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COVID-19 has been a devastating pandemic with little known of its neuropsychiatric complications. Delirium is one of the most common neuropsychiatric syndromes among hospitalized cancer patients with incidence ranging from 25% to 40% and rates of up to 85% in the terminally ill. Data on the incidence, risk factors, duration, and outcomes of delirium in critically ill cancer patients with COVID-19 are lacking.To report the incidence, risks and outcomes of critically ill cancer patients who developed COVID-19.This is a retrospective single-center study evaluating delirium frequency and outcomes in all critically ill cancer patients with COVID-19 admitted between March 1 and July 10, 2020. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit, performed twice daily by trained intensive care unit (ICU) nursing staff. Patients were considered to have a delirium-positive day if Confusion Assessment Method for Intensive Care Unit was positive at least once per day.A total of 70 patients were evaluated. Of those 70, 53 (75.7%) were found to be positive for delirium. Patients with delirium were significantly older than patients without delirium (median age 67.5 vs 60.3 y, P = 0.013). There were no significant differences in demographic characteristics, chronic medical conditions, neuropsychiatric history, cancer type, or application of prone positioning between the 2 groups. Delirium patients were less likely to receive cancer-directed therapies (58.5% vs 88.2%, P = 0.038) but more likely to receive antipsychotics (81.1% vs 41.2%, P = 0.004), dexmedetomidine (79.3% vs 11.8%, P0.001), steroids (84.9% vs 58.8%, P = 0.039), and vasopressors (90.6% vs 58.8%, P = 0.006). Delirium patients were more likely to be intubated (86.8% vs 41.2%, P0.001), and all tracheostomies (35.9%) occurred in patients with delirium. ICU length of stay (19 vs 8 d, P0.001) and hospital length of stay (37 vs 12 d, P0.001) were significantly longer in delirium patients, but there was no statistically significant difference in hospital mortality (43.4% vs 58.8%, P = 0.403) or ICU mortality (34.0% vs 58.8%, P = 0.090).Delirium in critically ill cancer patients with COVID-19 was associated with less cancer-directed therapies and increased hospital and ICU length of stay. However, the presence of delirium was not associated with an increase in hospital or ICU mortality.

Expert physiological and pharmacological care by anaesthetists is required in all stroke endovascular thrombectomy cases. RCTs show clinical benefits in recanalisation rates and functional recovery after endovascular thrombectomy with general anaesthesia compared with sedation. Many stroke centres will require wholesale reorganisation of stroke pathways to ensure anaesthesia services are available for all cases. Anaesthetists have an integral role in improving clinical outcomes in large vessel occlusion stroke.

The term Jingluo, translated as meridian or channel, is a core component of traditional Chinese medicine (TCM) and has played a fundamental role in guiding the clinical practice of acupuncture for thousands of years. However, the essence of the meridian remains elusive and is a source of both confusion and debate for researchers. In this study, a “4D” systemic view on the essence of the meridian, namely substantial, functional, chronological, and cultural dimensions, was proposed based on a review of the ancient medical classics, recent research developments, and results from clinical practice. Previous studies have primarily focused on the substantial dimension of the meridian system, with scant interpretation about its functional domain. Neither systemic data nor evaluations have been adequately documented. Additionally, a limited but increasing number of studies have focused on the chronological and cultural dimensions. More investigations that embody the holistic concept of TCM and integrate the systemic modes and advanced techniques with dominant diseases of TCM need to be performed to obtain a more comprehensive understanding of the essence of meridians. The goal of this study is to yield useful information in understanding the essence of meridians and provide a reference and perspective for further research.

Microorganisms can be defined as a small living forms of life, even can't be viewable with the naked eyes. The three types of microorganisms named Bacteria, Yeasts and Molds in which almost always there may be confusion with their functions, but they are just as real and alive as we are. They eat, grow, reproduce and die also. The tumour cells has also ability to reproduce themselves, to grow in numbers and die to reduce their density in some specific region. In this work we try show the growth for both tumour cells and microorganism with the help of mathematical model and also try to compare the numerical results with the help of Python. This model consists of a system of partial differential equations incorporated with different factors like migrating cells, proliferating cells and nutrient which effects the growth most. At last the results shows the variation of different classes of cell densities with respect to growth function and as well as with the total cell density.

The entire world has gotten caught and is now furious that the deadly corona virus is out. All and every person’s life across the globe has stopped. It took millions of lives already. The government of most countries agreed to follow the full lock-down of human activities due to its propensity to a high spread frequency. Therefore, this work of mine would be a accentuating the affectivity of the Aarogya Setu application in spreading realization amongst the masses that self- care in this situation of emergence is the only way not only of saving one’s own life but also of others. It would also effectively highlight that though, the use of virtual platform has benefitted all but its improper utilization can create loads of misunderstanding, confusion and can give rise to some devastating situation.

In a pattern called immune imprinting, individuals gain the strongest immune protection against the influenza strains encountered earliest in life. In many recent examples, differences in early infection history can explain birth year-associated differences in susceptibility (cohort effects). Susceptibility shapes strain fitness, but without a clear conceptual model linking host susceptibility to the identity and order of past infections, general conclusions on the evolutionary and epidemic implications of cohort effects are not possible. Failure to differentiate between cohort effects caused by differences in the set, rather than the order (path), of past infections is a current source of confusion. We review and refine hypotheses for path-dependent cohort effects, which include imprinting. We highlight strategies to measure their underlying causes and emergent consequences.

