Background: Hydrogenogenic small intestine bacterial overgrowth (SIBO) has been associated with growth stunting and neurodevelopmental deficits in children from low and middle-income countries. However, methanogenic overgrowth has yet to be studied in this population. We sought to determine if increased methane levels on glucose breath tests (GBT) could predict growth and neurodevelopment.
Methods: GBT was performed at 6, 12, and 18 months on Tanzanian infants as part of the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) study conducted in rural Tanzania. Area under the methane curve was calculated and averaged over the three tests (CH4 AUC). Neurodevelopment was assessed using the Malawi Developmental Assessment Tool (MDAT).
Results: Univariate and multivariate linear regressions were performed to determine if CH4 AUC predicted growth or neurodevelopment and to determine predictors driving CH4 AUC levels. There was significant seasonal variation in CH4 AUC levels per child birth-month, with the highest levels associated with the spring months (March-May). Multivariable analysis showed no significant association between CH4 AUC and length-for-age Z score at 18 months, MDAT total score, or MDAT component scores. Birth month was a significant predictor of CH4 AUC (F= 66.614, p<.001). However, when analyzing patients with significant methanogenic SIBO (as determined by the top 50% of valid CH4 AUC values), antimicrobial administration had a positive but non-significant association with growth LAZ18 ( p=0.05), and nicotinamide administration revealed a significant association for LAZ18 when controlling for significant descriptive variables ( p=0.005) as compared to antimicrobial and nicotinamide administration in patients with negligible methanogenic SIBO (p=0.08, p=0.53, respectively).
Conclusion: This initial study does support a relationship between methanogenic overgrowth and growth stunting through the positive growth effect in positive SIBO children who received nicotinamide treatment, an effect that was not seen in the children without SIBO. Further study is needed to understand the relationship between methanogenic overgrowth and environmental enteric dysfunction and/or gastrointestinal symptomatology.

Analyses of Methanogenic Small Intestine Overgrowth Effects on Growth in Tanzanian Children

Background: Obstructive sleep apnea (OSA) is associated with oxidative stress/inflammation, but indices of cytokine activation as measured by soluble cytokine levels, remains relatively unexplored. Moreover, how cytokine activation may be modified by continuous positive airway pressure (CPAP) and compliance to CPAP remains unknown. One critical molecular checkpoint for cytokine production is post-transcriptional control by microRNAs (miRs). The central hypothesis of this study was that cytokine activation occurs with OSA and is associated with a shift in a specific cassette of miRs which genetically map to these cytokines. Additionally, we postulated that CPAP would modify cytokine activation and miRs.

Methods: Following informed consent, plasma profiles for cytokine activation (Milliplex, multiplex array) and miRs (Qiagen, miRNA PCR array) were performed in OSA patients (N=50) at baseline and following 90 days of CPAP therapy. CPAP compliance was monitored across the therapeutic interval and graded based on Centers for Medicare and Medicaid Service (CMS) criteria. Profiles were indexed to referent normal subjects (N=18). 

Results: Cytokine activation was evident in OSA patients such as an 8-fold increase in tumor necrosis factor receptor superfamily, member 8 (sCD30) and a 2-fold increase in epidermal growth factor receptor (sEGFR) and vascular endothelial growth factor receptor 2 (sVEGFR2) (p<0.05). Following 3 months of CPAP, cytokine activation was reduced in CPAP compliant patients (N=22) as evidenced by an average 14% reduction in sCD30, sEGFR, Interleukin 1 receptor, type I (sIL1RI), interleukin 1 receptor, type II (sIL1RII), Interleukin 2 receptor, alpha (sIL2Ra), vascular endothelial growth factor receptor 1 (sVEGFR1), and sVEGFR2 whereas these values were unchanged in CPAP non-compliant patients (N=28). A total of 7 miRs were changed in OSA patients, which mapped to several cytokine pathways (p<0.05). Notably, hsa-miR233-3p, hsa-miR233-5p changed with CPAP compliance and maps to a localized inflammatory process- the inflammasome.

