Hilar lymph nodes with dense adhesion to the bronchus and pulmonary artery ("doornail" nodes) can be encountered unexpectedly during robot-assisted pulmonary resection. We report our experience managing these nodes and associated factors. This retrospective single-center cohort study included 1,185 patients undergoing robot-assisted pulmonary resection (March 2021-September 2024). Preoperative factors were analyzed using Firth penalized logistic regression in a clinically selected model (age, maximal voluntary ventilation [MVV], and tumor diameter). Operative time and blood loss were compared using robust regression models. Perioperative outcomes were compared descriptively between attempted separate dissection and en bloc stapling. Doornail hilar lymph nodes occurred in 48 of 1,185 patients (4.05%; 95% CI, 3.07-5.33%). Older age remained associated with this finding after adjusting for MVV and tumor diameter (adjusted OR per 10 years, 2.316; 95% CI, 1.533-3.596; P<0.001). Operative time was longer unadjusted (105 vs 92 min; P=0.027) but not after adjustment. Among these 48 patients, 45 (93.8%) received en bloc stapling with no blood loss exceeding 200 mL, transfusion, or prespecified in-hospital complication, whereas all 3 (6.3%) who underwent attempted separate dissection had substantial bleeding (700-2,400 mL), and 2 required transfusion. No conversion to thoracotomy occurred. Doornail hilar lymph nodes occurred in about 4% of patients; older age remained associated with this finding after adjusting for MVV and tumor diameter. Because strategy selection was non-random and groups differed in resection extent, comparative safety cannot be established; en bloc stapling after tissue thinning may be feasible when a node cannot be safely separated.
Thoracostomy tube placement is often a life-saving procedure for patients with pneumothoraces. It is frequently performed under emergent conditions because the faster the procedure is completed, the more likely the patient is to survive. However, because of the urgency of the procedure and the proximity to vital structures, damage to the thoracic organs is not uncommon. We present the case of a 10-year-old girl with cystic fibrosis and acute respiratory failure who required intubation and subsequently developed profound bilateral pneumothoraces and pneumomediastinum, prompting emergent bilateral chest tube insertion and cannulation onto veno-venous extracorporeal membrane oxygenation (VV-ECMO). Afterward, she was transferred to our hospital, where we unexpectedly found the left-sided pigtail chest tube catheter in the lingula while trying to obtain a bronchoalveolar lavage via flexible bronchoscopy. To the best of our knowledge, based on the available literature, this is a rare pediatric case of a malpositioned chest tube initially identified by flexible bronchoscopy. This case highlights the importance of vigilant evaluation of complex patients with lines, drains, and airways, as well as careful study of the way chest tubes such as pigtail catheters should appear on imaging. Additionally, it emphasizes the importance of a multidisciplinary team, including intensivists, pulmonologists, and surgeons, in patient care.
Oxygen-containing heterocycles (O-heterocycles), including tetrahydrofuran (THF) and 1,4-dioxane, are emerging water contaminants of growing concern because of their persistence and recalcitrance to conventional treatment processes. Biodegradation of these compounds requires ring cleavage, yet the enzymes responsible for this critical step have remained unidentified. By integrating affinity predictions with in vivo validation, we demonstrated that classical aromatic ring-cleaving dioxygenases, including the intradiol dioxygenases CatA1/CatA2 from Cupriavidus metallidurans ZM02 and the extradiol dioxygenase MhpB from Escherichia coli BL21, mediate the cellular cleavage of 2-hydroxytetrahydrofuran (2-OH THF), a key intermediate in THF metabolism, to yield 4-hydroxybutyric acid (GHB). This previously unrecognized activity occurs within the same substrate-binding pocket used for canonical aromatics, with residues E101 in CatA and H115/R212 in MhpB identified as key contributors to non-canonical heterocyclic cleavage through site-directed mutagenesis. Furthermore, catA genes are frequently redundant in bacteria degrading both O-heterocycles and aromatics, and their active sites are highly conserved, suggesting an evolutionary conserved strategy for coping with mixed pollutants. These findings expand the substrate spectrum of well-known dioxygenases to include O-heterocycles, establish a novel catalytic route for cyclic ether degradation in aquatic systems, and offer new opportunities for bioremediation and enzyme engineering in water treatment.
