bluuebunny/crossref_metadata_2025 huggingface dataset:
Atypical symptoms, SARS-CoV-2 test results and immunisation rates in 456 residents from eight nursing homes facing a COVID-19 outbreak
Authors: Blain Hubert , Gamon Lucie , Tuaillon Edouard , Pisoni Amandine , Giacosa Nadia , Albrand Mylène , Miot Stéphanie , Rolland Yves , Picot Marie-Christine , Bousquet Jean
Published: February 2021

Background

Frail older persons may have an atypical presentation of coronavirus disease 2019 (COVID-19). The value of real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nursing homes (NHs) residents is not known.

Objective

To determine whether (i) atypical symptoms may predict rRT-PCR results and (ii) rRT-PCR results may predict immunisation against SARS-CoV-2 in NH residents.

Design

A retrospective longitudinal study.

Setting

Eight NHs with at least 10 rRT-PCR-positive residents.

Subjects

A total of 456 residents.

Methods

Typical and atypical symptoms recorded in residents’ files during the 14 days before and after rRT-PCR testing were analysed. Residents underwent blood testing for IgG-SARS-CoV-2 nucleocapsid protein 6 to 8 weeks after testing. Univariate and multivariate analyses compared symptoms and immunisation rates in rRT-PCR-positive and negative residents.

Results

A total of 161 residents had a positive rRT-PCR (35.3%), 17.4% of whom were asymptomatic before testing. Temperature >37.8°C, oxygen saturation <90%, unexplained anorexia, behavioural change, exhaustion, malaise and falls before testing were independent predictors of a further positive rRT-PCR. Among the rRT-PCR-positive residents, 95.2% developed SARS-CoV-2 antibodies vs 7.6% in the rRT-PCR-negative residents. Among the residents with a negative rRT-PCR, those who developed SARS-CoV-2 antibodies more often had typical or atypical symptoms (P = 0.02 and <0.01, respectively).

Conclusion

This study supports a strategy based on (i) testing residents with typical or unexplained atypical symptoms for an early identification of the first SARS-CoV-2 cases, (ii) rT-PCR testing for identifying COVID-19 residents, (iii) repeated wide-facility testing (including asymptomatic cases) as soon as a resident is tested positive for SARS-CoV-2 and (iv) implementing SARS-CoV-2 infection control measures in rRT-PCR-negative residents when they have unexplained typical or atypical symptoms.
Medicaid reimbursement for pharmacist services: A strategy for the pharmacy profession
Authors: Schweitzer Pamela , Atalla Mark
Published: February 2021

Purpose

Reimbursement for pharmacist services is complex due to a different set of rules for each payer. State legislatures, regulators, and professional licensing bodies have expanded the scope of practice for pharmacists in many states, representing a significant opportunity for third-party payers, including the Centers for Medicare and Medicaid Services, to enable and expand patient access to, and receipt of, care from pharmacists. This paper will introduce the term “other licensed practitioner” and describe how a state Medicaid program may include covered services provided by a pharmacist practitioner using the Medicaid state plan amendment process.

In recent years, states have made great strides in training and educating high-quality pharmacist practitioners, expanding the scope of practice in all states, incorporating a credentialing and privileging process, and expanding the use of collaborative practice agreements with physicians and nurse practitioners. Pharmacists are well-positioned, essential members of the healthcare team, providing a spectrum of clinical and prevention services that increase access to care and improve health outcomes.

Conclusion

A broad coalition of stakeholders including states, the federal government, pharmacy organizations, and other parts of the health ecosystem, working together, can better address the health needs of a state and its Medicaid beneficiaries. Pharmacist practitioners across different settings of care can augment public health efforts, as well as primary and specialty care practices. State efforts should include enrollment and reimbursement of pharmacist practitioners as Medicaid providers for pertinent Medicaid-covered services.
Description of a pharmacist-managed/administered penicillin allergy skin testing service at a community hospital
Authors: Torney Nicholas P , Tiberg Michael D
Published: February 2021

Purpose

To describe how a pharmacist-managed and pharmacist-administered penicillin allergy skin testing (PAST) service was incorporated into an antimicrobial stewardship program at a community hospital.

Methods

A pharmacist-managed/administered PAST service was initiated in October 2015. Patients 18 years of age or older were considered for PAST if they had a reported history of a type I or unknown type of allergic reaction to penicillin that occurred more than 5 years previously. Patients with a vague allergy history were considered for PAST if the provider was uncomfortable prescribing a preferred β-lactam out of concern for penicillin allergy. Patients were excluded if they were pregnant, had a history of a non–type I allergic reaction, or recently received antihistamines. The primary outcome was the percentage of patients who underwent PAST and were subsequently transitioned to a preferred β-lactam.

Results

PAST was initiated in 90 patients from October 2015 to December 2019. Eighty-five out of 90 patients (94%) completed PAST. Seventy-six out of 90 patients (84.4%) who underwent PAST were transitioned to a preferred β-lactam. The most commonly administered antibiotics prior to PAST were vancomycin, cefepime, and metronidazole. The most commonly used antibiotics after PAST were penicillin, piperacillin/tazobactam, and ampicillin/sulbactam. Among the 90 patients who underwent PAST, alternative antibiotics were avoided for a total of 1,568 days, with a median of 11 days (interquartile range, 6-18 days) avoided per patient.

