bluuebunny/crossref_metadata_2025 huggingface dataset:
Chapter IV
Authors: Eliot George
Published: December 2020

In three months from the time of Caterina’s adoption—namely, in the late autumn of 1773—the chimneys of Cheverel Manor were sending up unwonted smoke, and the servants were awaiting in excitement the return of their master and mistress after a two years’...
Chapter XVIII
Authors: Eliot George
Published: December 2020

At twelve o’clock, when all search and inquiry had been in vain, and the coroner was expected every moment, Mr Gilfil could no longer defer the hard duty of revealing this fresh calamity to Sir Christopher, who must otherwise have it discovered to him...
Chapter XXI
Authors: Eliot George
Published: December 2020

On the 30th of May 1790, a very pretty sight was seen by the villagers assembled near the door of Foxholm church. The sun was bright upon the dewy grass, the air was alive with the murmur of bees and the trilling of birds,...
The Religion of Healthy-Mindedness
Authors: James William
Published: December 2020

If we were to ask the question: ‘What is human life’s chief concern?’ one of the answers we should receive would be: ‘It is happiness.’ How to gain, how to keep, how to recover happiness, is in fact for most men at all times...
The Tranter’s
Authors: Hardy Thomas
Published: December 2020

It was a long low cottage with a hipped roof of thatch, having dormer windows breaking up into the eaves, a chimney standing in the middle of the ridge and another at each end.* The window-shutters were not yet closed, and the...
Going the Rounds
Authors: Hardy Thomas
Published: December 2020

Shortly after ten o’clock the singing-boys arrived at the tranter’s house, which was invariably the place of meeting, and preparations were made for the start. The older men and musicians wore thick coats with stiff perpendicular collars, and coloured handkerchiefs wound round and round...
Christmas Morning
Authors: Hardy Thomas
Published: December 2020

The choir at last reached their beds and slept like the rest of the parish. Dick’s slumbers through the three or four hours remaining for rest, were disturbed and slight—an exhaustive variation upon the incidents that had passed that night in connection with the...
They Dance More Wildly
Authors: Hardy Thomas
Published: December 2020

Dick had at length secured Fancy for that most delightful of country-dances, opening with six-hands-round.*

“Before we begin,” said the tranter, “my proposal is that ’twould be a right and proper plan for every mortal man in the dance to pull off his jacket,...
Driving Out of Budmouth
Authors: Hardy Thomas
Published: December 2020

An easy bend of neck, and graceful set of head: full and wavy bundles of dark-brown hair: light fall of little feet: pretty devices on the skirt of the dress: clear deep eyes: in short, a bunch of sweets: it was Fancy! Dick’s heart...
Further Along the Road
Authors: Hardy Thomas
Published: December 2020

DICK’S spirits having risen in the course of these admissions of his sweetheart he now touched Smart with the whip—and on Smart’s neck, not far behind his ears. Smart, who had been lost in thought for some time, never dreaming that Dick could...
Second Thoughts
Authors: Hardy Thomas
Published: December 2020

The next morning the vicar rose early. The first thing he did was to write a long and careful letter to his friend in Yorkshire. Then, eating a little breakfast, he crossed the meadows in the direction of Casterbridge, bearing his letter in his...
Street-sellers of Fruit and Vegetables
Authors: Mayhew Henry
Published: December 2020

Of Covent Garden Market

On a Saturday—the coster’s business day—it is computed that as many as 2,000 donkey-barrows, and upwards of 3,000 women with shallows and head-baskets visit this market during the forenoon. About six o’clock in the morning is the best time for viewing...
Identification of a Flavin Monooxygenase-Like Flavonoid 8-Hydroxylase with Gossypetin Synthase Activity from Lotus japonicus
Authors: Hiraga Yasuhide , Shimada Norimoto , Nagashima Yoshiki , Suda Kunihiro , Kanamori Tina , Ishiguro Kanako , Sato Yuka , Hirakawa Hideki , Sato Shusei , Akashi Tomoyoshi , Tanaka Yoshikazu , Ohta Daisaku , Aoki Koh , Shibata Daisuke , Suzuki Hideyuki , Kera Kota
Published: December 2020

Lotus japonicus is a model legume that accumulates 8-hydroxyflavonol derivatives, such as gossypetin (8-hydroxyquercetin) 3-O-glycoside, which confer the yellow color to its petals. An enzyme, flavonoid 8-hydroxylase (F8H; LjF8H), is assumed to be involved in the biosynthesis, but the specific gene is yet to be identified. The LjF8H cDNA was isolated as a flavin adenine dinucleotide (FAD)-binding monooxygenase-like protein using flower buds and flower-specific EST data of L. japonicus. LjF8H is a single copy gene on chromosome III consisting of six exons. The conserved FAD- and NAD(P)H-dependent oxidase motifs were found in LjF8H. Phylogenetic analysis suggested that LjF8H is a member of the flavin monooxygenase group but distinctly different from other known flavonoid oxygenases. Analysis of recombinant yeast microsome expressing LjF8H revealed that the enzyme catalyzed the 8-hydroxylation of quercetin. Other flavonoids, such as naringenin, eriodictyol, apigenin, luteolin, taxifolin and kaempferol, also acted as substrates of LjF8H. This broad substrate acceptance was unlike known F8Hs in other plants. Interestingly, flavanone and flavanonol, which have saturated C–C bond at positions 2 and 3 of the flavonoid C-ring, produced 6-hyroxylflavonoids as a by-product of the enzymatic reaction. Furthermore, LjF8H only accepted the 2S-isomer of naringenin, suggesting that the conformational state of the substrates might affect product specificity. The overexpression of LjF8H in Arabidopsis thaliana and Petunia hybrida synthesized gossypetin and 8-hydroxykaempferol, respectively, indicating that LjF8H was functional in plant cells. In conclusion, this study represents the first instance of cloning and identification of F8Hs responsible for gossypetin biosynthesis.
Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints
Authors: Govind Jayantilal , Bogduk Nikolai
Published: December 2020

Objectives

The study sought to assess the utility of controlled diagnostic blocks in patients with probable cervicogenic headache by determining the prevalence of sources of pain among the upper and lower synovial joints of the cervical spine.