Androgenetic alopecia (AGA) is the most common cause of non-scarring hair loss in men. Although topical minoxidil and oral finasteride are established treatments, some patients show limited clinical response despite prolonged therapy. Evidence on the use of oral bicalutamide in male AGA remains scarce because of concerns about systemic adverse effects. We report the case of a 45-year-old man with treatment-resistant AGA who experienced clinically apparent hair regrowth during oral bicalutamide exposure after an inadequate response to conventional therapies. Treatment was accompanied by gynecomastia, mastodynia, decreased libido, erectile dysfunction, and mild elevations in hepatic enzymes, leading to drug discontinuation. Clinical adverse effects resolved after withdrawal of bicalutamide; however, follow-up hormonal evaluation and liver function tests were unavailable. This case describes a temporal association between androgen receptor blockade, clinically apparent hair regrowth, and clinically significant adverse effects. Although the findings provide additional insight into the role of androgen receptor signaling in AGA, they should not be interpreted as evidence supporting the use of oral bicalutamide in male patients. Further controlled studies are needed to better define the safety profile and potential role of androgen receptor antagonism in androgenetic alopecia.
A 77-year-old man was admitted due to radiologic suspicion of right hilar tumor progression and newly developed right-sided pleural effusion. He had known NSCLC of the left lower lobe (keratinizing squamous cell carcinoma), initially staged T4N1M1c (contralateral lesion and hepatic metastasis), stage IVb. Comorbidities included COPD II, peripheral arterial disease, coronary artery disease, hypertension, and type 2 diabetes. Current oncologic therapy consisted of carboplatin, paclitaxel, and pembrolizumab.The patient presented with exertional dyspnea and reduced breath sounds with dullness to percussion at the right lung base. Bronchoscopic re-biopsy (EBUS-TBNA and transbronchial biopsy) was performed. Pleural cytology was negative for malignancy; therefore, thoracoscopy was conducted, revealing chronic pleuritis without malignant involvement. Histology showed no metastatic disease but demonstrated diffuse alveolar damage (DAD), consistent with immune-related pneumonitis. A pronounced sarcoid-like granulomatous reaction was observed, also involving the pleura. Immune-related pneumonitis and pleuritis under PD-1 inhibitor therapy. Immune-related pneumonitis occurs in approximately 1-5% of patients receiving immune checkpoint inhibitors. Imaging often shows bilateral ground-glass opacities. Histologically, organizing pneumonia is most common; DAD is less frequent. Diagnosis is made by excluding infection and tumor progression.Pleural effusion in oncologic patients is usually interpreted as tumor progression. Immune-mediated pleural involvement is rare and reported only in isolated cases. PD-1 blockade enhances T-cell activation and IFN-γ release, which may promote granuloma formation.Treatment consists of systemic glucocorticoids. Ein 77-jähriger Patient wurde bei radiologischem Verdacht auf rechts hilären Tumorprogress und neu aufgetretenem rechtsseitigem Pleuraerguss stationär aufgenommen. Es bestand ein NSCLC im linken Unterlappen (verhorntes Plattenepithelkarzinom), initial T4N1M1c (kontralateraler Herd, hepatische Metastase), Stadium IVb. Vorerkrankungen: COPD II, pAVK, KHK, arterielle Hypertonie, Diabetes mellitus Typ 2. Die Therapie umfasste Carboplatin, Paclitaxel und Pembrolizumab.Klinisch zeigte sich Belastungsdyspnoe mit rechts basal abgeschwächtem Atemgeräusch und gedämpftem Klopfschall. Zur Abklärung eines Progresses erfolgte eine bronchoskopische Re-Biopsie (EBUS-TBNA, transbronchiale Biopsie). Die Pleurazytologie war negativ, daher wurde eine Thorakoskopie durchgeführt. Es zeigte sich eine chronische Pleuritis ohne Malignitätsnachweis.Histologisch kein Hinweis auf Metastasen. Nachweis eines diffusen Alveolarschadens (DAD) im Sinne einer immuntherapieassoziierten Pneumonitis. Zusätzlich bestand eine ausgeprägte sarkoidale granulomatöse Reaktion, auch pleural nachweisbar.Immuntherapieassoziierte Pneumonitis und Pleuritis unter PD-1-Inhibition.Immunvermittelte Pneumonitis tritt in 1–5% der Patienten unter Checkpoint-Inhibition auf 1. Radiologisch finden sich häufig bilaterale Milchglastrübungen. Histologisch überwiegt das Muster einer organisierenden Pneumonie, seltener DAD 2. Die Diagnose erfolgt durch Ausschluss von Infektion und Tumorprogress 2.Pleuraergüsse gelten bei onkologischen Patienten primär als Progresszeichen. Als immunvermittelte Nebenwirkung sind sie selten beschrieben 3. Die PD-1-Blockade führt zu gesteigerter T-Zell-Aktivität und IFN-γ-Freisetzung, was granulomatöse Reaktionen erklären kann 4 5.Therapeutisch erfolgt eine systemische Glukokortikoidgabe 2.