Conclusion

Incorporating a pharmacist-managed/administered PAST service into a community hospital’s antimicrobial stewardship program can improve the utilization of preferred antimicrobial therapy and help avoid use of more toxic, costly antimicrobials.
Update on methylphenidate and dexmethylphenidate formulations for children with attention-deficit/hyperactivity disorder
Authors: Pheils Jim , Ehret Megan J
Published: February 2021

Purpose

Current literature on the safety and efficacy of intermediate- and long-acting formulations of methylphenidate and dexmethylphenidate for attention-deficit/hyperactivity disorder (ADHD) is evaluated.

Methylphenidate has been an established treatment for ADHD, but due to its relatively short half-life, numerous intermediate- and long-acting products have been developed. While these extended-release products provide efficacy similar to that of immediate-acting products, the pharmacokinetics and adverse effects can vary. Intermediate-acting methylphenidate products have effects that can last as long as 8 hours, but clinically patients have still required twice-daily dosing. Long-acting products have helped to address these challenges, with recently developed products including controlled-release and bimodal-delivery systems and a patch formulation. Many of these products can be opened and sprinkled on applesauce for ease of administration.

Conclusion

Knowledge of the various formulations of methylphenidate and dexmethylphenidate is crucial for appropriate medication selection for control of ADHD symptoms. Knowledge of differences between release mechanisms and the pharmacokinetic properties are essential for appropriate use of these products.
Browning of Maillard reaction systems containing xylose and 4-hydroxy-5-methyl-3(2H)-furanone
Authors: Nakamura Miki , Mikami Yoko , Noda Kyoko , Murata Masatsune
Published: February 2021

Pentose is involved in the browning through the Maillard reaction of food derived of plant origin. During research on the Maillard reaction between xylose (Xyl) and lysine (Lys), we detected 4-hydroxy-5-methyl-3(2H)-furanone (HMFO) as a major decomposition product of Xyl. To clarify the chemical pathway of the browning of pentose system, the formation and decomposition of dicarbonyls from HMFO and Xyl were examined. In the HMFO system, HMFO was oxidatively hydrolyzed to form 2-hydroxy-3,4-dioxopentanal, which leads to the formation of methylglyoxal (MGO) and then diacetyl (DA). In the Xyl system, MGO was also the major dicarbonyl degradation product from 1-deoxyxylosone (1-DX). Among Xyl, HMFO, MGO, and DA, MGO turned brown most rapidly in the presence of Lys and formed melanoidin-like brown pigments. In the Xyl system, MGO derived from HMFO and 1-DX most contributed to the browning, although some low-molecular-weight pigments, a colorless polymer, and fluorescent substances were also formed.
Regulation of the activity of maize glutamate dehydrogenase by ammonium and potassium
Authors: Zhao Yanjie , Gao Jie , Su Shengzhong , Shan Xiaohui , Li Shipeng , Liu Hongkui , Yuan Yaping , Li He
Published: February 2021

Glutamate dehydrogenase (GDH) is an important enzyme in ammonium metabolism, the activity of which is regulated by multiple factors. In this study, we investigate the effects of ammonium and potassium on the activity of maize GDH. Our results show that both ammonium and potassium play multiple roles in regulating the activity of maize GDH, with the specific roles depending on the concentration of potassium. Together with the structural information of GDH, we propose models for the substrate inhibition of ammonium, and the elimination of substrate inhibition by potassium. These models are supported by the analysis of statistic thermodynamics. We also analyze the binding sites of ammonium and potassium on maize GDH, and the conformational changes of maize GDH. The findings provide insight into the regulation of maize GDH activity by ammonium and potassium and reveal the importance of the dose and ratio of nitrogen and potassium in crop cultivation.
Direct LC–ESI–MS/MS analysis of plant glucosylceramide and ceramide species with 8E and 8Z isomers of the long chain base
Authors: Yumoto Emi , Sato Masaki , Kubota Tomoyoshi , Enomoto Hirofumi , Miyamoto Koji , Yamane Hisakazu , Koga Jinichiro
Published: February 2021

Glucosylceramides and ceramides with 8E and 8Z isomers of the long chain base are found in plants. These isomers have been difficult to quantify separately using liquid chromatography–tandem mass spectrometry (LC–MS/MS) because the isomers have the same retention time, their precursor and product ions have the same m/z values, and plant ceramide standards are not commercially available. Here we tested trial separations using various ODS columns and prepared plant ceramide standards generated by human glucocerebrosidase (imiglucerase) using commercially available plant glucosylceramide standards as the substrates. Consequently, we were able to quantify the isomers based on differences in retention times in a TSKgel ODS-120A column (Tosoh, Tokyo Japan) using LC–electrospray ionization–MS/MS (LC–ESI–MS/MS).
(−)-Epigallocatechin-3-O-gallate at a high concentration may induce lipolysis via ATP consumption by activation of stress defense mechanisms
Authors: Suihara Satoki , Ishisaka Akari , Murakami Akira
Published: February 2021