Methods

Controlled diagnostic blocks were performed in 166 consecutive patients who clinically exhibited features consistent with a diagnosis of probable cervicogenic headache. Data were collected on how often a particular source of pain could be pinpointed and how often particular diagnostic blocks provided a positive yield.

Results

In patients in whom headache was the dominant complaint, diagnostic blocks succeeded in establishing the source of pain in 75% of patients. The C2-3 joint was the source of pain in 62%, followed by the C1-2 (7%) and C3-4 (6%). In patients in whom headache was less severe than neck pain, blocks were successful in 67%. C2-3 was the source of pain in 42%, followed by lower cervical joints in 18% and the C3-4 joint in 7%.

Conclusions

Controlled diagnostic blocks can establish the source of pain in the majority of patients presenting with probable cervicogenic headache, with C2-3 being the most common source. On the basis of pretest probability, diagnostic algorithms should commence investigations at C2-3. Second and third steps in the algorithm should differ according to whether headache is the dominant or nondominant complaint.
Evaluation of adjunctive mycophenolate for large vessel giant cell arteritis
Authors: Karabayas Maira , Dospinescu Paula , Fluck Nick , Kidder Dana , Fordyce Gillian , Hollick Rosemary J , De Bari Cosimo , Basu Neil
Published: December 2020

Objectives

GCA patients with large vessel involvement (LV-GCA) experience greater CS requirements and higher relapse rates compared with classical cranial GCA. Despite the distinct disease course, interventions in LV-GCA have yet to be investigated specifically. This study aimed to evaluate the CS-sparing effect and tolerability of first-line mycophenolate in LV-GCA.

Methods

A retrospective cohort study was conducted in patients with LV-GCA identified from a regional clinical database between 2005 and 2019. All cases were prescribed mycophenolate derivatives (MYC; MMF or mycophenolic acid) at diagnosis and were followed up for ≥2 years. The primary outcome was the cumulative CS dose at 1 year. Secondary outcomes included MYC tolerance, relapse rates and CRP levels at 1 and 2 years.

Results

A total of 37 patients (65% female; mean age 69.4 years, SD 7.9 years) were identified. All cases demonstrated large vessel involvement via CT/PET (n = 34), CT angiography (n = 5) or magnetic resonance angiography (n = 2). After 2 years, 31 patients remained on MYC, whereas 6 had switched to MTX or tocilizumab owing to significant disease relapse. The mean (±SD) cumulative prednisolone dose at 1 year was 4960 (±1621) mg. Relapse rates at 1 and 2 years were 16.2 and 27%, respectively, and CRP levels at 1 and 2 years were 4 [interquartile range (IQR) 4–6] and 4 (IQR 4–4) mg/l, respectively.

Conclusion

To our knowledge, this is the first attempt to assess the effectiveness of any specific agent in LV-GCA. MYC might be both effective in reducing CS exposure and well tolerated in this subpopulation. A future randomized controlled trial is warranted.
Persistence of biologic treatments in psoriatic arthritis: a population-based study in Sweden
Authors: Geale Kirk , Lindberg Ingrid , Paulsson Emma C , Wennerström E Christina M , Tjärnlund Anna , Noel Wim , Enkusson Dana , Theander Elke
Published: December 2020

Objectives

TNF inhibitors (TNFis) and IL inhibitors are effective treatments for PsA. Treatment non-persistence (drug survival, discontinuation) is a measure of effectiveness, tolerability and patient satisfaction or preferences in real-world clinical practice. Persistence on these treatments is not well understood in European PsA populations. The aim of this study was to compare time to non-persistence for either ustekinumab (IL-12/23 inhibitor) or secukinumab (IL-17 inhibitor) to a reference group of adalimumab (TNFi) treatment exposures in PsA patients and identify risk factors for non-persistence.

Methods

A total of 4649 exposures of adalimumab, ustekinumab, and secukinumab in 3918 PsA patients were identified in Swedish longitudinal population-based registry data. Kaplan–Meier curves were constructed to measure treatment-specific real-world risk of non-persistence and adjusted Cox proportional hazards models were estimated to identify risk factors associated with non-persistence.

Results

Ustekinumab was associated with a lower risk of non-persistence relative to adalimumab in biologic-naïve [hazard ratio (HR) 0.48 (95% CI 0.33, 0.69)] and biologic-experienced patients [HR 0.65 (95% CI 0.56, 0.76)], while secukinumab was associated with a lower risk in biologic-naïve patients [HR 0.65 (95% CI 0.49, 0.86)] but a higher risk of non-persistence in biologic-experienced patients [HR 1.20 (95% CI 1.03, 1.40)]. Biologic non-persistence was also associated with female sex, axial involvement, recent disease onset, biologic treatment experience and no psoriasis.

