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This study explored the therapeutic value of sharing artwork in a public exhibition called Bearing Witness by individuals who experienced trauma through stillbirth, infertility, or miscarriage. Thi...

Measles causes a substantial disease burden for all countries, while mortality is greatest in underserved, marginalized populations. Global measles eradication is feasible and the strategies critically rely upon well-functioning national immunisation programs and surveillance systems. All six regions of the World Health Organisation have adopted measles elimination targets. The Rule of Rescue and the principle of justice leave no ethical place for health programs, governments, global public health bodies or donors to hide if they impede efforts to eradicate measles globally by not taking all necessary actions to establish a global eradication target and committing the resources essential to achieve this goal.

This study compared final year nursing students’ error rate and use of strategies to maintain SA when undertaking specific nursing care in a simulated clinical environment pre and 10 weeks post a planned SA education intervention. Students were observed using a Performance Based Situation Awareness Observation Schedule (PBSAOS) undertaking two tasks in a simulated clinical environment pre and post the SA education. For task 1, post educational intervention, there was no significant increase in the error rate for any performance measures, and there were significant decreases in the error rates for three performance measures. For task 2, post educational intervention, there was a significant decrease in the error rate for two measures and a significant increase in the error rates for seven performance measures. In considering the overall group error rate when excluding uncompleted tasks, there was a significant (x = .0001) decrease in the error rate for task 1 post educational intervention (41.4% compared to 26.6%), and significant (x = 0.01) increase in the error for task 2 post educational intervention (39.6% compared to 47.3%). The findings of this study demonstrate that the implementation of an intervention designed to increase SA actually appear to have resulted in hyper-vigilance and subsequent non-completion of required tasks.

Background: Sarcoma is a heterogeneous group of malignancies comprising almost 80 subtypes of bone and soft tissue cancers. Previously, all subtypes were managed identically. Advancements in biological and genetic studies have revealed that sarcoma subtypes display varying characteristics and therefore require tailored treatments. Locally advanced soft tissue malignancies of both the trunk and the extremities can present significant challenges for treatment. At present, a negative surgical resection margin is the only definitive treatment despite attempts to use neoadjuvant and adjuvant therapies. In patients with locally advanced non-resectable soft tissue sarcoma (STS), the current practice would advocate amputation. However, studies suggest that limb salvage may be possible with radiotherapy or regional chemotherapy using isolated limb perfusion or isolated limb infusion (ILI). An ideal treatment modality for non-resectable STS would strive for preservation of anatomy and functionality as well as improve quality of life. The aim of the study was to investigate the efficacy of isolated limb infusion as an alternative treatment modality for non-resectable locally advanced STS. Methods: The efficacy of ILI was retrospectively investigated in 10 patients with STS. All patients received ILI with melphalan and actinomycin at the North Estonia Medical Centre Foundation, Tallinn, Estonia from September 1, 2014 to May 31, 2018. The procedures were performed in a lower extremity in 8 patients and in an upper extremity in 2 patients. The 6-month overall response rate was 78% and the overall limb salvage rate was 100%. The distant metastatis-free survival was longer for responders than for non-responders. Results and Conclusions: ILI is an alternative treatment modality for regional disease control and limb preservation in patients with cutaneous and soft tissue malignant neoplasms of the extremities. The short-term response rates are encouraging and the median overall survival shows good results in this highly complex patient population.

Background Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. Methods After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. Results A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). Conclusion In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. Level of evidence Therapeutic Level IV.

Introduction: Tricuspid regurgitation (TR) is often asymptomatic leading to delayed diagnosis. Predictors of decompensation and indications and timing for intervention are not well delineated. We studied the clinical and echocardiographic outcomes of patients with recent onset severe, secondary TR to identify risk factors for death, hospital readmission and hepatobiliary disease. Methods: We queried our institutional echo database to identify all patients with severe secondary TR in 2010 and a TTE within the previous two years prior showing less than moderate disease. Baseline and follow up clinical and echocardiographic variables over the subsequent 10 years were collected retrospectively. We analyzed our data for predictors of death, hospital readmission, and hepatobiliary disease. Results: We identified 34 patients. Over 10 years of follow up, 27/34 (79%) of the patients died. Elevated pulmonary artery systolic pressure (PASP) was a significant predictor of death. PASP was 48 mm Hg in those who died compared to 33 mm Hg in those who survived (p=0.02) (Figure 1). Pulmonary hypertension (PH) and pulmonary embolism (PE) were predictors of readmission. A history of PH was present in 7/10 (70%) of patients requiring readmission compared to 7/24 (29%) in those who did not require readmission (p=0.03). A history of PE was present in 2/10 (20%) of those requiring readmission compared to 0/24 (0%) of those who did not require readmission (p=0.02). No patients were diagnosed with hepatobiliary disease. Conclusions: New onset severe, secondary TR is associated with a high ten year mortality rate. Elevated PASP is a predictor of death and history of PE and pulmonary HTN are predictors for hospital readmission.

