Apple (Israel)

To first evaluate the association between postoperative electroencephalography findings and 24-month neurodevelopmental outcomes in neonates with congenital heart disease (CHD) undergoing cardiac surgery. Secondarily to explore the association between perioperative medication exposure and outcome. Single-center retrospective cohort study in a University-affiliated tertiary pediatric center, between February 2013 and September 2020. Neonates (postmenstrual age [PMA] > 36 wk) with CHD requiring cardiopulmonary bypass surgery at PMA younger than 44 weeks who had neurodevelopmental assessments at 24 months using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). None. Out of 345 neonates with complex CHD, there were 68 neonates in our clinical outcome cohort, and 32 of 68 (47%) in the postoperative electroencephalography cohort. In the electroencephalography group, a quantitative electroencephalography index of discontinuity index was calculated and averaged from postoperative recordings between 15 and 24 hours. Here, adjusted analyses showed greater postoperative electroencephalography discontinuity index was associated with lower BSID-III motor scores at 24 months (-0.48 [95% CI, -2.31 to -0.51]; p = 0.009). In the complete clinical cohort, linear regression models were used to explore the association between medication dosing (intraoperative, 24-hr postoperative, and cumulative doses) with BSID-III scores at 24 months. Higher early postoperative opioid doses were associated with better motor outcomes, as represented by the standardized coefficient, B, and its 95% CI, including: global motor composite scores (complete cohort, 0.33 [95% CI, 0.77-5.41]; p = 0.010 and d-transposition of the great arteries subgroup, 0.37 [95% CI, 0.67-5.41]; p = 0.013); fine motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.97]; p = 0.049); and gross motor scaled scores (complete cohort, 0.26 [95% CI, 0.01-0.94]; p = 0.047). Our single-center retrospective study shows an association between early postoperative electroencephalography findings and outcomes after neonatal cardiac surgery. Electroencephalography discontinuity may be a potential biomarker of later adverse motor outcomes. Future evaluations are needed to clarify the interaction between postoperative electroencephalography monitoring, pharmacologic exposures and later neurodevelopment.

Breastfeeding enhances maternal-newborn bonding, supports newborn nutritional requirements, and is recommended in mothers undergoing medication-assisted treatment (MAT) for opioid use disorder (OUD). Breastfeeding decision-making is complex and may be influenced by implicit biases among healthcare providers, negatively impacting maternal quality of care and breastfeeding outcomes in mothers with OUD. This integrative review aimed to synthesize current evidence on how healthcare professionals' implicit bias affects breastfeeding initiation, support, and continuation among women with OUD. Included studies focused on women with OUD, specifically those on MAT, and examined bias in relation to breastfeeding. Studies were excluded if they did not involve pregnant or postpartum women on MAT, focused solely on polysubstance use, or addressed only racial bias. A total of 117 articles underwent title and abstract review. Of the 117 articles initially identified through the database search, only 28met the preestablished inclusion and exclusion criteria and were ultimately included in this integrative review. Key themes emerged: stigma and discrimination, lack of social and institutional support, provider knowledge gaps, and maternal fears related to recovery. Studies included qualitative, quantitative, and mixed methods research. Educating healthcare providers with accurate, evidence-based information can reduce bias and better support women with OUD in achieving their breastfeeding goals. Future studies should examine how implicit bias impacts breastfeeding in this population to inform provider training and resource development.

Prehospital tracheal intubation intends to provide respiratory support and protect the airway from possible pulmonary aspiration. Trauma guidelines recommend tracheal intubation in patients with a Glasgow Coma Scale (GCS) score of <9. We hypothesised that in clinical practice, GCS scores before prehospital tracheal intubation are lower in trauma and medical patients. Retrospective observational cohort study. Swiss anaesthetist-staffed helicopter emergency medical system between 07 September 2020 and 11 December 2023. Intubated trauma and nontrauma patients ≥18 years and nonintubated patients with GCS <9 admitted to three tertiary referral Swiss hospitals. Prehospital tracheal intubation. GCS score before prehospital tracheal intubation. Association of GCS score before prehospital tracheal intubation with length of ventilator days, intensive care unit stay, hospitalisation, and 28-day survival. We screened 35 021 missions, of which 401 (335 intubated vs. 66 nonintubated) met inclusion criteria. The median GCS before prehospital tracheal intubation was 4 [IQR 3 to 6] for nontrauma and 6 [3 to 8] for trauma patients. Trauma patients with burns had a GCS score of 14 [13 to 15] before prehospital tracheal intubation. In the trauma cohort, women had a median GCS score of 5 [3 to 7] compared to men with 6 [3 to 8] ( P = 0.043). The GCS before prehospital tracheal intubation was associated with length of intensive care unit stay ( P = 0.042) and survival ( P = 0.036) but not with length of ventilation and hospital stay. Overall median GCS score before prehospital tracheal intubation was lower than 8. Our data suggests that the GCS score is not suitable as the sole indicator for prehospital tracheal intubation. Further randomised controlled trials should investigate more robust intubation criteria to be included in the guidelines for trauma and nontrauma patients. Finally, a patient-centred approach should be emphasised, especially in patients with burns.

