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Quantification of myocardial perfusion reserve (MPR) using vasodilator stress cardiac magnetic resonance is increasingly used to detect coronary artery disease. However, MPR can also be altered because of changes in microvascular function. We aimed to determine whether MPR can distinguish between ischemic cardiomyopathy (IC) secondary to coronary artery disease and non-IC (NIC) with microvascular dysfunction and no underlying epicardial coronary disease. A total of 60 patients (mean age 65 ± 14 years, 30% women), including 31 with IC and 29 with NIC, were identified from a pre-existing vasodilator stress cardiac magnetic resonance registry. Short-axis cine slices were used to measure left ventricular ejection fraction (LVEF) using the Simpson method of disks. MPR index (MPRi) was determined from first-pass myocardial perfusion images during stress and rest using the upslope ratio, normalized for the arterial input and corrected for rate pressure product. Patients in both groups were divided into subgroups of LVEF ≤35% and LVEF >35%. Differences in MPRi between the subgroups were examined. MPRi was moderately correlated with LVEF in patients with NIC (r = 0.53, p = 0.03), whereas the correlation in patients with IC was lower (r = 0.32, p = 0.22). Average LVEF in NIC and IC was 34% ± 8% and 35% ± 8%, respectively (p = 0.63). MPRi was not significantly different in IC compared with NIC (1.17 [0.88 to 1.61] vs 1.23 [1.07 to 1.66], p = 0.41), including the subgroups of LVEF (IC: 1.20 ± 0.56 vs NIC: 1.15 ± 0.24, p = 0.75 for LVEF ≤35% and IC: 1.35 ± 0.44 vs NIC: 1.58 ± 0.50, p = 0.19 for LVEF >35%). However, MPRi was significantly lower in patients with LVEF ≤35% compared with those with LVEF>35% (1.17 ± 0.40 vs 1.47 ± 0.47, p = 0.01). Similar difference between LVEF groups was noted in the patients with NIC (1.15 ± 0.24 vs 1.58 ± 0.50, p = 0.006) but not in the patients with IC (1.20 ± 0.56 vs 1.35 ± 0.44, p = 0.42). MPRi can be abnormal in the presence of left ventricular dysfunction with nonischemic etiology. This is a potential pitfall to consider when using this approach to detect ischemia because of epicardial coronary disease using myocardial perfusion imaging.

Objective: To see the effects of Raj Nirwan Bati (RNB) on the hematobiochemical parameters, coagulation tests, and histopathological changes in the lungs, liver, kidneys and spleen and also to evaluate the immunomodulatory activity of RNB in Wistar rats. Methods: A total of 24 adult albino Wistar rats (of bodyweight 200-250 g) of either sex were divided into 3 groups. In the normal control group (n=8), no drug was administered and in the rest of the groups (A and B), RNB@ 26 mg/kg body weight./day and 260 mg/kg body weight/day respectively were administered orally for a period of 14 d. The blood samples were collected from the jugular vein at zero d (before drug administration) and after the 14th d of drug administration in both groups (A and B). The organ samples (lungs, liver, kidneys, and spleen) were collected after euthanizing the rats using Ketamine anesthesia overdose intraperitoneally (IP) after the 14th d of drug administration. White Blood Cells (WBC), Red Blood Cells (RBC), Hemoglobin (Hb), Hematocrit (HCT), Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin(MCH), Mean Corpuscular Hemoglobin Concentration(MCHC), number of platelets, Differential Leucocyte Count(DLC) i.e. the percentage of neutrophils, lymphocytes, eosinophils, monocytes and basophils, neutrophil adhesion percentage, Prothrombin test (PT), Activated Partial Thromboplastin Time (APTT), fibrinogen, D-dimer, Lactate Dehydrogenase (LDH), urea, creatinine, Aspartate Amino Transferase (AST), Alanine amino Transferase (ALT), Alkaline Phosphatase (ALP), C-Reactive Protein (CRP) were evaluated and histological examination of organs were done. Results: After statistical analysis, it was found that the decrease in TLC, RBC, Hb, HCT, and LDH in Wistar rats after RNB intervention in Group A as compared to that of before RNB intervention, was found to be statistically significant (P=0.001, P=0.002, P=0.001, P=0.039, and P=0.008). On the other hand, an increase was observed in MCV, Urea, Creatinine and ALT values in the Wistar rats after RNB intervention in Group ‘A’ as compared to that of before RNB intervention and this increase in values was statistically significant (P=0.007, P=0.001, P

