in the TT-only group compared to the NMES-RT+TT at higher speeds [90 deg/sec and 270 deg/sec] and attained a trend towards lower passive torque at 180 deg/sec [180 deg/sec: 15.5%, p = 0.05]. Conclusions: Evoking skeletal muscle hypertrophy did not increase spasticity indices at different angular velocities following sixteen weeks of NMES-RT+TT or TT in persons with chronic SCI. Augmenting muscle hypertrophy is likely to attenuate the hyper reflexive slope of the extensor spasticity. The findings may suggest that evoking muscle hypertrophy following NMES-RT does not increase indices of spasticity after SCI. The clinical implications are highly important in managing spasticity after SCI.

Physical activity may be an important factor for understanding health and psychosocial outcomes following military service. The purpose of this analysis was to evaluate the association between physical activity and biopsychosocial outcomes in post-9/11 Veterans. We also evaluated the interaction of physical activity with posttraumatic stress disorder (PTSD) diagnosis and traumatic brain injury (TBI) history. Data were cross-sectional from 549 post-9/11 Veterans. Hierarchical linear regression models were used to investigate relationships between self-reported physical activity and biopsychosocial outcomes. Physical activity was significantly associated with better outcomes beyond PTSD and TBI, including depression (B = - 1.03), neurobehavioral symptoms (B = - 1.06), sleep quality (B = - 0.36), pain interference (B = - 0.18), and quality of life (B = 1.38). Promoting physical activity could enhance mental and physical health in Veterans, independent of PTSD diagnosis or TBI history. Exercise programs may be particularly beneficial for addressing specific biopsychosocial concerns among Veterans.

Various imaging technologies, including radiographic imaging, panoramic imaging, computed tomography, handheld devices, and cone beam devices have been widely used in dental imaging. This chapter provides an overview of those imaging techniques and their related safety and quality issues. Radiation dose and image quality are examined, along with evaluations of potential risks and safety concerns. Quality assurance and quality control requirements are reviewed. Relevant regulations, guidelines, and regulatory bodies are discussed. The integration of AI tools that assist in diagnosing, decision-making, and treatment prognosis prediction is explored. Ongoing efforts to improve quality and patient safety are also discussed.

Fluoroscopy is a widely utilized imaging modality for diagnosis and interventional procedures. This chapter provides an overview of different fluoroscopy configurations, their related imaging techniques, patient safety concerns, and image quality concerns. Special attention is paid to patient safety, especially regarding radiation dose and the methods available to manage it. Following that, fluoroscopy quality control requirements are reviewed, with a discussion of relevant regulations and guidelines. A brief primer on the use of artificial intelligence (AI) tools in interventional radiology and cardiac catheterization is also included in the chapter. Finally, organizational and industry efforts to improve quality and safety in fluoroscopy are presented.

This chapter reviews the available technologies commonly used for measuring bone mineral density: dual-energy x-ray absorptiometry (DEXA) and quantitative computed tomography (qCT). Quality and patient safety associated with these modalities are discussed, highlighting relevant quality assurance and quality control practices. Regulatory guidelines governing the use of these modalities are reviewed. Emerging AI-based tools for fracture diagnosis are also reviewed, along with ongoing efforts to improve quality and patient safety in clinical practice.

Radiography is the most commonly used radiological imaging modality, offering quick and detailed views for clinical diagnosis. This chapter provides an overview of patient safety and quality concerns in radiography, beginning with the fundamental principles of digital radiographic devices. It extensively discusses patient safety, including common technologies and techniques to minimize patient radiation exposure while maintaining diagnostic quality. The chapter also highlights the importance of quality control and image quality, along with tools available to help radiology staff and departments achieve consistent, high-quality images. Current regulatory and industry initiatives focused on enhancing quality and patient safety in radiographic imaging are also discussed.

Despite efforts to reduce and prevent incidents, bullying behaviors remain prevalent in schools, leading to poor outcomes for all involved. While the Olweus Bullying Prevention Program is one of the most extensively implemented school environment interventions in the USA, it has yet to yield consistently positive results across contexts, necessitating efforts to understand strategies to bolster its success and that of similar school-wide prevention efforts. This qualitative study used data from focus group discussions with 39 school staff—teachers, administrators and administrative assistants, other non-teaching staff—on the factors associated with implementing the OBPP in their schools. It specifically distilled their perspectives on potential strategies that could further improve the odds of implementation success and impact. Additionally, it examined similarities and differences in these personnel’s perspectives based on their respective roles and responsibilities. The data yielded seven themes, including intensifying training, increasing the efficacy of staff discussions, addressing issues related to time and conflicting priorities intensifying communication, increasing student involvement, increasing parent involvement, and providing staff support to help with implementation. Personnel’s perspectives aligned with their responsibilities in the program, offering insights into the importance of triangulating data from multiple sources while prompting considerations about the school-wide applicability and feasibility of suggestions offered. The potential and feasibility of these thematic suggestions are discussed in the context of the OBPP intervention’s components and provisions and findings from other school-based interventions. Implications for sustainability-based studies of the OBPP and other school-based interventions are also discussed.