Introduction Advanced practice in physiotherapy represents a development in the practice of physiotherapy and has developed in different ways around the world. There is growing evidence to support advanced physiotherapy practice. In May 2019, the member organisations adopted the first World Physiotherapy policy on advanced practice in physiotherapy. However, to date, there is no evidence on the nature and extent of this practice globally. Objectives To investigate the extent to which advanced practice is present within the global physiotherapy community, to document the titles used, to describe the pathway to become an advanced physiotherapy practitioner and to investigate the barriers and facilitators to the development of the roles. Design An online cross-sectional survey was sent to the various national associations of the World Physiotherapy. Participants Participants were the member organisations (MOs) of World Physiotherapy. Instrument The survey comprised 14 questions. The questions were developed based on a review of the evidence around advanced practice and in-depth discussions with the expert group set up by World Physiotherapy. Results A total of 82/112 MOs responded to the survey representing a 73% response rate. Fourteen respondents (14/82, 17%) indicated that they had formal roles in their country/territory. The terms specialist and advanced physiotherapy practitioner were often used interchangeably and were a source of confusion. Seventy-nine (11/14, 79%) percent stated that most advanced physiotherapy practitioners have a combination of clinical practice and a Master’s or Doctoral degree. The major facilitators to the development and sustainability of the role were the research evidence, advocacy by the professional organisation, the need to reduce cost and the support received by the advanced physiotherapy practitioners from their employers. Conclusion The outcomes of this study provide a clearer understanding of how member organisations of World Physiotherapy defined advanced practice in physiotherapy and what titles are used. It provides insights into the barriers and facilitators to the development of advanced practice in physiotherapy.

Introduction and Objectives Implantable cardiac defibrillator (ICD) has been established as a therapy for malignant ventricular arrhythmias in patients at high risk of suffering them. Some studies suggest a possible relationship between the development of cancer and some prosthetic materials. Likewise, some investigations describe a higher incidence of cancer in patients with an ICD that suggest a potential relationship. Methods Retrospective cohort study of patients that underwent implantation of an ICD in the Complejo Hospitalario de Navarra between 2000 and 2016. The follow-up finished in June 2018. Sociodemographic, comorbidities and oncological data was analysed. Cancer incidence rates were estimated and compared with the general population data and with data of a cohort of patients with reduced LVEF heart failure. Risk of cancer models were adjusted by competitive risk models. Results 497 patients were included, mostly male (89.1%), with a mean age of 59.98 (14.98) years and a proportion of smokers of 67.6% and of ischaemic heart disease of 51.6%. The cancer incidence rate in the sample was 1230.9 per 100.000 person-year. In our study, features associated with cancer were older age, higher tobacco use and ischaemic cardiopathy. Conclusions In our sample of ICD carriers the incidence of cancer is high. This finding mainly seems to be related to tobacco usage and higher age.

Organoids, or miniaturized organs formed in vitro, hold potential to revolutionize how researchers approach and answer fundamental biological and pathological questions. In the context of cardiac biology, development of a bona fide cardiac organoid enables study of heart development, function, and pathogenesis in a dish, providing insight into the nature of congenital heart disease and offering the opportunity for high-throughput probing of adult heart disease and drug discovery. Recently, multiple groups have reported novel methods for generating in vitro models of the heart; however, there are substantial conceptual and methodological differences. In this review we will evaluate recent cardiac organoid studies through the lens of the core principles of organoid technology: patterned self-organization of multiple cell types resembling the in vivo organ. Based on this, we will classify systems into the following related types of tissues: developmental cardiac organoids, chamber cardiac organoids, microtissues, and engineered heart tissues. Furthermore, we highlight the interventions which allow for organoid formation, such as modulation of highly conserved cardiogenic signaling pathways mediated by developmental morphogens. We expect that consolidation and categorization of existing organoid models will help eliminate confusion in the field and facilitate progress towards creation of an ideal cardiac organoid.

Acute respiratory distress syndrome is a common condition among critically ill patients, but remains under-recognized and undertreated. Under-recognition may result from confusion over the clinical inclusion criteria, as well as a misunderstanding of the complex relationship between the clinical syndrome, the variable histopathologic patterns, and the myriad clinical disorders that cause acute respiratory distress syndrome. The identification of the clinical syndrome and determination of the causal diagnosis are both required to optimize patient outcomes. Here we review the definition, discuss pitfalls in recognizing acute respiratory distress syndrome and consider an approach to ascertain specific etiologies of acute respiratory distress syndrome.

Aim Delirium is a common presenting symptom among older patients. Patients who presented with delirium may have a higher morbidity and mortality rate due to older age, other comorbidities, and atypical COVID-19 presentation. Currently, the evidence supporting delirium as one of the predictors of poor outcome of COVID-19 is still insufficient. This study aims to explore the potential association between delirium and poor outcomes from COVID-19. Methods We systematically searched the PubMed and Google Scholar databases using specific keywords related to our aims until January 30th, 2021. All articles published on COVID-19 and delirium were retrieved. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies and Joanna Briggs Institute (JBI) Critical Appraisal Tools for case-series studies. Statistical analysis was done using Review Manager 5.4 software. Results Our meta-analysis of 20 studies showed that delirium symptoms on admission was associated with poor outcomes from COVID-19 [OR 2.36 (95% CI 1.80–3.09), p