Conclusion: A specific set of soluble cytokine receptors and regulatory miRs, including: sCD30, sEGFR, sIL1RII, sVEGFR2, hsa-miR233-3p, hsa-miR233-5p, may serve as a marker of inflammation severity in patients with OSA, and as an approach to determine therapeutic responses to treatment strategies such as CPAP.


Obstructive sleep apnea causes cytokine activation and alters microRNA levels; Effects of continuous positive airway pressure

Background 

Deposition of amyloid plaques in brain is considered as an index event in the pathophysiology of Alzheimer’s disease (AD) which leads to series of events resulting in cognitive impairment. AD commonly involves non-cognitive symptoms like depression, anxiety, etc. We attempted to explore whether amyloid burden is directly related to depressive symptoms, or this relationship is mediated by cognitive symptoms.

Methods 

We examined the relationship between quantitative amyloid PET data (Standardized Uptake Value Ratios), cognition measured with cognitive function instrument (CFI), and depression measured with geriatric depression scale among 4486 cognitively unimpaired older adults who were screened for a multisite secondary prevention trial (A4 study; Anti-Amyloid Treatment in Asymptomatic Alzheimer's study). The relationships among the variables were assessed through path analysis using structural equation modeling (SEM).

Results 

Our path analysis showed that amyloid burden is not directly related to depression and this association is mediated by cognitive performance, objectively measured as well as subjectively reported. All variables were controlled for age and education. Our model showed good fit (Model 1; CFI= 0.0931, RMSEA= 0.058 & Model 2; CFI = 0.9205, RMSEA = 0.086). Greater amyloid burden correlated with greater subjective cognitive impairment (p < 0.001) and greater objective cognitive impairment (p < 0.001). In both models, increased cognitive impairment was associated with increased depression scores (p < 0.001) and (p = 0.03), respectively. 


Conclusion 

Our findings indicate that amyloid burden is not directly correlated with depression, but rather its relationship with depression is mediated through cognitive impairment. This mediation may also be secondary to intermediate steps between amyloid deposition and cognitive alteration. Identifying this relationship will have implications for targeted interventions to mitigate depressive symptoms and improve the quality of life for individuals in the preclinical stages of Alzheimer’s disease.

Associations Between Amyloid Burden, Cognitive Impairment, and Depression in Preclinical Alzheimer's

INTRODUCTION:
Leveraging electronic health records (EHR) and linked biorepositories has the potential to elevate quality, efficiency and
sample size of studies evaluating etiology of rotator cuff tears (RCT). To date, no functionally validated algorithm reliably
identifies rotator cuff tear cases and controls form EHR systems. To facilitate this major need, we developed universal
phenotypic algorithms to classify RCT cases and controls from EHRs.
METHODS:
Using ICD9/10 diagnostic, CPT procedure codes and natural language processing (NLP), two versions of the algorithm
were developed to assess case and control status: a platinum, with image verification, and a silver, without image
verification. Both versions are ICD/CPT based with the option to add NLP. The algorithms were developed and validated
through manual blinded chart review of 525 medical records in the Vanderbilt University Medical Center (VUMC) Synthetic
Derivative.
RESULTS:
Only algorithms performing at 80% predictive value (PV) or higher were considered. Algorithms that only relied on ICD
diagnostic codes for rotator cuff tear had PV < 80%, and were substantially improved by adding evidence of imaging (+PV
=87%). Code based Algorithms relying on surgical CPT codes had the greatest PV of code based algorithms
(+PV=88.7%). For both cases and controls, NLP improved PV (+PV cases: ICD/CPT only= 82%, w/NLP = 98%; -PV
Controls: ICD/CPT only= 96.7%, w/NLP= 94.7%). For cases, addition of NLP increased sample size (ICD/CPT
only=12,777, w/NLP=66,907). Generally, requiring imaging marginally increased PV but substantially decreased sample
size for both cases and controls (Platinum: Cases n= 10,048, Controls n= 14,236; Silver Cases n=69,615, Controls
n=1,825,797).
DISCUSSION AND CONCLUSION:
We successfully developed algorithms that can be applied to any EHR system to identify RCT case/control status. These
phenotypic algorithms will allow the field to efficiently scale up high-quality data from EHRs, paving the way for previously
unimaginable big-data studies in understanding the etiology of RCT.