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Benzodiazepine immunoassays are commonly used for urine drug screening but have historically demonstrated poor detection of glucuronidated metabolites, resulting in false-negative results. A reformulated Roche benzodiazepine immunoassay (BNZ2) incorporating β-glucuronidase was developed to improve detection of glucuronidated benzodiazepines. This study evaluated the impact of BNZ2 implementation on false-positive rates in a tertiary medical center. A retrospective observational study compared urine benzodiazepine screening results from 12 months before and after BNZ2 implementation. Screening was performed using Roche BENZ Plus or BNZ2 reagents on the Roche Cobas Pro c503 analyzer. Presumptive positive results underwent reflex confirmatory testing by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Amphetamine screening served as an internal control. With BENZ Plus, 363/4513 (8.0%) screens were presumptive positive, compared with 827/4665 (17.7%) following BNZ2 implementation. Confirmatory testing demonstrated false-positive rates of 1.2-1.5% with BENZ Plus and 5.9-7.8% with BNZ2 (p < 0.001). Medication review for patients with false-positive samples identified some common prescriptions but could not identify a causal agent. Amphetamine false-positive rates remained stable across periods (16.2% vs 16.3%, p > 0.05). Following BNZ2 implementation, lorazepam became the most frequently confirmed benzodiazepine (36.7%, n = 269), with substantial increases in lorazepam-only positive samples. BNZ2 reformulation improved detection of glucuronidated benzodiazepines, particularly lorazepam, but was associated with a significant increase in false-positive results. In this population, 1 in 8 additional presumptive positive samples on BNZ2 was a false positive. These findings demonstrate a trade-off between improved analytical sensitivity and reduced specificity, resulting in increased confirmatory testing requirements and potential downstream effects on laboratory workflow and clinical decision-making.
Extra-pelvic endometriosis is a rare and complex condition characterized by endometriotic implants located outside the pelvis. It commonly poses significant diagnostic challenges and considerable surgical management difficulties. A 32 year-old primiparous woman presented with severe abdominal pain, deep dyspareunia and right-sided shoulder pain. Laparoscopic excision of deep infiltrating endometriosis on the anterior abdominal wall, under the ovaries and uterosacral ligaments was completely performed as well as pre-vesical shaving and ovarian cystectomy. However, resection of diaphragmatic endometriotic lesion was not performed due to multiple limitations, the procedure was conducted in a gynecology clinic without a multidisciplinary team, including thoracic surgeons and the lack of specialized equipment. The patient received hormone therapy for 5 months, including 2 GnRH agonist injections followed by 3 months of dienogest 2 mg. Abdominal pain resolved completely, however, right-sided shoulder pain became mild and tolerable. This case emphasizes the diagnostic and surgical challenges of extra-pelvic endometriosis and highlights the need of a multidisciplinary and individualized approach.