Introduction: Stroke is a medical emergency requiring timely intervention to optimize patient outcomes. Intravenous (IV) thrombolytics, the only treatment currently FDA-approved for acute stroke, require pertinent medical history for treatment decisions. Key details are often missed in the prehospital setting and during hand-off communication between Emergency Medical Services (EMS) and hospital staff, which can delay the time to treatment. We evaluated if utilization of a ‘stroke alert sticker’ by EMS to capture standardized information in the field would decrease time to thrombolytic administration. Methods: A bright orange sticker, to be placed directly on the patient, was disseminated to our local EMS agency for use with all stroke-alert patients. It includes key elements that are important to timely treatment decision, including time last known well, contact information, symptoms, and relevant medications. We evaluated the impact of use of this sticker on acute ischemic stroke treatment metrics, including IV thrombolytic “door to needle” (DTN) time. Results: The study included 220 stroke-alert patients brought to our Comprehensive Stroke Center by EMS from May 2021 through February 2022. Mean NIHSS on arrival was 11 (± 9); mean age was 67 (± 16) years; and 52 % were female. 21 patients were treated with an IV thrombolytic. Overall, sticker utilization rate was 40% in the stroke-alert population, but utilization was 60% in patients administered an IV thrombolytic. With sticker utilization, DTN time was reduced by 20 minutes (31 ± 11 min with sticker vs 51 ± 20 min without, p=0.03). In patients who received IV thrombolytics, pre-hospital notification was 100% with sticker use compared to 75% without (p=0.01). Conclusion: Utilization of the stroke-alert sticker significantly improved DTN times for acute ischemic stroke patients compared to patients without the sticker. This evidence supports continued use of the stroke alert stickers to improve DTN times and improve patient outcomes. Further research is ongoing in a larger patient cohort.

not available Dhaka University Law Journal, Vol. 32(1), 2021 P.152-173

Three new ferrocene appended heteroleptic dithiocarbamate complexes have been synthesized and used as sensitizers/co-sensitizers in DSSCs.

Stress cardiovascular magnetic resonance imaging (CMR) is a cost-effective, noninvasive test that accurately assesses myocardial ischemia, myocardial viability, and cardiac function without the need for ionizing radiation. There is a large body of literature, including randomized controlled trials, validating its diagnostic performance, risk stratification capabilities, and ability to guide appropriate use of coronary intervention. Specifically, stress CMR has shown higher diagnostic sensitivity than single-photon emission computed tomography imaging in detecting angiographically significant coronary artery disease. Stress CMR is particularly valuable for the evaluation of patients with moderate to high pretest probability of having stable ischemic heart disease and for patients known to have challenging imaging characteristics, including women, individuals with prior revascularization, and those with left ventricular dysfunction. This paper reviews the basics principles of stress CMR, the data supporting its clinical use, the added-value of myocardial blood flow quantification, and the assessment of myocardial function and viability routinely obtained during a stress CMR study.

As clinicians have gained experience in treating patients with the novel SARS-CoV-2 (COVID-19) virus, mortality rates for patients with acute COVID-19 infection have decreased. The Centers for Disease Control (CDC) has identified the African American population as having increased risk of COVID-19 associated mortality, however little is known about echocardiographic markers associated with increased mortality in this patient population. We aimed to compare the clinical and echocardiographic features of a predominantly African American patient cohort hospitalized with acute COVID-19 infection during the first (March–June 2020) and second (September–December 2020) waves of the COVID-19 pandemic, and to investigate which parameters are most strongly associated with composite all-cause mortality. We performed consecutive transthoracic echocardiograms (TTEs) on 105 patients admitted with acute COVID-19 infection during the first wave and 129 patients admitted during the second wave. TTE parameters including left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LVGLS), right ventricular global longitudinal strain (RVGLS), right ventricular free-wall strain (RVFWS), and right ventricular basal diameter (RVBD) were compared between the two groups. Clinical and demographic characteristics including underlying co-morbidities, biomarkers, in-hospital treatment regimens, and outcomes were collected and analyzed. Univariable and multivariable analyses were performed to determine variables associated with all-cause mortality. There were no significant differences between the two waves in terms of age, gender, BMI, or race. Overall all-cause mortality was 35.2% for the first wave compared to 14.7% for the second wave (p

