Hemodynamic Deterioration of Trauma Patients Undergoing Interhospital Transfer

INTRODUCTION

Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process.

METHODS

We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis.

RESULTS

Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis.

CONCLUSIONS

Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.

Endoscopic Posterior Cervical Foraminotomy under Lateral Decubitus Position with Local Anesthesia

Endoscopic posterior cervical foraminotomy is gaining popularity among endoscopic spine surgeons for the treatment of radiculopathy caused by foraminal stenosis. This study describes a technique utilizing lateral decubitus position for an endoscopic posterior cervical foraminotomy under Monitored Anesthesia Care (MAC) and local anesthesia only. 10 patients with contraindications to general anesthesia underwent the procedure, resulting in an improvement in cervical radicular pain with no perioperative complications. The findings suggest that this approach is a viable alternative for high-risk patients for general anesthesia care, expanding the surgical options for the treatment of radiculopathy.

Photocoagulation Up to Ora Serrata in Diabetic Vitrectomy to Prevent Recurrent Vitreous Hemorrhage

PURPOSE

To evaluate the role of performing photocoagulation up to ora serrata during vitrectomy in preventing recurrent vitreous hemorrhage (VH) in patients undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR).

METHODS

This retrospective, nonrandomized study included 60 eyes from 60 patients who had undergone PPV for VH due to PDR. These patients were divided into two groups: group 1, those who underwent photocoagulation up to ora serrata using the scleral indentation technique during surgery; and group 2, those who did not undergo scleral indentation when photocoagulation and underwent photocoagulation up to vortex veins. Their hospital records were analyzed to investigate the recurrence rate of VH, the time until recurrence of VH after surgery, logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) measured before surgery and at 1, 2, and 3 years after surgery, and the occurrence of complications such as neovascular glaucoma (NVG) during follow-up.

RESULTS

Group 1 exhibited lower recurrence rate of VH (2 of 30 [6.7%] vs. 10 of 30 [33.3%], p = 0.01) and lower occurrence of postoperative NVG (2 of 30 [6.7%] vs. 8 of 30 [26.7%], p = 0.038) compared with group 2. There were no statistically significant differences in logMAR BCVA measured at 1, 2, and 3 years between the two groups (at 1 year: 0.54 ± 0.43 vs. 0.54 ± 0.44, p = 0.954; at 2 years: 0.48 ± 0.47 vs. 0.55 ± 0.64, p = 0.235; at 3 years: 0.51 ± 0.50 vs. 0.61 ± 0.77, p = 0.200). Logistic regression analysis showed that among several factors that could affect recurrence rate of VH, only range of photocoagulation performed was a statistically significant factor (odds ratio, 0.119; 95% confidence interval, 0.022-0.659; p = 0.015).

CONCLUSIONS

Photocoagulation treatment over a wider range with scleral indentation could be a beneficial adjunct procedure for preventing postoperative recurrent VH following diabetic vitrectomy.

Search for Evidence of Baryogenesis and Dark Matter in B^{+}→ψ_{D}+p Decays at BABAR

A new dark sector antibaryon, denoted ψ_{D}, could be produced in decays of B mesons. This Letter presents a search for B^{+}→ψ_{D}+p (and the charge conjugate) decays in e^{+}e^{-} annihilations at 10.58 GeV, using data collected in the BABAR experiment. Data corresponding to an integrated luminosity of 398  fb^{-1} are analyzed. No evidence for a signal is observed. Branching fraction upper limits in the range from 10^{-7}-10^{-5} are obtained at 90% confidence level for masses of 1.0 Collapse

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HER2-low expression in patients with advanced or metastatic solid tumors

BACKGROUND

Human epidermal growth factor receptor 2 (HER2)-low is a newly defined category with HER2 1+ or 2+ expression by immunohistochemistry (IHC) and lack of HER2 gene amplification measured by in situ hybridization (ISH). Much remains unknown about the HER2-low status across tumor types and changes in HER2 status between primary and metastatic samples.

PATIENTS AND METHODS

HER2 expression by IHC was evaluated in 4701 patients with solid tumors. We have evaluated the HER2 expression by IHC and amplification by ISH in paired breast and gastric/gastroesophageal (GEJ) primary and metastatic samples. HER2 expression was correlated with ERBB2 genomic alterations evaluated by next-generation sequencing (NGS) in non-breast, non-gastric/GEJ samples.