Avascular necrosis of the scaphoid, often referred to as Preiser's disease, is little known despite the scaphoid being the second most frequently involved location in avascular pathology of the carpal bones after the lunate (Kienböck's disease). Nonetheless, very few cases have been reported in the medical literature over the last century. Its pathophysiology is not completely elucidated although the unique vascularization of the scaphoid and several risk factors seem to be recurrently incriminated. Two new classifications based on modern imaging have appeared in the last decade and are now considered essential supplements to Herbert and Lanzetta's original radiographic classification. Because of the lack of formal treatment guidelines, a wide range of different treatments have been explored over time, contributing to the confusion around this pathology. Adding to this confusion, are the numerous terms used to designate the condition and lack of knowledge concerning its pathophysiology, risk factors, clinical and radiographic presentation. The aim of this review is therefore to explore and clarify Preiser's disease in terms of history, terminology, pathophysiology, clinical considerations and imaging and to propose a simple updated treatment algorithm based on the results provided by a thorough review of literature (53 publications, 170 patients) since Georg Preiser's original and controversial description in 1910.

This article provides an overview of the nutrition requirements for athletes, and gives insight into why this is often an area of confusion for both the athletic community and the general population. In addition, the prevalence of eating disorders and disordered eating in athletes is reviewed, and how and why they may go unnoticed. In addition, a discussion is provided on the harmful effects of unhealthy food behaviors on health and performance, and how to assess and establish a care team for an athlete who is struggling.

Near the end of 2019, a new betacoronavirus started to efficiently transmit between humans, resulting in the current COVID-19 pandemic. Unprecedented worldwide efforts were made to identify and repurpose antiviral therapeutics from collections of approved drugs and known bioactive compounds. Typical pitfalls of this approach (promiscuous/cytotoxic compounds leading to false positives), combined with bypassing antiviral drug development parameters due to urgency have resulted in often disappointing outcomes. A flood of publications, press-releases, and media posts, created confusion in the general public and sometime mobilized precious resources for clinical trials with minimal prospect of success. Breakthroughs have been made, not in the laboratory but in the clinic, resulting from the empiric identification of mitigators of clinical signs such as the discovery of improved disease management through immunomodulators. This opinion piece will aim to capture some of the lessons that we believe the COVID-19 pandemic has taught about drug repurposing screens.

Oppositional defiant disorder includes distinct but inseparable dimensions of chronic irritability and oppositional behavior. The dimensions have been identified in early childhood to adulthood, and show discriminant associations with internalizing and externalizing psychopathology. The introduction of disruptive mood dysregulation disorders and the requirements that it take precedence over oppositional defiant disorder diagnostically are not supported by evidence and introduce confusion about the structure and linkages of irritability and oppositional behavior, and obscure the importance of the behavioral dimension in explaining and predicting poor outcomes. A dimensional framework with irritability, oppositionality, callous-unemotional traits, and aggression may more fully describe antisocial outcomes.

Objectives: To explore and visualize the relationships among multiple symptoms in people living with HIV (PLWH) and compare centrality indices and the density of symptom networks among groups of individuals with different HIV-positive durations. Methods: We conducted a secondary analysis of data from the HIV-related Symptoms Monitoring Survey conducted in China. Networks were constructed among 27 symptoms. Centrality properties, including strength and closeness, and network density were used to describe relationships among symptoms in 5 different HIV-positive duration groups. Results: The findings showed that PLWH with longer HIV-positive durations did not have more severe symptoms; instead, their symptom networks were denser than those of their newly HIV-diagnosed counterparts (F = 27.073, P < 0.001). Fatigue was the most severe and central symptom in PLWH with an HIV-positive duration 10 years. Conclusion: This study demonstrates a need to include an assessment of PLWH symptom networks as an essential component of HIV care. We recommended evaluating cognitive function and cognitive training as essential components of HIV care for long-term survivors, even in younger populations (aged ≤50 years).

Magnetic resonance imaging (MRI) has become the gold standard for the diagnosis of many pathologies. Using MRI in patients with auditory implants can however raise concerns due to mutual interactions between the implant and imaging device, resulting in potential patient risks. Several implant manufacturers have been working towards more MRI safe devices. Older devices are however often labelled for more stringent conditions, possibly creating confusion with patients and professionals. With this myriad of different devices that are implanted in patients for lifetimes of at least 20 years, it is crucial that both patients and professionals have a clear understanding of the safety of their devices. This work aims at providing an exhaustive overview on the MRI safety of active auditory implants. The available industry standards that are followed by manufacturers are outlined and an overview of the latest scientific developments focusing on the last five years is provided. In addition, based on the analysis of the adverse events reported to the Food and Drug Administration (FDA) and in literature within the past ten years, a systematic review of the most commonly occurring issues for patients with auditory implants in the MRI environment is provided. Results indicate that despite the release of more MRI conditional active hearing implants on the market, adverse events still occur. An extensive overview is provided on the MRI safety of active auditory implants, aiming to increase the understanding of the topic for healthcare professionals and contribute to safer scanning conditions for patients. ispartof: Journal of Otology vol:16 issue:3 pages:185-198 ispartof: location:China status: Published online