Sudden unexpected death in epilepsy (SUDEP) is the most common cause of epilepsy-related mortality. Although most witnessed SUDEPs follow seizures, mechanisms are uncertain. Investigations into the pathophysiology of SUDEP have relied on models and rare recordings of brain function at the time of the event. The brain-responsive neurostimulation (RNS) device from Neuropace offers a therapeutic option for drug-refractory epilepsy (DRE), enabling the recording of brain activity and the preemptive termination of seizures. Therefore, patients who experience SUDEP while being treated with an RNS device can provide insights into neural activity at the moment of this event. We report the history and electrocorticographic (ECoG) recordings of a patient with DRE who experienced SUDEP years after RNS placement. A girl with Phelan-McDermid syndrome and Lennox-Gastaut syndrome had an RNS device implanted at the age of 14 to treat DRE. Initially, electrodes were positioned in the right orbitofrontal (OF) and right premotor frontal regions, with the OF lead later changed to the centromedian thalamic nucleus. At age 19, the patient was found unconscious and in cardiac arrest by her parents. Although spontaneous circulation returned en route to the hospital, the patient did not regain consciousness and died. Subsequent analysis of ECoGs from RNS recordings at the time of death indicated seizure onset in the right premotor frontal cortex, which persisted despite seizure termination attempts by the RNS. We present a patient with SUDEP associated with the onset of RNS-refractory seizures. The significance of this report is highlighted by the rarity of literature on neuronal function at the time of SUDEP. Moreover, it underscores the potential for devices capable of monitoring ECoG activity to shed light on the mechanisms underlying SUDEP and to inform interventions.
Incidental findings are commonly identified on emergency department (ED) imaging, often unrelated to the reason for encounter. While system-level interventions have aimed to improve notification and follow-up, less is known about patients' experiences of receiving these unexpected results. We sought to explore ED patients' perspectives on incidental finding notification. A qualitative analysis was conducted of semi-structured interviews of 16 adult ED patients undergoing abdominal CT or ultrasound imaging at a large academic ED. Interviews were originally collected for a larger implementation trial of an electronic health record-based incidental finding notification system. Interviews explored patient preferences for communication of incidental findings including preferred communicator and desired information. The analytic team employed inductive thematic analysis, using iterative coding and team reconciliation to ultimately develop themes. Descriptive statistics were used to characterize the sample. Forty-four percent of the 16 participants were aged 35-44 (25% were aged 45-54 years; 31% were 55 years or older); 62.5% female (Table 1). Only 25% of participants reported awareness of the concept of incidental findings prior to the interview. Four themes emerged: (1) Empathetic expert communication is preferred; (2) Incidental findings trigger diverse health, emotional, and financial concerns; (3) Details of both the finding and cause are valued; and (4) Information and support are desired for next steps. Patients view incidental findings as unexpected and often stressful information requiring clear, empathetic, and actionable communication. Incorporating these preferences into ED notification processes may improve understanding, reduce distress, and support timely follow-up. Standardizing incidental finding disclosure to include plain language explanations of the finding, its cause, and detailed next steps may support ED patients as they navigate future care and the myriad concerns that arise from an unexpected result. Achieving such standardization will likely require both communication training and electronic health record integration. In ED practice, this should include a brief verbal disclosure paired with EHR-supported written instructions that identify the finding, explain urgency, name the appropriate follow-up clinician, and specify patient and clinician next steps.
Crisis resource management (CRM) training focuses on developing these high-stakes, unexpected event-handling skills. The abilities under non-technical skills (NTS) are not directly connected to technical competence but are still vital for preserving patient safety, collaboration, the environment, facilities, and all ICU members. This scoping review article aimed to demonstrate how to manage a crisis in an intensive care unit using non-technical skills. This review article presented crisis resource management (CRM) training and major components of crisis management including leadership, effective communication, anticipation and planning, resource utilization, workload distribution, situational awareness and triage, and prioritization. This review identified non-technical skills used for crisis management in the ICU for patient safety and favorable outcomes. Uncorrected crisis management could lead to unintended patient outcomes that impact morbidity and mortality. Crisis resource management (CRM) training focuses on developing these high-stakes, unexpected event-handling skills. Non-technical skills application with well-evident different approaches of crisis management usually leads to the least side effects and complications.