RESULTS

HER2 expression (HER2 IHC 1-3+) was found in half (49.8%) of the cancers, with HER2-low (1 or 2+) found in many tumor types: 47.1% in breast, 34.6% in gastric/GEJ, 50.0% in salivary gland, 46.9% in lung, 46.5% in endometrial, 46% in urothelial, and 45.5% of gallbladder cancers. The concordance evaluation of HER2 expression between primary and metastatic breast cancer samples showed that HER2 3+ remained unchanged in 87.1% with a strong agreement between primary and metastatic samples, with a weighted kappa (Κ) of 0.85 (95% confidence interval 0.79-0.91). ERBB2 alterations were identified in 117 (7.5%) patients with non-breast, non-gastric/GEJ solid tumors who had NGS testing. Of 1436 patients without ERBB2 alterations, 512 (35.7%) showed any level HER2 expression by IHC.

CONCLUSION

Our results show that HER2-low expression is frequently found across tumor types. These findings suggest that many patients with HER2-low solid tumors might benefit from HER2-targeted therapies.

Hypertension in Pregnancy and Preeclampsia: Variation in Clinical Management Strategies Among Obstetric/Gynecologic Provider Type

Background

Preeclampsia, a condition in pregnancy characterized by new onset high blood pressure and proteinuria, complicates 2%-8% of pregnancies globally. Early detection, careful monitoring, and treatment of high blood pressure are crucial in preventing mortality related to preeclampsia disorders. There is limited data that examines obstetric/gynecologic (OBGYN) provider-type practices concerning management of hypertensive disorders of pregnancy to reduce early onset preeclampsia (EOP). We assessed the knowledge and practice patterns of OBGYN management to reduce EOP.

Methods

We conducted a semistructured survey with OBGYN residents, maternal-fetal medicine fellows, and attending physicians (OBGYN and family medicine) at a single academic medical center to assess the management of hypertensive disorders to EOP.

Results

Thirty-one participants (71% residents/fellows 29% attendings) completed the survey. Seventy-eight percent of attendings indicated they discuss blood pressure and preeclampsia with all patients compared to 50% of residents/fellows (p = 0.31). Eighty-nine percent of attendings reported they are extremely likely to monitor high-risk patients compared to 36% of residents/fellows (p = 0.07).

Conclusion

Attending physicians were more likely to appropriately manage hypertension in women at risk for pregnancy compared to residents/fellows. Further research is needed on monitoring high-risk patients.

Nodding syndrome is unlikely to be an autoimmune reaction to leiomodin-1 after infection by Onchocerca volvulus

Nodding syndrome is a neurological disease of children in northern Uganda. Infection with the nematode parasite Onchocerca volvulus has been epidemiologically implicated as the cause of the disease. It has been proposed that an autoantibody directed against the human protein leiomodin-1 cross reacts with a tropomyosin-like nematode protein, thus suggesting that nodding syndrome is an autoimmune brain disease due to extra-cerebral parasitism. This hypothesis is dependent on constitutive neuronal expression of leiomodin-1. We tested this hypothesis by studying the distribution of leiomodin-1 in the normal human brain and other human tissues using immunohistochemistry. We found that immunostaining for leiomodin-1 follows a smooth muscle cell specific pattern. In the brain, it is confined to the smooth muscle cells of cerebral blood vessels and is not generally present in neurons or glia. However, immunoreactivity was identified in human Purkinje cell membrane and the body wall of C. elegans (as a proxy for Onchocerca volvulus) but only when immunostained with an antibody recognizing the N-terminal of leiomodin-1. Homology between leiomodin-1 and tropomodulin, specifically at the N-terminus, could explain why leiomodin-1 antibody cross reactivity between human Purkinje cells and C. elegans. However, we cannot provide proof confirming that the immunoreactivity in the membranes of Purkinje cells is specifically caused by the expression of tropomodulin. To overcome this limitation, further investigations using additional immunohistochemical and biochemical studies are required to corroborate our findings and provide more comprehensive evidence. Nevertheless, our findings do not support to the autoimmunity hypothesis involving Onchocerca volvulus and leiomodin-1. To gain a more comprehensive understanding of the cause and pathogenesis of NS, it is essential to explore alternative hypotheses.

Best Practices for FACE-Q Aesthetics Research: A Systematic Review of Study Methodology

BACKGROUND

The FACE-Q Aesthetics module is a validated patient-reported outcome measure (PROM) that evaluates perspectives on facial aesthetic treatments. Improper administration and poor study methodology can compromise the validity and interpretation of this PROM.

OBJECTIVES

This systematic review sought to evaluate the administration and scoring of the FACE-Q Aesthetics scales within the literature.