When performing Mohs micrographic and dermatologic surgery for high-risk cutaneous malignancies, particularly aggressive scalp tumors, there may be positive or indeterminate deep margins overlying clinically uninvolved bony cortex (outer table). To ensure complete tumor extirpation in these situations, the authors performed superficial bone decortication and report their case series. Over six consecutive months, superficial bone decortication was performed using a microdrill with rosehead bur after 10 Mohs micrographic surgery cases and one incomplete skin cancer excision. Cases included eight squamous cell carcinomas, two pleomorphic dermal sarcomas, and one basal cell carcinoma. The mean preoperative largest tumor diameter was 37.2 mm, and the mean postoperative largest defect diameter was 49.4 mm. Patients completed mixed-methods questionnaire with a Likert scale, dichotomous, and open-questions. The median pain value was 0 (mean 0.4) during the decortication surgery. All patients receiving Mohs surgery preferred superficial bone decortication under local anesthetic on the day of Mohs rather than referral for another day under general anesthetic.Analysis of open questions determined the procedure was similar to dental drilling -noisy with a vibratory sensation but caused little discomfort. Superficial bone decortication is a well-tolerated and safe procedure in an outpatient setting and can be readily performed after Mohs micrographic surgery in clinically uninvolved bone.

BACKGROUND Day of surgery cancellation (DOSC) for elective surgery occurs in 18% of elective surgeries worldwide with resultant impacts on patients and healthcare systems. Accurate prediction of such cancellations could yield significant benefit. OBJECTIVE This systematic review synthesises evidence to inform future efforts at gold-standard statistical modelling. DESIGN Systematic review and qualitative synthesis using the ‘Synthesis Without Meta-Analysis’ (SWiM) framework. DATA SOURCES MEDLINE, Embase, Scopus and Web of Science, 2013–2024 ELIGIBILITY CRITERIA Studies were considered eligible if they presented the development, validation or update of a model to predict DOSC. Risk of bias for included studies was assessed using the prediction model risk of bias assessment tool (PROBAST). Data was collected on included variables, method of prediction, whether prediction was made at the level of the patient or the system, and training and assessment processes. RESULTS Literature searching identified 7154 unique studies, 6 of which were included in the final synthesis. These studies encompassed total of 759 337 elective surgical procedures, of which 47 609 were cancellations, across a variety of adult and paediatric surgery. Methods of prediction included logistic regression models, machine learning, and spatial regression models. These used demographic, socioeconomic, comorbidity, surgical, appointment and other factors as predictors. The best discrimination achieved by models in each study, quantified by area under the receiver operator curve, ranged from 0.75 to 0.92 in development and 0.70 to 0.74 in validation datasets. One study demonstrated better calibration at the census tract level of spatial regression models when incorporating local survey data compared with individual-prediction-aggregation models. CONCLUSIONS Models to predict DOSC identified in this review demonstrated moderate discrimination ability but there was significant heterogeneity between studies and reports of calibration were limited. This review serves as a valuable synthesis of current models to predict DOSC and should serve as a core reference for emerging studies in this field.

The growing complexity of cyber threats coupled with the widening cybersecurity knowledge gap presents new challenges in the organisational security domain of the business sector. This paper introduces SentinelSphere, an innovative platform that redesigns cybersecurity defense by integrating advanced threat detection with interactive cybersecurity awareness education, creating a unified approach to building organisational cyber resilience. SentinelSphere employs an Enhanced Deep Neural Network model with specialised feature engineering to significantly reduce false positives while maintaining high detection accuracy across diverse attack vectors. The system includes a Traffic Light System (TLS) to transform complex threat intelligence into intuitive visual indicators, serving simultaneously as an operational tool for security professionals and an educational interface for non-technical users. This paper further presents a Large Language Model that delivers real-time, context-aware cybersecurity guidance and training. This conversational AI agent operates efficiently on standard enterprise hardware, making advanced security education accessible without requiring specialised infrastructure. SentinelSphere is validated using industry-standard datasets, achieving enterprise-grade performance in threat detection with a 94% F1 score and 69.5% reduction in false positives compared to baseline models. The system successfully processed nearly 11 million security events in 30 minutes, demonstrating scalability for enterprise deployment. This work contributes to the cybersecurity field by demonstrating that effective defense requires not just technological sophistication but also systematic enhancement of human security awareness.