BACKGROUND Late gadolinium enhancement (LGE) imaging in patients with implantable cardioverter-defibrillators (ICD) is limited by device-related artifacts (DRA). The use of wideband (WB) LGE protocols improves LGE images, but their efficacy with different ICD types is not well known. PURPOSE To assess the effects of WB LGE imaging on DRA in different non-MR conditional ICD subtypes. STUDY TYPE Retrospective. POPULATION A total of 113 patients undergoing cardiac magnetic resonance imaging with three ICD subtypes: transvenous (TV-ICD, N = 48), cardiac-resynchronization therapy device (CRT-D, N = 48), and subcutaneous (S-ICD, N = 17). FIELD STRENGTH/SEQUENCE 5 T scanner, standard LGE, and WB LGE imaging with a phase-sensitive inversion recovery segmented gradient echo sequence. ASSESSMENT DRA burden was defined as the number of artifact-positive short-axis LGE slices as percentage of the total number of short-axis slices covering the left ventricle from based to apex, and was determined for WB and standard LGE studies for each patient. Additionally, artifact area on each slice was quantified. STATISTICAL TESTS Shapiro-Wilks, Kruskal-Wallis analysis of variance, Dunn tests with Bonferroni correction, and Mann-Whitney U-test. RESULTS In patients with TV-ICD, DRA burden was significantly reduced and nearly eliminated with WB LGE compared to standard LGE imaging (median [interquartile range]: 0 [0-7]% vs. 18 [0-50]%, P

A 3D supramolecular coordinated polymer with formula [Cd2(L)2(bib)(H2O)2] (1) (H2L = 4,4’-(1,2-phenlenebis(methyleneoxy))dibenzoic acid and bib = 1,4- bis(1-imidazoly)benzene), has been synthesized and characterized. A one-dimensional (1D) chain structure of 1 with poly-rotaxane was confirmed by a single crystal X-ray approach. This structure was woven for reaching a 3D supramolecular architecture held by hydrogen-bonded and packing intermolecular interactions between adjacent motifs. The luminescence sensing experiments indicates that it is a fluorescent sensor for the detection of antibiotics in 1. It is a highly sensitive/selective polymer towards sulfamethazine (SMZ) that revealed a low detection limit of 1.05 ppm with a high KSV value of 2.98 × 103 M− 1. Its antibiotics sensing mechanism was also studied by theoretical calculations.

With the increase in the number of avenues for production of data everywhere including logistics, using this data has become an obvious next step. In this paper, we look at the major logistics problems in details as discussed in a seminal work in highlighting the problems in logistics by X. Li in 2014. Together with discussing the problems, we also look at the trends in solving these problems using machine learning. We look at the recent work done in the particular fields using machine learning (ML) and develop the correlation of the trends of using supervised, unsupervised and reinforcement learning in solving these problems. This correlation is developed using a table and a diagram showing ML techniques and the trends in the fields of the problems are discussed. COVID-19 has greatly accelerated these trends. This paper serves as a gentle introduction to ML techniques in the field of logistics for researchers who are new to the field.

We synthesized PbS/CdS core/shell quantum dots (QDs) to have functional single-emitter properties for room-temperature, solid-state operation in the telecom O and S bands. Two shell-growth methods—cation exchange and successive ionic layer adsorption and reaction (SILAR)—were employed to prepare QD heterostructures with shells of 2–16 monolayers. PbS/CdS QDs were sufficiently bright and stable to resolve photoluminescence (PL) spectra representing both bands from single nanocrystals using standard detection methods, and for a QD emitting in the O-band a second-order correlation function showed strong photon antibunching, important steps toward demonstrating the utility of lead chalcogenide QDs as single-photon emitters (SPEs). Irrespective of type, few telecom-SPEs exist that are capable of such room-temperature operation. Access to single-QD spectra enabled a direct assessment of spectral line width, which was ∼70–90 meV compared to much broader ensemble spectra (∼300 meV). We show inhomogeneous broadening results from dispersity in PbS core sizes that increases dramatically with extended cation exchange. Quantum yields (QYs) are negatively impacted at thick shells (>6 monolayers) and, especially, by SILAR-growth conditions. Time-resolved PL measurements revealed that, with SILAR, initially single-exponential PL-decays transition to biexponential, with opening of nonradiative carrier-recombination channels. Radiative decay times are, overall, longer for core/shell QDs compared to PbS cores, which we demonstrate can be partially attributed to some core/shell sizes occupying a quasi-type II electron–hole localization regime. Finally, we demonstrate that shell engineering and the use of lower laser-excitation powers can afford significantly suppressed blinking and photobleaching. However, dependence on shell thickness comes at a cost of less-than-optimal brightness, with implications for both materials and experimental design.