Conclusion

Ustekinumab exhibits a favourable treatment persistency profile relative to adalimumab overall and across lines of treatment. The performance of secukinumab is dependent on biologic experience. Persistence and risk factors for non-persistence should be accounted for when determining an optimal treatment plan for patients.
The cost-effectiveness of different approaches to exercise and corticosteroid injection for subacromial pain (impingement) syndrome
Authors: Oppong Raymond , Jowett Sue , Lewis Martyn , Roddy Edward , Ogollah Reuben O , Zwierska Irena , Datta Praveen , Hall Alison , Hay Elaine , Shufflebotham Julie , Stevenson Kay , van der Windt Danielle A , Young Julie , Foster Nadine E
Published: December 2020

Objectives

To determine whether physiotherapist-led exercise intervention and US-guided subacromial CS injection is cost-effective when compared with standard advice and exercise leaflet and unguided injection in patients with subacromial pain (impingement) syndrome.

Methods

An incremental cost–utility analysis using patient responses to the five-level EuroQoL-5D (EQ-5D-5L) questionnaire was undertaken from a healthcare perspective alongside a 2 × 2 factorial randomized trial with 256 participants over a 12-month follow-up period. Uncertainty was explored through the use of cost-effectiveness acceptability curves.

Results

The cost–utility analysis indicated that physiotherapist-led exercise was associated with an incremental cost of £155.99 (95% CI 69.02, 241.93) and 0.031 (95% CI −0.01, 0.07) additional quality-adjusted life-years (QALYs), an incremental cost-effectiveness ratio (ICER) of £5031 per QALY gained and an 85% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with the advice and exercise leaflet. US-guided injection was associated with an incremental cost of £15.89 (95% CI −59.36, 109.86) and 0.024 (95% CI −0.02, 0.07) additional QALYs, an ICER of £662 per QALY gained and a 83% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with unguided injection.

Conclusion

Physiotherapist-led exercise was cost-effective compared with the advice and exercise leaflet, and US-guided injection was cost-effective when compared with unguided injection.

Clinical trial registration

ISRCTN, http://www.isrctn.com, ISRCTN42399123
Diversification, Introgression, and Rampant Cytonuclear Discordance in Rocky Mountains Chipmunks (Sciuridae: Tamias)
Authors: Sarver Brice A J , Herrera Nathanael D , Sneddon David , Hunter Samuel S , Settles Matthew L , Kronenberg Zev , Demboski John R , Good Jeffrey M , Sullivan Jack
Published: December 2020

Evidence from natural systems suggests that hybridization between animal species is more common than traditionally thought, but the overall contribution of introgression to standing genetic variation within species remains unclear for most animal systems. Here, we use targeted exon capture to sequence thousands of nuclear loci and complete mitochondrial genomes from closely related chipmunk species in the Tamias quadrivittatus group that are distributed across the Great Basin and the central and southern Rocky Mountains of North America. This recent radiation includes six overlapping, ecologically distinct species (Tamias canipes, Tamias cinereicollis, Tamias dorsalis, T. quadrivittatus, Tamias rufus, and Tamias umbrinus) that show evidence for widespread introgression across species boundaries. Such evidence has historically been derived from a handful of markers, typically focused on mitochondrial loci, to describe patterns of introgression; consequently, the extent of introgression of nuclear genes is less well characterized. We conducted a series of phylogenomic and species-tree analyses to resolve the phylogeny of six species in this group. In addition, we performed several population-genomic analyses to characterize nuclear genomes and infer coancestry among individuals. Furthermore, we used emerging quartets-based approaches to simultaneously infer the species tree (SVDquartets) and identify introgression (HyDe). We found that, in spite of rampant introgression of mitochondrial genomes between some species pairs (and sometimes involving up to three species), there appears to be little to no evidence for nuclear introgression. These findings mirror other genomic results where complete mitochondrial capture has occurred between chipmunk species in the absence of appreciable nuclear gene flow. The underlying causes of recurrent massive cytonuclear discordance remain unresolved in this group but mitochondrial DNA appears highly misleading of population histories as a whole. Collectively, it appears that chipmunk species boundaries are largely impermeable to nuclear gene flow and that hybridization, while pervasive with respect to mtDNA, has likely played a relatively minor role in the evolutionary history of this group. [Cytonuclear discordance; hyridization; introgression, phylogenomics; SVDquartets; Tamias.]
Effects of a Multi-Faceted Education Program on Enrollment, Learning and Gender Equity: Evidence from India
Authors: Delavallade Clara , Griffith Alan , Thornton Rebecca
Published: December 2020

The Sustainable Development Goals set a triple educational objective: improve access to, quality of, and gender equity in education. This paper documents the effectiveness of a multifaceted educational program, pursuing these three objectives simultaneously. Using an experiment in 229 schools in rural Rajasthan (India), the study measures the effects of the program on students’ school participation and academic performance over two years, while also examining heterogeneous impacts across gender and initial learning ability. It finds that the program increased student enrollment, with the largest effects among girls (7.2 percent in the first year, 12.8 percent in the second). There were large learning gains of 0.329 standard deviations (SDs) in the first year and 0.206 SDs at the end of the second year. The learning component of the intervention targeted both boys and girls – boys and girls benefited equally from the program in terms of test score gains.
Diet Quality of Workers and Retirees: A Cross-sectional Analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)
Authors: da Silva Vanderlei C , Gorgulho Bartira M , Marchioni Dirce M , Lotufo Paulo A , Benseñor Isabela M , Chiavegatto Filho Alexandre D P
Published: December 2020

