bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiative feedback for supermassive star formation in a massive cloud with H2 molecules in an atomic-cooling halo
Authors: Sakurai Yuya , Haiman Zoltán , Inayoshi Kohei
Published: October 2020

Recent three-dimensional cosmological simulations of protogalaxy formation have suggested that supermassive stars (SMSs) can form in gas clouds in which H2 cooling is suppressed by dynamical heating prior to the activation of atomic cooling, but they stopped short of the following growth of a central protostar. Here, we examine whether accretion on the protostellar core in this cloud is sufficiently rapid, in the face of the radiation feedback, to produce an SMS. We perform one-dimensional radiation-hydrodynamical simulations of the hot collapsing cloud with non-equilibrium chemical reactions directly adopting the cloud properties from Wise et al. as an initial condition. We find that the stellar Lyman–Werner (LW) radiation from the SMS dissociates H2 in the inner regions of the gas flow, increasing gas temperature and thermal pressure, and temporarily stopping the accretion. However, this negative feedback ceases when the self-gravity and inward ram pressure force on larger scales push the gas inwards. The central protostar is unable to expand an H ii region due to the high density, and grows to a mass of ${\gtrsim}10^5\, {\rm M}_{\odot }$. Our results suggests the successful formation of SMSs, and resulting massive (${\sim}10^5\, {\rm M}_{\odot }$) remnant black holes in the clouds, but need to be confirmed in two- or three-dimensional simulations.
Platalina genovensium(Chiroptera: Phyllostomidae)
Authors: Ossa Gonzalo , Zamora Hugo T , Velazco Paúl M
Published: October 2020

Platalina genovensium Thomas, 1928 is a bat commonly called Peruvian long-tongued bat. P. genovensium is characterized by having a greatly elongated muzzle, rostrum clearly longer than the braincase, and premaxillary bones projecting beyond the canines. The dorsal pelage is long and bicolored; the venter is lighter than the dorsum. P. genovensium is distributed from west of the Andes in Peru to northern Chile, with a few records reported from the Andes in Peru. It feeds in desert areas characterized by the presence of columnar cacti from which it obtains nectar and fruits; it has been recorded at elevations from near sea level up to about 2,600 m. It is listed as “Near Threatened” by the International Union for Conservation of Nature and Natural Resources.
Telemedicine review in neuro-oncology: comparative experiential analysis for Barrow Neurological Institute and Geisinger Health during the 2020 COVID-19 pandemic
Authors: Fonkem Ekokobe , Gatson Na Tosha N , Tadipatri Ramya , Cole Sara , Azadi Amir , Sanchez Marvin , Stefanowicz Edward
Published: October 2020

Coronavirus disease 2019 (COVID-19) has grossly affected how we deliver health care and how health care institutions derive value from the care provided. Adapting to new technologies and reimbursement patterns were challenges that had to be met by the institutions while patients struggled with decisions to prioritize concerns and to identify new pathways to care. With the implementation of social distancing practices, telemedicine plays an increasing role in patient care delivery, particularly in the field of neurology. This is of particular concern in our cancer patient population given that these patients are often at increased infectious risk on immunosuppressive therapies and often have mobility limitations. We reviewed telemedicine practices in neurology pre– and post–COVID-19 and evaluated the neuro-oncology clinical practice approaches of 2 large care systems, Barrow Neurological Institute and Geisinger Health. Practice metrics were collected for impact on clinic volumes, institutional recovery techniques, and task force development to address COVID-19 specific issues. Neuro-Oncology divisions reached 67% or more of prepandemic capacity (patient visits and slot utilization) within 3 weeks and returned to 90% or greater capacity within 6 weeks of initial closures due to COVID-19. The 2 health systems rapidly and effectively implemented telehealth practices to recover patient volumes. Although telemedicine will not replace the in-person clinical visit, telemedicine will likely continue to be an integral part of neuro-oncologic care. Telemedicine has potential for expanding access in remote areas and provides a convenient alternative to patients with limited mobility, transportation, or other socioeconomic complexities that otherwise challenge patient visit adherence.
Receipt of Cessation Treatments Among Medicaid Enrollees Trying to Quit Smoking
Authors: Wang Xu , Babb Stephen , Xu Xin , Ku Leighton , Glover-Kudon Rebecca , Armour Brian S
Published: October 2020

Introduction

Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown.

Aims and Methods

Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis.

Results

Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease.

Conclusions

The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states.