The mitral valve is a dynamic, three-dimensional (3D) structure consisting of the mitral annulus, leaflets, tendinous chordae, and papillary muscles. Mitral regurgitation (MR) is defined as an abno...

Traumatic ventricular septal defects due to penetrating cardiac injury are uncommon. Transthoracic echocardiography is an essential tool in diagnosis. Options for closure include either surgical or percutaneous repair. We present a case of a trauma-related ventricular septal defect in a young patient that was successfully repaired by using a percutaneous approach. (Level of difficulty: Intermediate.).

Background: Strokes that occur during inpatient hospitalization require rapid identification and stroke-alert activation from hospital staff in heterogeneous settings, often resulting in overutilization of stroke team resources on stroke mimics. An understanding of the factors that impact accuracy of identification of inpatient strokes would assist in improving care in this population. Methods: This was a retrospective analysis from a single Joint-Commission certified Comprehensive Stroke Center. All patients for whom an inpatient stroke alert was called between 2/1/2019 - 4/30/2021 were included. Metrics captured in our local stroke-alert registry were analyzed, with comparisons made between patients who were determined to have a true stroke versus stroke mimic. Results: Of 705 inpatient alerts, mean patient age was 66 years, 50% were male, 62% occurred in the daytime, and mean NIHSS was 12. The majority of alerts were stroke mimics (76%); most common non-stroke diagnoses were encephalopathy, medical decompensation, and seizure. Among patients with true stroke, 86% were ischemic, with 13 patients receiving thrombolytics and 21 patients undergoing mechanical thrombectomy. One stroke mimic received thrombolytics. Although most alerts originated from medicine units (38%) and floor beds (49%), true stroke was most often diagnosed on cardiology (39%) and hematology/oncology (38%) units, and in the ICU or intermediate care setting (54%). Logistic regression adjusted for age and time of day showed true strokes were significantly associated with male sex, location (stratified by specialty), shorter time to CT completion, and higher initial NIHSS (p Conclusions: A majority of inpatient alerts are stroke mimics, particularly on medicine floors. Stroke education could be tailored to staff to incorporate these findings to ensure that stroke patients are not missed, while stroke team resources are not overutilized on mimics.

Introduction: Creatine kinase BB isoenzyme (CK-BB) levels in CSF after cardiac arrest (CA) have been shown to predict never awakening though have not been evaluated in patients treated with therapeutic hypothermia (TH). Clinically, CSF CK-BB is tested in those who have not already awakened and are suspected of having a poor prognosis. We aimed to evaluate CSF CK-BB as a prognostic biomarker in the era of TH. Methods: We performed a retrospective cohort study at a single institution of CA patients admitted between 2010 and 2020 and with CSF CK-BB assayed between 36 and 84 hours after CA. We examined the proportion of patients who awakened at hospital discharge and latest follow up in the electronic health record for various CSF CK-BB thresholds. We examined concordance and additive value somatosensory evoked potentials (SSEP). Awakening was defined as following commands or having comprehensible speech. Results: Among 214 eligible patients, mean age was 55 ± 15 years, 72% were male, 33% were non-white, 17% had initial ventricular fibrillation or tachycardia, 90% were out-of-hospital CA, and 83% had TH. A total of 19 (9%) awoke at a mean of 22 ± 28 days. Two patients in a vegetative state at discharge later awoke at 73 (CSF CK-BB 163 U/L) and 101 days (228 U/L). A CSF CK-BB cut-off of ≥ 230 U/L predicted never awakening with a specificity of 100% (binomial 95% CI 82-100%) and a sensitivity of 69% (95% CI 62-76%). When combined with bilaterally absent SSEP, the specificity remained 100% while the sensitivity increased to 80% (95% CI 73-85%). Results were similar after excluding 165 (77%) who had withdrawal of life-sustaining treatment. Discordant findings among 149 patients who had both studies were seen in 13 (9%) with intact SSEP bilaterally but CSF CK-BB ≥ 230 U/L and in 20 (13%) with absent SSEP bilaterally but CSF CK-BB < 230, none of whom awoke. Conclusion: CSF CK-BB levels accurately predict never awakening among CA survivors treated with TH. As part of multimodal prognostic testing with SSEP, the CSF CK-BB cutoff of 230 can optimize sensitivity while maintaining a specificity of 100%. These results are susceptible to a self-fulfilling prophecy, and specificity has a large confidence interval because only a small number of eligible patients awakened.