The objective of this study was to cross-sectionally analyze the diet quality of active workers and retirees to identify possible differences by gender and subgroups of working and nonworking retirees using baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a cohort study of employees of six higher education centers in Brazil. In the first phase of the study, which occurred between 2008 and 2010, the diets of 7,667 participants between 50 and 69 years of age (3,393 [44%] men and 4,274 [56%] women) were analyzed using a Food Frequency Questionnaire. Diets were evaluated using the Brazilian Healthy Eating Index-Revised. We used logistic regression models stratified by sex and adjusted for demographic, social, and health conditions to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association of diet quality with working and nonworking retirees. Using active workers as the reference group, the results showed better diet quality among male retirees who were no longer working (OR: 1.58; 95% CI: 1.03–2.41), whereas no difference was detected in male retirees who returned to work (OR: 1.17; 95% CI: 0.80–1.72) in the adjusted models. Among women, the association did not remain significant after multivariate adjustment for confounders. Our results showed gender differences in diet quality between workers and working and nonworking retirees possibly because of worse diet quality among men than among women. Work cessation after retirement is mandatory to improve diet quality among male retirees.
Morphological phylogenetics provide new insights into the classification and evolution of fossil soldier beetles from Mid-Cretaceous Burmese amber (Coleoptera: Cantharidae)
Authors: Hsiao Yun , Li Yun , Ren Dong , Pang Hong
Published: December 2020

Cantharidae is a diverse group of soft-bodied beetles and frequently occurs in the Mid-Cretaceous (c. 99 Mya) amber of Myanmar. In the present paper, three new soldier beetles, Cretocantharis veda gen. & sp. nov., Palaeocantharispanna gen. & sp. nov. and Hukawngichthyurus maha sp. nov. are reported. A phylogenetic reconstruction of Cantharidae, including all extant subfamilies and tribes, corroborates a distinct lineage comprising cantharine-like cantharids from Burmese amber as sister to Silini (Silinae), revealing that the current subfamilial placement is probably inadequate. Together with our results and recent molecular phylogenetic frameworks, it reveals that subfamilies of Cantharidae evolved during the Cretaceous period and highlights a probable Gondwanan ancestry of main cantharid groups. Our topology also proposes that the systematically controversial tribe Tytthonyxini of Silinae constitutes an independent clade sister to Malthininae, rather than the component of Silinae. Furthermore, Archaeomalthodes rosetta, previously placed in Malthininae, is recovered as a member of Dysmorphocerinae, representing the oldest fossil record for this subfamily and enhancing the Gondwanan origin hypothesis of Burmese amber biota. The previous interpretation of reticulated elytra as a lycid-mimicry for the Cretaceous cantharid fossils and pleisiomorphy of Cantharidae are challenged and discussed.
Effect of Abamectin on Fungal Growth and Its Efficacy as a Miticide in the Laboratory
Authors: Sebestyen Dana , Perez-Gonzalez Gabriel , Ghoshal Mrinalini , Goodell Barry
Published: December 2020

Abamectin was tested for use with solid agar media in the laboratory to eliminate or kill the common mold mite Tyrophagus spp. in fungal cultures of Phaeomoniella chlamydospora and Phaeoacremonium minimum, two important grape pathogens involved in grapevine trunk disease. Abamectin concentrations tested were at or below the recommended dosage for abamectin in greenhouse spray applications (≤625 µg/ml) to control mites and determine the following: (i) if fungal growth would be inhibited and (ii) if mites would be killed or their activity suppressed. Abamectin was either added to the media before autoclaving or filter-sterilized and added after autoclaving to test the effects of autoclaving on abamectin efficacy. Streptomycin (100 µg/ml) was also added to a set of treatments to determine whether this commonly used antibiotic would affect abamectin efficacy against mites or have an effect on fungal growth when combined with abamectin. Filter-sterilized abamectin in the range of 62.5 to 312 µg/ml, delivered to the media after autoclaving, provided the most effective control of mites while also showing limited inhibition of fungal growth on solid agar media in the absence of streptomycin. The addition of filter-sterilized streptomycin had no significant effect on fungal growth for Phaeomoniella chlamydospora, whereas for Phaeoacremonium minimum a small but significant reduction in growth with streptomycin occurred at abamectin concentrations >62.5 µg/ml.
Single-Leg Stance Times in a Diverse Group of Survivors of Cancer and the Relationship to History of Recent Falls
Authors: Marker Ryan J. , Kakar Rumit Singh , Scorsone Jared J. , Peters John C. , Purcell W. Thomas
Published: December 2020

Background:

Balance impairments are present in cancer survivors for many reasons and increase risk of falls, though specific investigation of these impairments, and assessments to identify them, is not widely reported.

Objective:

Describe the performance of a large diverse cancer survivor population on a single-leg stance (SLS) test and assess relationships between this test and clinical and patient characteristics, including recent falls.

Methods:

This was a retrospective cross-sectional study. Data were collected from baseline assessments of 412 cancer survivors joining a clinical exercise program.

Measurements:

The primary outcome was an SLS test, performed with eyes opened and closed. Clinical and patient characteristics included age, body mass index (BMI), gender, cancer diagnosis and treatment, quality of life (QOL), and a recent history of falls (within the past 6 weeks).

Results:

Approximately one-third of the population was unable to reach 30 seconds on at least one leg with eyes open. Age and BMI had a negative influence on SLS with eyes open, while only age had a negative influence with eyes closed, in participants impaired in these conditions (N = 137 and N = 254, respectively). QOL was not related to SLS. SLS identified participants with a recent history of falls (sensitivity = 0.83; specificity = 0.58).