Background: Warfarin anticoagulation presents a common barrier to undergoing cardiac catheterization procedures. Using radial access and other bleeding mitigation strategies, it is not known if elevated INR truly portends an increased risk of adverse events. We sought to understand the relationship between in hospital mortality and bleeding with INR in patients undergoing coronary interventional catheterization procedures. Methods: The prospectively-collected Dartmouth Dynamic Registry was queried for all patients who underwent catheterization with coronary intervention from 2014 to 2018. Of the 5015 patients identified, 2120 patients had a recorded INR value within 24 hours of the procedure. Demographics, procedural variables, and in hospital outcomes were collected. Patients were divided into two groups: INR &lt1.8 and INR &gt1.8. Incidence of bleeding (access site hematoma &gt5cm, post procedure blood transfusion) as well as in-hospital mortality were queried for each group. Stata was used to determine statistical significance, using chi-square analysis for categorical variables and standard t-test for continuous variables. Results: Of the 2120 patients with INR values, 1968 patients were identified with INR &lt1.8 (median INR 1.1; range 0.7-1.7) and 152 patients with INR &gt1.8 (median INR 2.2; range 1.8-11.1). Patients with elevated INRs had higher acuity (urgent or emergent cases) and were older. Other baseline and procedural characteristics were similar. Outcomes between those with elevated INR and those with lower INR values were similar, including access site injury, hematoma, and need for transfusion (Table I). Overall mortality did not differ between the two groups. Conclusion: When compared to patients with INR &lt1.8, patients with INR &gt1.8 are more likely to undergo coronary intervention on an urgent or emergent basis. Despite this, there is no difference in bleeding, need for transfusion, or overall in-hospital mortality.

Introduction: The pandemic of COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection. Studies published so far raise concerns for cardiac complications in the infected individuals.The aim of our study is to determine the prevalence of cardiac complications in COVID-19. Methods: A systematic electronic search was performed in PubMed, Embase, Google Scholar. Retrospective studies having original hospitalized patient data were included in our study; while studies focussed only on intensive care unit (ICU) patients were excluded to prevent selection bias. Pooled analysis using a random effects model (Mantel-Haenszel test) was performed to look at the incidence of troponin elevation and association between elevated troponin levels, admission to the ICU and associated mortality. Results: 18 studies from 6 countries with over 9,500 patients were included in our analysis. Troponin elevation was reported in 16% (1123/7130) of patients. Heart failure was reported in 1 study and cardiac arrhythmia was reported in 2 studies. Elevated troponin levels were associated with higher rates of ICU admission (OR 26.17, 7.06-96.94; p Conclusion: Heart failure was reported in around 20% of the patients in 1 study, while troponin elevation was seen in 16% of the patients in 10 different studies. This is similar to the rate of cardiac complications reported in severe community acquired pneumonia. Troponin elevation in itself was associated with higher rates of ICU admission and mortality. This should alert the clinicians to check for troponin levels in these patients and triage them accordingly. More studies are needed to better understand specific mechanisms of cardiac injury in COVID-19 patients.