Green tea catechins have thus far been demonstrated to have antiobesity effects in a variety of experimental models. However, upstream molecular events triggering those phenomena remain to be identified. In this study, we found that (−)-epigallocatechin-3-O-gallate (EGCG) promoted lipolysis in lipid-loaded Huh7 human hepatoma cells. Notably, EGCG at a high concentration induced both oxidative stress and protein stress (proteo-stress), leading to activation of stress defense mechanisms, such as mRNA expressions of antioxidant and phase-2 detoxifying enzymes, and heat shock proteins. Furthermore, EGCG decreased the level of intracellular ATP, while glucose uptake from culture media was promoted possibly for energy homeostasis. EGCG also upregulated the expression of adipose triglyceride lipase, and activated AMP-activated protein kinase. Collectively, these results suggest that EGCG induces lipolysis to compensate for ATP reduction derived from activation of stress defense systems against its oxidative and proteo-stress properties.
Progression of electrocardiogram changes in an untreated fabry disease: a case report
Authors: Mattig Isabel , Canaan-Kühl Sima , Tillmanns Christoph , Knebel Fabian
Published: February 2021

Background

Fabry disease (FD) is a rare lysosomal storage disorder with multiorgan manifestation and associated with an increased morbidity and mortality. Fabry cardiomyopathy includes left ventricular ‘hypertrophy’ (LVH), cardiac arrhythmias, and heart failure. We report a case of an untreated FD with characteristic findings in electrocardiogram (ECG) over a follow-up period of 10 years.

Case summary

A 53-year-old man with FD presented to our outpatient department. He suffered from symptomatic ventricular extrasystoles. Echocardiography detected LVH and reduced global longitudinal strain. Twelve years ago, first examination was conducted due to ventricular arrhythmias. Electrocardiogram showed a short PQ minus P-wave (PendQ) interval and negative T-waves. Over time, the number of leads with negative T-waves increased. Moreover, the echocardiography revealed a thickened left ventricular wall. Without any further examinations at that time, the patient was treated for arterial hypertension with proteinuria. Ten years after first symptoms appeared, FD was diagnosed utilizing cardiac magnetic resonance imaging and genetic tests. Hence, enzyme replacement therapy was initiated.

Discussion

The ECG is a fast diagnostic method and it may — even without additional organ manifestations — provide preliminary suspicion of FD. In particular, as shown in our case, a short PendQ and QT interval indicate FD. Over time, disease progression can be detected through ECG changes. T-waves correlate with an increasing LVH and a reduction in longitudinal function in echocardiographic examinations. Unexplained LVH must be followed by differential diagnosis. In case of confirmed FD, patients should be treated by multidisciplinary teams in experienced centres.
Subepicardial aneurysm with free wall rupture and its successful surgical intervention: a case report
Authors: Fukui Tomoki , Kitabayashi Katsukiyo , Ogasawara Nobuyuki , Hasegawa Shinji
Published: February 2021

Background

Subepicardial aneurysm (SEA) is an uncommon but potentially fatal complication of acute myocardial infarction (MI) associated with an increased risk of free wall rupture (FWR) leading to sudden death. We describe a rare case of a silent myocardial infarction complicated by SEA and subsequent FWR, resulting in cardiac tamponade.

Case summary

A 68-year-old man with no previous chest symptoms presented with syncope. Cardiac computed tomography incidentally revealed a small aneurysmal cavity at the inferolateral wall of the left ventricle, which was overlooked on initial transthoracic echocardiography. Coronary angiography demonstrated a narrowed first obtuse marginal branch with coronary slow flow, suggesting that spontaneous recanalization of the occluded obtuse marginal branch induced SEA and subsequent FWR. The patient underwent an emergency left ventricular aneurysm repair. The post-operative course was uneventful, and the patient was discharged from the hospital on post-operative day 20.

Discussion

This case emphasizes the importance of prompt detection and surgical intervention for SEA. Subepicardial aneurysm should be suspected in patients with pericardial effusion and suspected MI. Cardiac computed tomography is not only useful in the detection of such cases but also facilitates the development of a successful surgical strategy.
The effect of confounding data features on a deep learning algorithm to predict complete coronary occlusion in a retrospective observational setting
Authors: Brisk Rob , Bond Raymond , Finlay Dewar , McLaughlin James , Piadlo Alicja , Leslie Stephen J , Gossman David E , Menown Ian B , McEneaney D J , Warren S
Published: February 2021

Aims

Deep learning (DL) has emerged in recent years as an effective technique in automated ECG analysis.

Methods and results

A retrospective, observational study was designed to assess the feasibility of detecting induced coronary artery occlusion in human subjects earlier than experienced cardiologists using a DL algorithm. A deep convolutional neural network was trained using data from the STAFF III database. The task was to classify ECG samples as showing acute coronary artery occlusion, or no occlusion. Occluded samples were recorded after 60 s of balloon occlusion of a single coronary artery. For the first iteration of the experiment, non-occluded samples were taken from ECGs recorded in a restroom prior to entering theatres. For the second iteration of the experiment, non-occluded samples were taken in the theatre prior to balloon inflation. Results were obtained using a cross-validation approach. In the first iteration of the experiment, the DL model achieved an F1 score of 0.814, which was higher than any of three reviewing cardiologists or STEMI criteria. In the second iteration of the experiment, the DL model achieved an F1 score of 0.533, which is akin to the performance of a random chance classifier.