Limitations:

This population was biased, determined by provider referral or participant choice to join. The population was diverse in cancer diagnoses and treatment, limiting subgroup observations.

Conclusions:

Cancer survivors demonstrate a wide range of performance on the SLS test, which may show promise as a screen for fall risk.
Roadmap: one anesthesiology department's strategic approach to COVID-19
Authors: Coombs Alice A. Tolbert , Lawson Tamara , Daniel Ronsard , Kim Christin , Rashid Megan M.
Published: December 2020

Purpose of review

The COVID-19 pandemic has driven transformation in every aspect of the healthcare delivery system. The unpredictable onset and magnitude of COVID-19 infections resulted in wide gaps in preparedness for healthcare systems. The development of protocols to address both scarcity of resources and staff protection continues to be essential for risk mitigation.

Recent findings

The northeast region of the United States had a rapid early surge of COVID-19 infections leading to the exhaustion of critical care capacity. In addition, northeastern hospitals experienced decrease in elective surgical interventions, including organ transplantation. Limited availability of COVID-19 testing and personal protective equipment further fueled the pandemic. This commentary highlights a comprehensive innovative approach to addressing the operating room and hospital demands, as well as the shortages in resources and staffing during the pandemic.

The VCU Department of Anesthesiology operated at 40% of its regular operating room volume throughout the COVID-19 pandemic because of the increased demand from emergency cases. The delay in the peak surge allowed Virginia Commonwealth University, Department of Anesthesiology to develop a comprehensive infrastructure resulting in resulting is maximal workforce risk mitigation.
Fast-spiking Interneurons Contribute to Propofol-induced Facilitation of Firing Synchrony in Pyramidal Neurons of the Rat Insular Cortex
Authors: Koyanagi Yuko , Oi Yoshiyuki , Kobayashi Masayuki
Published: December 2020

Background

The general anesthetic propofol induces frontal alpha rhythm in the cerebral cortex at a dose sufficient to induce loss of consciousness. The authors hypothesized that propofol-induced facilitation of unitary inhibitory postsynaptic currents would result in firing synchrony among postsynaptic pyramidal neurons that receive inhibition from the same presynaptic inhibitory fast-spiking neurons.

Methods

Multiple whole cell patch clamp recordings were performed from one fast-spiking neuron and two or three pyramidal neurons with at least two inhibitory connections in rat insular cortical slices. The authors examined how inhibitory inputs from a presynaptic fast-spiking neuron modulate the timing of spontaneous repetitive spike firing among pyramidal neurons before and during 10 μM propofol application.

Results

Responding to activation of a fast-spiking neuron with 150-ms intervals, pyramidal cell pairs that received common inhibitory inputs from the presynaptic fast-spiking neuron showed propofol-dependent decreases in average distance from the line of identity, which evaluates the coefficient of variation in spike timing among pyramidal neurons: average distance from the line of identity just after the first activation of fast-spiking neuron was 29.2 ± 24.1 (mean ± SD, absolute value) in control and 19.7 ± 19.2 during propofol application (P < 0.001). Propofol did not change average distance from the line of identity without activating fast-spiking neurons and in pyramidal neuron pairs without common inhibitory inputs from presynaptic fast-spiking neurons. The synchronization index, which reflects the degree of spike synchronization among pyramidal neurons, was increased by propofol from 1.4 ± 0.5 to 2.3 ± 1.5 (absolute value, P = 0.004) and from 1.5 ± 0.5 to 2.2 ± 1.0 (P = 0.030) when a presynaptic fast-spiking neuron was activated at 6.7 and 10 Hz, respectively, but not at 1, 4, and 13.3 Hz.

Conclusions

These results suggest that propofol facilitates pyramidal neuron firing synchrony by enhancing inhibitory inputs from fast-spiking neurons. This synchrony of pyramidal neurons may contribute to the alpha rhythm associated with propofol-induced loss of consciousness.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New
Establishing the Injury Severity of Subaxial Cervical Spine Trauma
Authors: Schroeder Gregory D. , Canseco Jose A. , Patel Parthik D. , Divi Srikanth N. , Karamian Brian A. , Kandziora Frank , Vialle Emiliano N. , Oner F. Cumhur , Schnake Klaus J. , Dvorak Marcel F. , Chapman Jens R. , Benneker Lorin M. , Rajasekaran Shanmuganathan , Kepler Christopher K. , Vaccaro Alexander R.
Published: December 2020

Study Design.

Global cross-sectional survey.

Objective.

The aim of this study was to validate the AO Spine Subaxial Cervical Spine Injury Classification by examining the perceived injury severity by surgeon across AO geographical regions and practice experience.

Summary of Background Data.

Previous subaxial cervical spine injury classifications have been limited by subpar interobserver reliability and clinical applicability. In an attempt to create a universally validated scheme with prognostic value, AO Spine established a subaxial cervical spine injury classification involving four elements: injury morphology, facet injury involvement, neurologic status, and case-specific modifiers.

Methods.

A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. Respondents graded the severity of each variable of the classification system on a scale from zero (low severity) to 100 (high severity). Primary outcome was to assess differences in perceived injury severity for each injury type over geographic regions and level of practice experience.

Results.