METHODS

A search of Ovid Medline, Embase, Cochrane, and Web of Science was performed on December 20, 2022, with the assistance of a health-research librarian (CRD42022383676). Studies that examined facial aesthetic interventions using the FACE-Q Aesthetics module as a primary or secondary outcome measure were included for analysis.

RESULTS

There were 114 studies included. The Face Overall (n = 52, 45.6%), Psychological (n = 45, 39.4%), and Social (n = 43, 37.7%) scales were most frequently reported. Errors in FACE-Q administration were identified in 30 (26.3%) studies. The most common error was the presentation of raw ordinal scores rather than the converted Q score (n = 23). Most studies reported a time horizon for their primary analysis (n = 76, 66.7%); however, only 4 studies provided a rationale for this selection. Sample size calculations for the primary outcome were rarely performed (n = 9, 7.9%).

CONCLUSIONS

There continues to be limitations in PROM administration and the quality of articles that report FACE-Q Aesthetic scale data. The authors suggest that future investigators using the FACE-Q refer to the User's Guide regarding administration and scoring of this scale, report a rationale for the study time horizon, and provide an a priori sample size calculation for the primary outcome of interest.

Learning curve for endoscopic posterior cervical foraminotomy

PURPOSE

While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF.

METHODS

The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation.

RESULTS

There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6 min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7 min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8 min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve.

CONCLUSION

PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

Computed Tomography Measurements in Assessment of Idiopathic Vocal Fold Paralysis

OBJECTIVE

Our study aimed to both identify the incidence and clinical presentation of patients presenting with idiopathic vocal fold paralysis (IVFP). Secondarily we aimed to assess the radiographic findings of computed tomography (CT) studies along the course of the vagus and recurrent laryngeal nerves (RLN), specifically measuring for potential areas of compression at the skull base and mediastinum. We hypothesized that a proportion of patients diagnosed with IVFP would have significant differences in measurements when compared to age-gender matched controls on CT imaging.

STUDY DESIGN

Institutional review board approved retrospective cohort study METHODS: We assessed patients presenting to a tertiary voice care center between 2003 and 2019 with diagnosis of vocal fold paralysis. Data collected includes demographics, clinical exam findings, and CT measurements including dimensions at bilateral jugular foramen, aortopulmonary (AP) window and surrounding vascular structures. Statistical analysis was then performed using Pearson χ², and Mann Whitney U tests to determine differences variables of interest.

RESULTS

A total of 606 patients were reviewed. Of these patients 60 (9.9%) patients were determined to have IVFP. Left-sided VFP was seen more commonly in 78.3% (N = 47) of idiopathic patients. Our IVFP group had an overall higher incidence of cardiovascular disease [OR = 3.378, 95%CI 1.907-5.941, P < 0.001] compared to those with identified causes for paralysis. Specifically, IVFP patients showed a higher incidence of combined cardiovascular co-morbidities (P < 0.001), mitral valve stenosis (P = 0.007), pulmonary hypertension (P < 0.0001) and congestive heart failure (P < 0.001). When evaluating CT imaging, the AP window was mentioned in only 2 (3.3%) of our idiopathic patients CT reports. The IVFP cohort had a lower median AP window volume (P = 0.020) when compared to age-gender matched controls. This significantly smaller AP window volume was also seen when only left sided IVFP compared to both right-sided paralysis (P < 0.001) and age matched control patients (P < 0.001).

CONCLUSION

The significance of cardiovascular comorbidities combined with findings of statistically narrowed AP window may help provide an explanation of a subset of patients diagnosed with IVFP.

Anatomical study of the thoracolumbar radiculomedullary arteries, including the Adamkiewicz artery and supporting radiculomedullary arteries

OBJECTIVE

The aim of this paper was to identify and characterize all the segmental radiculomedullary arteries (RMAs) that supply the thoracic and lumbar spinal cord.

METHODS

All RMAs from T4 to L5 were studied systematically in 25 cadaveric specimens. The RMA with the greatest diameter in each specimen was termed the artery of Adamkiewicz (AKA). Other supporting RMAs were also identified and characterized.

RESULTS

A total of 27 AKAs were found in 25 specimens. Twenty-two AKAs (81%) originated from a left thoracic or a left lumbar radicular branch, and 5 (19%) arose from the right. Two specimens (8%) had two AKAs each: one specimen with two AKAs on the left side and the other specimen with one AKA on each side. Eight cadaveric specimens (32%) had 10 additional RMAs; among those, a single additional RMA was found in 6 specimens (75%), and 2 additional RMAs were found in each of the remaining 2 specimens (25%). Of those specimens with a single additional RMA, the supporting RMA was ipsilateral to the AKA in 5 specimens (83%) and contralateral in only 1 specimen (17%). The specimens containing 2 additional RMAs were all (100%) ipsilateral to their respective AKAs.