Conclusion

The dataset was too small for the second model to achieve meaningful performance, despite the use of transfer learning. However, ‘data leakage’ during the first iteration of the experiment led to falsely high results. This study highlights the risk of DL models leveraging data leaks to produce spurious results.
Role of social support in the relationship between financial hardship and multimorbidity—a causal mediation analysis
Authors: Singh Ankur , Contreras Suarez Diana , You Emily , Fleitas Alfonzo Ludmila , King Tania
Published: February 2021

Background

Social disadvantage is a key determinant of multimorbidity. Pathways through which social disadvantage leads to multimorbidity are yet undefined. In this study, we first examined the causal effect of moving into financial hardship on multimorbidity among Australian adults, and then the role of social support as a mediator of the relationship between financial hardship and multimorbidity.

Methods

Data were obtained from the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2009–2013). We identified individuals who moved into financial hardship between 2010 and 2011 (n = 5775). Inverse probability treatment weighting with regression adjustment was used to examine the relationship between financial hardship and multimorbidity. Causal mediation analysis was applied to decompose the total effect of financial hardship on multimorbidity into the proportion attributable to social support and the proportion not occurring through measured pathways. We accounted for baseline covariates including age, sex, marital status, educational attainment, employment status, income, country of birth, multimorbidity and social support. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs).

Results

The risk of multimorbidity was higher in those with financial hardship by 19% [relative risk 1.19 (95% CI: 1.02–1.37) and absolute risk difference 0.036 (95% CI: 0.004–0.067)] than those without financial hardship. Social support accounted for 30% of the total effect of financial hardship on multimorbidity, risk difference 0.009 (95% CI: 0.003–0.018).

Conclusions

Financial hardship leads to increased risk of multimorbidity. Interventions directed at increasing social support among those in financial hardship may reduce their risk of multimorbidity.
Identification of pathways modulating vemurafenib resistance in melanoma cells via a genome-wide CRISPR/Cas9 screen
Authors: Goh Corinna Jie Hui , Wong Jin Huei , El Farran Chadi , Tan Ban Xiong , Coffill Cynthia R , Loh Yuin-Han , Lane David , Arumugam Prakash
Published: February 2021

Vemurafenib is a BRAF kinase inhibitor (BRAFi) that is used to treat melanoma patients harboring the constitutively active BRAF-V600E mutation. However, after a few months of treatment patients often develop resistance to vemurafenib leading to disease progression. Sequence analysis of drug-resistant tumor cells and functional genomic screens has identified several genes that regulate vemurafenib resistance. Reactivation of mitogen-activated protein kinase (MAPK) pathway is a recurrent feature of cells that develop resistance to vemurafenib. We performed a genome-scale CRISPR-based knockout screen to identify modulators of vemurafenib resistance in melanoma cells with a highly improved CRISPR sgRNA library called Brunello. We identified 33 genes that regulate resistance to vemurafenib out of which 14 genes have not been reported before. Gene ontology enrichment analysis showed that the hit genes regulate histone modification, transcription and cell cycle. We discuss how inactivation of hit genes might confer resistance to vemurafenib and provide a framework for follow-up investigations.
Evaluating short-term forecasting of COVID-19 cases among different epidemiological models under a Bayesian framework
Authors: Li Qiwei , Bedi Tejasv , Lehmann Christoph U , Xiao Guanghua , Xie Yang
Published: February 2021

Background

Forecasting of COVID-19 cases daily and weekly has been one of the challenges posed to governments and the health sector globally. To facilitate informed public health decisions, the concerned parties rely on short-term daily projections generated via predictive modeling. We calibrate stochastic variants of growth models and the standard susceptible-infectious-removed model into 1 Bayesian framework to evaluate and compare their short-term forecasts.

Results

We implement rolling-origin cross-validation to compare the short-term forecasting performance of the stochastic epidemiological models and an autoregressive moving average model across 20 countries that had the most confirmed COVID-19 cases as of August 22, 2020.

Conclusion

None of the models proved to be a gold standard across all regions, while all outperformed the autoregressive moving average model in terms of the accuracy of forecast and interpretability.
A study of the lateral heterogeneity with the ellipticity of Rayleigh waves derived from microtremors
Authors: Du Qingling , Liu Zhengping , Liu Shijie , Zhang Li , Yu Wenfu
Published: February 2021