Universal Algorithms for the Identification of Rotator Cuff Cuff Tear Status From 
Electronic Health Record Systems

Background
Current measures of vaginoplasty success are adapted from tools validated for use in cisgender women, such as the Female Genital Self-Image Scale (FGSIS) and Female Sexual Function Index (FSFI). There is little research on whether post-operative gender congruence, quality of life (QoL), sexual function, and aesthetic satisfaction are of equal importance for vaginoplasty patients. The survey goal was to examine patient-reported vaginoplasty outcomes related to gender incongruence, post-surgical satisfaction and sexual function.

Methods
Transgender patients receiving surgical care at a single academic center were invited to complete post-surgery surveys. From August 2019 to May 2022, 157 patients who had undergone surgery between September 2016 and March 2022 were contacted. 40 completed consent and post-surgery survey. Questions were selected based on prior literature and FGSIS and FSFI adaptations. Statistical analyses were carried out in RStudio.

Results
Among 40 respondents, mean age was 45.8 years (SD = 14.0) and mean time since surgery was 237.3 days (SD = 260.8). Thirty-two (78.0%) had neovaginoplasty and 9 (22.0%) had genital remodeling without creation of a vaginal opening. Thirty-nine (97.5%) respondents were happier after their operation than they were before. Of the 23 respondents who had engaged in sexual activity in the past month, 10 (43.5%) were often or almost always satisfied with their arousal during sexual activity and 9 (39.1%) were satisfied with their ability to reach orgasm with sexual stimulation. Among this group, 19 (82.6%) felt positively about their genitals, 19 (82.6%) were satisfied with the appearance of their genitals, and 23 (100.0%) were happier after surgery than before. Seventeen respondents (42.5%) did not report sexual activity in the past month. Of these individuals, 15 (88.2%) felt positively about their genitals, 11 (68.8%) were satisfied with the appearance of the genitals and 16 (94.1%) were happier after surgery.

Conclusion
These findings indicate a discordance between the positive psychosocial outcomes of vaginoplasty and post-surgical sexual function. Patient-reported outcomes measures that center sexual function as a primary measure of vaginoplasty success may not accurately capture the QoL benefit afforded by improved gender congruence. While sexual function is important to overall QoL, patients in this study reported high rates of surgical satisfaction and improved happiness regardless of whether they had engaged in sexual activity or were satisfied with their arousal and ability to reach orgasm. More work is needed to develop measures that address the complex relationship between sexual function, sexuality, gender identity, and satisfaction with surgery.

Post-genital surgery survey of transgender and non-binary adults assigned male at birth

Background: Mental illnesses following an ICU stay are prevalent among patients and can be triggered by physical and emotional stress associated with critical illness, compounded by invasive procedures and sedatives administered in the ICU setting. Despite their frequency, these conditions are often not recognized or addressed in the ICU setting. However, in recent years, the mental health outcomes of patients who have survived an ICU stay have been a growing concern, and evolving methodologies are on the ascent particularly in European countries. The goal of this study is to assess the efficacy of existing methods for prevention of post-ICU mental health disorders and to analyze advancing techniques implemented in other countries.
Methods: This study employed a systematic literature review utilizing PubMed, EMBASE, and Wiley online databases to investigate the mental health outcomes linked to ICU experiences and the efficacy of current methods of prevention.
Results: Mental health conditions are frequently observed in patients following an ICU stay, with anxiety occurring in 12% to 43%, depression in 10% to 30%, and PTSD in 64% of patients. Current preliminary approaches to prevention include ICU journals, psychological counseling, and follow-up care in outpatient settings. The aforementioned strategies have shown varying statistical efficacy in terms of reducing the incidence of new onset mental health disorders. A systematic review on the impact of ICU diaries reported that four of five randomized trials showed a significantly reduced rate of new onset PTSD after 3 months with the use of ICU diaries. In addition, a meta-analysis of studies on psychological interventions, such as counseling, found that these interventions can significantly reduce symptoms of anxiety and depression. Furthermore, one study found that follow-up consultations may reduce the symptoms of PTSD after ICU admission, although they did not significantly improve other factors such as quality of life, anxiety, or depression.
Conclusion: Patients that survive an ICU stay are at a significant risk for developing a mental illness following their discharge. While the aforementioned studies provide evidence for the efficacy of these approaches, further research is needed to determine the most effective strategies for preventing new-onset mental health diagnoses in patients after ICU stay, with the ultimate objective of establishing proper guidelines to better navigate this issue. By prioritizing mental health in the ICU setting and providing appropriate resources to address these conditions, we can improve outcomes for patients and support their overall well-being beyond the acute care setting.