CONCLUSIONS

The segmental RMAs supplying the thoracic and lumbar spinal cord can be unilateral, bilateral, or multiple. Multiple AKAs or additional RMAs supplying a single anterior spinal artery are common and should be considered when dealing with the spinal cord at the thoracolumbar level.

Quantitative analysis of cornea endothelial cell damage from enucleation, corneal buttoning, and storage in donor corneas using trypan blue dye staining

We aimed to quantitatively analyze the corneal endothelial cell damage by measuring the area stained with trypan blue dye, and to confirm the degree of corneal endothelial cell damage resulting from enucleation, corneal buttoning, and storage in donor corneas intended for use in human corneal transplantation. This study was a retrospective analysis of medical records and videos recorded during keratoplasty. Twenty-one corneal buttons of 21 donors that underwent endothelial cell staining using trypan blue for the donor preparation during DALK or DMEK were included in the study. The percentage of stained area in entire corneal endothelia and the percentage of the stained area in the 8-mm diameter circle were quantitatively analyzed using Adobe Photoshop. The mean percentage of the stained area in the entire corneal endothelia in 13 corneas was 8.1 ± 13.3% (range, 0.0-56.1%), and the mean percentage of the stained area in a circle with a diameter of 8 mm in 21 corneas was 3.4 ± 5.2% (range, 0.0-18.9%). The correlations between the death-to-preservation time, the training duration of the residents who performed donor corneal buttoning, and the percentage of the stained area in the 8-mm diameter circle were not significant(P = .441, P = .495, respectively). Cornea thickness and endothelial cell density did not differ between 10 eyes in the group with the percentage of the stained area in a circle with a diameter of 8 mm <5% and 5 eyes in the group with the percentage more than 5% damage (P = .854, P = .358). The corneal endothelial cell damage could be quantitatively analyzed using trypan blue staining before keratoplasty in donor cornea. The amount of corneal endothelial cell damage in the central 8-mm circle was mostly acceptable, but some cases showed significantly severe endothelial cell damage. The corneal thickness and endothelial cell density did not differ between 10 eyes in the group with the percentage of the stained area in a circle with a diameter of 8 mm <5% and 5 eyes in the group with the percentage more than 5% damage. Therefore, pachymetry and specular microscopy are not sufficient for evaluating donor corneas before keratoplasty.

Risk of Bias Assessment in Non-Randomized Studies of Interventions for Premenstrual Syndrome: A Systematic Review

Objective: Premenstrual syndrome (PMS) is a very prevalent condition that affects premenopausal women and can result in monthly debilitating emotional and physical symptoms. The objective of this systematic review was to determine which predictive factors were associated with an increased amount of bias in non-randomized studies (NRSs) of PMS. Materials and methods: A search of the EMBASE and Medline electronic databases was completed from January 1, 2010 to December 2021. The methodological quality of the included studies was independently evaluated and critically appraised using the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-1) tool. Associations of different factors with the risk of bias levels were assessed using a univariate logistic regression. Odds ratio and 95% confidence interval (CI) were reported. Results: Of the 1668 studies, 38 were determined to be eligible for inclusion. The ROBINS-1 tool identified that 12 studies were of low/moderate risk of bias (31.6%) and 26 were of serious/critical risk (68.4%). Evidence of relationships between the ROBINS-1 score and impact factor (OR=0.20; 95% CI, 0.07 to 0.57; p= 0.003) and number of authors (OR=0.65; 95% CI, 0.43 to 0.99; p= 0.046) were identified, whereas no relationships were found with the number of citations, the sample size, the funding type, or the conflict-of-interest statement. Conclusion: The systematic review concludes that the methodological rigor of non-randomized studies of PMS can vary, with fewer authors and a lower impact factor showing evidence of association with a decreased quality of evidence.  

Diagnostic Accuracy of Ankle-Brachial Pressure Index Compared with Doppler Arterial Waveforms for Detecting Peripheral Arterial Disease: A Systematic Review

GENERAL PURPOSE

To present the results of a research study evaluating the diagnostic accuracy of the ankle-brachial pressure index (ABPI) compared with that of Doppler arterial waveforms (DAWs) to detect peripheral arterial disease (PAD).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, the participant will:1. Summarize the evidence the authors considered when comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.2. Select the characteristics of the participants in the studies the authors analyzed.3. Identify the results of the authors' study comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.4. Distinguish the authors' conclusions about the advantages of using Doppler arterial waveforms to detect PAD.