Aims Although myocardial scar assessment using late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging is frequently indicated for patients with implantable cardioverter defibrillators (ICDs), metal artefact can degrade image quality. With the new wideband technique designed to mitigate device related artefact, CMR is increasingly used in this population. However, the common clinical indications for CMR referral and impact on clinical decision-making and prognosis are not well defined. Our study was designed to address these knowledge gaps. Methods and results One hundred seventy-nine consecutive patients with an ICD (age 59 ± 13 years, 75% male) underwent CMR using cine and wideband pulse sequences for LGE imaging. Electronic medical records were reviewed to determine the reason for CMR referral, whether there was a change in clinical decision-making, and occurrence of major adverse cardiac events (MACEs). Referral indication was the most common evaluation of ventricular tachycardia (VT) substrate (n = 114, 64%), followed by cardiomyopathy (n = 53, 30%). Overall, CMR resulted in a new or changed diagnosis in 64 (36%) patients and impacted clinical management in 51 (28%). The effect on management change was highest in patients presenting with VT. A total of 77 patients (43%) experienced MACE during the follow-up period (median 1.7 years), including 65 in patients with evidence of LGE. Kaplan–Meier analysis showed that ICD patients with LGE had worse outcomes than those without LGE (P = 0.006). Conclusion The clinical yield from LGE CMR is high and provides management changing and meaningful prognostic information in a significant proportion of patients with ICDs.

Simulation-based participatory modelling allows integration of all types of knowledge including empirical, technical and scientific from all disciplines and domains. Thus, in recent years, the use of participatory modelling has been continuously increasing in many fields including logistics. With a view of achieving better understanding of the subject, this article systematically reviews the advances made in participatory modelling in the field of urban and production logistics in the last decade. It further reports the findings transparently following a categorization based on (i) the purpose of participatory modelling in the domain, and (ii) depending on the purpose how data is collected, processed and outcomes are presented. The review resulted in 97 articles which were analysed and categorized based on the above two questions formulated in the literature surveyed. The review revealed that apart from the three existing categories of purposes, namely, reflexive, descriptive and normative there is an emerging fourth category that was analytical in nature and 15 out of 97 articles analyzed belonged to this category. The authors decided to call this category analytical field empirical modelling which is primarily based on mathematical modelling and use of computational methods. We present these results with the help of a categorization. During the analysis for the second research question, we discovered that though the conventional ways of data collection and processing, such as interviews and workshops, which remain significantly present, in electronic data crowdsourcing and data processing via computational methods are emerging.

Two new metal–organic coordination polymers (CPs), aqua-2,2′-bipyridine-5-(4′-carboxylphenoxy)isophthalatezinc(II) polymer [Zn(HL)(2,2′-bipy)(H2O)]n (1) and tris-4,4′-bipyridine-bis-5-(4′-carboxylphenoxy)isophthalatetrizinc(II) polymer [Zn3(L)2(4,4′-bipy)3]n (2) (H3L = 5-(4′-carboxylphenoxy)isophthalic acid, 4,4′-bipy = 4,4′-bipyridine and 2,2′-bipy = 2,2′-bipyridine), were obtained under hydrothermal conditions and characterized by microanalysis, FTIR spectroscopy and single crystal X-ray diffraction. The single crystal X-ray diffraction indicated that in both the CPs the coordination networks exhibited varied topologies and coordination modes around the Zn(II) centers. CP 1 exhibits a one-dimensional (1D) chain structure, which further forms a 3D supramolecular architecture via intermolecular π⋯π and hydrogen bonding interactions, while 2 possesses a 3D framework generated from a 2D layered motif comprising zinc and tripodal carboxylate subunits pillared by 4,4′-bpy ligands. Apart from the structural investigation, the photocatalytic performances of both the coordination polymers to photodecompose an aqueous solution of methyl violet (MV) were examined. The results indicated that both the CPs displayed the potential to photodecompose aromatic dyes and in particular 2 showed good photocatalytic activity for dye degradation under light irradiation. The photocatalytic mechanism through which these CPs executed degradation of dyes has been explained with the assistance of band gap calculations using density of states (DOS) and its decomposed partial DOS calculations.