Preventing New Onset Mental Health Diagnoses After ICU Stay: Current and Emerging Approaches

**Scoring is only possible in the semifinals hall**

**Abstract:**



Hospital Characteristics and Perioperative Complications of Hispanic Patients Following Reverse Shoulder Arthroplasty – A Large Database Study

Background: It is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine. Methods: A retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining in- testine as well as the type of intestine were recorded for each patient. KaplaneMeier analyses were conducted to compare the subgroups.
Results: Children with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon.
Conclusions: The preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients.

Importance of Ileum and Colon in Children with Short Bowel Syndrome

Background
Hypertonic saline is a mainstay treatment of cerebral edema in neurological emergencies. The risk of acute kidney injury (AKI) with use of balanced versus unbalanced hypertonic saline solutions is equivocal across studies. Hypertonic sodium acetate (NaOAc) instead of hypertonic sodium chloride (NaCl) has been used as an alternative to prevent renal injury, with little evidence supporting this. We evaluated patients receiving either NaCl or NAOAc to evaluate the risk of development of AKI.

Methods
We performed a retrospective analysis of patients admitted to our neuroscience ICU from June 2013 to February 2023 who have received continuous intravenous infusions of either NaCl or NaOAc at either 2% or 3% concentration for therapeutic hypernatremia. We excluded patients receiving renal replacement therapy, patients who expired within 24 hours of administration of hypertonic saline, and those receiving treatment for hyponatremia. Renal injury was based of KDIGO criteria (elevation in serum creatinine greater than 0.3 mg/dL within 48 hours of starting intravenous infusion).

Results
Out of 1133 patients who received hypertonic saline, 880 met study inclusion criteria, with 812 patients receiving NaCl and 68 patients receiving NaOAc. Of these patients, 30.4% had acute ischemic strokes, 29.7% had intracerebral hemorrhages, 15.0% had subarachnoid hemorrhages, and 24.9% had other intracranial pathologies. 399 (38.5%) of the patients were female. 79 patients (9.7%) receiving sodium chloride developed AKI, while 11 patients (16.2%) receiving sodium acetate developed an AKI (X2 = 2.8408, p = 0.092) within 48 hours of initiation of intravenous therapy. 

Conclusion
Contrary to some reported observations, we found no statistical difference in the development of AKI as defined by KDIGO criteria in patients treated with NaCl versus NaOAc. Our study is limited by a small subset of patients receiving NaOAc. A larger cohort is needed to establish the protective effect of balanced hypertonic saline on AKI.

Effects of Balanced Versus Unbalanced Hypertonic Saline on Renal Function in Neurocritical Care