Implications

Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees’ use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.
Parent fiduciary breach
Authors: Flannigan Robert
Published: October 2020

Parents who serve as trustees, and solicitors who draft trusts that involve family relations, may need to address whether parents are free to entertain conflicts and benefits that may be attributable to parent status. I discuss in broad terms the kinds of conflicts and benefits that normally should not be objectionable. The definitive consideration is the social definition of when parent access is a limited access.
A cross-sectional survey of the knowledge, attitudes and practices regarding schistosomiasis among rural schoolchildren in Taiz governorate, southwestern Yemen
Authors: Alharazi Talal H , Al-Mekhlafi Hesham M
Published: October 2020

Background

This cross-sectional survey aimed to assess the knowledge, attitudes and practices (KAP) towards schistosomiasis among rural schoolchildren in Taiz governorate, southwestern Yemen.

Methods

A total of 406 children were screened for urogenital and intestinal schistosomiasis. A pretested questionnaire was used to collect the children's demographic and socio-economic information and their KAP towards schistosomiasis.

Results

Overall, 73 children (18%) were found to be infected by Schistosoma mansoni. None of the children were positive for Schistosoma haematobium. The prevalence of intestinal schistosomiasis was significantly higher among boys than girls (22.1% vs 12%; p=0.010). Approximately two-thirds (63.3% [257/406]) of the children had heard about schistosomiasis, however, only 38.5%, 53.6%, 28.4% and 38.1% had correct knowledge concerning the causes, symptoms, transmission and prevention, respectively. A significantly higher level of knowledge was observed among boys and Schistosoma-infected children compared with girls and non-infected children (p<0.05). However, a better level of knowledge does not seem to translate directly into the performance of hygienic practices. Multivariate logistic regression showed that sex and infection status were the significant predictors of good knowledge.

Conclusions

Intestinal schistosomiasis is prevalent among schoolchildren in rural Yemen. The findings reveal that children's knowledge about schistosomiasis is inadequate. Therefore, besides mass drug administration, integrated control programmes should also include health education and the provision of improved drinking water and proper sanitation.
Genome Sequence of Fusarium oxysporum f. sp. conglutinans, the Etiological Agent of Cabbage Fusarium Wilt
Authors: Yu Fangwei , Zhang Wei , Wang Shenyun , Wang Hong , Yu Li , Zeng Xiaoping , Fei Zhangjun , Li Jianbin
Published: October 2020

Fusarium oxysporum f. sp. conglutinans is the causal agent of Fusarium wilt of cabbage (Brassica oleracea var. capitata L.), which results in severe yield loss. Here, we report a high-quality genome sequence of a race 1 strain (IVC-1) of F. oxysporum f. sp. conglutinans, which was assembled using a combination of PacBio long-read and Illumina short-read sequences. The assembled IVC-1 genome has a total size of 71.18 Mb, with a contig N50 length of 4.59 Mb, and encodes 23,374 predicted protein-coding genes. The high-quality genome of IVC-1 provides a valuable resource for facilitating our understanding of F. oxysporum f. sp. conglutinans–cabbage interaction.

[Formula: see text] Copyright © 2021 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license .
The Voices on Zika Study: Reproductive Autonomy and Shared Decision Making in the Time of Zika [3S]
Authors: Delgado Stephanie , Latortue-Albino Paula , Mehta Pooja
Published: October 2020

INTRODUCTION:

The purpose of our study was to explore the relationship between reproductive autonomy and shared decision making in women exposed to Zika virus during pregnancy.

METHODS:

We used a participatory action approach to conduct an exploratory qualitative study of English and Spanish- speaking women who were offered serum or ultrasound screening due to Zika exposure during pregnancy or immediately postpartum. We performed qualitative interviews in the patient's native language based on the Reproductive Autonomy scale and the Three Talk Model for shared decision making. Two coders used modified grounded theory to analyze transcribed interviews by hand.

RESULTS:

We interviewed 18 patients, at an inner city safety net hospital from May to December 2017. Most participants were Spanish speaking (72%), Hispanic (77%), and reported unplanned pregnancies (61%). Participant narratives demonstrated reproductive autonomy in pregnancy decision-making with community-based decision support, fatalism around pregnancy continuation, and very limited engagement around decisions regarding Zika virus testing. Hierarchy in provider dynamics, perceived stigma around emigration and travel, and language barriers impacted participant engagement in shared decision making-including choice, options, and decision talk. Narratives demonstrated limited participant perception of personal and fetal risk, and limited knowledge around Zika virus screening and treatment, which was inadequately addressed during counseling discussions.