Introduction:Prehospital use of lung ultrasound (LUS) by paramedics to guide the diagnoses and treatment of patients has expanded over the past several years. However, almost all of this education has occurred in a classroom or hospital setting. No published prehospital use of LUS simulation software within an ambulance currently exists.Study Objective:The objective of this study was to determine if various ambulance driving conditions (stationary, constant acceleration, serpentine, and start-stop) would impact paramedics’ abilities to perform LUS on a standardized patient (SP) using breath-holding to simulate lung pathology, or to perform LUS using ultrasound (US) simulation software. Primary endpoints included the participating paramedics’: (1) time to acquiring a satisfactory simulated LUS image; and (2) accuracy of image recognition and interpretation. Secondary endpoints for the breath-holding portion included: (1) the agreement between image interpretation by paramedic versus blinded expert reviewers; and (2) the quality of captured LUS image as determined by two blinded expert reviewers. Finally, a paramedic LUS training session was evaluated by comparing pre-test to post-test scores on a 25-item assessment requiring the recognition of a clinical interpretation of prerecorded LUS images.Methods:Seventeen paramedics received a 45-minute LUS lecture. They then performed 25 LUS exams on both SPs and using simulation software, in each case looking for lung sliding, A and B lines, and seashore or barcode signs. Pre- and post-training, they completed a 25-question test consisting of still images and videos requiring pathology recognition and formulation of a clinical diagnosis. Sixteen paramedics performed the same exams in an ambulance during different driving conditions (stationary, constant acceleration, serpentines, and abrupt start-stops). Lung pathology was block randomized based on driving condition.Results:Paramedics demonstrated improved post-test scores compared to pre-test scores (P Conclusion:Paramedics can correctly acquire and interpret simulated LUS images during different ambulance driving conditions. However, simulation techniques better adapted to this unique work environment are needed.

The coronavirus disease‐2019 (COVID‐19) is a viral illness with heterogenous clinical manifestations, ranging from mild symptoms to severe acute respiratory distress syndrome and shock caused by the severe acute respiratory syndrome coronavirus‐2. The global healthcare community is rapidly learning more about the effects of COVID‐19 on the cardiovascular system, as well as the strategies for management of infected patients with cardiovascular disease. There is minimal literature available surrounding the relationship between COVID‐19 infection and acute coronary syndrome. We describe the case of a woman who presented with an acute anterior ST‐elevation myocardial infarction managed by primary percutaneous coronary intervention, who subsequently developed severe COVID‐19 infection and ultimately succumbed to multisystem organ failure.

Background Atrial fibrillation (AF) is the most frequent arrhythmia with a high risk for thromboembolic events. The presence of left atrial appendage (LAA) thrombus is associated with a greater risk for stroke, yet few papers investgated predictor factors for LAA thrombus. Platelets indices-Mean platelet volume (MPV) and plateletcrit (PTC)-have been correlated with platelet reactivity, thrombogenicity and a high cardiovascular risk. Purpose The aim of this study is to determine if MPV-to-PCT and MPV-to-platelet (PLT) ratios could predict the presence of LAA thrombus in nonvalvular AF patients. Methods This retrospective study includes 112 patients screened with trans-esophageal echography (TEE) for LAA thrombus from January 2018 to Aprilie 2019. We excluded patients with manifest, deep vein thrombosis, pulmonary trombembolism and malignancies. The platelets indices were measured on admission. ROC curve analysis and the Youden index associated criterion was used to determine the cut-off values and Chi –square test to estimate associated risks. Results The focus group consisted of 112 AF patients, with a mean age of 67 ± 10.02 and 52.3% males. 71% patients had persistent AF, 19.64% (22) patients had LAA thrombi. Higher MPV-to-PCT, respectively MPV-to-PLT ratios were associated with LAA thrombus. In ROC curve analysis MPV-to-PLT ratio (AUC 0.618 95% CI 0.521 to 0.708, p = 0.0729) and MPV-to-PCT ratio (AUC 0.627, 95% CI 0.530 to 0.716, p = 0.05) predicted LAA thrombi, with a cut-off value of >38 for MPV-to-PCT and >0.049 for MPV-to-PLT ratio. Patients with an MPV-to-PCT ratio > 38 had a risk ratio of 1.21 (95% CI 1.03 - 1.44, p = 0.039) and those with an MPV-to-PLT ratio> 0.049 a risk ratio of 1.27 (95%CI 1.03 - 1.58, p = 0.01 ) of having a LAA thrombus. Conclusion Platelets indices are cost efficient, readily available thrombogenesis biomarkers that could be auxilliary parameters useful for the associtation of LAA thrombi in non-valvular AF patients undergoing TEE before cardioversion. We suggest the cut-off values of MPV-to-PCT> 38 and MPV-to-PLT > 0.049 to be considered as risk indicator.

The authors discusses the nature and extent of opioid addiction in the United States and examines the critical role that law enforcement officers can play in reversing the lethal effects of...