Cerebral palsy (CP) is the leading cause of childhood physical disability. Children with CP receive several therapies designed to improve gross motor skills, but further research is needed to understand the impact of these therapies on motor learning and optimal therapeutic dose.
The aim of this study is to compare motor learning and variability between children with CP and typically developing (TD) children. We hypothesize that (1) children with CP and TD children will have differing patterns of motor learning, and (2) children with CP will show greater variability in motor learning compared to TD peers, but this variability will reduce for both groups with training.
The motor task involved a stability platform. Participants were instructed to keep the platform within 5 degrees of its horizontal position. Training consisted of 15, 30 s trials/day for 5 days, pre- and post-testing were 5, 30 s trials/day. Performance was determined by quantifying time the participant maintained the platform within 5 degrees of horizontal and variability by time spent on either side of the 5 degrees.
Mixed-model ANOVA was performed with time (pre-test vs. post-test) as the within-subject variable and group (CP vs. TD) as the between-subject variable. Dependent variables were mean center time and variability. 
TD children improved an average of 6.7 seconds (20.8 s to 27.5 s) from pre-test to post-test. Children with CP improved an average of 11.9 seconds (9.85 to 21.7 s). TD children decreased variability an average of 3.35 seconds (4.58 to 1.23 s). Children with CP decreased variability an average of 6 seconds (10.1 to 4.1 s). 
ANOVA showed significant main effects for time on mean center time (F (1,40) = 26.0, p < 0.001) and group on mean center time (F (1,40) = 20.9, p < 0.001), as well as time on variability (F (1,40) = 1, p < 0.001) and group on variability (F (1,40) = 1, p < 0.001). 
Both groups showed motor learning with five days of balance training. Children with CP showed greater variability in their balance performance than TD children. 
While TD children achieved almost maximum performance with training, children with CP may need more training to achieve this same performance. Alternatively, children with CP may reach maximum motor learning potential after a certain dose, therefore requiring other therapeutic interventions. Participant recruitment and data collection is ongoing. 


Differences in Motor Learning Between Children with Cerebral Palsy and Typically Developing Peers Using a Dynamic Balance Task

Background 
Dynamic lumbar instability evaluated on flexion-extension radiographs has been a longstanding convention in clinical decision-making for the management of low back pain by interventionalists and surgeons. However, these radiographs often underestimate the degree of lumbar spondylolisthesis, limiting their diagnostic utility. Significant variability remains in current guidelines regarding the most appropriate imaging modalities to adequately evaluate instability. Thus, identifying more efficacious imaging techniques to improve diagnostic utility, minimize radiation exposure, and reduce unnecessary healthcare costs is warranted. We compared different diagnostic images of single-level anterior spondylolisthesis and hypothesize that positional changes will affect the degree of dynamic instability, with spondylolisthesis observed in prone position providing greater sensitivity for instability compared to standing or supine positions. 

Methods 
Single center retrospective cohort of L4-5 anterolisthesis between 2014 – 2022 with standing radiographs (CR), prone CT scans (CT), or supine MRI images (MRI). Exclusion criteria: presence of lumbar hardware, patients with missing imaging modalities (either CR, CT or MRI), time between any modalities exceeding 13 months, no evidence of anterolisthesis, or poor image quality precluding the ability to fully visualize and assess spondylolisthesis. 

Results 
The average translation (± SD) measured were 4.9 ± 2.2 mm (CR), 2.5 ± 2.6 mm (CT), and 3.7 ± 2.6 mm (MRI) (p < 0.001). The mean difference in anterolisthesis among imaging modalities were 2.7 ± 1.8 mm between CR and CT (p < 0.001) and 1.8 ± 1.4 mm between CR and MRI (p < 0.001). Ninety two of 102 patients (90.2%) showed greater anterolisthesis on CR compared to CT, 72 of 102 (70.6%) comparing CR to MRI, and 27 of 102 (26.5%) comparing CT to MRI.  

Comparing CR with MRI, we found that 17.6% of patients exhibited > 3 mm anterior translation, whereas 38.2% patients were identified comparing CR with CT imaging, indicating a 20.6% difference in missed lumbar instability (χ2 test p = 0.0009, post-hoc Fisher’s exact test p = 0.0006 between CR and CT). Only a small percentage of patients showed increased segmental translation between flexion-standing (5.9%) and extension-standing radiographs (11.8%). We identified comparable results using 2 mm and 4.5 mm thresholds. 

Conclusion 
Comparing standing CR versus prone CT revealed the greatest degree of single level lumbar segmental translation (L4-5. Prone positioning also significantly reduced L4-5 anterolisthesis compared to flexion-extension standing X-rays, suggesting that comparing prone positioning to standing lateral views may increase detection of dynamic instability at L4-5 compared to standard stress views.