A total of 189 responses were received. Overall, the classification system exhibited a hierarchical progression in subtype injury severity scores. Only three subtypes showed a significant difference in injury severity score among geographic regions: F3 (floating lateral mass fracture, P = 0.04), N3 (incomplete spinal cord injury, P = 0.03), and M2 (critical disk herniation, P = 0.04). When stratified by surgeon experience, pairwise comparison showed only two morphological subtypes, B1 (bony posterior tension band injury, P = 0.02) and F2 (unstable facet fracture, P = 0.03), and one neurologic subtype (N3, P = 0.02) exhibited a significant difference in injury severity score.

Conclusion.

The AO Spine Subaxial Cervical Spine Injury Classification System has shown to be reliable and suitable for proper patient management. The study shows this classification is substantially generalizable by geographic region and surgeon experience, and provides a consistent method of communication among physicians while covering the majority of subaxial cervical spine traumatic injuries.

Level of Evidence: 4
Clinically Meaningful Improvement Following Cervical Spine Surgery: 30% Reduction Versus Absolute Point-change MCID Values
Authors: Khan Inamullah , Pennings Jacquelyn S. , Devin Clinton J. , Asher Anthony M. , Oleisky Emily R. , Bydon Mohamad , Asher Anthony L. , Archer Kristin R.
Published: December 2020

Study Design.

Retrospective analysis of prospectively collected registry data.

Objective.

The aim of this study was to compare the performance of 30% reduction to established absolute point-change values for measures of disability and pain in patients undergoing elective cervical spine surgery.

Summary of Background Data.

Recent studies recommend using a proportional change from baseline instead of an absolute point-change value to define minimum clinically important difference (MCID).

Methods.

Analyses included 13,179 patients who underwent cervical spine surgery for degenerative disease between April 2013 and February 2018. Participants completed a baseline and 12-month follow-up assessment that included questionnaires to assess disability (Neck Disability Index [NDI]), neck and arm pain (Numeric Rating Scale [NRS-NP/AP], and satisfaction [NASS scale]). Participants were classified as met or not met 30% reduction from baseline in each of the respective measures. The 30% reduction in scores at 12 months was compared to a wide range of established absolute point-change MCID values using receiver-operating characteristic curves, area under the receiver-operating characteristic curve (AUROC), and logistic regression analyses. These analyses were conducted for the entire patient cohort, as well as for subgroups based on baseline severity and surgical approach.

Results.

Thirty percent reduction in NDI and NRS-NP/AP scores predicted satisfaction with more accuracy than absolute point-change values for the total population and ACDF and posterior fusion procedures (P < 0.05). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0–20%: 16.8%) and bed-bound disability (ODI 81%–100%: 16.6%) categories. For pain, there was a 1.9% to 11% and 1.6% to 9.6% AUROC difference for no/mild neck and arm pain (NRS 0–4), respectively, in favor of a 30% reduction threshold.

Conclusion.

A 30% reduction from baseline is a valid method for determining MCID in disability and pain for patients undergoing cervical spine surgery.

Level of Evidence: 3
Risk Factors for Facial Pressure Ulcers in Patients Who Underwent Prolonged Prone Orthopedic Spine Surgery
Authors: Techanivate Anchalee , Athibai Nutwara , Siripongsaporn Suvimol , Singhatanadgige Weerasak
Published: December 2020

Mini

This study evaluated incidence and risk factors associated with the development of facial pressure ulcers (FPU) in patients who underwent spine surgery in prone position. A total of 300 cases were studied. The incidence of FPU after prone spine surgery using head padded device >3 hours was 27.3%. Hypotension, higher temperature, prolonged operation time, and much crystalloid therapy were the independent risk factors

Study Design.

Retroprospective study.

Objectives.

The aim of this study was to identify the incidence and the risk factors associated with the development of facial pressure ulcers (FPU) in patients who underwent spine surgery in prone position for at least 3 hours.

Summary of Background Data.

FPU is a serious complication that can occur after prolonged surgery in the prone position.

Methods.

A total of 300 cases were studied (160 retrospective cases and 140 prospective cases). Preoperative, intraoperative, and postoperative data were collected using a structured record form. Patients were divided into FPU group and normal group. A univariate and multivariate logistic regression was used to determine the association of predictor variables.

Results.

FPU occurred in 82 patients (27.3%), 129 zones, and 151 lesions. The average age was 61.9 years (11–89), the average operating time was 3.8 hours (3–8.3). The locations of FPU were the forehead, maxillary, and chin zone (33.3%, 34.1%, and 32.5%, respectively). The severity was mostly stage I or II except one patient who developed stage III on the entire face. Patients in the FPU group had significant difference in: operation time (4.4 vs. 3.6 hours), anesthetic time (5.2 vs. 4.0 hours), hypotension (79% vs. 56%), lowest blood pressure, total blood loss, total crystalloid, colloid and blood replacement, highest temperature (36.5 C° vs. 36.2 C°) compared to the normal group (P < 0.05). Factors related to FPU were hypotension odds ratio (OR) 2.75 (95% confidence interval [CI] 1.4–5.2, P = 0.002), highest temperature OR 1.95 (95% CI 1.1–3.3, P = 0.013), operation time OR 1.44 (95% CI 1.0–1.9, P = 0.014), and total crystalloid therapy OR 1.07 (95% CI 1.0–1.1, P = 0.042).

Conclusion.

The incidence of FPU after prone spine surgery using head padded device >3 hours was 27.3%. The risk factors of developing FPU included: hypotension, higher temperature, prolonged operation time, and much crystalloid therapy.

Level of Evidence: 4
Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia
Authors: Li Jie , Fink James B. , Augustynovich Ashley E. , Mirza Sara , Kallet Richard H. , Dhand Rajiv
Published: December 2020

Objectives:

To evaluate the effects of inhaled epoprostenol and prone positioning, individually and in combination in mechanically ventilated patients with coronavirus disease 2019 and refractory hypoxemia.