CONCLUSION:

Participants demonstrated autonomy in reproductive decision-making that did not extend to decisions related to perinatal Zika testing. Shared decision making tools that address provider-patient relationship and stigma, in addition to clinical content may improve shared decision making and patient engagement in the management of complex pregnancies in vulnerable populations.
Entrustment Decision Making: Extending Miller’s Pyramid
Authors: ten Cate Olle , Carraccio Carol , Damodaran Arvin , Gofton Wade , Hamstra Stanley J. , Hart Danielle E. , Richardson Denyse , Ross Shelley , Schultz Karen , Warm Eric J. , Whelan Alison J. , Schumacher Daniel J.
Published: October 2020

The iconic Miller’s pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education (“knows,” “knows how,” “shows how,” “does”). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level (“shows how”); however, the “does” level, assessment in the workplace, remained a largely uncharted area.

In the 30 years since Miller’s conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the “does” level.

Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of “doing” in practice (the “does” level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level “trusted” to the apex of Miller’s pyramid.
Use of cannabis and cannabinoids in palliative care setting
Authors: AR Karthik , Bhatnagar Sushma
Published: October 2020

Purpose of review

Cannabis products have been used for various ailments since ancient times. But their use diminished in the medical community due to the legal and social concerns of substance abuse. With evolving evidence of their use in alleviating various symptoms, resurgence of interest in their medicinal use is seen in the past decade.

Recent findings

Clinical evidence for cannabis products in treating various ailments has been far from robust. Their use is based on anecdotal and low-quality evidence. This review attempts to revisit the recent medical literature available on the merits and demerits of cannabinoid use in palliative medicine.

A few symptoms in palliative care setting can be difficult to treat in a few patients with the available treatment measures. Anecdotal reports and early clinical data have proved cannabinoids to be a promising pharmacological option in managing this subset of patients. However, absence of robust clinical data in proving that cannabinoids have definitely favorable risk–benefit ratio, precludes the inclusion of cannabinoids in the routine recommendation for palliative symptom management. Before cannabinoids enter the broader market with patient-driven and industry-driven hype, high-quality clinical evidence is emergently needed.
A Retrospective Cohort Study Examining the Utility of Perinatal Urine Toxicology Testing to Guide Breastfeeding Initiation
Authors: Harris Miriam , Joseph Kathleen , Hoeppner Bettina , Wachman Elisha M. , Gray Jessica R. , Saia Kelley , Wakeman Sarah , Bair-Merritt Megan H. , Schiff Davida M.
Published: October 2020

Objective:

National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum.

Methods:

Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use.

Results:

Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use.

Conclusions:

Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.
Biopsychosocial Characteristics of Patients With Chronic Pain Expecting Different Levels of Pain Relief in the Context of Multidisciplinary Treatments
Authors: Cormier Stéphanie , Lévesque-Lacasse Alexandra
Published: October 2020

Objectives:

Evidence suggests that patients’ expectations predict chronic pain treatment outcomes. Although patients vary in terms of expected pain relief, little is known about individual factors related to such variations. This study aims to investigate how patients with various levels of pain relief expectations differ on the basis of biopsychosocial baseline characteristics in the context of multidisciplinary chronic pain treatment.

Materials and Methods:

Data from 3110 individuals with chronic pain attending one of 3 multidisciplinary pain treatment centers were considered. Participants completed a self-reported measure of pain relief expectations and provided information pertaining to biological, psychological, and social variables.

Results:

A backward stepwise regression helped identify biopsychosocial variables that significantly predicted expected pain relief. Subsequent analyses suggest that patients reporting low, moderate, high, and very high expectations of pain relief differed significantly in terms of pain duration and depressive symptoms. Significant between-group differences were also found with regard to overall physical health, age, sex, and ethnicity.

Discussion:

Identifying characteristics related to different levels of pain relief expectations is a fundamental step in generating a more comprehensive understanding of how expectations can be of use in the successful management of chronic pain conditions.
Role of Dexmedetomidine in Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Scoping Review
Authors: Liu Hongtao , Busl Katharina M. , Doré Sylvain
Published: October 2020

Dexmedetomidine (DEX), an α2-adrenergic agonist, has been widely used for anesthesia, pain control, and intensive care unit sedation. Besides sleep-like sedation, DEX has many other beneficial effects, such as anti-inflammation, antioxidation, and anticell death. Subarachnoid hemorrhage (SAH), a severe and potentially fatal form of stroke, is a complex disease that is divided into 2 phases: early brain injury and delayed cerebral ischemia. In each phase, several pathologic changes are involved, including disturbed intracranial homeostasis, metabolic failure, blood-brain barrier damage, vasospasm, microthrombosis, and cortical spreading depolarization. DEX has been shown to have an effect on these SAH-related pathologic processes. Research shows that DEX could serve as a protective therapy for patients with SAH due to its ability to maintain stable intracerebral homeostasis, balance coagulation-fibrinolysis, repair a damaged blood-brain barrier as well as prevent vasospasm and suppress cortical spreading depolarization by anti-inflammatory, antioxidative, antiapoptotic, and vasoconstriction-dilation effects. In this scoping review, we critically assess the existing data on the potential protective effect of DEX after SAH. So far, only 1 retrospective clinical trial assessing the effect of DEX on clinical outcomes after SAH has been performed. Hence, more trials are still needed as well as translational research bringing results from bench to bedside.
“Unstable” Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications
Authors: Atassi Omar , Fontenot Philip B. , Busel Gennadiy , De La Fuente Guadalupe , Donohue David , Maxson Benjamin , Shah Anjan R. , Watson David T. , Infante Anthony F. , Downes Katheryne , Sanders Roy W. , Mir Hassan R.
Published: October 2020