Made available in DSpace on 2021-06-25T11:13:08Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-06-01 Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Introduction: The coronavirus disease of 2019 pandemic has changed university routines affecting student mental health. The aims of this study were to survey aspects related to mental health of pharmaceutical course students considering previous and current contexts. Methods: The Depression, Anxiety, and Stress Scale (DASS-21), Impact of Event Scale-Revised, and Brunel Mood Scale were used. DASS-21 was completed pre- and post-pandemic. The validity and reliability of the data were verified. The prevalence (95% CI) of mental health symptoms was estimated. The relationship between the time spent watching/reading the news and mean scales scores was evaluated (Pearson's correlation coefficient). Results: The prevalence of depression symptoms in students pre-pandemic was 66.7% (95% CI = 65.3–68.1) and during the pandemic was 81% (95% CI = 79.8–82.2). More than 70% (95% CI = 69.8–72.6) of participants had some psychological impact as a result of the pandemic (mild: 16.7% [95% CI = 15.6–17.8]; moderate: 9.1% [95% CI = 8.2–10]; severe: 45.4% [95% CI = 43.9–46.9]). High values of tension, depressed mood, mental confusion, and anger were observed. There was a significant correlation between the time spent following the news of the pandemic and symptoms of anxiety (r = 0.356; P

The Advisory Committee on Immunization Practices (ACIP) was created out of the need to formalize vaccine recommendations for the United States. Annually, ACIP delivers recommendations to the CDC director for guidance about United States vaccine use and publishes the Adult Immunization Schedule. Updated schedules feature changes to vaccine recommendations as well as changes to the schedule's usability for physicians. The objective of this study was to determine physicians' attitudes about the Adult Immunization Schedule. Surveys were administered to a sentinel physician network from October 2019 through January 2020. Physicians that responded were comfortable using the Adult Immunization Schedule, but reported confusion about some medical condition-based indications. Physicians reported a lack engagement with mobile applications, CDC Vaccine Schedules and Shots by STFM (the Society for Teachers of Family Medicine). Future work should focus on increasing clarity regarding the recommendations with medical condition-based indications and increasing knowledge of mobile applications for physicians.

BACKGROUND. We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS. Consecutive cardiac surgery patients (n=298) at a university hospital were assessed for preoperative frailty using Fried’s phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year postoperatively. RESULTS. Preoperative frailty presented in 85 (28.5%) and POD developed in 38 (12.8%) participants. Frail participants were at increased risk of POD (odds ratio=4.9; P

Background Meta-analyses are widely used to strengthen available evidence and obtain more precise estimates of treatment effect than any individual trial. Paradoxically, multiplication of meta-analyses on the same topic can lead to confusion as practitioners no longer benefit from a rapid and synthetic response. This phenomenon may appear disproportionate when the number of published meta-analyses exceeds the number of original studies. Objectives To describe an example of redundant meta-analyses published in the same area with the same randomized clinical trials (RCTs). Methods A systematic review was performed to identify all published meta-analyses of original RCTs that compared direct oral anticoagulants with low molecular weight heparins in cancer patients with venous thromboembolism (VTE). Forest plots were used to represent the meta-analyses results for efficacy (VTE recurrence) and safety (major bleeding) endpoints. An authors' network was constructed to explore the links between the authors of the published meta-analyses. Results In the past 3 years, four original RCTs were the subject of 20 published meta-analyses by 142 authors: five, four, and 11 meta-analyses pooled the data of two, three, and four RCTs, respectively. The results of meta-analyses were similar regarding the risks of VTE recurrence and major bleeding. The 11 meta-analyses of four RCTs were published within 6 months of the publication of the last RCT. Conclusions The epidemic proportions of such redundant literature and authorship could be moderated by developing "living" meta-analyses and encouraging authors of new RCTs to update the corresponding meta-analysis in the same paper as their original research.

Objective To develop and evaluate a new method for identifying gait disorientation due to vestibular dysfunction. Design The gait disorientation test (GDT) involves a timed comparison of the ability to walk 6.096 m with eyes open versus eyes closed. In this prospective study, participants were grouped based on vestibular function. All participants completed a clinical examination, self-report- and performance-based measures relevant to vestibular rehabilitation, and the tasks for the GDT. Vestibular-impaired participants underwent the criterion standard, videonystagmography and/or rotational chair testing. Setting Ambulatory clinic, tertiary referral center. Participants Participants (N=40) (20 vestibular-impaired, 30 women, 49.9±16.1years old) were enrolled from a convenience/referral sample of 52 adults. Main Outcome and Measure(s) We determined test-retest reliability using the intraclass correlation coefficient model 3,1; calculated the minimal detectable change (MDC); examined concurrent validity through Spearman correlation coefficients; assessed criterion validity with the area under the curve (AUC) from receiver operator characteristic analysis; and computed the sensitivity, specificity, diagnostic odds ratio (DOR), likelihood ratios for positive (LR+) and negative (LR−) tests, and posttest probabilities of a diagnosis of vestibulopathy. The 95% confidence interval demonstrates measurement uncertainty. Results Test-retest reliability was 0.887 (0.815, 0.932). The MDC was 3.7 seconds. Correlations with other measures ranged from 0.59 (0.34, 0.76) to −0.85 (−0.92, −0.74). The AUC was 0.910 (0.822, 0.998), using a threshold of 4.5 seconds. The sensitivity and specificity were 0.75 (0.51, 0.91) and 0.95 (0.75, 1), respectively. The DOR=57 (6, 541.47), LR+ =15 (2.18, 103.0), and LR− =0.26 (0.12, 0.9). Positive posttest probabilities were 89%-94%. Conclusions and Relevance The GDT has good reliability, excellent discriminative ability, strong convergent validity, and promising clinical utility.