Introduction The impact of required self-directed activities (SDAs) measured by written exam on advanced pharmacy practice experiences (APPEs) has not been reported. The primary objective of this study was to determine the validity and reliability of a pre/post exam to measure knowledge when SDAs are incorporated into primary care APPEs. Secondary objectives included assessment of pre/post exam scores and students' perceptions of their learning through SDAs. Methods Two faculty implemented required SDAs and a pre/post-exam in their APPEs. Face and content validity were assessed using expert consensus. A retrospective exam of student performance from May 2016 to April 2018 was performed (n = 42). Additional APPE assessment scores were also collected to determine correlations and establish criterion validity. Students who completed the APPE during May 2016 to February 2017 (n = 17) were invited to complete an anonymous, 15-item cross-sectional survey to assess student perceptions of the activities. Differences in self-rated knowledge before and after the rotation were assessed. Results Pre-exam and post-exam scores positively correlated with journal club and the APPE grading rubric and final scores. Overall, interrater reliability was excellent. Significant improvement was seen between pre-/post exam scores with a mean (SD) change of 21.5% (9.4%). Thirteen (77%) students completed the anonymous survey and rated their perceived knowledge significantly higher after completing the SDAs. Conclusions The pre/post exam was valid, reliable, and positively correlated with other graded assignments. Significant improvements in exam scores and survey results support SDAs as an effective teaching method on primary care APPEs.

Summary Background Patients with advanced gastric or gastro-oesophageal junction cancer that progresses on chemotherapy have poor outcomes. We compared pembrolizumab with paclitaxel in patients with advanced gastric or gastro-oesophageal junction cancer that progressed on first-line chemotherapy with a platinum and fluoropyrimidine. Methods This randomised, open-label, phase 3 study was done at 148 medical centres in 30 countries. Eligible patients were randomised (1:1) in blocks of four per stratum with an interactive voice-response and integrated web-response system to receive either pembrolizumab 200 mg every 3 weeks for up to 2 years or standard-dose paclitaxel. Primary endpoints were overall survival and progression-free survival in patients with a programmed cell death ligand 1 (PD-L1) combined positive score (CPS) of 1 or higher. Safety was assessed in all patients, irrespective of CPS. The significance threshold for overall survival was p=0·0135 (one-sided). This trial is registered at ClinicalTrials.gov, number NCT02370498. Findings Between June 4, 2015, and July 26, 2016, 592 patients were enrolled. Of the 395 patients who had a PD-L1 CPS of 1 or higher, 196 patients were assigned to receive pembrolizumab and 199 patients were assigned to receive paclitaxel. As of Oct 26, 2017, 326 patients in the population with CPS of 1 or higher had died (151 [77%] of 196 patients in the pembrolizumab group and 175 [88%] of 199 patients in the paclitaxel group). Median overall survival was 9·1 months (95% CI 6·2–10·7) with pembrolizumab and 8·3 months (7·6–9·0) with paclitaxel (hazard ratio [HR] 0·82, 95% CI 0·66–1·03; one-sided p=0·0421). Median progression-free survival was 1·5 months (95% CI 1·4–2·0) with pembrolizumab and 4·1 months (3·1–4·2) with paclitaxel (HR 1·27, 95% CI 1·03–1·57). In the total population, grade 3–5 treatment-related adverse events occurred in 42 (14%) of the 294 patients treated with pembrolizumab and 96 (35%) of the 276 patients treated with paclitaxel. Interpretation Pembrolizumab did not significantly improve overall survival compared with paclitaxel as second-line therapy for advanced gastric or gastro-oesophageal junction cancer with PD-L1 CPS of 1 or higher. Pembrolizumab had a better safety profile than paclitaxel. Additional trials of pembrolizumab in gastric and gastro-oesophageal cancer are ongoing. Funding Merck Sharp & Dohme, a subsidiary of Merck & Co.

Summary: Activating germline mutations in STAT3 were recently identified as a cause of neonatal diabetes mellitus associated with beta-cell autoimmunity. We have investigated the effect of an activating mutation, STAT3K392R, on pancreatic development using induced pluripotent stem cells (iPSCs) derived from a patient with neonatal diabetes and pancreatic hypoplasia. Early pancreatic endoderm differentiated similarly from STAT3K392R and healthy-control cells, but in later stages, NEUROG3 expression was upregulated prematurely in STAT3K392R cells together with insulin (INS) and glucagon (GCG). RNA sequencing (RNA-seq) showed robust NEUROG3 downstream targets upregulation. STAT3 mutation correction with CRISPR/Cas9 reversed completely the disease phenotype. STAT3K392R-activating properties were not explained fully by altered DNA-binding affinity or increased phosphorylation. Instead, reporter assays demonstrated NEUROG3 promoter activation by STAT3 in pancreatic cells. Furthermore, proteomic and immunocytochemical analyses revealed increased nuclear translocation of STAT3K392R. Collectively, our results demonstrate that the STAT3K392R mutation causes premature endocrine differentiation through direct induction of NEUROG3 expression. : Saarimäki-Vire et al. use iPSCs derived from a patient with permanent neonatal diabetes to demonstrate that an activating STAT3 mutation leads to premature NEUROG3 expression and concomitant differentiation of pancreatic progenitors through increased nuclear shuttling of the mutant protein. Keywords: monogenic diabetes, STAT3, NEUROG3, iPSC, stem cells, CRISPR, genome editing, pancreatic differentiation, beta cell, endocrine cells