Age-group specific disparities for dentalcare use persist in the United States. The COVID-19 led to delays in non-urgent dentalcare. We provide national estimates on dentalcare use and influencing factors for the U.S. population before and during the COVID-19. We used nationally representative Medical Expenditure Panel Survey for over pre-COVID-19 years (2018-2019) and COVID-19 years (2020-2021) We estimated yearly survey-weighted trends in mean non-zero dental visits by age followed Poisson regression, controlling for a comprehensive set of confounders across five domains of influence. Dentalcare visits were defined as visits to any dentalcare provider. Overall analytic sample included non-institutionalized community living persons (unweighted n=6518, weighted N∼320 million) grouped as ages 0-17, 18-44, 45-64, 65-74 and 75+ present in all four years The prevalence ratio (PR) for dental visits was slightly higher for ages 75+ in comparison to ages 65-74 across years 2018-2021 and increased from 1.73 (95% CI: 1.4, 2.1) to 1.84 (95% CI: 1.5, 2.3) to 2.13 (95% CI: 1.7, 2.7) from 2018 to 2020 but rebounding to near pre-pandemic level in 2021 to 1.66 (95% CI, 1.3, 2.0). Consistent factors during COVID-19 pandemic years 2020-2021 that increased dental visits included dental insurance, high income, and having a usual source of care (p < 0.01). Dentalcare use rebounded for older adults in 2021 but remained below pre-pandemic levels. Increasing dentalcare visits across ages remains a key policy priority. Continued monitoring of dentalcare use trends beyond COVID-19 among older adults is critical to improve their oral health.

In our previous report, we described a surgical technique for cochlear implantation in canal wall down (CWD) ears. Specifically, this involved extending the endaural incision superiorly, harvesting a large temporal fascia flap, completely removing the tympanic epithelium, inserting the electrode array, obliterating the middle ear cavity with the temporal fascia flap, and sealing the external auditory canal with a tragal cartilage plug. This report details the safe application of this technique in a patient with severe ear malformation and suspected CHARGE syndrome, supplemented with a brief literature review. The patient was a 28-year-old woman with malformations of the auricle, middle ear, and inner ear, as well as patent ductus arteriosus, amblyopia, and mild intellectual disability.Temporal bone CT revealed significant inferior displacement of the emissary vein, precluding standard electrode insertion via the posterior tympanotomy approach to the round window. We therefore applied our previously reported technique to this malformed ear without prior surgical history. Sequential bilateral implantation was performed. Surgical duration was 96 minutes (right) and 167 minutes (left). Wide bony exposure via CWD facilitated uneventful electrode insertion bilaterally, with minimal bleeding. Postoperative sound-field aided thresholds were favorable at 35dB (right) and 38.3dB (left). Speech discrimination scores were 90% at 60dB (right) and 0% (left). The cochlear implantation technique for CWD ears was safely adapted to this patient with congenital malformation. This approach represents a viable surgical option for cases with severe malformations such as CHARGE syndrome.

Academic support programs are used in prelicensure nursing education to improve retention, progression, and equity. However, the literature is inconsistent and fragmented. This scoping review mapped academic support interventions for U.S. prelicensure nursing students, identified outcome measures, and highlighted gaps in the literature. Following JBI methodology and PRISMA‑ScR guidelines, 4 databases - PubMed‑MEDLINE, Academic Search Complete, CINAHL, and Web of Science - were searched, with the final search completed on September 16, 2025. Studies were included if they reported empirical outcomes of academic support interventions for prelicensure nursing students. Twenty-two studies met criteria. Most were observational. Common interventions included mentoring, tutoring, coaching, and psychosocial support. Delivery methods were typically multimodal. Outcomes included retention, course performance, NCLEX pass rates, and engagement. Few studies used theoretical frameworks or assessed developmental outcomes. Findings support the need for early, theory-informed academic support programs evaluated with consistent measures of academic and developmental outcomes.

Individuals with severe mental illness (SMI), including schizophrenia, schizoaffective disorder, and bipolar disorder, face twice the risk of cardiovascular disease compared with the general population. However, disparities in cardiovascular care access persist. We established a cardiopsychiatry clinic to assess cardiovascular risk and initiate evidence-based treatment in this population. From November 2022 to July 2023, patients with SMI but no known cardiovascular disease were referred from outpatient psychiatry clinics to a tertiary care hospital in Canada. Cardiovascular risk factors were recorded, and the 10-year Framingham Risk Score was calculated. Treatment was initiated based on clinical guidelines. Among 23 participants (mean age 52.6 ± 10.8 years; 30% female), schizophrenia was the most common SMI (65%). The mean Framingham Risk Score was 13.8% ± 8.1. Smoking (61%) and obesity (74%) were the most prevalent risk factors. More than half (57%) had newly identified cardiovascular risks, leading to pharmacological treatment initiation for metabolic syndrome/dyslipidemia (N = 7), hypertension (N = 7), and diabetes (N = 2). The cardiopsychiatry clinic is a pilot project that highlights the need for integrated cardiovascular screening and treatment for individuals with SMI. Larger studies are required to address persistent gaps in cardiovascular care for this high-risk population.