International audience; Vasodilator-stress CT perfusion imaging in addition to CT coronary angiography (CTCA) may provide a single-test alternative to nuclear stress testing, commonly used to assess hemodynamic significance of stenosis. Another alternative is fractional flow reserve (FFR) calculated from cardiac CT images. We studied the concordance between these two approaches and their relationship to outcomes. We prospectively studied 150 patients with chest pain, who underwent CTCA and regadenoson CT. CTCA images were interpreted for presence and severity of stenosis. Fused 3D displays of subendocardial X-ray attenuation with coronary arteries were created to detect stress perfusion defects (SPD) in each coronary territory. In patients with stenosis > 25%, CT-FFR was quantified. Significant stenosis was determined by: (1) combination of stenosis > 50% with an SPD, (2) CT-FFR ≤ 0.80. Patients were followed-up for 36 ± 25 months for death, myocardial infarction or revascularization. After excluding patients with normal arteries and technical/quality issues, in final analysis of 76 patients, CTCA depicted stenosis > 70% in 13/224 arteries, 50-70% in 24, and < 50% in 187. CT-FFR ≤ 0.80 was found in 41/224 arteries, and combination of SPD with > 50% stenosis in 31/224 arteries. Inter-technique agreement was 89%. Despite high incidence of abnormal CT-FFR (30/76 patients), only 7 patients experienced adverse outcomes; 6/7 also had SPDs. Only 1/9 patients with CT-FFR ≤ 0.80 but normal perfusion had an event. Fusion of CTCA and stress perfusion can help determine the hemodynamic impact of stenosis in one test, in good agreement with CT-FFR. Adding stress CT perfusion analysis may help risk-stratify patients with abnormal CT-FFR.

Background: This study evaluated the timing of dog owner ectoparasiticide purchases to estimate administration compliance and assess the consequent impact of dose purchase gaps on the proportion of time that dogs are protected over a 12-month period. Methods: Ectoparasiticide purchase transactions over a 12-month period were evaluated for dogs from 626 U.S. veterinary hospitals to determine dose purchase timing and identify consequent gaps between dose administration. Orally administered prescription ectoparasitic medications with active ingredients from the isoxazoline family (afoxolaner, fluralaner, lotilaner, or sarolaner) are included in the analysis. A period was calculated for each of the four isoxazoline-containing medications that represented the duration of protection provided by two doses of ectoparasiticide plus the average gap between these two doses. The maximum percentage of time possible for ectoparasiticide protection for this aggregate period was then calculated for each active. Results: Ectoparasiticide transaction records were analyzed for 506,637 dogs. Of these, 43% of dog owners purchased just one dose over the 12 months. If a dog owner purchased more than one dose, then the timing of these transactions could create a time gap between the completion of ectoparasite protection from the first dose and onset of protection from the subsequent purchase and administration of the second dose. Such gaps were observed in purchases made by 31-65% of dog owners depending on the selected active ingredient and number of doses. The average gap duration between dose purchases was calculated for all possible dose combinations over 12 months of ectoparasite protection. Time gaps between the first and second doses are as follows: for sarolaner (20.3 weeks), afoxolaner (12.9 weeks), fluralaner (12.8 weeks), and lotilaner (8.9 weeks). The proportion of time when protection was provided during the aggregate period between administration of the first and second doses was fluralaner 65%, lotilaner 49%, afoxolaner 40,% and sarolaner 30%. Conclusions: Dog owner ectoparasiticide purchase transactions show that there are time gaps between doses leading to reduced ectoparasite protection. The longer re-administration interval of fluralaner, which results from its extended duration, results in dog owners gaining the greatest proportion of ectoparasite protection time compared with shorter-acting monthly re-treatment medications.