We examine the potential of frequency-dependent Rayleigh wave ellipticity, derived from microtremors, for the investigation of heterogeneous subsurface structure. Based on numerical simulation, we analyse the effects of interference waves in microtremors, primarily the various propagation directions of the Rayleigh waves, linear polarization waves and white noise, on the ellipticity frequency-dependent estimation of the Rayleigh waves. A data processing scheme to separate the Rayleigh waves from the interference waves is proposed and verified by synthetic data. We performed a field experiment in the mountainous areas of Southwest China to show that the ellipticity frequency dependence of Rayleigh waves in the period range of 0.05–5 s can be estimated from the microtremor records with the proposed data processing scheme. In addition, the method is feasible for investigating lateral heterogeneity within the top several hundred metres in the mountain regions. The study also reveals that the features of the ellipticity anomaly of a local heterogeneity are related to the propagation directions of the Rayleigh waves, and to reduce the ambiguity of the anomaly, the propagation direction of the waves picked for the ellipticity estimation should be consistent with (along or opposite to) that of the survey line. Then, to eliminate the effects of the phase differences due to the propagation direction, or time, the ellipticity for each location should be estimated by a single event rather than multiple events from the derived Rayleigh wave arrivals.
The Epidemiology of Stunted Growth in Refugee Patients with Chronic Burn Injuries
Authors: Makkawi Kareem W , Hajjar Marwan S , Hatabah Dunia E , Abu-Sittah Ghassan S
Published: February 2021

The aim of this study is to identify the prevalence of stunted growth in Syrian refugee children with chronic burn injuries and to compare it to other children (±burn) of similar socioeconomic status. This is a retrospective medical chart review conducted on 142 Syrian refugee children (≤18 years of age) who have sustained war-related and nonwar-related chronic burn injuries between 2014 and 2020. Stunted growth was measured using the height-for-age z score. The majority of burn injuries were among children below 5 years of age. The prevalence of stunting was 9.2% in our sample, with an overall mean z-score of –0.491 (SD = 1.1). There was no statistically significant difference in z-scores between males and females. The majority of stunted patients are those who sustain their burn injuries at an early age. Early management of burn injuries is key in preventing adverse outcomes associated with stunting. Further research, planning, funding, and targeted interventions are required by stakeholders to alleviate the burden of stunting in the pediatric refugee population, along with the health and economic consequences that it entails.
“Let Me Confess”: Confession, Complicity, and #MeToo in Junot Díaz'sThis is How You Lose Herand “The Silence: The Legacy of Childhood Trauma”
Authors: McHugh-Dillon Ruth
Published: February 2021

Confession plays a crucial yet ambivalent role in Junot Díaz’s fiction and paratexts. While scholarship has emphasized confession as a powerful means of witnessing male misbehavior, the #MeToo era urges readers to question who or what, beyond mere representation, confession serves. I suggest that protagonist Yunior’s compulsive confessions of lying, cheating and womanizing in This is How You Lose Her (2012) expose how his sense of self is split between an authoritarian Dominican past and an oppressive US present. Yunior’s macho behavior conjures the historical specter of Dominican strongman dictator, Trujillo, while his confessions make readers complicit in his immorality, echoing Trujillo’s manipulation of information for control. Forging this uneasy textual intimacy between reader and narrator further underscores mainstream expectations, in the US present, that minority writers “confess” their intimate lives for entertainment, conscribing how and what they express. Yet Yunior’s narrative also conscribes female representation by centering—and then absolving—male misbehavior through a confession that looks like a dialogue (addressing “you”) but in fact functions as a monologue. I also interrogate Díaz’s authorial interviews and apply Lili Loofbourow’s idea of the “male self-pardon” to Díaz’s autobiographical essay “The Silence: The Legacy of Childhood Trauma” (2018), in which he reveals surviving childhood sexual assault and confesses that he subsequently “hurt” intimate female partners. I argue that confession—whether Yunior’s or Díaz’s—perpetuates a masculine monologue that marginalizes women’s voices. Masculine confessions reach for intimacy but fail when they cannot imagine women as fully as men.
Whole-genome Sequencing of SARS-CoV-2: Using Phylogeny and Structural Modeling to Contextualize Local Viral Evolution
Authors: Nazario-Toole Ashley E , Xia Hui , Gibbons Thomas F
Published: February 2021

Introduction

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a global pandemic resulting in over 1 million deaths worldwide. In the Department of Defense (DoD), over 129,000 personnel (civilians, dependents, and active duty) have been infected with the virus to date. Rapid estimations of transmission and mutational patterns of virus outbreaks can be accomplished using whole-genome viral sequencing. Deriving interpretable and actionable results from pathogen sequence data is accomplished by the construction of phylogenetic trees (from local and global virus sequences) and by the creation of protein maps, to visualize and predict the effects of structural protein amino acid mutations.

Materials and Methods

We developed a sequencing and bioinformatics workflow for molecular epidemiological SARS-CoV-2 surveillance using excess clinical specimens collected under an institutional review board exempt protocol at Joint Base San Antonio, Lackland AFB. This workflow includes viral RNA isolation, viral load quantification, tiling-based next-generation sequencing, sequencing and bioinformatics analysis, and data visualization via phylogenetic trees and protein mapping.

Results

Sequencing of 37 clinical specimens collected at JBSA/Lackland revealed that by June 2020, SAR-CoV-2 strains carrying the 614G mutation were the predominant cause of local coronavirus disease 2019 infections. We identified 109 nucleotide changes in the coding region of the SARS-CoV-2 genome (which lead to 63 unique, non-synonymous amino acid mutations), one mutation in the 5ʹ-untranslated region (UTR), and two mutations in the 3ʹUTR. Furthermore, we identified and mapped six additional spike protein amino acid changes—information which could potentially aid vaccine design.