Patients with Alzheimer's disease (AD) related dementia and mild cognitive impairment experience difficulties with spatial navigation (SN). However, SN has rarely been investigated in individuals with subjective cognitive decline (SCD), a preclinical stage with elevated progression rate to symptomatic AD. In this study, 30 SCD subjects and 30 controls underwent cognitive scale (CS) evaluation, a 2D computerized SN test, and resting-state functional magnetic resonance imaging scanning. Two SN brain networks (ego-network and allo-network), each with 10 selected spherical regions, were defined. We calculated the average network functional connectivity (FC) and region-to-region FC within the two networks and evaluated correlations with SN performance. Compared with the controls, the SCD group performed worse in the SN test and showed decreased FC between the right retrosplenial and right prefrontal cortices in the ego-network, and between the right retrosplenial cortex and right hippocampus in the allo-network. The logistic regression model based on SN and FC measures revealed a high area under the curve of .880 in differentiating SCD individuals from controls. These results suggest that SN network disconnection contributes to spatial deficits in SCD, and SN and FC measures could benefit the preclinical detection of subjects with incipient AD dementia.

Methodological shortcomings in prognostic modeling for patients with spinal disorders are highly common. This general commentary discusses methodological challenges related to the specific nature of this field. Five specific methodological challenges in prognostic modeling for patients with spinal disorders are presented with their potential solutions, as related to the choice of study participants, purpose of studies, limitations in measurements of outcomes and predictors, complexity of recovery predictions, and confusion of prognosis and treatment response. Large studies specifically designed for prognostic model research are needed, using standard baseline measurement sets, clearly describing participants’ recruitment and accounting and correcting for measurement limitations.

Background: Victims of flame burns invariably inhale smoke which contains potentially toxic gases that may contribute to their morbidity and mortality. The most significant inhalational toxin in many fires is carbon monoxide (CO). This study aimed to assess clinical evidence for possible CO poisoning and measure Carboxyhemoglobin (COHb) levels on fire casualties presenting to a tertiary teaching and referral hospital in Kenya. The gold standard, serum COHb spectrophotometry was unavailable hence pulse CO-oximetry was utilised to measure carboxyhemoglobin saturation (SpCO). Methodology: This was a prospective descriptive study. It was approved by institutional ethics committee. Eighty non-pediatric patients presenting with acute (10% indicating CO toxicity. However, the majority recorded nontoxic levels of

Inflammatory myofibroblastic tumor (IMT) is a rare tumor with an indolent course. It is less often reported as a second tumor that occurs after treatment of malignant tumors in pediatric patients. Here, we report a case of IMT following Wilms tumor (WT), and conduct a literature review concerning IMTs and WT to evaluate the diagnostic possibility of IMT as a second tumor. The coexistence of the 2 tumors may cause confusion as to whether they share genetic links or that IMTs may appear as late effects of the treatment of WT.

The objective of this article is to review the difficulties with the design and interpretation of surgical clinical trials. Few surgical procedures are evaluated in a randomized fashion. There are a number of factors that make the design of surgical trials diffiuclt, and many surgical questions cannot be answered with a clinical trial. Issues with standardization of the surgical procedure, variability of surgical skills, and changes in surgical expertise over time further complicate the design and implementation of surgical trials. Statistical methods for surgical trials often require a noninferiorty design and are more complicated to interpret than the more common superiority trial. Even when properly conducted, both superiority and noninferiority trials are often misinterpreted. Because of the relatively high success rate in surgery, trials require large numbers of patients and noninferiority trials are often inconclusive with respect to the primary outcome. Surgical trials are often misinterpreted or over interpreted, and there can be confusion in how the findings of these trials should be incorportated into clinical practice. The interpretation of the results of a surgical trial often differ significantly from the primary and secondary outcomes that were specified in the trial design.

Charcot neuroarthropathy secondary to diabetes mellitus is a serious complication, requiring specialist management. As a relatively rare pathology bearing similarity to other, more common diseases, it may be misdiagnosed at initial presentation, potentially leading to delays in appropriate management. We conducted a 2-part online survey of primary care physicians within an academic medical institution to assess knowledge of presentation, complications, diagnosis, and treatment of Charcot neuropathy. The first section was designed to assess physician knowledge of Charcot foot, while the second section was completed only by physicians who were familiar with the condition and was designed to gauge their level of knowledge. Most clinicians were familiar with Charcot, encountering it at least annually. They identified common signs of Charcot (eg, swelling, pain) and complications due to its mismanagement (eg, ulcer, amputation). However, there was some disagreement on how to diagnose the pathology, with some relying on film, others referring to specialists, and some saying they were unsure. There was uncertainty on when to choose surgical options; fewer than half referred to specialists for help with this decision, and a quarter were unsure how to make the decision. While, in general, clinicians were aware of Charcot and its characteristics, there was confusion regarding how to diagnose or appropriate nonsurgical treatment.

Resume L’auteur propose une reflexion sur le parallele que l’on peut etablir entre l’entite syndromique qu’est la confusion et l’etat de perplexite et de sideration observe dans la population generale suite a l’apparition de la pandemie a SARS-CoV-2. Comme toute explication organiciste, cette comparaison trouvera rapidement ses limites, mais elle permet de penser un contexte inedit et une necessaire vigilance quant aux decisions et justifications prises hâtivement en periode de confusion.