Objectives:

To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications.

Design:

Retrospective cohort study.

Setting:

One Level 1 and One Level 2 academic trauma centers.

Patients/Participants:

One hundred one pediatric femoral shaft fractures treated from 2006 to 2018.

Main Outcome Measurement:

Major and minor complications.

Results:

One hundred one femurs met inclusion criteria. The average age was 7 years (range 3–12 years). The average weight was 29.0 kg (range 16–55 kg). The average follow-up was 11 months (6–36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were “unstable” patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including “unstable” fractures (P = 0.78).

Conclusion:

Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as “unstable.”

Level of Evidence:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
“Don’t Make the Gap” Surgical Technique and Case Series for Chronic Achilles Rupture
Authors: Arthur Jacob M. , Venrick Connor B. , Ryan Paul M.
Published: October 2020

Chronic Achilles tendon ruptures continue to be difficult conditions to treat, with no gold standard surgical procedure agreed upon. There are many previously described techniques for treating chronic rupture; however, these typically include excision of the interposed scar tissue. This study describes a technique that avoids resection of this scar tissue that allows for maximum final tendon length without the risk of gap formation. In addition, this study reports a case series of 7 patients who underwent the described technique at an average of 30 weeks after injury. These patients were followed-up for an average of 36 months, with similar outcome scores as shown in previous literature. This series demonstrates that good surgical outcomes are attainable while avoiding scar excision for patients with chronic Achilles tendon ruptures.

Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Thumb Carpometacarpal Suspension Arthroplasty With Flexor Carpi Radialis Ligament Reconstruction and Tendon Interposition Using An Absorbable Interference Screw: A Volar Approach Technique
Authors: Plancher Kevin D. , Stelma Sarah V. , Wong Linda M. , Petterson Stephanie C.
Published: October 2020

The goal of operative intervention for pantrapezial arthritis is to relieve pain, maintain or improve motion, stability, and strength, and restore function. The purpose of this article is to present a volar approach to thumb carpometacarpal suspension arthroplasty using an absorbable interference screw for flexor carpi radialis ligament reconstruction and tendon interposition in the treatment of pantrapezial arthritis. This technique allows for visualization of the volar beak and avoidance of the radial artery and the branches of the superficial radial nerve while allowing optimal surgical manipulation for suspensionplasty with interference screw fixation and tendon interposition at the carpometacarpal joint.
Advances in Hip Arthroscopy
Authors: Su Charles A. , Trivedi Nikunj N. , Salata Michael J. , Voos James E.
Published: October 2020

Hip arthroscopy is a rapidly progressing field of orthopedic surgery. The development of preoperative planning software and post-less hip joint distraction, improvements in soft tissue management including the capsule and labrum, and improvements in postoperative pain control are just a few areas of recent advancement in hip arthroscopy. The future of hip arthroscopy is exciting and the potential clinical benefits to patients are very promising.
Acute Kidney Injury in Traumatic Brain Injury Patients: Results From the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study
Authors: Robba Chiara , Banzato Erika , Rebora Paola , Iaquaniello Carolina , Huang Chao-Yuan , Wiegers Eveline J. A. , Meyfroidt Geert , Citerio Giuseppe
Published: October 2020

OBJECTIVES:

Acute kidney injury is frequent in polytrauma patients, and it is associated with increased mortality and extended hospital length of stay. However, the specific prevalence of acute kidney injury after traumatic brain injury is less recognized. The present study aims to describe the occurrence rate, risk factors, timing, and association with outcome of acute kidney injury in a large cohort of traumatic brain injury patients.

DESIGN:

The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury is a multicenter, prospective observational, longitudinal, cohort study.

SETTING:

Sixty-five ICUs across Europe.

PATIENTS:

For the present study, we selected 4,509 traumatic brain injury patients with an ICU length of stay greater than 72 hours and with at least two serum creatinine values during the first 7 days of ICU stay.