Dynamic Instability is Underestimated on Standing Flexion-Extension films when compared to Prone CT Imaging

Background: Since the FDA has mandated a boxed warning on all psychostimulants due to risks for misuse and death, coupled with nationwide shortages, clinicians have utilized non-stimulants, such as alpha-2-agonists for hyperactivity/impulsivity and the norepinephrine reuptake inhibitor atomoxetine for inattention, as safer alternatives. However, these agents lack comparable efficacy with delayed onset compared to psychostimulants. Insurers require generic atomoxetine prior to covering Viloxazine ER (VER), a novel 5-HT2B antagonist, 5-HT2C partial agonist, and 5-HT7 antagonist. We wanted to know whether patients taking atomoxetine would experience improvement in ADHD symptoms after switching to VER.
Methods: 50 patients (35 children) received mean doses of atomoxetine 60 mg (25-100 mg once daily) followed by VER 300 mg (100-600 mg once daily) after 5-day atomoxetine washout. Both atomoxetine and VER were flexibly titrated according to FDA guidelines. The pediatric ADHD-Rating Scale-5 (ADHD-RS-5) and the Adult Investigator Symptom Rating Scale (AISRS) were completed prior to starting atomoxetine; 4 weeks after treatment with atomoxetine or upon earlier response or discontinuation due to side effects, whichever occurred first; same protocol after treatment with VER. We conducted a retrospective chart review of these 50 patients. Statistical analysis was performed using a within-subject, 2-tailed t-test with significance level of p < 0.05.
Results: From baseline total ADHD-RS-5 mean score (40.3+10.3), improvements were greater on VER (13.9+10.2) than atomoxetine (33.1+12.1) (t = -10.12, p < 0.00001), in Inattention (t = -8.57, p < 0.00001) and in Hyperactivity/Impulsivity (t = -9.87, p < 0.00001). From baseline total AISRS mean score (37.3+11.8), improvements were greater on VER (11.9+9.4) than atomoxetine (28.8+14.9) (t = -4.18, p = 0.0009), in Inattention (t = -3.50, p < 0.004) and in Hyperactivity/Impulsivity (t = -3.90, p < 0.002). 86% of patients on VER reported positive response by 2 weeks versus 14% on atomoxetine. 36% discontinued atomoxetine for side effects, including GI upset (6 patients), irritability (6), fatigue (5), insomnia (1) versus 4% who discontinued VER due to fatigue. 96% preferred VER over atomoxetine with 85% (22/26) able to taper psychostimulants following stabilization on VER. 
Conclusion: Pediatric and adult ADHD patients, who have experienced less than optimal response to atomoxetine, demonstrate rapid improvement in inattention and in hyperactivity/impulsivity with greater tolerability on viloxazine extended-release, which deserves consideration as a new first-line ADHD treatment option

Underline digital video library

Analyses of Methanogenic Small Intestine Overgrowth Effects on Growth in Tanzanian Children

Obstructive sleep apnea causes cytokine activation and alters microRNA levels; Effects of continuous positive airway pressure

Associations Between Amyloid Burden, Cognitive Impairment, and Depression in Preclinical Alzheimer's

Universal Algorithms for the Identification of Rotator Cuff Cuff Tear Status From Electronic Health Record Systems

Post-genital surgery survey of transgender and non-binary adults assigned male at birth

Preventing New Onset Mental Health Diagnoses After ICU Stay: Current and Emerging Approaches

Hospital Characteristics and Perioperative Complications of Hispanic Patients Following Reverse Shoulder Arthroplasty – A Large Database Study

Importance of Ileum and Colon in Children with Short Bowel Syndrome

Effects of Balanced Versus Unbalanced Hypertonic Saline on Renal Function in Neurocritical Care

Differences in Motor Learning Between Children with Cerebral Palsy and Typically Developing Peers Using a Dynamic Balance Task

Dynamic Instability is Underestimated on Standing Flexion-Extension films when compared to Prone CT Imaging

Viloxazine Extended-Release As A Paradigm Shift In The Treatment Of ADHD

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