Search for an Axionlike Particle in B Meson Decays

Axionlike particles (ALPs) are predicted in many extensions of the standard model, and their masses can naturally be well below the electroweak scale. In the presence of couplings to electroweak bosons, these particles could be emitted in flavor-changing B meson decays. We report herein a search for an ALP, a, in the reaction B^{±}→K^{±}a, a→γγ using data collected by the BABAR experiment at SLAC. No significant signal is observed, and 90% confidence level upper limits on the ALP coupling to electroweak bosons are derived as a function of ALP mass, improving current constraints by several orders of magnitude in the range 0.175  GeV<m_{a}<4.78  GeV.

Search for Lepton Flavor Violation in ϒ(3S)→e^{±}μ^{∓}

We report on the first search for electron-muon lepton flavor violation (LFV) in the decay of a b quark and b antiquark bound state. We look for the LFV decay ϒ(3S)→e^{±}μ^{∓} in a sample of 118 million ϒ(3S) mesons from 27  fb^{-1} of data collected with the BABAR detector at the SLAC PEP-II e^{+}e^{-} collider operating with a 10.36 GeV center-of-mass energy. No evidence for a signal is found, and we set a limit on the branching fraction B[ϒ(3S)→e^{±}μ^{∓}]<3.6×10^{-7} at 90% C. L. This result can be interpreted as a limit Λ_{NP}/g_{NP}^{2}>80  TeV on the energy scale Λ_{NP} divided by the coupling-squared g_{NP}^{2} of relevant new physics (NP).

Search for Darkonium in e^{+}e^{-} Collisions

Collider searches for dark sectors, new particles interacting only feebly with ordinary matter, have largely focused on identifying signatures of new mediators, leaving much of dark sector structures unexplored. In particular, the existence of dark matter bound states (darkonia) remains to be investigated. This possibility could arise in a simple model in which a dark photon (A^{'}) is light enough to generate an attractive force between dark fermions. We report herein a search for a J^{PC}=1^{--} darkonium state, the ϒ_{D}, produced in the reaction e^{+}e^{-}→γϒ_{D}, ϒ_{D}→A^{'}A^{'}A^{'}, where the dark photons subsequently decay into pairs of leptons or pions, using 514  fb^{-1} of data collected with the BABAR detector. No significant signal is observed, and we set bounds on the γ-A^{'} kinetic mixing as a function of the dark sector coupling constant for 0.001<m_{A^{'}}<3.16  GeV and 0.05<m_{ϒ_{D}}<9.5  GeV.

Trends in hospitalized patients with cancer and stress cardiomyopathy

Introduction

Although cardiovascular disease (CVD) and cancer remain the top two causes of death worldwide, novel therapeutics have resulted in a decreased mortality rate in both groups. Accordingly, there has been a heightened awareness of patients with cancer experiencing stress cardiomyopathy (SC). In patients with cancer, the emotional stress of the diagnosis of cancer is compounded by the physical stress of treatments such as surgery, chemotherapy, immunotherapy, and radiotherapy. Previous studies have shown that SC in patients with cancer is associated with higher odds of in-hospital mortality when compared to patients with SC alone. No studies have examined the differences between patients with active cancer and SC compared to patients with active cancer without SC.

Purpose

To explore the unique impact that a diagnosis of SC has on patients with specific types of cancer, so that clinicians may recognize these phenomena and reduce morbidity associated with this disease.

Methods

We queried the 2016 United States National Inpatient Sample, which is the largest publicly available all-payer inpatient healthcare database, to identify demographic characteristics and outcomes in patients with active cancer and SC.

Results

Of 30,195,722 adult hospitalized patients, 4,719,591 (15.63%) had active cancer of whom 568,239 (12.04%) had SC. Among patients with active cancer, patients with SC versus those without SC were significantly more likely to have the following characteristics: female sex, white race, commercial insurance, hypertension, anemia, thrombocytopenia, and coagulation disorder (p&lt;0.003 for all variables). The five most common primary malignancies in patients with SC were breast (13.4%), lung (10.2%), skin (9.5%), colon (8.1%), and leukemia (4.8%) (Figure 1).