Maladaptive self-beliefs are a core symptom of major depressive disorder. These beliefs are perpetuated by a negatively biased integration of self-related feedback. Understanding the neurocomputational mechanisms of biased belief updating may help to counteract maladaptive beliefs and the maintenance of depression. The present study uses a belief-updating task and functional neuroimaging to examine the neurocomputational mechanisms associated with self-related feedback processing in individuals with major depression (n = 35) and matched healthy controls (n = 32). We hypothesized that increased symptom burden in depression is associated with negatively biased self-belief updating and altered hemodynamic responses to social feedback. Our findings show that, in the clinical sample, the incorporation of unexpected positive feedback was reduced with greater symptom burden, and that insula reactivity was generally elevated to unexpected negative feedback. The interplay of increased hemodynamic responsiveness to negative feedback and the reduced learning from positive feedback provide new insights into cognitive distortions in depression and may explain the persistence of maladaptive self-beliefs and, thus, the maintenance of depression.
Non-thrombotic pulmonary embolism (NTPE) represents a heterogeneous and underrecognized group of conditions characterized by the obstruction of the pulmonary vasculature by non-thrombotic material, often associated with complex pathogenetic mechanisms and non-specific clinical presentations. Despite their potential to cause sudden and unexpected death, comprehensive forensic studies on NTPE remain limited. This study presents a 30-year retrospective forensic analysis (1993-2024) of autopsy cases performed at the Institute of Legal Medicine of Milan, aimed at identifying and characterizing deaths attributable to NTPE. Among 325 fatal pulmonary embolisms, 32 cases (9.8%) were classified as NTPE. Bone marrow embolism was the most frequent subtype (37.5%), followed by septic (25%), fat (21.8%), and amniotic fluid embolism (9.4%), with single cases of air and neoplastic embolism. NTPE occurred predominantly in traumatic and iatrogenic settings and were frequently associated with surgical or invasive procedures. Macroscopic findings were often non-specific, whereas histopathological examination proved decisive for diagnosis, frequently requiring targeted histochemical techniques to identify the nature of the embolic material. These findings highlight the intrinsic diagnostic complexity of NTPE and the risk of under recognition in the absence of systematic post-mortem investigation. In this context, a comprehensive forensic autopsy approach remains essential for the accurate identification and classification of these entities. Increased awareness of NTPE, together with the integration of histopathological and ancillary analyses, may contribute to improving diagnostic accuracy and to a more reliable interpretation of sudden and unexpected deaths.
Serious reportable and sentinel events are preventable events that cause death or serious injuries to patients. Such events within the field of psychiatry include abscondment, inpatient suicide, unexpected deaths, sexual assaults, and serious physical assaults. This review aimed to examine the contributing risk factors and preventive strategies of serious reportable or sentinel events. PRISMA for scoping reviews and the updated Arksey and O'Malley methodological framework for conducting scoping reviews guided the methodology of the review. Databases (CINAHL, Embase, PsycINFO, PubMed, ScienceDirect, and Scopus) were searched. Twenty-nine articles were included. The articles explored (1) inpatient suicide [n=18 (62.07%)]; (2) general adverse events [n=5 (17.24%)]; (3) serious assaults [n=2 (6.90%)]; (4) abscondment [n=2 (6.90%)]; and (5) inpatient sexual events [n=2 (6.90%)]. Preventive strategies were as follows: (1) suicide (means restriction, allocation of high‑risk patients to higher‑dependency wards, safe prescribing, psychiatrist review of high-risk patients around the clock); (2) unexpected death (routine medical review, prompt activation of the code blue team); and (3) sexual incidents (segregation of genders). Consistent preventive strategies common to all adverse events, including establishment and continual review of guidelines, optimal staffing, and training, a secured ward with surveillance and no blind spots, rigorous observation, individualized risk assessments, and supportive counseling to patients. Consistent factors were associated with varying serious reportable or sentinel events. These factors were associated with patient and ward profiles, management, staffing, training, observation, risk assessments, and treatment. Bolstering factors related to the prevention of these events can enhance patient safety and the provision of quality care for psychiatric inpatients.