Conclusion

The workflow presented here is designed to enable DoD public health officials to track viral evolution and conduct near real-time evaluation of future outbreaks. The generation of molecular epidemiological sequence data is critical for the development of disease intervention strategies—most notably, vaccine design. Overall, we present a streamlined sequencing and bioinformatics methodology aimed at improving long-term readiness efforts in the DoD.
The Potential Role of Functional Motor Competence to Promote Physical Military Readiness: A Developmental Perspective
Authors: Silvey Kyle , Porter Jason , Sacko Ryan S , Hand Amy F , Terlizzi Bryan M , Abrams Thomas C , Stodden David F
Published: February 2021

Decreased physical fitness in military recruiting populations is problematic for the development of physical military readiness (PMR) and presents a threat to national security. The demonstration of low levels of fitness may be an indicator of a more foundational problem in the physical development of military recruits. We propose the development of functional motor competence (FMC) across childhood and adolescence as a necessary antecedent to advanced PMR training and military-specific tasks (i.e., rucking and obstacle course navigation) and as an integral part of sustained PMR. The development of FMC supports increases in cardiovascular and muscular endurance through repeated efforts performed during practice and in sport, as well as muscular power as many FMC movements mimic plyometrics in a strength in conditioning sense. We posit that an inadequate foundation in FMC will serve as a barrier to achieving sufficient PMR and combat success of the fighting force. We propose three possible solutions to ensure sufficient PMR levels through the implementation of developmentally appropriate FMC-based training. First would be promoting FMC-based training in junior reserve officer training corp and ROTC programs. Second would be a more global approach, on the scale of the National Defense Education Act, specifically focusing on promoting quality daily physical education that could reach millions of children. Third, individual branches could begin promoting the tenets of foundational FMC training concepts in their physical training manuals, which ideally would address FMC before and throughout basic training, as well as subsequent active duty training.
Shallow Water Diving-Associated Alveolar Hemorrhage in an Active Duty Sailor: A Case Report
Authors: Inman Brannon L , Bridwell Rachel E , Cibrario Amber , Goss Sarah , Oliver Joshua J
Published: February 2021

Breath-hold diving is a common practice as a part of military dive training. An association between prior lung injury and a propensity for lung barotrauma may have the potential to impact mission readiness for combat divers, Pararescue, Combat Controllers, Army Engineer divers, and various units in Naval Special Warfare and Special Operations. Barotrauma is a common complication of diving, typically occurring at depths greater than 30 m (98.4 ft). Individuals with abnormal lung anatomy or function may be at increased risk of barotrauma at shallower depths than those with healthy lungs, rendering these service members unfit for certain missions. We describe the case of a 25-year-old male, with a remote history of polytrauma and resultant pulmonary pleural adhesions, whose dive training was complicated by lung barotrauma at shallow depths. In missions or training utilizing breath-hold diving, the association with secondary alterations in lung or thoracic anatomy and function may limit which service members can safely participate.
Anterior Mediastinal Mass Causing Intermittent Atrial Fibrillation
Authors: Spanier Adam M , Evans Garrett R , Hiller Hugh M
Published: February 2021

Mediastinal masses are a rare finding in the emergency department and typically present with vague chest complaints such as chest discomfort, chest pain, or dyspnea. Rarely do these tumors present with dysrhythmias, and when dysrhythmias are present, they typically arise secondary to endocrine or metabolic effects exerted by the tumor. Here we report a case of a patient who presented to the emergency department with atrial fibrillation with rapid ventricular response, concomitant with a history of recurrent palpitations that were previously aborted with self-induced vagal maneuvers. Upon further investigation, the patient had an anterior mediastinal mass, diagnosed as a thymoma, suspected to be contributing to his presenting dysrhythmia through mass effect.
Identifying Best Practices in Pharmacy Experience: An Analysis of Military Treatment Facilities With the Highest Pharmacy Patient Experience Scores
Authors: Frazier Chantell , Marshall-Aiyelawo Kimberley , Gliner Melissa , Holden Craig , Fowler Tara , Black Cydny
Published: February 2021

Introduction

Pharmacy patient experience within military treatment facilities (MTFs) is a significant indicator of healthcare quality, as hospital admissions correlate with medication use (Budnitz et al., 2006) and pharmacists have a unique opportunity to influence patients’ health (Dalton & Byrne, 2017). To improve patient care across the military health system (MHS), we investigated best practices within MTF pharmacies with the highest patient experience scores.

Materials and Methods

Researchers performed semi-structured telephone interviews with pharmacists, pharmacy technicians, and patient experience officers from three of the highest ranked MTF pharmacies according to outpatient satisfaction survey results to glean “best practice” approaches to patient care. Researchers utilized the Gioia approach as a guiding theory for qualitative analysis of the interview data, and the study was excluded from a requirement to obtain institutional review board approval due to the number of respondents in accordance with the Paperwork Reduction Act of 1980 guidelines.

Results

Interview participants from highly rated pharmacies emphasized the importance of communication among and between staff and patients, staff engagement and morale, and supportive leadership at their facilities for creating a positive patient experience and clinical environment.