Design:

Retrospective study.

Setting:

Academic hospital adult ICUs.

Patients:

Adult patients who received inhaled epoprostenol and prone positioning during invasive ventilation were enrolled. Patients were excluded if inhaled epoprostenol was initiated: 1) at an outside hospital, 2) after prone positioning was terminated, 3) during extracorporeal membrane oxygenation or cardiopulmonary resuscitation, and 4) with Pao
2/Fio
2 greater than 150 mm Hg.

Interventions:

Inhaled epoprostenol and prone positioning.

Results:

Of the 43 eligible patients, 22 and seven received prone positioning and inhaled epoprostenol alone, respectively, prior to their use in combination, Pao
2/Fio
2 was not different pre- and post-prone positioning or inhaled epoprostenol individually (89.1 [30.6] vs 97.6 [30.2] mm Hg; p = 0.393) but improved after the combined use of inhaled epoprostenol and prone positioning (84.0 [25.6] vs 124.7 [62.7] mm Hg; p < 0.001). While inhaled epoprostenol and prone positioning were instituted simultaneously in 14 patients, Pao
2/Fio
2 was significantly improved (78.9 [27.0] vs 150.2 [56.2] mm Hg, p = 0.005) with the combination. Twenty-seven patients (63%) had greater than 20% improvement in oxygenation with the combination of inhaled epoprostenol and prone positioning, and responders had lower mortality than nonresponders (52 vs 81%; p = 0.025).

Conclusions:

In critically ill, mechanically ventilated patients with coronavirus disease 2019 who had refractory hypoxemia, oxygenation improved to a greater extent with combined use of inhaled epoprostenol and prone positioning than with each treatment individually. A higher proportion of responders to combined inhaled epoprostenol and prone positioning survived compared with nonresponders. These findings need to be validated by randomized, prospective clinical trials.
Racial Differences in a Detroit, MI, ICU Population of Coronavirus Disease 2019 Patients
Authors: Lazar Michael H. , Fadel Raef , Gardner-Gray Jayna , Tatem Geneva , Caldwell Martina T. , Swiderek Jennifer , Jennings Jeffrey H.
Published: December 2020

OBJECTIVES:

To investigate the potential influence of racial differences in outcomes of patients infected by coronavirus disease 2019-positive patients who require intensive care in an urban hospital.

DESIGN:

Retrospective cohort study.

SETTING:

Henry Ford Health System Multidisciplinary ICU, a total of 156 beds spread throughout the hospital in Detroit, MI.

PATIENTS:

We obtained data from the electronic medical record of all adult severe acute respiratory syndrome coronavirus-2-positive patients managed in the ICU of Henry Ford Hospital in Detroit, MI, between March 13, 2020, and July 31, 2020. Included patients were divided into two groups: people of color (including Black, Asian, Hispanic/Latino, and Arab) and White.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

A total of 365 patients were evaluated: 219 were Black (60.0%), 129 were White (35.3%), two were Asian (0.6%), eight were Hispanic/Latino (2.2%), and seven were Arab (1.9%). People of color were younger (62.8 vs 67.1; p = 0.007), with equal distribution of sex. People of color had less coronary artery disease (34 [14.4%] vs 35 [27.1%]; p =0.003) and less self-reported use of regular alcohol consumption (50 [21.2%] vs 12 [9.3%]; p = 0.004) than Whites, with no differences in diabetes (125 [53.0%] vs 66 [51.2%]; p = 0.742), hypertension (188 [79.7%] vs 99 [76.8%]; p = 0.516), congestive heart failure (41 [17.4%] vs 32 [24.8%]; p = 0.090), or chronic kidney disease (123 [54.1%] vs 55 [42.6%]; p = 0.083).

There was no difference in ICU length of stay between people of color (18 d [CI, 7–47 d]) and Whites (18 d [CI, 6–48 d]; p = 0. 0.979). Neither frequency (72.5% vs 71.3%; p = ns) nor median time to mechanical ventilation between people of color (9 d [CI, 6–15 d]) and Whites (10 d [CI, 5–16 d]; p = 0.733) was different. Overall, 188 patients (51.5 %) died in the hospital. The 28-day mortality was lower in people of color (107/236; 45.3%) versus Whites (73/129; 56.6%) (adjusted odds ratio 0.60; p = 0.034), and there was an increased median survival time in people of color (20 d) versus Whites (13.5 d; hazard ratio 0.62; p = 0.002). The inhospital mortality was lower in people of color versus White, but the difference was not statistically significant (113 [47.9%] vs 75 [58.1%], respectively; p = 0.061). Finally, there was no significant difference in days of symptoms prior to admission, frequency of presenting symptoms, or frequency or severity of acute respiratory distress syndrome between the two groups.

CONCLUSIONS:

In critically ill patients infected with coronavirus disease 2019, people of color had a lower 28-day mortality than Whites with no difference in hospital mortality, ICU length of stay, or rates of intubation. These findings are contrary to previously held beliefs surrounding the pandemic.
The Association of Platelet Decrease Following Continuous Renal Replacement Therapy Initiation and Increased Rates of Secondary Infections
Authors: Griffin Benjamin R. , Wu Chaorong , O’Horo John C. , Faubel Sarah , Jalal Diana , Kashani Kianoush
Published: December 2020

Objectives:

Thrombocytopenia is common in critically ill patients treated with continuous renal replacement therapy and decreases in platelets following continuous renal replacement therapy initiation have been associated with increased mortality. Platelets play a role in innate and adaptive immunity, making it plausible that decreases in platelets following continuous renal replacement therapy initiation predispose patients to development of infection. Our objective was to determine if greater decreases in platelets following continuous renal replacement therapy correlate with increased rates of secondary infection.