MEASUREMENTS AND MAIN RESULTS:

We classified acute kidney injury in three stages according to the Kidney Disease Improving Global Outcome criteria: acute kidney injury stage 1 equals to serum creatinine × 1.5–1.9 times from baseline or an increase greater than or equal to 0.3 mg/dL in 48 hours; acute kidney injury stage 2 equals to serum creatinine × 2–2.9 times baseline; acute kidney injury stage 3 equals to serum creatinine × three times baseline or greater than or equal to 4 mg/dL or need for renal replacement therapy. Standard reporting techniques were used to report incidences. A multivariable Cox regression analysis was performed to model the cause-specific hazard of acute kidney injury and its association with the long-term outcome. We included a total of 1,262 patients. The occurrence rate of acute kidney injury during the first week was as follows: acute kidney injury stage 1 equals to 8% (n = 100), acute kidney injury stage 2 equals to 1% (n = 14), and acute kidney injury stage 3 equals to 3% (n = 36). Acute kidney injury occurred early after ICU admission, with a median of 2 days (interquartile range 1–4 d). Renal history (hazard ratio = 2.48; 95% CI, 1.39–4.43; p = 0.002), insulin-dependent diabetes (hazard ratio = 2.52; 95% CI, 1.22–5.197; p = 0.012), hypernatremia (hazard ratio = 1.88; 95% CI, 1.31–2.71; p = 0.001), and osmotic therapy administration (hazard ratio = 2.08; 95% CI, 1.45–2.99; p < 0.001) were significantly associated with the risk of developing acute kidney injury. Acute kidney injury was also associated with an increased ICU length of stay and with a higher probability of 6 months unfavorable Extended Glasgow Outcome Scale and mortality.

CONCLUSIONS:

Acute kidney injury after traumatic brain injury is an early phenomenon, affecting about one in 10 patients. Its occurrence negatively impacts mortality and neurologic outcome at 6 months. Osmotic therapy use during ICU stay could be a modifiable risk factor.
Clinical management of cerebral small vessel disease: a call for a holistic approach
Authors: Clancy Una , Appleton Jason P. , Arteaga Carmen , Doubal Fergus N. , Bath Philip M. , Wardlaw Joanna M.
Published: October 2020

Cerebral small vessel disease (SVD) is a common global brain disease that causes cognitive impairment, ischemic or hemorrhagic stroke, problems with mobility, and neuropsychiatric symptoms. The brain damage, seen as focal white and deep grey matter lesions on brain magnetic resonance imaging (MRI) or computed tomography (CT), typically accumulates “covertly” and may reach an advanced state before being detected incidentally on brain scanning or causing symptoms. Patients have typically presented to different clinical services or been recruited into research focused on one clinical manifestation, perhaps explaining a lack of awareness, until recently, of the full range and complexity of SVD.

In this review, we discuss the varied clinical presentations, established and emerging risk factors, relationship to SVD features on MRI or CT, and the current state of knowledge on the effectiveness of a wide range of pharmacological and lifestyle interventions. The core message is that effective assessment and clinical management of patients with SVD, as well as future advances in diagnosis, care, and treatment, will require a more “joined-up”’ approach. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. It requires more clinical trials in order to improve pharmacological interventions, lifestyle and dietary modifications. A deeper understanding of the pathophysiology of SVD is required to steer the identification of novel interventions. An essential prerequisite to accelerating clinical trials is to improve the consistency, and standardization of clinical, cognitive and neuroimaging endpoints.
A Novel Calcium Channel Blocker: Etripamil
Authors: Weintraub Spencer , Frishman William H.
Published: October 2020

Symptomatic paroxysmal cardiac arrhythmias are common cardiac conditions that lead to a decreased quality of life, increased healthcare costs, and significant morbidity. Many cardiac arrhythmias increase in frequency with age, and as the elderly population continues to increase, so will the incidence and prevalence of cardiac arrhythmias. The long-term treatment options for patients with paroxysmal arrhythmias include ablation procedures and daily oral antiarrhythmics. Acute management entails vagal maneuvers, intravenous antiarrhythmics, and synchronized cardioversion. However, there are limited treatment options for patients with less frequent and less severe arrhythmias, ablation refractory disease, or who are poor candidates for ablative procedures, For abortive therapy, oral anti-arrhythmic medications are ineffective due to their slow onset of action and intravenous medications require treatment at an acute care facility, which is both costly and stressful to the patient. Etripamil is a novel intranasal non-dihydropyridine calcium channel blocker that has begun phase III clinical trials for the treatment of paroxysmal supraventricular tachycardias. Due to its intranasal mode of delivery, etripamil has a rapid onset of action, and could feasibly be administered by the patient themselves. Clinical phase II trials of etripamil in moderate to high doses demonstrated efficacy comparable to the standard of care, and took an average of 3 minutes from drug administration to conversion to sinus rhythm. In this article, we have conducted an extensive literature review of intranasal drug delivery, calcium channel blockers, and etripamil, to discuss the future possibilities of using this new medication.
Continuous Aerobic Exercise Prevents Detrimental Remodeling and Right Heart Myocyte Contraction and Calcium Cycling Dysfunction in Pulmonary Artery Hypertension
Authors: Silva Franciany de Jesus , Drummond Filipe Rios , Fidelis Meilene Ribeiro , Freitas Maíra Oliveira , Leal Tiago Ferreira , de Rezende Leonardo Mateus Teixeira , de Moura Anselmo Gomes , Carlo Reis Emily Correna , Natali Antônio José
Published: October 2020