Selective breeding in aquaculture is necessary to establish food security and meet demand for sustainably produced protein. An informed selective breeding program requires understanding how population structure, environmental adaptation, and human activities shape natural genetic variation in wild conspecifics. Unfortunately, wild variation remains poorly characterised for many commercially important aquaculture species. Here, we conduct the first range-wide study of genomic population structure for the eastern oyster (Crassostrea virginica) across thousands of miles (Texas, USA to Eastern Canada) using a 200K SNP array. We integrate population structure analyses, genotype-environmental associations, and structural variant detection to identify adaptive loci and quantify human-mediated genetic impacts. Our data confirm two ancestral clusters with a phylogeographic break between the Gulf and Atlantic (FST = 0.16) and highlight patterns of substructure within each region. We find evidence of unexpected patterns of genomic variation in two locations: evidence of Gulf ancestry in a mid-Atlantic estuary (Chesapeake Bay), and evidence of Atlantic ancestry in a Gulf estuary (Apalachicola Bay). While we cannot definitively determine the causes of these unexpected patterns, we show that they are consistent with direct and indirect human impacts in these estuaries. Genotype-environment association analyses with in situ temperature and salinity measurements were used to identify putatively adaptive loci, including SNPs within large structural variants (> 1 Mb). Our results identified genomic targets for aquaculture breeding programs aimed at climate resilience, reveal complex patterns of human impacts in managed systems, and demonstrate how seascape genomics can be used to improve aquaculture outcomes.
Problem: In Taiwan's hierarchical medical culture, postgraduate year (PGY) physicians face significant workplace challenges, exacerbated by Confucian values of hierarchical deference and collective harmony, which discourage open discussion of power imbalances. Approaches rooted in individualism, such as speaking-up initiatives and direct feedback pedagogies, encounter cultural barriers in this high-power-distance, collectivist context. While digital-native trainees increasingly use medical memes to express workplace frustrations, these community-generated expressions have not been systematically used for structured reflection in hierarchical medical education contexts. Intervention: In this pilot study, we designed a meme-based reflective learning curriculum integrating Kolb's experiential learning cycle, Palmer's "third things" approach, and Schön's mediating artifacts. Eight PGY physicians completed six monthly 90-minute sessions (January-June 2024), with follow-up interviews conducted six months post-intervention (December 2024). We curated memes from Taiwanese medical social media that depict workplace challenges, including hierarchical powerlessness, interprofessional tensions, emotional regulation, unclear workplace rules, time management, and patient-doctor communication. Sessions guided participants through Kolb's cycle: concrete experience (meme viewing), reflective observation (discussions), abstract conceptualization (consensus-building), and active experimentation (implementation). Context: The study was conducted at a medical center in Taiwan, where PGY physicians, competing for residency positions through an informal but widespread internal recruitment practice, faced intense pressure to maintain favorable impressions among seniors. This precarious status fostered reluctance to voice concerns as they navigated monthly rotations across departments with different cultures and unwritten rules. Impact: Participants demonstrated learning across all Kolb stages. Framed as an untested feasibility, the approach made previously unspeakable experiences discussable, creating resonance as participants recognized shared struggles. They developed practical strategies for emotional regulation and for navigating interprofessional relationships. However, encountering systemic barriers to implementation prompted an unexpected transformation: participants developed critical consciousness, shifting from seeking adaptation strategies to questioning the structures themselves. They articulated, "The problem isn't us. It's the whole unreasonable system," shifting the focus from coping to why this system exists. This evolution, which moves beyond an adaptation-focused curriculum toward Freire's dialogical education, emerged alongside a sense of powerlessness, as participants lacked the authority to enact structural change. Lessons learned: Drawing on Freire's concept of generative words, we theorize that community-generated memes functioned as generative artifacts: culturally embedded materials that fostered both workplace reflection and critical consciousness. This approach reframes Confucian collectivist orientations as empowering resources through what we term "safe subversion," in which humor's incongruity, ambiguity, and collective ownership keep critique within culturally tolerable limits. However, translating consciousness into structural change requires strategic alliances with educators who wield hierarchical authority in service of learning, bridging trainee awareness and institutional reform.