Current U.S. Air Force medical standards allow applicants to enter pilot training with up to 1.50 D of astigmatism. However, waivers are considered for individuals with up to 3.00 D of astigmatism. Although typically a benign finding, higher levels of astigmatism may be progressive and can be associated with corneal ectasia (e.g., keratoconus or pellucid marginal degeneration) leading to reduced visual acuity with spectacles and/or soft contact lenses. The goal of this study was to evaluate the long-term outcomes of pilot applicants waivered into training with astigmatism exceeding the aeromedical standard.Subjects were identified on the basis of their enrollment in the Excessive Astigmatism Management Group maintained by the Aeromedical Consultation Service, Ophthalmology branch at Wright-Patterson Air Force Base, Ohio. Metrics evaluated included refractive status, visual acuity, aeromedical waiver status, safety data, and the development of corneal ectasia.Seventy-six subjects were tracked for up to 10 years, with an average follow-up period of 5.5 years. Mean astigmatism at initial examination was 1.91 D, although mean astigmatism on the basis of the most recent examination was 2.19 D. Subjects with excessive astigmatism who were waivered into pilot training showed an average increase in astigmatism of slightly less than 0.05 D annually, which equates to a total increase in astigmatism of approximately 0.25 D for the duration of the study. No subjects developed ectasia or were disqualified from flying for vision or refractive reasons. No mishaps were identified with vision being a causative or contributing factor.This study supports continuation of current Air Force waiver policy, although a longer follow-up period is required to consider modifying the aeromedical standard for astigmatism.

Background Psychosocial evaluation of candidates for advanced heart failure (HF) therapies identifies risk factors for poor outcomes. The degree of psychosocial risk considered acceptable to proceed with advanced therapies varies between centers. We hypothesized that rates of patients declined for advanced therapies because of mental health disorders, substance abuse and inadequate social support would differ for urban versus rural candidates, as community resources to mitigate risk factors vary. Methods Medical records for 213 consecutive patients undergoing psychosocial evaluation for advanced HF therapies between May 2014 and October 2017 were reviewed. Patients were separated into rural or urban categories based on home zip codes and urban influence codes from the United States Department of Agriculture. Demographics, comorbidities and psychosocial characteristics were collected. Categorical variables were compared using Fisher's exact test and continuous variables using the Student's t-test. Results The overall population was 54 years old, 27% female, and 23.5% African American with prevalent comorbidities. Regional codes identified 62 patients as rural and 151 patients as urban. Demographics and prevalence of medical and psychosocial comorbidities were similar between the two cohorts. There were no significant differences in the frequency of cited medical or social barriers alone to advanced therapies between cohorts. The combination of medical and social barriers was more commonly cited as the reason for ineligibility for transplant in rural patients (p=0.04). Conclusion Rural patients are more often declined for transplant due to combinations of medical and psychosocial concerns, despite similar prevalence of individual stressors. Further study is required to describe the differences in resources available to heart failure patients, standardize criteria among centers, and improve disparities in access to advanced therapies.

Background Vascular air embolism is a rare but potentially deadly phenomenon. Early diagnosis allows providers to initiate measures aimed at preventing further air entry, preventing the migration of air to the lungs, and mitigating the hemodynamic effects of pulmonary air embolism. Case Report An emergency physician used point-of-care ultrasound to identify intravascular air before embolization to the pulmonary vasculature. Why Should an Emergency Physician Be Aware of This? Bedside ultrasound can be used as a tool for early diagnosis of intravascular air. Emergency physicians should be aware of the typical sonographic manifestations of intravascular air and the initial steps in treating vascular air embolism.