In machine learning-augmented propensity score-adjusted multivariable regression fully adjusting for age, race, income, and presence of metastases, the only primary malignancies that significantly increased the likelihood of SC were lung cancer (OR 1.25; p=0.003) and breast cancer (OR 1.81; p&lt;0.001) (Table 1). In separate regression, neither SC alone nor having both SC and cancer was significantly associated with mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; p=0.032).

Conclusion

In patients with active cancer, SC was not associated with in-hospital mortality. In addition, patients with both SC and breast cancer had significantly reduced mortality when compared to all patients with cancer. Further investigation will be necessary to confirm these findings and determine the possible protective factors in patients with SC and breast cancer. Furthermore, clinicians should be aware, early during hospitalization, of the increased likelihood of SC in patients with lung cancer and breast cancer, in order to reduce morbidity associated with these diagnoses.

Funding Acknowledgement

Type of funding sources: None.

Biologic Use in Pediatric Patients With Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

There is currently at least 1 biologic (adalimumab) approved in North America for treatment of Hidradenitis Suppurativa in the pediatric population. However, no reviews or clinical trials have specifically analyzed the effectiveness and safety data of biologic use in this population. The objective of this systematic review is to identify and summarize the outcomes of biologic therapy in pediatric patients with HS.

METHODS

MEDLINE and EMBASE databases were used to conduct the search on Sept 18, 2020.

RESULTS

The 15 included studies consisted of 26 patients, with the mean age of 15 ± 2.3 years. Females accounted for 53.8% (n = 14/26) of cases. The mean duration of HS prior to biologic initiation was 3.5 ± 2.9 years, with the majority having Hurley Stage II. The 26 patients received 34 biologics in total: 85.3% treated with TNF alpha inhibitors (adalimumab n = 17, infliximab n = 10, etanercept n = 1, unspecified n = 1), 5.9% with IL-12/23 inhibitors (ustekinumab n = 2), 5.9% with IL-1 inhibitors (i.e., anakinra n = 2) and 2.9% received IL-23 inhibitors (i.e., guselkumab n = 1) biologics. Of the 26 patients, 23.1% (n = 6/26) experienced complete resolution (CR), 73.1% (n = 19/26) experienced partial resolution (PR), and 3.8% (n = 1/26) had no resolution outcomes reported. The time to resolution of HS lesions after biologic initiation ranged from 10 days to 11.5 months (mean: 5.1 months). No adverse events were reported in the studies.

CONCLUSION

Although anti-TNF alpha were the most common biologics used for HS in pediatric cases, large-scale trials specific to pediatric patients with HS are needed to confirm these findings.

Unconventional supercurrent phase in Ising superconductor Josephson junction with atomically thin magnetic insulator

In two-dimensional (2D) NbSe₂ crystal, which lacks inversion symmetry, strong spin-orbit coupling aligns the spins of Cooper pairs to the orbital valleys, forming Ising Cooper pairs (ICPs). The unusual spin texture of ICPs can be further modulated by introducing magnetic exchange. Here, we report unconventional supercurrent phase in van der Waals heterostructure Josephson junctions (JJs) that couples NbSe₂ ICPs across an atomically thin magnetic insulator (MI) Cr₂Ge₂Te₆. By constructing a superconducting quantum interference device (SQUID), we measure the phase of the transferred Cooper pairs in the MI JJ. We demonstrate a doubly degenerate nontrivial JJ phase (ϕ), formed by momentum-conserving tunneling of ICPs across magnetic domains in the barrier. The doubly degenerate ground states in MI JJs provide a two-level quantum system that can be utilized as a new dissipationless component for superconducting quantum devices. Our work boosts the study of various superconducting states with spin-orbit coupling, opening up an avenue to designing new superconducting phase-controlled quantum electronic devices.

Van der Waals structures provide a new platform to explore novel physics of superconductor/ferromagnet interfaces. Here, NbSe₂ Josephson junction with Cr₂Ge₂Te₆ enables non-trivial Josephson phase by spin-dependent interaction, boosting the study of superconducting states with spin-orbit coupling and phase-controlled quantum electronic device.

Using a Systematic Approach to Teach Analysis of the Aging Face

Objective

To assess the efficacy of a novel systematic approach aimed at improving a resident physician’s ability to perform analysis of the aging face.

Study Design

Prospective randomized case-control study.

Setting

Accreditation Council for Graduate Medical Education accredited Otolaryngology–Head and Neck Surgery residency program.

