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Patients with septic shock are under an intense inflammatory burden, which is closely associated with increased oxidative stress and depletion of antioxidants such as vitamin C. We hypothesized that patients with septic shock would present with elevated oxidative stress (assessed as F

BACKGROUND: Intravenous vitamin C is known to interfere with some point-of-care blood glucose meters. We aimed to determine the concentrations at which ascorbate interferes with glucose concentrations measured using a point-of-care blood glucose meter. We also compared the point-of-care meter and an arterial blood gas (ABG) analyser in the intensive care unit with laboratory glucose monitoring in septic patients receiving intravenous vitamin C infusions. METHODS: Blood samples containing normal, depleted and supplemented glucose and increasing concentrations of ascorbate (0.1–1.0 mmol/L) were tested using an Accu-Chek Inform II (Roche Diagnostics, USA) glucometer. For the in vivo study, 41 individual blood samples were drawn daily from septic patients n = 16) receiving infusions of 25 mg/kg of vitamin C every 6 hours. The glucose values of matched blood samples were assessed using Accu-Chek, ABG and laboratory glucose methods. RESULTS: For every 1 mmol/L of ascorbate added, the glucose concentration measured by the point-of-care monitor increased by 1.4 mmol/L (95% CI, 1.0–1.8; P < 0.001). Analysis of matched blood samples collected following intravenous vitamin C infusion indicated that 98% of the ABG and 83% of the Accu-Chek values met the International Organization for Standardization (ISO) 15197:2013 accuracy criteria. One patient had severe renal impairment, which contributed to elevated plasma vitamin C concentrations (median, 0.95 mmol/L; range, 0.64–1.10 mmol/L), resulting in elevated Accu-Chek readings and presenting a moderate clinical risk for the highest value. CONCLUSIONS: Vitamin C concentrations < 0.8 mmol/L do not interfere with point-of-care glucose monitoring. Intravenous vitamin C infusion of 25 mg/kg every 6 hours does not interfere with point-of-care glucose monitoring unless the patient has renal impairment, in which case laboratory glucose tests should be used.

Pandemic-related restrictions increased the risk of delayed emergency response of bystanders to sudden cardiac arrest among youth athletes. Education and SCA emergency preparedness, implemented by nurse leaders and adapted to environmental changes, can greatly reduce the risks associated with an SCA episode.A nurse-led, quality improvement pilot project was implemented in a recreational youth soccer league. The project included the implementation of an emergency action plan (EAP; with or without the pandemic and social-distancing restrictions) for bystanders responding to SCA.Participants showed significant improvement in knowledge and perceptions of SCA and emergency response (p.001). Willingness to initiate cardiopulmonary resuscitation (CPR) improved (p = .127), and fear to engage in EAP decreased (p = .119) following an educational intervention on SCA.Nurse-led SCA education and implementation of youth league EAP successfully demonstrated safety in SCA preparedness and best practice recommendations for youth sports from the Interassociation Task Force.

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Depot medroxyprogesterone acetate (DMPA) is a highly-effective, injectable contraceptive method that requires injections every 12 to 15 weeks. The need for return visits to a healthcare provider may present barriers to access, use, and continuation of DMPA. Studies demonstrate that self-administration of subcutaneous DMPA (DMPA-SC) outside clinical settings is safe, effective, feasible, acceptable, and can improve continuation. Based on existing evidence and potential to improve contraceptive access and autonomy, the Society of Family Planning recommends that DMPA-SC self-administration be made widely available as an additional option for patients. Provider-administered DMPA must also remain available to meet patients' individual needs and preferences.

Background End-stage Eisenmenger syndrome (ES) due to unrepaired atrial septal defect (ASD) or ventricular septal defect (VSD) is an indication for lung transplantation (LTx) or heart-lung transplantation (HLTx). Limited evidence exists as to the optimal transplant strategy for this unique population. Aim To describe waitlist characteristics and post-transplant outcomes in patients with ES-ASD or ES-VSD. Methods Using the ISHLT Registry, data were extracted for all ES-ASD or ES-VSD patients who underwent transplantation between 1987 and 2018. Additional data were sought for patients listed for LTx or HLTx in the OPTN Registry during the same period. Early era was defined as 1987-2004, and current era was defined as 2005-2018. Results In the current era, patients with ES-ASD or ES-VSD represented a lessening proportion of all LTx and HLTx. Compared to LTx for other indications, the odds of transplantation were significantly less for both ES-ASD 0.18 [0.07-0.50] and ES-VSD 0.03 [0.004-0.22]. In the early era, an equivalent survival was observed for ES-ASD who underwent HLTx versus LTx (p = 0.47), and superior survival for ES-VSD (p = 0.015). In contrast, ES-ASD patients who underwent LTx from the current era displayed better survival compared with HLTx, 10-year survival 52% vs 30% p = 0.036. Similar survival were observed for ES-VSD for both transplant strategies (p = 0.68). Conclusion LTx shows superior survival outcomes in the current era for ES ASD patients, and equivalent outcomes for ES-VSD. In the current era, ES-ASD or ES-VSD patients were less likely to be transplanted than other candidates for LTx.