Since its initial description in the 2nd century, the suboccipital nerve has maintained a number of varying terminologies. Many of these terms were created in the 18th and 19th centuries to describe the first set of cervical spinal nerves that exited the spinal cord between the cranium and the atlas. Though the many terminologies have been reduced to mainly the suboccipital nerve, there are still two prevalent definitions used for this nerve. Herein, we discuss the history of the first spinal nerve and its branches with special attention to varying terminologies over time. Recent literature has described the suboccipital nerve as the entire nerve or as simply the dorsal ramus of the C1 spinal nerve. This interchangeability may lead to confusion about the specific part of the nerve being discussed. Following a review of the literature, we recommend the term C1 spinal nerve be applied to the entire nerve, whereas, suboccipital nerve be reserved solely for the posterior branch of the C1 spinal nerve.

The inappropriate combustion of furniture-industry waste can be a source of serious environmental problems. We proposed a method which is capable to distinguish the emission resulting from the combustion of wood-based materials, the essential component of such waste. The originality of the approach consists in the classification of gas mixtures instead of focussing on the individual pollutants emitted to the atmosphere. The classification of emission was based on the measurements applying differential ion mobility spectrometry (DMS) and Fourier transform infrared (FTIR) spectrometry, for comparison. There were successfully distinguished emissions associated with combustion of wood-based materials: OSB board, MDF board and plywood (≥95% correct classifications in the class (ccc)) and wood: pellet and kindling wood (≥92% ccc). Results of classification based on DMS and FTIR measurements were similar. Emissions from the combustion of individual materials were best distinguished using DMS (100% ccc), as compared with FTIR, which offered lower performance, mostly >90% ccc. Regarding pairwise classification, the most distinctive were emissions from the combustion of plywood (DMS: 99% ccc; FTIR: 99% ccc), MDF board (DMS: 99% ccc; FTIR: 99% ccc) and OSB board (DMS: 99% ccc; FTIR: 98% ccc). Emissions form kindling wood (DMS: 100% ccc; FTIR: 95% ccc) and pellet (DMS: 97% ccc; FTIR: 98% ccc) caused a bit more confusion. In most cases, results of classification based on DMS and FTIR measurements were comparable. The success of classification based on DMS measurements proved that it is possible to detect the harmful emission without determining the chemical composition of the flue gas. This solution represents a new approach to air quality monitoring, which recently attracts increasing attention.

Although genetics shapes our sense of taste to prefer some foods over others, taste sensation is plastic and changes with age, disease state, and nutrition. We have known for decades that diet composition can influence the way we perceive foods, but many questions remain unanswered, particularly regarding the effects of chemosensory plasticity on feeding behavior. Here, we review recent evidence on the effects of high-nutrient diets, especially high dietary sugar, on sweet taste in vinegar flies, rodents, and humans, and discuss open questions about molecular and neural mechanisms and research priorities. We also consider ways in which diet-dependent chemosensory plasticity may influence food intake and play a role in the etiology of obesity and metabolic disease. Understanding the interplay between nutrition, taste sensation, and feeding will help us define the role of the food environment in mediating chronic disease and design better public health strategies to combat it.

Nearby flanking objects degrade visual resolution. If the flankers are similar to the acuity target, this influence is called crowding (CW), whereas if the flanking stimuli are simple bars then the phenomenon is known as contour interaction (CI). The aim of this study was to compare the influence of the number and position of flankers on foveal CW and CI to investigate possible differences in mechanism of these two effects. Five normal observers viewed single, foveally presented Sloan letters surrounded by 1, 2 or 4 flankers (either a Sloan letter or one-stroke-width bars), presented at several edge-to-edge separations. Single flankers were presented in the right, left, top or bottom position, 2 flankers were placed equally to the right and left or top and bottom of the central target, and 4 flankers were equally spaced in all four directions. Percent correct letter identification was determined for each type, number, position and separation of flankers and confusion matrices were constructed for separations equal to 20% and 100% letter width. Increasing the number of flankers caused an increase in the magnitude of both phenomena. CW showed a greater magnitude than CI for higher numbers of flankers. Analysis of confusion matrices suggests that in addition to the edge-to-edge interaction that appears to mediate CI, letter substitution and feature pooling contribute significantly to CW when higher numbers of flankers are presented. Foveal CW is more strongly influenced by an increase in the number of flankers than CI, which can be explained by the presence of additional interaction effects.

Summary At the industrial level, separation of a variety of mixtures is predominantly carried out by thermally driven processes such as distillation. Nevertheless, the current literature seems to suggest that much is to be gained by replacing these processes with alternative non-thermal methods, which will potentially require a fraction of the energy used by distillation. This is primarily due to the widespread perception that thermal separation processes, particularly those that involve vaporization, are highly energy intensive. However, this belief is not well founded, because it is based on extrapolation from comparisons in the literature, many of which make ad-hoc assumptions and result in incorrect conclusions. Our analysis shows that this confusion arises because the processes utilize different types of energy: heat and electricity. Here, we present a consistent framework that enables a fair comparison between different processes that consume different forms of energies. Using this framework, we refute the general perception that thermal separation processes are inherently the most energy intensive and conclusively show through the examples of two challenging mixtures constituting components with low relative volatilities, that distillation processes, when run properly, can consume remarkably lower fuel than non-thermal membrane alternatives, which have often been touted as more energy efficient.