eConsultant is an asynchronous, digital, clinician-to-clinician advice service, giving general practitioners rapid remote access to specialist support for patient care. This study aimed to assess the feasibility, acceptability, and appropriateness of a model triaging selected endocrinology and neurology specialist outpatient referrals to eConsultant in an Australian healthcare setting. The proof of concept was conducted for general practitioner (GP) referrals to Mater Hospital Brisbane. The evaluation included analysis of clinical data from the eConsultant platform, GP surveys, and qualitative interviews with patients, GPs, and specialist stakeholders. Survey data and qualitative interview transcripts were analysed to understand acceptability and appropriateness of Triaging Referrals to eConsultant (TReC) to patients and providers. For 11 months (October 2024-August 2025), 51 (21%) endocrinology and 77 (6%) neurology referrals were triaged to eConsultant. Specialists spent on average 20 minutes completing the response, which was provided to GPs in an average of 3.5 business days (s.d. 2.5). The predominant presenting conditions for referrals were unexpected findings on imaging and migraine for neurology, and osteoporosis and hyperthyroidism for endocrinology. Close-out surveys were received from GPs for 14.8% (n = 19) of referrals triaged to eConsultant and in nine cases GPs reported a change to patient care as a result. Interviews highlighted the benefits to patients, including reduced treatment delays, convenience, and continuity of care. The option for continuing with a face-to-face specialist appointment, following receipt of eConsultant advice, was required and preferred by some GPs and patients. TReC is feasible in the Australian context and has the potential to reduce treatment delays.
Safety is the fundamental guarantee of power production. The safety of power operation personnel is closely related to public welfare and the sustained and stable development of the power industry. However, factors endangering the safety of power operation personnel cover multiple dimensions, including personnel operation, equipment status, working environment, and management system, which pose considerable challenges to the comprehensiveness and accuracy of risk identification. This study integrates scenario construction theory into power operation practice. Based on the grey relational degree and Bayesian network method, a risk assessment method suitable for power operation personnel is constructed and applied in typical power operation scenarios. In this paper, risk assessment methods are used to identify risk factors, calculate their weights, and conduct logical analysis for the operation of live-line connecting branch leads on 10 kV overhead lines. Through scenario construction, the operation is divided into four key stages with distinct dominant risk factors in each stage. The results show that human factors and environmental factors account for relatively high overall weights, which is consistent with the pattern of actual accidents. Among them, the impact of operators' physical and mental health is unexpected and requires special attention. Meanwhile, there is a significant risk transmission effect among procedures, and the quality of preceding procedures directly determines the safety of subsequent operations. The calculated results provide direct data support and a reference for decision-making on the precise control of power operation safety, thereby improving the scientific rigor and effectiveness of safety prevention and control measures for power operations.
Transfer RNA (tRNA)-modifying enzymes are emerging as key regulators of bacterial physiology. MiaA, a tRNA isopentenyltransferase, is well studied in model organisms, but its role in the opportunistic pathogen Pseudomonas aeruginosa remains unclear. Using LC-MS, nanopore tRNA sequencing, as well as transcriptional, translational, and proteomic profiling, we mapped MiaA-dependent tRNA modifications and revealed unexpected effects of MiaA loss. Impaired translation of MiaA-sensitive codons reduced quorum-sensing-controlled virulence gene expression and attenuated pathogenicity in Galleria mellonella. Ribosome stalling at trp codons in miaA mutants overrides the attenuation-controlled repression of tryptophan biosynthesis, causing overproduction of tryptophan, along with upregulation of cognate tRNAs, thereby linking translation to global metabolic adaptation. MiaA is tightly regulated and is so central to bacterial physiology that its expression level correlates directly to virulence in clinical isolates, highlighting its role as a hub connecting translation, transcription, metabolism, and pathogenicity. These findings position MiaA as a key integrator of cellular processes critical for pathogen fitness and host interactions.