Background Little is known about outcomes associated with the combination of osseointegration (OI) and targeted muscle reinnervation (TMR) in upper limb amputation (ULA). Objectives To describe functional outcomes of three cases with OI and TMR who used myoelectric prostheses and compare outcomes to matched control groups. Design An observational cohort, quasiexperimental design with nonequivalent control groups was used. Wilcoxon Mann–Whitney and Fisher's exact tests compared outcomes between OI cases, control group 1 (six myoelectric/hybrid users without TMR or OI), and control group 2 (seven myoelectric/hybrid users with TMR but not OI). Hedges' g effect sizes (ES) were calculated. Setting Community dwelling adults. Participants U.S. veterans and civilians with transhumeral ULA. Interventions OI and TMR. Main Outcome Measures We employed 11 dexterity measures, 5 functional measures, 5 prosthesis satisfaction measures, 4 quality of life measures, 7 patient experience measures, 4 measures of prosthesis use, and 10 pain measures. Results Comparison 1: Cases had higher scores than controls on Brief Activity Measure for ULA (ES = 1.59; p = .08), Prosthesis Evaluation Questionnaire Residual Limb Health (ES = 1.54; p = .09), Patient Experience Measure Intuitiveness (2.33; p = .07), and h/d of prosthesis use (ES = 1.40; p = .09). Comparison 2: Cases had better prosthesis satisfaction as measured by the Trinity Amputation and Prosthesis Experience Satisfaction Scale (ES = 2.36; p = .05); Orthotics and Prosthetics User Survey Client Satisfaction with Devices (CSD) 8 (ES = −2.70; p = .08); CSD‐W Comfort (ES = 3.51; p = .05); and the CSD‐W Appearance (ES = 2.36; p = .09), higher scores of the Upper Extremity Functional Scale for Prosthesis Users One‐handed Task scale (ES = 2.27; p = .05); the Modified Prosthesis Evaluation Questionnaire (PEQ) Residual Limb Health scale (ES = 1.95; p = .07); and Patient Experience Measure (PEM) Intuitiveness scales (ES = 2.28; p = .05). Cases had greater prosthesis use, measured by d/wk of wear, d/wk of use, h/d of wear, and h/d of use with ES ranging from 0.93 to 2.03 and p values from .05 to .08 for nonparametric tests. Conclusion Cases with OI and TMR reported better residual limb health, greater intuitiveness, and more hours of daily prosthesis use than controls. Further study with larger samples is warranted to investigate the additive benefit of both OI and TMR.

Background The effects of phosphodiesterase 5 (PDE5) inhibitors on the incidence of long‐term outcomes in patients with cardiovascular disease are not well understood. Objective: We studied the association between PDE5 inhibitor therapy and the incidence of adverse cardiovascular major adverse cardiovascular events (MACE) in patients undergoing coronary angiography and intervention. Methods We studied 4582 consecutive patients undergoing coronary angiography and intervention. The incidence of MACE at 1 year, defined as urgent revascularization, myocardial infarction, admission for heart failure or all‐cause death, was considered the primary outcome. Results Of the 4582 patients, 562 (12.3%) had current prescriptions for PDE5 inhibitors before the procedure and 4020 (87.7%) did not. The incidence of MACE was 171 (30.4%) among patients of the PDE5 inhibitor group versus 1482 (36.9%) in the non‐PDE5 inhibitor group ( p = 0.003). In a propensity score‐matched analysis of 1124 of patients, 171 (30.4%) patients in the PDE5i group and 175 (31.1%) patients in the non‐PDE5i group had a MACE ( p = 0.84). On multivariable analysis, the treatment with PDE5 inhibitors was not significantly associated with the risk of MACE (odds ratio [OR] = 0.99, 95% CI 0.93–1.06; p = 0.86). Conclusion In this cohort of veterans undergoing coronary angiography/cardiac catheterization, chronic PDE5i therapy was not associated with an increased risk of MACE at 1 year.

This paper introduces a fully automated and unsupervised technique for detecting step changes in synchrophasor measurements, without prior knowledge or learning data features , and without applying the complex task of baselining and parameter tuning. Step changes in synchrophasor measurements occur due to shunt switching, controller set point changes, etc. With increasing grid oscillations from inverter-based resources (IBRs), step changes are vital for tracking grid response and anticipating IBR controller-related oscillations. This study identifies step changes through a nonorthogonal discrete wavelet transform that relies on smoothed gradient estimation. A non-linear filter based on a multiscale point-wise product of wavelet coefficients is proposed, which takes advantage of the broadband feature of step changes within the space of wavelet coefficients. This filter also eliminates unwanted signal elements, thus decreasing the occurrence of false positives. Finally, through the statistical characterization of multi-scale products, we use an adaptive multiscale dependent threshold for detecting steps amidst real-world measurement noise and grid oscillations. Our studies indicate the effectiveness of our method in detecting step changes in synchrophasor data, supported by showcasing real-world case studies and discussing practical applications. Our method also significantly outperforms the relevant baseline detection methods by measuring Accuracy, F1 Score, and Precision under both ambient (noise) and step change conditions.