The purpose of the study is to find the best shells available in Linux Operating System. The study has been narrowed down to seven most prominent shells in use today. With so many different Linux distributions and a plethora of shells, there exists a problem of plenty, which is rather a good problem to have. Amid all this confusion, one wonders which shell to use. Which is most suitable to one’s requirement, is modern, up to date and provides all sort of features which fulfils the desire of the user as well as the developer. The article deals in brief about Linux and its distributions, its philosophy and the freedom it provides. Shells, its scripting and shell types have been explained, one gets an idea of the study from the introduction. The seven Linux shells have been explained in detail to familiarize the reader with the most popular and most used shells available. A clear, concise and comparative analysis of the shells based on their general, interactive, programming and security features has been given. Programming features are important for the developers while a good interface makes everyone happy. Security features are a must for anyone who values their privacy and would like no intrusion in their system or their files. The mechanism of communication is important for I/O handling, as well as managing, interrupts. The speed of the system is greatly affected by the level of efficiency of inter-process communication.

Objective For patients with a new cancer diagnosis, the pathology report is a critical tool to support diagnosis and decision-making, yet they are designed for providers, not patients. We sought to qualitatively explore patients’ experiences receiving and interpreting pathology reports for breast and colorectal cancers. Methods We conducted four focus groups with patients (n = 23) who had received diagnostic or surgical pathology reports for breast cancer, colorectal cancer or polypectomy. Focus groups discussed patients’ experiences with pathology reports and recommendations for improving the patient-centeredness of report design. Focus groups were transcribed and thematic analysis was used to explore patient perspectives. Results Participants described experiences with pathology reports that were fraught with confusion and variability. Three central themes were identified related to how 1) the experience receiving the pathology report, 2) the pathology report language, and 3) the format of pathology reports all influence patient understanding and ability to engage in treatment decision-making. Conclusion Due to their complex medical language and challenging framing, traditional pathology reports can contribute to the confusion and uncertainty patients experience as they navigate a new cancer diagnosis.

Aim: Carbon monoxide (CO) is a colorless, odorless gas and tasteless. CO poisoning (COP) is one of the most frequently encountered inhalation poisonings. The most common cause of morbidity in COP is delayed neurological sequelae (DNS). DNS is the occurrence of neuropsychiatric findings within 2–240 days after discharge of patients with COP and there are no definitive diagnostic criteria. The aim of our study is; to determine the risk factors and incidence of DNS. Method: Our study is a retrospective, observational study. Patients with the diagnosis of COP in the emergency department between 2015 and 2016 were included in the study. Patients age, gender, findings in the initial physical examination (PE) and neurological examination (NE), blood carboxyhemoglobin (COHb) level, relation between hyperbaric oxygen (HBO) treatment and DNS were assessed. Results: Total of 72 patients were included in the study. Mean age was 33.43 ± 20.89. It was determined that pathological findings in the initial NE are a significant predictive factor for DNS (Odds ratio 18.600, p:0.004). Significant relation between NE and HBO treatment was present (p:00.1). There was no statistically significant relationship between initial COHb level and receiving HBO treatment (p:0.9). Median COHb level of patients with DNS was 30 (min:10, max: 43), median COHb level of patients without DNS was 25 (min:10, max:44) and there was no statistically significant relationship between the two groups according to COHb levels (p:0.7). Conclusion: Pathological findings in the initial neurological examination had a predictive value for delayed neurological sequelae in patients with carbon monoxide poisoning. © 2019 Elsevier Inc.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Zebra mussels (Dreissena polymorpha) are commonly used as sentinel organisms in freshwater biomonitoring. The displacement of this species by quagga mussels (Dreissena rostriformis bugensis) has raised the issue of their discrimination after field sampling. Even if those two species exhibit specific morphological characteristics, confusion can occur. However, behind the visible phenotypes lie important physiological and metabolic differences that may affect the interpretation of biomarkers in risk assessment. In this study, we present a characterization of Cu/Zn-SODs (superoxide dismutases) in Dreissena spp. with a comparison of activity profiles from individuals originating from North America and Europe. A phylogenetic tree was constructed and dreissenid SOD sequences appear to be closely related to clam species sequences. A specific isoform at an isoelectric point value of 4.95 was observed only for quagga mussels independently of their origin, while zebra mussels exhibited several polymorphic profiles, even for a single sampling site. A comparison of transcript sequences was conducted and the observed differences were highlighted. Alignment of amino acid sequences shows a high level of identity between the two species associated with minor changes in the predicted secondary structures.

The goal of this research is to investigate customer confusion and its antecedents, specifically price complexity and alternative attractiveness, and to validate a link between confusion and hotel online booking decisions. Price complexity and alternative attractiveness are demonstrated to have significant influences on three types of confusion: overload confusion, similarity confusion, and ambiguity confusion. Moreover, these three types of confusion cause customers to defer purchase decisions. An online survey was used to collect data from customers who booked hotels online within the past six months in both the United States and Canada. The study findings suggest that hotels should focus on improving price presentation and traveler interactivity to reduce consumer perceptions of price complexity. Furthermore, hotels need to re-evaluate the cooperation with OTAs to overcome the challenges of having too many attractive options for travelers

Widespread confusion and controversy exists on the association between menopausal hormone therapy and breast cancer risk, partly due to the incorrect use of menopausal hormone therapy as a generalized term without consideration of the specific hormone components, particularly the much-blamed progestin component. A recent meta-analysis published in the esteemed medical journal, The Lancet, again triggered debates regarding the role of progestins in the aetiology of breast cancer, even though only three progestins were evaluated. Debunking the idea that all progestins will increase breast cancer risk is vital to our insight into progestin-specific effects in breast cancer. Recent advances in our understanding of progestin action in the breast show that it is complex and can involve multiple steroid receptors and nonclassical mechanisms.