OBJECTIVE: To examine factors associated with obtaining abortion at 12 or more weeks gestation in Texas after implementation of a restrictive law. STUDY DESIGN: In this retrospective cohort study, we collected data from eight Texas abortion clinics that provided services at 12 or more weeks gestation from April 1, 2015 to March 30, 2016, after a restrictive abortion law enacted in November 2013 shuttered many of the state’s clinics. We examined factors associated with obtaining in-clinic abortion services between 3–11 versus 12–24 weeks gestation including patient race-ethnicity, income level, and driving distance to the clinic using chi-square tests and calculating odds ratios. We further subcategorized abortion between 15–24 weeks to determine who may be most affected by a Texas law banning dilation and evacuation (D&E). RESULTS: Among 24,555 in-clinic abortions, 19.2% (n=4,714) occurred at 12 or more weeks gestation. Compared to patients who obtained care between 3–11 weeks, those who obtained care at 12 or more weeks were more likely to be Black than White (OR 1.18; 95% CI 1.05–1.31), live ≤110% of the federal poverty level than have higher income (OR 2.09; 95% CI 1.94–2.26), and drive 50+ miles than 1–24 miles to obtain care (OR 1.25; 95% CI 1.15–1.38). These associations remained for those obtaining care between 15–24 weeks. Even after adjusting for race-ethnicity and driving distance, low-income patients had greater odds of obtaining care in between 15–24 weeks (aOR 1.52; 95% CI 1.21–1.91). CONCLUSIONS: Patients obtaining abortion at 12 or more weeks gestation in Texas are more likely to be Black, low-income, and travel far distances to obtain in-clinic care. IMPLICATIONS: In Texas, patients who are Black, low-income, and travel the farthest are more likely to obtain in-clinic abortion between 15–24 weeks gestation, commonly performed via D&E. If Texas Senate Bill 8 (SB8) banning D&E goes into effect, these patients may be prevented from obtaining care.

Objective Reelin (RELN) is a large glycoprotein involved in synapse maturation and neuronal organization throughout development. Deficits in RELN signaling contribute to multiple psychological disorders, such as autism spectrum disorder, schizophrenia, and bipolar disorder. Nutritional stress alters RELN expression in brain regions associated with these disorders; however, the involvement of RELN in the neural circuits involved in energy metabolism is unknown. The RELN receptors apolipoprotein E receptor 2 (ApoER2) and very low-density lipoprotein receptor (VLDLR) are involved in lipid metabolism and expressed in the hypothalamus. Here we explored the involvement of RELN in hypothalamic signaling and the impact of diet-induced obesity (DIO) on this system. Methods Adult male mice were fed a chow diet or maintained on a high-fat diet (HFD) for 12–16 weeks. HFD-fed DIO mice exhibited decreased ApoER2 and VLDLR expression and increased RELN protein in the hypothalamus. Electrophysiology was used to determine the mechanism by which the central fragment of RELN (CF-RELN) acts on arcuate nucleus (ARH) satiety-promoting proopiomelanocortin (POMC) neurons and the impact of DIO on this circuitry. Results CF-RELN exhibited heterogeneous presynaptic actions on inhibitory inputs onto ARH-POMC-EGFP neurons and consistent postsynaptic actions. Additionally, central administration of CF-RELN caused a significant increase in ARH c-Fos expression and an acute decrease in food intake and body weight. Conclusions We conclude that RELN signaling is modulated by diet, that RELN is involved in synaptic signaling onto ARH-POMC neurons, and that altering central CF-RELN levels can impact food intake and body weight., Highlights • Diet-induced obesity alters reelin protein levels and expression of ApoER2 and VLDLR. • Reelin has direct, but divergent actions on GABAergic inputs onto POMC neurons. • Central administration of reelin protein decreases food intake and body weight.

Diatoms perform an estimated 20% of global photosynthesis, form the base of the marine food web, and sequester carbon into the deep ocean through the biological pump. In some areas of the ocean, diatom growth is limited by the micronutrient cobalamin (vitamin B12), yet the biochemical ramifications of cobalamin limitation are not well understood. In a laboratory setting, we grew the diatom Thalassiosira pseudonana under replete and low cobalamin conditions to elucidate changes in metabolite pools. Using metabolomics, we show that the diatom experienced a metabolic cascade under cobalamin limitation that affected the central methionine cycle, transsulfuration pathway, and composition of osmolyte pools. In T. pseudonana, 5'-methylthioadenosine decreased under low cobalamin conditions, suggesting a disruption in the diatom's polyamine biosynthesis. Furthermore, two acylcarnitines accumulated under low cobalamin, suggesting the limited use of an adenosylcobalamin-dependent enzyme, methylmalonyl CoA mutase. Overall, these changes in metabolite pools yield insight into the metabolic consequences of cobalamin limitation in diatoms and suggest that cobalamin availability may have consequences for microbial interactions that are based on metabolite production by phytoplankton.