Methods

Twenty otolaryngology–head and neck surgery residents were randomized into 2 groups with even representation in each postgraduate year level in each cohort. One group used traditional materials (textbooks), and the other group was given exclusive access to the online learning module featuring a systematic approach to aging-face analysis. Both groups completed preactivity, postactivity, and retention assessments to gauge their ability to perform a comprehensive analysis of the aging face.

Results

When compared with a matched control cohort, the residents who used the systematic approach performed more comprehensive facial aging assessments immediately after the intervention and at a retention time point.

Conclusion

A systematic approach delivered via an 11-minute online module can significantly improve a resident physician’s ability to perform analysis of the aging face. This systematic approach could be easily integrated into other online or traditional educational curriculums. Moreover, this methodology could be applied to additional areas in which residents have limited exposure but must develop expertise.

Blue and UV-B light synergistically induce anthocyanin accumulation by co-activating nitrate reductase gene expression in Anthocyanin fruit (Aft) tomato

The tomato accession LA1996, which carries a dominant allele of anthocyanin fruit (Aft) locus, accumulates anthocyanins in the epidermis of fruits when exposed to sunlight. The involvement of blue, UV-A, UV-B and a combination of these wavelengths on anthocyanin accumulation and the molecular mechanism of their regulation was investigated in LA1996. The most effective treatment for inducing anthocyanin biosynthesis in Aft fruits was co-irradiation with blue and UV-B (blue + UV-B) light. Finding the correlated genes is an important approach towards understanding their molecular mechanisms. In the present study, the nitrate reductase (NR) gene SlNIA was isolated using RNA-seq profiling of Aft fruits given different light treatments. The functions of NR-mediated anthocyanin induction by blue + UV-B were confirmed using a series of chemical treatments, followed by assessment of NR activity and nitric oxide (NO) detection. The expression of NR was highly induced by blue + UV-B, and this specificity was also confirmed with the enzyme activity of NR and the NO concentration. The NR inhibitors, which reduce NO generation, the expression levels of anthocyanin related genes and decreased anthocyanin accumulation in LA1996. Our results suggest that NR plays a key role in blue + UV-B-mediated anthocyanin accumulation in LA1996 fruits.

Postmortem radiologic and pathologic findings in COVID-19: The Toronto experience with pre-hospitalization deaths in the community

Over a year after the initial emergence of the disease, the COVID-19 pandemic continues to strain healthcare systems worldwide. The value of feedback and connection between clinical care, public health, and death investigation systems has never been more clear. To this end, knowledge of the radiologic and histopathologic features of fatal COVID-19 is critical for those working with the living and the dead. Most of the medical descriptions of COVID-19 are either focused on clinical in vivo medical imaging or autopsies performed following an intensive course of treatment over days to weeks prior to death, rather than deaths in the community prior to hospitalization. Here we report the postmortem computed tomography (PMCT) and lung histopathology in five fatal cases of COVID-19 that were subject to medicolegal death investigation. All individuals died in the community without medical treatment, or after a brief terminal admission to hospital. In these cases, the main PMCT findings included: diffuse lung changes including ground glass-type opacifications, a “crazy paving” appearance, variable areas of more dense consolidation, and relatively few areas of spared/less involved lung parenchyma. The unifying histopathology was diffuse alveolar damage in various stages of cellular evolution. In all cases, the pattern of PMCT and the lung histopathology corroborated the diagnosis of COVID-19. We propose the routine use of PMCT as a potential screening tool for the identification of COVID-19 related fatalities in the medicolegal setting where a paucity of historical information may not otherwise permit the identification of this disease prior to autopsy.

Nutrition and Physical Activity Clinical Practice Guidelines for Older Adults Living with Frailty

Background: We developed clinical practice guidelines to provide health care providers with evidence-based recommendations for decisions related to the effective management of frailty and pre-frailty using nutrition and physical activity interventions. Methods: We based the recommendations on two systematic reviews with meta-analyses. Nutrition, physical activity, and combined nutrition and physical activity interventions for adults ≥65y were considered if study populations were identified as frail using a frailty tool or assessment. Risk of bias and certainty of evidence were evaluated. We included physical outcomes, mobility, frailty, cognitive function, activities of daily living, falls, quality of life, diet quality, energy/fatigue levels, health services use, and caregiver outcomes. Results: Overall, mobility improvements were moderate with nutritional strategies that optimize dietary intake, various types of physical activity interventions, and interventions that combine nutrition and physical activity. Physical outcomes, such as body mass and muscle strength, improved moderately with nutritional strategies and interventions that combined nutrition with physical activity. Frailty status improved with multi-component physical activity interventions. Strong recommendations include optimizing dietary intake, performing physical activity, and adopting interventions that combine nutrition and physical activity. We strongly recommend various types of physical activity including muscle strengthening activities, mobilization or rehabilitation exercises, and multi-component physical activity interventions. Interpretation: Tailored nutrition and physical activity interventions based on individual goals and health status are associated with improved clinical and physical outcomes. While the recommendations facilitate shared decision-making, we identified sparse application of validated frailty assessments and lack of standardized research outcomes as critical gaps in knowledge.