Pulmonary artery hypertension (PAH) imposes right heart and lung detrimental remodeling which impairs cardiac contractility, physical effort tolerance, and survival. The effects of an early moderate-intensity continuous aerobic exercise training on the right ventricle and lung structure, and on contractility and the calcium (Ca2+) transient in isolated myocytes from rats with severe PAH induced by monocrotaline were analyzed. Rats were divided into control sedentary (CS), control exercise (CE), monocrotaline sedentary (MS), and monocrotaline exercise (ME) groups. Animals from control exercise and ME groups underwent a moderate-intensity aerobic exercise on a treadmill (60 min/d; 60% intensity) for 32 days, after a monocrotaline (60 mg/kg body weight i.p.) or saline injection. The pulmonary artery resistance was higher in MS than in control sedentary (1.36-fold) and was reduced by 39.39% in ME compared with MS. Compared with MS, the ME group presented reduced alveolus (17%) and blood vessel (46%) wall, fibrosis (25.37%) and type I collagen content (55.78%), and increased alveolus (52.96%) and blood vessel (146.97%) lumen. In the right ventricle, the ME group exhibited diminished hypertrophy index (25.53%) and type I collagen content (40.42%) and improved myocyte contraction [ie, reduced times to peak (29.27%) and to 50% relax (13.79%)] and intracellular Ca2+ transient [ie, decreased times to peak (16.06%) and to 50% decay (7.41%)] compared with MS. Thus, early moderate-intensity continuous aerobic exercise prevents detrimental remodeling in the right heart and lung increases in the pulmonary artery resistance and dysfunction in single myocyte contraction and Ca2+ cycling in this model.
Pulmonary Hypertension in Pregnancy
Authors: MONI SAILA S. , MURTHY SANDHYA
Published: October 2020

Pulmonary hypertension in pregnancy carries a high maternal and fetal morbidity, and mortality. In recent times, there has been significant progress in the field of pulmonary vascular disease with a better understanding of the disease and novel targeted therapies, which have ultimately resulted in improved outcomes. In addition, the development of an individualized and multidisciplinary approach to the management of pulmonary hypertension during pregnancy is essential for improved outcomes.
Ocular Surface and Conjunctival Cytology Findings in Patients With Confirmed COVID-19
Authors: Bozkurt Erdinç , Özateş Serdar , Muhafız Ersin , Yılmaz Fatma , Calıskan Okan
Published: October 2020

Purpose:

To assess the effect of severe acute respiratory syndrome coronavirus-2 infection on the conjunctiva and tear film.

Methods:

Thirty-eight patients with confirmed COVID-19 and 31 healthy controls were included in this prospective and observational study. Individuals with COVID-19 formed the patient group, and healthy individuals formed the control group. Conjunctival impression cytology (CIC), TBUT, Schirmer II test, and ocular surface disease index were evaluated in all participants.

Results:

No significant difference was observed regarding the mean age and gender between the groups (P=0.786 and P=0.122, respectively). The mean TBUT and Schirmer II test results did not differ between the two groups (P=0.496 and P=0.447, respectively). The CIC results revealed decreased density and cell size of goblet cells and moderate to high enlargement, squamous changes, and increased nucleocytoplasmic ratio in nongoblet epithelial cells in the COVID-19 group compared with the control group. Based on the Nelson classification in CIC samples, 60.6% of the COVID-19 group and 19.4% of the control group had changes consistent with grade 2 or above. The presence of neutrophils in CIC was significantly higher in the COVID-19 group (P<0.001), whereas the presence of lymphocyte was similar between the two groups (P=0.247).