Conclusion

These findings provide valuable insights to improve public health in military-connected populations through improved patient care practices in pharmacies across the MHS. Initiatives aimed at improving health care for pharmacy patients should prioritize improved communication and structural support for team members to create patient-friendly environments, which enables pharmacists and technicians to connect with patients and positively impact health outcomes. Limitations include lack of comparison data for lower performing pharmacies; future research will explore practices at lower ranking pharmacies to provide insights into communication practices, environments, and staff relationships impacting patient experience scores as well as the role patient demographics (e.g., retirees vs. active duty) and characteristics including facility size play in potential improvements.
Bidirectional Ventricular Tachycardia in a Young Female: A Case of Andersen-Tawil Syndrome
Authors: Ransom Jacob L , Wong Ka C , Kircher Jacqueline , Usry Courtney , Larson Christopher
Published: February 2021

Bidirectional ventricular tachycardia (VT) is a rare ventricular dysrhythmia with a limited differential diagnosis that includes digitalis toxicity, catecholaminergic polymorphic VT, aconite poisoning, and genetic channelopathy syndromes, specifically, Andersen–Tawil syndrome (ATS). We present a case of a young female with palpitations found to have bidirectional VT on cardiac event monitor and strong family history of cardiac dysrhythmias. Her physical examination findings included minor dysmorphic features of mandibular hypoplasia, hypertelorism, and clinodactyly. The patient was clinically diagnosed with ATS and started on a beta-blocker for control of ectopy. A second Holter review demonstrated markedly decreased burden of ventricular ectopy compared to the initial monitoring. She was referred for genetic testing, which revealed a KCNJ2 mutation. Bidirectional VT is an uncommon ventricular dysrhythmia that has a limited differential diagnosis, one of which is ATS—a rare genetic disorder that results from mutations in the KCNJ2 gene. The condition is frequently associated with developmental, skeletal, and cardiac abnormalities. Although there are no strong recommendations that exist for treatment of ventricular dysrhythmias associated with this genetic disorder, we demonstrate a case of clinical improvement in a patient with ATS by using the beta-blocker metoprolol succinate. Furthermore, we propose that ATS patients may not need exercise restrictions as overall ventricular ectopy burden decreased with exercise and there was no prolongation of the QT interval. This patient will continue to follow up in our clinic to reassess symptom burden and for continued monitoring for the development of any new features.
Treatment of Mal de Debarquement Syndrome in a Computer-Assisted Rehabilitation Environment
Authors: Hoppes Carrie W , Vernon Michael , Morrell Rebecca L , Whitney Susan L
Published: February 2021

Individuals with mal de debarquement syndrome (MdDS) describe symptoms of swaying, rocking, and/or bobbing after sea or air travel. These symptoms may be because of maladaptation of the vestibulo-ocular reflex (VOR) to roll of the head during rotation. Dai and colleagues have developed a treatment paradigm that involves passive roll of the patient’s head while watching optokinetic stripes, resulting in adaption of the VOR and improvement of MdDS. The purpose of this case report is to describe replication of this treatment paradigm in a virtual reality environment with successful resolution of symptoms in two visits. A 39-year-old female reported swaying and rocking after returning from a 7-day cruise. The patient was treated with two sessions in a computer-assisted rehabilitation environment (CAREN). The patient canceled her third visit because of complete resolution of her symptoms. Her Global Rating of Change was +7 (on a 15-point scale of −7 to +7). She had returned to her prior level of function. This case report is the first to describe use of the CAREN for effective treatment of MdDS by replicating the treatment paradigm developed by Dai and colleagues.
What’s limbs got to do with it? Real-world movement correlates with feelings of ownership over virtual arms during object interactions in virtual reality
Authors: Lavoie Ewen , Chapman Craig S
Published: February 2021

Humans will initially move awkwardly so that the end-state of their movement is comfortable. But, what is comfortable? We might assume it refers to a particular physical body posture, however, humans have been shown to move a computer cursor on a screen with an out-of-sight hand less efficiently (curved) such that the visual representation appears more efficient (straight). This suggests that movement plans are made in large part to satisfy the demands of their visual appearance, rather than their physical movement properties. So, what determines if a body movement is comfortable—how it feels or how it looks? We translated an object-interaction task from the real-world into immersive virtual reality (IVR) to dissociate a movement from its visual appearance. Participants completed at least 20 trials in two conditions: Controllers—where participants saw a visual representation of the hand-held controllers and Arms—where they saw a set of virtual limbs. We found participants seeing virtual limbs moved in a less biomechanically efficient manner to make the limbs look similar to if they were interacting with a real-world object. These movement changes correlated with an increase in self-reported feelings of ownership over the limbs as compared to the controllers. Overall this suggests we plan our movements to provide optimal visual feedback, even at the cost of being less efficient. Moreover, we speculate that a detailed measurement of how people move in IVR may provide a new tool for assessing their degree of embodiment. There is something about seeing a set of limbs in front of you, doing your actions, that affects your moving, and in essence, your thinking.
Nerve Graft Length and Recovery of Elbow Flexion Muscle Strength in Patients With Traumatic Brachial Plexus Injuries: Case Series
Authors: Socolovsky Mariano , di Masi Gilda , Bonilla Gonzalo , Lovaglio Ana , Krishnan Kartik G
Published: February 2021

BACKGROUND

Traumatic brachial plexus injuries cause long-term maiming of patients. The major target function to restore in complex brachial plexus injury is elbow flexion.