Background This study evaluated the timing of dog owner ectoparasiticide purchases to estimate administration compliance and assess the consequent impact of dose purchase gaps on the proportion of time that dogs were protected over a 12-month period. Methods Ectoparasiticide purchase transactions over a 12-month period were evaluated for 626 US veterinary hospitals to determine dose purchase timing and identify consequent gaps between dose administration in dogs. Orally administered prescription ectoparasitic medications with active ingredients from the isoxazoline family (afoxolaner, fluralaner, lotilaner, or sarolaner) were included in the analysis. A period was calculated for each of the four isoxazoline-containing medications that represented the duration of protection provided by two doses of ectoparasiticide plus the average gap between these two doses. The maximum percentage of time possible for ectoparasiticide protection for this aggregate period was then calculated for each active ingredient. Results Ectoparasiticide transaction records of owners were analyzed for 506,637 dogs. These showed that 43% of dog owners purchased just one dose over the 12-month period considered. If a dog owner purchased more than one dose, then the timing of their transactions could create a time gap between the completion of ectoparasite protection from the first dose and onset of protection from the subsequent purchase and administration of the second dose. Such gaps were observed in purchases made by 31–65% of dog owners, depending on the selected active ingredient and number of doses. The average gap duration between dose purchases was calculated for all possible dose combinations over 12 months of ectoparasite protection. Time gaps between the first and second doses are as follows: for sarolaner, 20.3 weeks; for afoxolaner, 12.9 weeks; for fluralaner ,12.8 weeks; and for lotilaner, 8.9 weeks. The proportion of time when protection was provided during the aggregate period between administration of the first and second doses was as follows: for fluralaner, 65%; for lotilaner, 49%; for afoxolaner, 40%; and for sarolaner, 30%. Conclusions Dog owner ectoparasiticide purchase transactions showed that there were time gaps between doses leading to reduced ectoparasite protection. The longer re-administration interval for fluralaner, a consequence of its extended duration of activity, resulted in dog owners gaining the greatest proportion of ectoparasite protection time with this medication compared with shorter-acting monthly re-treatment medications. Graphical Abstract

Background Tracheostomy represents one important and value-laden treatment decision after severe acute brain injury (SABI). Whether to pursue this life-sustaining treatment typically hinges on intense conversations between family and clinicians. The aim of this study was, among a cohort of patient who had undergone tracheostomy after SABI, to explore the long-term reflections of patients and their families as they look back on this decision. Methods For this qualitative study, we reviewed the electronic medical records of patients with SABI who underwent tracheostomy. We included all patients who were admitted to our 30-bed neuro-intensive care unit with SABI and underwent tracheostomy between November 2017 and October 2019. Using purposive sampling, we invited survivors and family members to participate in telephone interviews greater than 3 months after SABI until thematic saturation was reached. Interviews were audiotaped, transcribed, and analyzed by using thematic analysis. Results Overall, 38 patients with SABI in the neuro-intensive care unit underwent tracheostomy. The mean age of patients was 49 (range 18–81), with 19 of 38 patients diagnosed with traumatic brain injury and 19 of 38 with stroke. We interviewed 20 family members of 18 of 38 patients at a mean of 16 (SD 9) months after hospitalization. The mean patient age among those with an interview was 50 (range 18–76); the mean modified Rankin Scale score (mRS) was 4.7 (SD 0.8) at hospital discharge. At the time of the interview, ten patients lived at home and two in a skilled nursing facility and had a mean mRS of 2.6 (SD 0.9), and six had died. As families reflected on the decision to proceed with a tracheostomy, two themes emerged. First, families did not remember tracheostomy as a choice because the uncertain chance of recovery rendered the certain alternative of death unacceptable or because they valued survival above all and therefore could not perceive an alternative to life-sustaining treatment. Second, families identified a fundamental need to receive supportive, consistent communication centering around compassion, clarity, and hope. When this need was met, families were able to reflect on the tracheostomy decision with peace, regardless of their loved one’s eventual outcome. Conclusions After SABI, prognostic uncertainty almost transcends the concept of choice. Families who proceeded with a tracheostomy saw it as the only option at the time. High-quality communication may mitigate the stress surrounding this high-stakes decision. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01335-9.