Conclusion:

This study revealed the pathological conjunctival alterations in patients with COVID-19 and demonstrated that pathological ocular surface alterations may present even at the beginning of COVID-19 without clinically significant ocular manifestation.
Ocular Outcome of Brazilian Patients With Congenital Toxoplasmosis
Authors: Lago Eleonor Gastal , Endres Mariana Miranda , Scheeren Marôla Flores da Cunha , Fiori Humberto Holmer
Published: October 2020

Background:

Retinochoroiditis is the most frequent manifestation of congenital toxoplasmosis. We aimed to describe the ocular outcome and factors that may influence the visual prognosis of these patients.

Methods:

Cohort of patients with confirmed congenital toxoplasmosis seen between 1996 and 2017 in Porto Alegre, southern Brazil.

Results:

Seventy-seven patients were included, of which 65 (85.5%) were identified by routine screening. Median age at the end of the follow-up was 10 years (minimum 2, maximum 25). Retinochoroiditis was present in 55 patients (71.4%). New retinochoroidal lesions developed after the first year of life in 77.8% of the patients who began treatment after the fourth month of life, compared with 35.2% among those treated before 4 months of life (relative risk = 0.45, 95% confidence intervals: 0.27–0.75, P = 0.02) and 33.3% among those treated before 2 months of life (relative risk = 0.42, 95% confidence intervals: 0.25–0.72, P = 0.01). There was a peak incidence of new retinochoroidal lesions between 4 and 5 years and another peak between 9 and 14 years, the latter only among girls. Thirty-four patients with retinochoroiditis were followed up for 10 years or more, and the school performance was appropriate in 28 (82.4%).

Conclusions:

The high incidence of new retinochoroidal lesions during the follow-up period indicates the importance of long-term follow-up of patients with congenital toxoplasmosis. Initiating treatment within the first 4 months of life, especially within the first 2 months, was a protective factor against the later development of retinochoroiditis. Despite the usual favorable prognosis, the high morbidity of congenital toxoplasmosis in Brazil was confirmed.
Pros and Cons of Different Types of Mechanical Circulatory Support Device in Case of Postinfarction Ventricular Septal Defect
Authors: Gambaro Alessia , Rosenberg Alex , Galiatsou Eftychia , Stock Ulrich A.
Published: October 2020

Postinfarction ventricular septal defect (VSD) is an uncommon but almost lethal complication. The optimal timing for VSD repair is matter of debate, and mechanical circulatory support (MCS) devices allow to hemodynamically support the patient and postpone the VSD closure until myocardial tissue is less friable and the patient’s condition is less compromised. However, data are lacking to guide the choice of the best types of MCS in case of VSD. We present a case of a large postinfarction VSD and the use of central venoarterial extracorporeal membrane oxygenation support to stabilize the patient until the VSD surgical repair. This case offers the opportunity to revise the indications and characteristics of different MCS, highlighting pros and cons of each one.
Physician prediction of 1-year mortality in the cardiac catheterization laboratory: comparison to a validated risk score
Authors: Sarathy Kiran , Jung Richard G. , Simard Trevor , Parlow Simon , Di Santo Pietro , Moreland Robert , Jung Young , Abdel-Razek Omar , Boland Paul , Russo Juan J , Chong Aun-Yeong , So Derek , Froeschl Michael , Dick Alexander , Glover Christopher , Labinaz Marino , Le May Michel , Hibbert Benjamin
Published: October 2020

Background

Physician perception of procedural risk and clinical outcome can affect revascularization decision making. Public reporting of percutaneous coronary intervention outcomes accentuates the need for accuracy in risk prediction in order to avoid a treatment paradox of undertreating the highest risk patients. Our study compares a validated risk score to physician prediction (PP) of 1-year mortality based on clinical impression at the time of invasive angiography.

Methods and results

We performed a cohort study between August 2015 and May 2018 to determine the discriminative accuracy of interventional cardiologists on one-year mortality of the treated patient. PP of one-year mortality was compared to the New York State Percutaneous Coronary Intervention Reporting System (NYPCIRS) score in predicting mortality. Three thousand seven hundred ninety-two patients were followed with a median follow-up period of 14.4 months (interquartile range 12.4–18.1 months) and 165 patients (4.4%) died within one-year. PP of mortality was associated with one-year mortality with a hazard ratio of 8.78 (95% confidence interval 5.24–14.71, P < 0.0001). Clinical presentation in the form of cardiogenic shock, return of spontaneous circulation, and liver and renal dysfunction were associated with PP. Diagnostic accuracy and specificity were improved in PP compared to NYPCIRS. The combination of PP to NYPCIRS improved the overall c-statistic and diagnostic yield.