OBJECTIVE

To retrospectively analyze the correlation between the length of the nerve graft and the strength of target muscle recovery in extraplexual and intraplexual nerve transfers.

METHODS

A total of 51 patients with complete or near-complete brachial plexus injuries were treated with a combination of nerve reconstruction strategies. The phrenic nerve (PN) was used as axon donor in 40 patients and the spinal accessory nerve was used in 11 patients. The recipient nerves were the anterior division of the upper trunk (AD), the musculocutaneous nerve (MC), or the biceps branches of the MC (BBs). An index comparing the strength of elbow flexion between the affected and the healthy arms was correlated with the choice of target nerve recipient and the length of nerve grafts, among other parameters. The mean follow-up was 4 yr.

RESULTS

Neither the choice of MC or BB as a recipient nor the length of the nerve graft showed a strong correlation with the strength of elbow flexion. The choice of very proximal recipient nerve (AD) led to axonal misrouting in 25% of the patients in whom no graft was employed.

CONCLUSION

The length of the nerve graft is not a negative factor for obtaining good muscle recovery for elbow flexion when using PN or spinal accessory nerve as axon donors in traumatic brachial plexus injuries.
Modified Sternocleidomastoid Sparing Approach for Vertebral Artery (V1) to Common Carotid Artery Transposition: 2-Dimensional Operative Video
Authors: Travers Sarah , Siddiq Farhan
Published: February 2021

Vertebral artery (VA) V1 segment to common carotid artery (CCA) transposition is an uncommon operation with existing literature describing dissection of the sternoclavicular head of the sternocleidomastoid (SCM) muscle.
1,2
We present a modified approach for transposition without cutting the SCM. Our patient is a 76-yr-old female with history of a previous cerebellar stroke. Despite taking aspirin, she presented with another stroke resulting in severe dysarthria, vertigo, and gait disturbance. Magnetic resonance imaging (MRI) demonstrated several cerebellar infarcts. Catheter angiography demonstrated bilateral vertebral artery occlusion with filling from ascending cervical branches and a dominant left VA. We planned a left V1 to CCA transposition with a modified SCM-sparing approach for which the patient provided written informed consent. She was positioned supine with neck extended and face turned to the right. Neuromonitoring was utilized. A linear incision along the anterior border of the SCM was made, stopping 1.5 cm above the clavicular head. Neurovascular structures of the carotid sheath were dissected circumferentially and mobilized medially. The longus coli muscle over the C6 lateral mass was reflected medially. The vertebral artery was dissected to expose the maximum possible length. The inferior thyroid artery was sacrificed for better exposure. VA was ligated and transected. CCA was clamped. VA to CCA bypass was performed in a standard fashion. Surgical site was closed. The patient clinically did well postoperatively with immediate symptom improvement. Our video demonstrates an SCM-sparing technique of V1 to CCA transposition, which can be a less-extensive operation compared to the traditional approaches, which require transection of SCM head.
Microsleep disturbances are associated with noradrenergic dysfunction in Parkinson’s disease
Authors: Doppler Christopher E J , Smit Julia A M , Hommelsen Maximilian , Seger Aline , Horsager Jacob , Kinnerup Martin B , Hansen Allan K , Fedorova Tatyana D , Knudsen Karoline , Otto Marit , Nahimi Adjmal , Borghammer Per , Sommerauer Michael
Published: February 2021

Study Objectives

Parkinson’s disease (PD) commonly involves degeneration of sleep-wake regulating brainstem nuclei; likewise, sleep-wake disturbances are highly prevalent in PD patients. As polysomnography macroparameters typically show only minor changes in PD, we investigated sleep microstructure, particularly cyclic alternating pattern (CAP), and its relation to alterations of the noradrenergic system in these patients.

Methods

We analyzed 27 PD patients and 13 healthy control (HC) subjects who underwent overnight polysomnography and 11C-MeNER positron emission tomography for evaluation of noradrenaline transporter density. Sleep macroparameters, as well as CAP metrics, were evaluated according to the consensus statement from 2001. Statistical analysis comprised group comparisons and correlation analysis of CAP metrics with clinical characteristics of PD patients as well as noradrenaline transporter density.

Results

PD patients and HC subjects were comparable in demographic characteristics (age, sex, body mass index) and polysomnography macroparameters. CAP rate as well as A index differed significantly between groups, with PD patients having a lower CAP rate (46.7 ± 6.6% versus 38.0 ± 11.6%, p = 0.015) and lower A index (49.0 ± 8.7/hour versus 40.1 ± 15.4/hour, p = 0.042). In PD patients, both CAP metrics correlated significantly with diminished noradrenaline transporter density in arousal prompting brainstem nuclei (locus coeruleus, raphe nuclei) as well as arousal propagating brain structures like thalamus and bitemporal cortex.

Conclusions

Sleep microstructure is more severely altered than sleep macrostructure in PD patients and is associated with widespread dysfunction of the noradrenergic arousal system.