Design:

Retrospective

cohort analysis.

Setting:

This study uses a continuous renal replacement therapy database from Mayo Clinic (Rochester, MN), a tertiary academic center.

Participants:

Adult patients who survived until ICU discharge and were on continuous renal replacement therapy for less than 30 days were included. A subgroup analysis was also performed in patients with thrombocytopenia (platelets < 100 × 103/µL) at continuous renal replacement therapy initiation.

Measurements and Main Results:

The primary predictor variable was a decrease in platelets from precontinuous renal replacement therapy levels of greater than 40% or less than or equal to 40%, although multiple cut points were analyzed. The primary outcome was infection after ICU discharge, and secondary endpoints included post-ICU septic shock and post-ICU mortality. Univariable, multivariable, and propensity-adjusted analyses were used to determine associations between the predictor variable and the outcomes.

Results:

Among 797 eligible patients, 253 had thrombocytopenia at continuous renal replacement therapy initiation. A greater than 40% decrease in platelets after continuous renal replacement therapy initiation was associated in the multivariable-adjusted models with increased odds of post-ICU infection in the full cohort (odds ratio, 1.49; CI, 1.02–2.16) and in the thrombocytopenia cohort (odds ratio, 2.63; CI, 1.35–5.15) cohorts.

Conclusions:

Platelet count drop by greater than 40% following continuous renal replacement therapy initiation is associated with an increased risk of secondary infection, particularly in patients with thrombocytopenia at the time of continuous renal replacement therapy initiation. Further research is needed to evaluate the impact of both continuous renal replacement therapy and platelet loss on subsequent infection risk.
The Practice and Complications of Midline Catheters: A Systematic Review
Authors: Tripathi Sandeep , Kumar Shruti , Kaushik Shubhi
Published: December 2020

OBJECTIVE:

Midline catheters are considered “midway” regarding vascular access. The objective of this systematic review was to explore the current practice, dwell time, and complication rates of midline catheters.

DESIGN:

Systematic review.

SETTING:

Search on four databases, PubMed, CINAHL, Scopus, and Embase, were conducted for English language articles published after the year 2000.

MEASUREMENTS AND MAIN RESULTS:

A total of 987 articles were identified, of which 31 manuscripts met the inclusion criteria and were selected for review. Quality assurance was performed based on the Newcastle-Ottawa score. Average dwell time and complication rates were calculated for studies involving adult patients and adjusted for sample size. This analysis included data from the placement of 18,972 midline catheters across five countries. Aside from two randomized control trials, most of the studies analyzed were cohort studies. One pediatric and two neonatal studies were included. The average dwell time was 16.3 days (n = 4,412). The adjusted mean infection rate was 0.28/1,000 catheter days, with 64% of studies not reporting any infection with midline catheter. The failure rate of midline catheters was 12.5%. Adjusted average rates of other significant complications included the following: deep vein thrombosis (4.1%), dislodgement (5.0%), occlusion (3.8%), phlebitis (3.4%), and infiltration (1.9%).

Conclusions:

The dwell times and failure rates of midline catheters compare favorably against published data on other types of catheters. Their infection rates are also lower than the reported rates of central venous catheters; however, they have a higher rate of mechanical complications. Active surveillance of infections due to midline catheters is recommended. More data are needed from pediatric and neonatal populations.
Effect of Bariatric Surgery on Natriuretic Peptide Levels
Authors: Anvari Sama , Lee Yung , Lam Megan , Wong Jorge A. , Hong Dennis , Doumouras Aristithes G.
Published: December 2020

The effect of bariatric surgery on natriuretic peptide levels in patients with obesity is unclear. The purpose of this study was to conduct a systematic review and meta-analysis to determine the effect of bariatric surgery on B-type natriuretic peptide (BNP) and aminoterminal BNP (NT-proBNP) levels. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched to February 2020. Primary outcomes included change in NT-proBNP or BNP levels following bariatric surgery and change in weight and body mass index. Secondary outcomes included change in blood pressure, echocardiographic findings, and heart failure symptoms. MINORS tool was used to assess quality of evidence. Twelve studies with 622 patients were included. Most patients underwent Roux-en-Y gastric bypass (RYGB) (70.5%). Mean absolute reduction in body mass index was 23%. NT-proBNP levels increased significantly from baseline at 6 months (mean difference [MD] 53.67 pg/mL; 95% confidence interval [CI], 28.72–78.61; P ≤ 0.001, I2 = 99%; 8 studies) and 12 months (MD 51.16 pg/mL; 95% CI, 20.46–81.86; P = 0.001, I2 = 99%; 8 studies) postbariatric surgery. BNP levels also increased significantly at 6 months (MD 17.57 pg/mL; 95% CI, 7.62–27.51; P < 0.001, I2 = 95%; 4 studies). Systolic and diastolic blood pressure decreased significantly 12 months after surgery. Studies measuring echocardiographic findings saw improvement in left ventricle mass and the E/A ratio, but no significant change in ejection fraction. Bariatric surgery is associated with increased natriuretic peptide levels in the absence of deteriorating cardiac function, and may be associated with improved cardiac and metabolic function after the procedure.