Conclusion

PP appears to be especially specific and accurate for prediction of mortality compared to NYPCIRS though it lacks sensitivity. Furthermore, the combination of PP with NYPCIRS improved the c-statistic and diagnostic yield. Overall, the utility of PP with an objective risk score improves the diagnostic accuracy of mortality prediction.
Pre-infarction angina is associated with improved prognosis in diabetic patients with ST-elevation myocardial infarction – data from a contemporary cohort
Authors: Fontes Oliveira Marta , Costa Ricardo , Frias André , Santos Raquel , Brochado Bruno , Santos Mário , Silveira João , Cabral Sofia , Luz André , Torres Severo
Published: October 2020

Background

Pre-infarction angina (PIA) is associated with improved prognosis in patients with ST-elevation myocardial infarction (STEMI). Some studies suggest that diabetes may blunt the effect of ischaemic preconditioning. We sought to study the impact of PIA in diabetic patients with STEMI.

Methods

Consecutive patients with STEMI who underwent primary angioplasty were included. PIA was defined as ≥1 episode of chest pain during the week preceding STEMI diagnosis. Incident major adverse cardiovascular events (MACE) were defined as the first occurrence of all-cause death, stroke or acute myocardial infarction.

Results

Of the 1143 included patients, 25% were diabetic and 32% had a history of PIA. Diabetic patients with PIA had smaller infarct sizes as estimated by peak creatine kinase (CK) [1144 (500–2212) vs. 1715 (908–3309) U/L, P = 0.003] and peak troponin [3.30 (1.90–6.58) vs. 4.88 (2.50–9.58) ng/ml, P = 0.002], compared to diabetics without PIA. They also had a lower likelihood of evolving with moderate to severe reduced left ventricle ejection fraction (LVEF) (25.6%, n = 22 vs. 46.6%, n = 82, P = 0.001). In non-diabetic patients, PIA was associated with reduced peak CK [1549 (909–2909) vs. 1793 (996–3078), P = 0.0497], but not troponin (3.74 [2.23–7.11] vs. 4.56 [2.44–7.77] ng/ml, P = 0.19), and was not associated with reduced LVEF (32.0%, n = 85 vs. 37.4%, n = 207, P = 0.13). Both diabetic and non-diabetic patients with PIA had a lower likelihood of evolving with a Killip class III/VI (non-diabetic patients: 5.6% vs. 14.1%, P = 0.002; diabetic patients: 12.8% vs. 24.6%, P = 0.049). Over a median follow-up of 18.0 (12.1–25.5) months, PIA was associated with a significant reduction in the incidence of MACE [hazard ratio 0.52, 95% confidence interval (CI) 0.37–0.74, P < 0.001], irrespective of diabetes status.

Conclusion

PIA is an independent predictor of favourable outcomes in the setting of STEMI for both diabetic and non-diabetic patients.
Delirium is an important predictor of mortality in elderly patients with ST-elevation myocardial infarction: insight from National Inpatient Sample database
Authors: Patil Shivaraj , Gonuguntala Karthik , Rojulpote Chaitanya , Kumar Manish , Corradi John P. , Chen Kai
Published: October 2020

Objective

Delirium is a frequently encountered clinical condition in hospitalized patients and is known to be associated with poor outcomes. This study aims to assess the impacts of delirium in elderly patients undergoing percutaneous coronary intervention (PCI) following ST-elevation myocardial infarction (STEMI).

Methods

We queried the National Inpatient Samples from 2010 to 2014 to identify all patients aged 65 and older, and admitted with a primary diagnosis of STEMI undergoing PCI by using the International Classification of Diseases-Ninth Edition-Clinical Modification diagnosis codes. The patients with delirium from this cohort were further evaluated. Multivariate regression model with SPSS Statistics 25.0 (IBM Corp., Armonk, New York, USA) was used to study the association between delirium and clinical outcomes including in-hospital mortality and length of stay (LOS).

Results

Out of weighted 42 980 patients aged ≥65 years with STEMI and PCI, delirium was present in 774 patients, accounting for 1.8% of this cohort. These patients were found to be older and had more underlying co-morbidities, compared to those without delirium [Median Charlson score 2 (1; 3) vs. 0 (0; 2); P < 0.001]. In-hospital mortality in STEMI patients with delirium was significantly higher than those without delirium [42.7% vs. 7.6%; unadjusted odds ratio (OR) 9.07; 95% confidence interval (CI) 6.55–12.57; P < 0.001; adjusted OR 1.86; 95% CI 1.13–3.04; P = 0.014].

Conclusion

Older age and comorbidities are known predisposing factors for delirium, which is in turn associated with higher in-hospital mortality and increased LOS in elderly patients with STEMI who undergo PCI. This study underscores the role of delirium and implicates the importance of further studies in recognition and targeted care of delirium.