Cyclical and sustained engagement throughout and beyond individual climate assessment cycles ensures that assessments (1) meet the user need of the moment; (2) reach the broadest possible decision-making community; and (3) evolve from cycle to cycle, building on feedback in each iteration. In short, engagement is critical for the creation of an assessment that is useful, usable, and used. There is a vast range of modes and methods of engagement, from highly interactive, to more passive forms—all of which, when implemented strategically, can contribute to a user-informed assessment. Public engagement can help assessments to grow as a process that brings people together in a “network of networks” that spans disciplines, geographies, and demographics. This paper draws on the experience of engagement specialists from several assessments across geographic scales (national, regional, state, Tribal, and local), highlighting key lessons learned and making recommendations for future assessors.

INTRODUCTION Spontaneous bacterial peritonitis prophylaxis (SBPPr)-related practices are evolving, with recent studies showing almost half of potential subjects not being initiated on it. Determine practice dilemmas regarding SBPPr among US-based hepatology providers. METHODS A questionnaire regarding primary and secondary SBPPr using quantitative and qualitative (open-ended) approaches was sent to US-based hepatology providers electronically. RESULTS A total of 113 clinicians (86% physicians, 73% academic centers) responded. 54% started Primary and 72% secondary SBPPr in 50% of eligible patients. However, the issues related to antimicrobial resistance and ineffectiveness lead to SBPPr usage variations and restrictions on a patient-specific basis. Most respondents (>70%) would withdraw/not initiate SBPPr with data regarding ineffectiveness and harms. Open-ended answers showed that most believed newer trials to reduce reliance on weaker older evidence are needed. DISCUSSION A survey of US-based hepatologists demonstrates a major dilemma between usual care of initiating SBPPr versus not initiating/withdrawing SBPPr that needs newer randomized trials.

Adult users of traditional tobacco products like combustible cigarettes (CC) or moist smokeless tobacco (MST) products can reduce exposure to toxicants by switching to potentially less harmful alternatives such as tobacco‐free nicotine pouches (NP). Nicotine exposure assessment is an important consideration to determine the switching potential of NPs. These measurements are often conducted using randomized clinical studies. However, characterizing nicotine exposure under real‐world use conditions can further inform these assessments. We propose a framework based on physiologically based pharmacokinetic (PBPK) modeling that integrates typical use patterns and clinical pharmacokinetic (PK) data to predict nicotine exposure under actual use conditions. A tissue permeation model precedes the PBPK modeling and is characterized by two physiological parameters, nicotine diffusivity, and effective tissue thickness, which were determined and validated using literature data. A product‐specific tissue uptake fraction was determined by regression of nicotine pharmacokinetics measured under controlled use conditions and applied consistently for alternative use scenario analyses. Nicotine PK profiles were predicted under various use scenarios for cigarette smoking or MST use and compared to that from the use of two NPs, namely on! ® and on! PLUS™ NPs (Test Products). The nicotine PK parameters predicted under real‐world use conditions were not higher for Test Products relative to cigarettes or MST. The proposed modeling here can further inform nicotine exposure under actual use conditions. PBPK modeling can be a fit‐for‐purpose tool for predicting nicotine exposure under various use scenarios.

Traumatic brain injury (TBI) causes neuroinflammation and can generate long-term pathological consequences, including motor and visual impairments, cognitive deficits, and depression. In our previous study, we found that Fat1⁺-transgenic mice with higher endogenous n-3 polyunsaturated fatty acids (n-3 PUFA) were protected from post-TBI behavioral deficits and exhibited reduced levels of TBI-induced microglial activation, inflammatory factors, and sphingolipid ceramide, a lipid mediator of inflammation and cell death. This study’s objective was to evaluate if feeding n-3 PUFA (EPA and docosahexaenoic acid, DHA 2:1) could restrict the elevation of ceramide in brain tissue and prevent TBI-mediated sensory-motor and behavioral deficits. Wildtype C57/BL6 mice were gavage pre-fed with PUFA (EPA: DHA = 2:1) at 500 mg/kg body weight/week for 2 weeks before and 4 weeks after exposure to left side focal cranial air-blast (50 psi) TBI or sham-blast (0-psi). Saline-gavaged mice served as controls. Following blast injury, various motor, visual, and behavioral tests were conducted, and brain tissues were collected for histological and biochemical assays. Lipidomics analysis confirmed a significant elevation of EPA in the plasma and brain tissue of PUFA-fed mice. TBI-Blast brain tissues were found to have elevated ceramide levels in control mice but not in PUFA-fed mice. Moreover, PUFA-fed mice demonstrated protection against motor impairment, photoreceptor dysfunction, depression, oculomotor nerve degeneration, and microglia activation in the optic tract. Our results demonstrate that EPA-mediated suppression of ceramide biosynthesis and neuroinflammatory factors in PUFA-fed mice is associated with significant protection against the visual, motor, and emotional deficits caused by TBI.