Coronavirus disease 2019 (COVID-19) represents a new pandemic caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2). A previous pooled analysis clearly identified elevated D-dimer levels as being associated with severity of COVID-19. Since then, several other studies have provided clearer support for this initial evidence. However, potentially under-recognized by those reporting on D-dimer is the considerable variation in reporting units for D-dimer, and thus also the potential for misreporting of D-dimer data based on poor or incomplete reporting. A PubMed search was used to identify recent papers reporting on D-dimers in COVID-19-based studies. We report that: (1) most publications did not identify either the manufacturer or D-dimer product used; (2) most did not identify whether D-dimer values were reported as D-dimer units (DDU) or fibrinogen equivalent units (FEU) (~2 × differences); (3) nearly half did not identify normal cut-off values; (4) some did not report numerical findings or units for D-dimer; (5) where reported, most identified units as either mg/L or μg/mL; (6) we identified at least four errors in reporting from 21 papers. It may not be possible to truly standardize D-dimer assays, but it should be feasible to harmonize D-dimer assays to a single unit of measurement.

This paper addresses a confusing issue of preputial anatomy of the mouse. The term "internal prepuce" was used in 2013 to describe a preputial structure integral to the mouse glans penis. Subsequently in 2015 the same term was applied by another group to describe entirely different morphology, generating confusion in the literature. Because it is inappropriate to use the same term to describe entirely different structures, we take this opportunity to provide further descriptive information on the internal prepuce of the mouse employing gross dissection, analysis of serial histologic section sets, three-dimensional reconstruction, scanning electron microscopy and immunohistochemistry. For this purpose, we review and illustrate the relevant literature and provide some additional new data using standard morphological techniques including immunohistochemistry. The mouse internal prepuce is integral to the glans penis and clearly is involved in sexual function in so far as it contains a major erectile body innervated by penile nerves. The development of the mouse internal prepuce is described for the first time and related to the development of the corpus cavernosum glandis.

Introduction An important cause of laboratory test misordering and overutilization is clinician confusion between tests with similar sounding names or similar indications. We identified an area of test ordering confusion with iron studies that involves total iron binding capacity (TIBC), transferrin, and transferrin saturation. We observed concurrent ordering of direct transferrin along with TIBC at many hospitals within our health system and suspected this was unnecessary. Methods We extracted patient test results for transferrin, TIBC and other biomarkers. Using these data, we evaluated both patterns of test utilization and test result concordance. We implemented a clinical decision support (CDS) alert to discourage unnecessary orders for direct transferrin. Results Using linear regression, we were able to predict transferrin from either TIBC alone or TIBC with other analytes with a high degree of accuracy, demonstrating that in most cases, direct transferrin in combination with TIBC provides little if any additional diagnostic information beyond TIBC alone. The CDS alert proved highly effective in reducing transferrin test utilization at four different hospitals. Conclusions Concurrent ordering of direct transferrin and TIBC should usually be avoided. Removal of transferrin or TIBC from the test menu or implementation of CDS may improve utilization of these tests.

International audience; There is a higher incidence of status epilepticus in the older adult population that commonly presents as nonconvulsive status epilepticus (NCSE). NCSE most often corresponds to prolonged focal seizures with impaired consciousness with three main clinical presentations: i) an unexplained acute confusional state, ii) subtle eye, motor or behavioral signs or mood changes and iii) typical temporal or frontal seizures with impaired consciousness. Focal seizures without impaired consciousness or de novo absence status of late onset may also be met. The identified risk factors for NCSE onset are: a precession by a generalized tonic-clonic seizure, a known history of epilepsy, female gender, and an acute symptomatic cause or a known brain injury (especially a stroke sequelae). Diagnosis in this population may be difficult, as the clinical presentation is often not very suggestive (stupor, confusion, even coma), and requires an unrestricted use of EEG with an EEG diagnosis based on the EEG with now accepted criteria (so-called Salzburg EEG criteria). The treatment is based first on the injection of benzodiazepines and in the second line on intravenous or oral or gastric tube administration of antiepileptic drugs. It is not recommended to resort to an intubation-ventilation (except necessary to treat respiratory distress, multi-organ failure…). Prognosis is poor with about 30% mortality.

A fluoroscopic upper gastrointestinal series is the most commonly used investigation for the diagnosis of malrotation and midgut volvulus. However, both false positive and false negative results can occur causing diagnostic confusion. Several physiologic states and pathologic conditions can mimic fluoroscopic appearance of malrotation. Proper fluoroscopic technique is essential to maximize diagnostic accuracy. In this pictorial essay, we discuss common diagnostic challenges in the diagnosis of malrotation and strategies radiologists can use to clarify the diagnosis in equivocal cases.

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

We report on an unusual failure pattern resulting from thermally driven fracture of laser amplifier single crystals. The pattern led to some confusion with regard to the point of initiation due to the coalescence of hackle lines to a region within the fracture surface, rather than the more common divergence of hackle away from the origin. The pattern leads to new fracture terms: Hackle node - the coalescence of hackle marks to a point of prior compression. The feature is produced as a thermally-generated, centrally-located compressive region transforms to tension thereby drawing crack propagation and hackle to the compressive region, forming an internal terminus. Hackle terminus – a hackle node formed by final crack propagation within the component. As part of the analysis, the fracture toughness and slow crack growth constants of neodymium doped, yttrium ortho-vanadate (Nd:YVO4) were measured. Nd:YVO4 exhibits slow crack growth and is very brittle with a fracture toughness of only 0.48 MPa√m.

Introduction Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early. Objective This review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician. Discussion The most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound. Conclusions The emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.