High-bandwidth, variable-resistance differential noise thermometry

We have developed Johnson noise thermometry applicable to mesoscopic devices with variable source impedance with high bandwidth for fast data acquisition. By implementing differential noise measurement and two-stage impedance matching, we demonstrate noise measurement in the frequency range of 120 MHz-250 MHz with a wide sample resistance range of 30 Ω-100 kΩ tuned by gate voltages and temperature. We employed high-frequency, single-ended low noise amplifiers maintained at a constant cryogenic temperature in order to maintain the desired low noise temperature. We have achieved thermometer calibration with temperature precision up to 650 μK measuring a 200 mK temperature modulation on a 10 K background with 30 s of averaging. Using this differential noise thermometry technique, we measured thermal conductivity on a bilayer graphene sample spanning the metallic and semiconducting regimes in a wide resistance range, and we compared it to the electrical conductivity.

Precision Measurement of the Ratio B(ϒ(3S)→τ^{+}τ^{-})/B(ϒ(3S)→μ^{+}μ^{-})

We report on a precision measurement of the ratio R_{τμ}^{ϒ(3S)}=B(ϒ(3S)→τ^{+}τ^{-})/B(ϒ(3S)→μ^{+}μ^{-}) using data collected with the BABAR detector at the SLAC PEP-II e^{+}e^{-} collider. The measurement is based on a 28  fb^{-1} data sample collected at a center-of-mass energy of 10.355 GeV corresponding to a sample of 122 million ϒ(3S) mesons. The ratio is measured to be R_{τμ}^{ϒ(3S)}=0.966±0.008_{stat}±0.014_{syst} and is in agreement with the standard model prediction of 0.9948 within 2 standard deviations. The uncertainty in R_{τμ}^{ϒ(3S)} is almost an order of magnitude smaller than the only previous measurement.

Search for a Dark Leptophilic Scalar in e^{+}e^{-} Collisions

Many scenarios of physics beyond the standard model predict the existence of new gauge singlets, which might be substantially lighter than the weak scale. The experimental constraints on additional scalars with masses in the MeV to GeV range could be significantly weakened if they interact predominantly with leptons rather than quarks. At an e^{+}e^{-} collider, such a leptophilic scalar (ϕ_{L}) would be produced predominantly through radiation from a τ lepton. We report herein a search for e^{+}e^{-}→τ^{+}τ^{-}ϕ_{L}, ϕ_{L}→ℓ^{+}ℓ^{-} (ℓ=e, μ) using data collected by the BABAR experiment at SLAC. No significant signal is observed, and we set limits on the ϕ_{L} coupling to leptons in the range 0.04<m_{ϕ_{L}}<7.0  GeV. These bounds significantly improve upon the current constraints, excluding almost entirely the parameter space favored by the observed discrepancy in the muon anomalous magnetic moment below 4 GeV at 90% confidence level.

Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial

Importance

Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation.

Objective

To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation.

Design, Setting, and Participants

This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol.

Interventions

After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg.

Main Outcomes

The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality.

Results

One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02).

Conclusions and Relevance

Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality.

Trial Registration

ClinicalTrials.gov identifier: NCT01611935.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Measurements of the Absolute Branching Fractions of B^{±}→K^{±}X_{cc[over ¯]}

A study of the two-body decays B^{±}→X_{cc[over ¯]}K^{±}, where X_{cc[over ¯]} refers to one charmonium state, is reported by the BABAR Collaboration using a data sample of 424  fb^{-1}. The absolute determination of branching fractions for these decays are significantly improved compared to previous BABAR measurements. Evidence is found for the decay B^{+}→X(3872)K^{+} at the 3σ level. The absolute branching fraction B[B^{+}→X(3872)K^{+}]=[2.1±0.6(stat)±0.3(syst)]×10^{-4} is measured for the first time. It follows that B[X(3872)→J/ψπ^{+}π^{-}]=(4.1±1.3)%, supporting the hypothesis of a molecular component for this resonance.