Background: Mechanical thrombectomy (MT) is now standard of care for patients with acute large vessel occlusion (LVO) ischemic stroke, after several trials showed significant functional improvement at 90 days. Despite this expected duration for recovery, withdrawal of life sustaining treatment (WLST) often occurs within less than 5 days after MT. We aimed to identify determinants of early WLST and better understand decisions that led to it. Methods: Retrospective chart review at a single academic stroke center from 1/2015 to 8/2020 using mixed methods. We compared patient characteristics and hospital course in those with early WLST (within 5 days) to those without WLST. Six authors conducted in-depth qualitative analysis of family meeting notes among a subgroup of 16 purposively sampled early WLST patients. Results: Among 402 patients (mean age 68.0, SD 14.7 years; 53.7% male) who underwent MT, 88 (21.9%) had WLST, of which 52 (12.9%) were early WLST (mean 2.2, SD 1.3 days). Logistic regression adjusted for sex, race, LVO location, time of MT from last known normal, and post-procedural hemorrhage showed early WLST compared to no WLST was significantly associated with older age, inpatient stroke, increased stroke severity, unsuccessful MT, no tPA given, post-procedural need for craniectomy, and palliative care consultation (p Conclusion: Early WLST after MT occurs frequently in patients with severe stroke and high medical complexity, especially if progression to cerebral herniation. Clear communication before and after MT regarding expected prognosis and trajectory of recovery could allow for improved decision making and prevent potentially premature WLST by providers or families. Prior knowledge of patient’s goals-of-care may also reduce patient or caregiver suffering and improve resource utilization for the healthcare system in patients with severe stroke.

Manganese-based Metal-organic Frameworks (Mn-MOFs) represents a unique sub-class of MOFs with low toxicity, oxidative ability, and biocompatibility, which plays vital role in the application of this class of MOFs in medical field. Mn-MOFs show great potential in biomedical applications, and has been extensively studied as compared to other MOFs in transition metal series. They are important in medical applications because Mn(II) possess large electron spin number and longer electron relaxation time. They display fast water exchange rate and could be employed as a potential MRI contrast agent because of their strong targeting ability. Manganese complexes with different ligands also display prospective applications in area such as carrier for drug targeting in anti-tumor and antimicrobial therapy. In the review presented herewith, the application of Mn-based complexes and Mn-MOFs have been emphasized in the area such as imaging viz. MRI, multimodal imaging, antitumor activities such as chemodynamic therapy, photodynamic therapy, sonodynamic therapy and antimicrobial applications. Also, how rational designing and syntheses of targeted Mn-based complexes and Mn-MOFs can engender desired applications.

Dengue fever, caused by dengue virus (DENV), is the most prevalent arthropod-borne viral disease and is endemic in many tropical and subtropical parts of the world, with an increasing incidence in temperate regions. The closely related flavivirus Zika virus (ZIKV) can be transmitted vertically in utero and causes congenital Zika syndrome and other birth defects. In adults, ZIKV is associated with Guillain-Barré syndrome. There are no approved antiviral therapies against either virus. Effective antiviral compounds are urgently needed. Amaryllidaceae alkaloids (AAs) are a specific class of nitrogen-containing compounds produced by plants of the Amaryllidaceae family with numerous biological activities. Recently, the AA lycorine was shown to present strong antiflaviviral properties. Previously, we demonstrated that Crinum jagus contained lycorine and several alkaloids of the cherylline, crinine, and galanthamine types with unknown antiviral potential. In this study, we explored their biological activities. We show that C. jagus crude alkaloid extract inhibited DENV infection. Among the purified AAs, cherylline efficiently inhibited both DENV (50% effective concentration [EC50], 8.8 μM) and ZIKV replication (EC50, 20.3 μM) but had no effect on HIV-1 infection. Time-of-drug-addition and -removal experiments identified a postentry step as the one targeted by cherylline. Consistently, using subgenomic replicons and replication-defective genomes, we demonstrate that cherylline specifically hinders the viral RNA synthesis step but not viral translation. In conclusion, AAs are an underestimated source of antiflavivirus compounds, including the effective inhibitor cherylline, which could be optimized for new therapeutic approaches.

BACKGROUND: Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering. METHODS: We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation. RESULTS: TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05). CONCLUSIONS: The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions. (J Am Soc Echocardiogr 2020;33:1316–23.)