Introduction Heart failure (HF) affects platelet activation, function, as well as the production of platelets from megakaryocytes. Low platelet counts have been described in HF patients, however without clear distinction whether this is a consequence of HF severity or an independent comorbidity contributing to worse outcomes. Aim Our purpose was to assess the prognostic role of thrombocytopenia in HF patients. Methods Patients with HF admitted to our Cardiology Department were included in this study, after excluding acute coronary syndromes, pulmonary embolisms, infections, malignancy and hepatic cirrhosis. Thrombocytopenia was defined as a platelet number below 15ehz747.0353/uL and classified as severe below 5ehz747.0353/uL and moderate between 5ehz747.0353–1ehz747.03530/uL. Patients with a left ventricular ejection fraction (LVEF) All-cause mortality was assessed after a mean follow-up of 5.5 years. Results We included 1142 patients, with a mean age of 72.45±10.53 and 51.6% female. 121 (10.6%) patients had thrombocytopenia, of which 3 had severe thrombocytopenia and 21 had moderate thrombocytopenia. All-cause long-term mortality was 43.8%. Patients with acute decompensated heart failure had similar prevalence of thrombocytopenia as those with stable heart failure (12.3% vs 9.5%, p=0.22). Patients with thrombocytopenia had a higher risk ratio for all-cause mortality compared to patients with normal platelet counts (RR 1.35, 95% CI 1.14–1.60, p=0.002). Patients with severe thrombocytopenia had a risk ratio of 2.29 (95% CI 2.14–2.45, p=0.049), those with moderate thrombocytopenia had a risk ratio of 1.80 (95% CI 1.39–2.33, p=0.006) and those with mild thrombocytopenia had a risk ratio of 1.23 (95% CI 1.01–1.51, p=0.06) of all-cause long-term mortality, compared to patients with normal platelet counts. Patients with thrombocytopenia and HFpEF (RR 1.66, 95% CI 1.16–2.37, p=0.021) or HFrEF (RR 1.35, 95% CI 1.09–1.68, p=0.03) had higher risk of all-cause long-term mortality, but not those with HFmrEF and thrombocytopenia (RR 1.09, 95% CI 0.67–1.76, p=0.73), possibly due to the predominance of mild thrombocytopenia (80.9%). In multiple regression analysis, after adjusting for age and sex, alongside NT-proBNP levels and left ventricular ejection fraction, moderate thrombocytopenia (p=0.031) was an independent predictor of all-cause long-term mortality, but not mild thrombocytopenia (p=0.415). Due to the very low number of patients, no multiple regression analysis could be computed with severe thrombocytopenia. Conclusions Thrombocytopenia is an independent predictor of mortality in HF patients, especially platelet counts below 1ehz747.03530/uL. In both patients with HFrEF and HFpEF this biomarker should be assessed for prognosis.

Background Isolated limb infusion (ILI) with cytotoxic agents is a simple and effective treatment option for patients with melanoma in-transit metastases (ITMs) confined to an extremity. Data for ILIs performed in Europe are sparse and to date no Eastern European ILI experience has been reported. The aim of the current study was to evaluate the efficacy of ILI in Estonia. Patients and methods Data for twenty-one patients were collected and analysed. All patients had melanoma ITMs and underwent an ILI between January 2012 and May 2018. The cytotoxic drug combination of melphalan and actinomycin-D was used. Drug circulation times were 20–30 min under mildly hyperthermic conditions (38–39 °C). Primary outcome measures were treatment response and overall survival. Results Nineteen lower limb and two upper limb ILIs were performed. The female to male ratio was 18:3. The overall response rate (complete + partial response) was 76% (n = 16), with a complete response in 38% (n = 8). The overall long-term limb salvage rate was 90% (n = 19). During follow-up, eight patients (38%) died, two due to metastatic melanoma. Five-year overall survival was 57%. Conclusion This first Eastern European report of ILI for melanoma ITMs shows results comparable to those from other parts of the world. In this era of effective targeted and immune therapies, ILI remains a useful treatment option, with a high overall response rate and durable responses in patients with melanoma ITMs confined to a limb.

Background Stump appendicitis (SA) is a rare entity in patients with a history of appendectomy and may result in missed or delayed diagnosis. We report a case of SA diagnosed by emergency department (ED) point-of-care ultrasound (PoCUS) in an elderly woman, thus expediting her care. Case presentation An elderly female patient with a history of appendectomy 27 years ago was referred by her physician to the ED with right lower quadrant pain for 2 days. Using PoCUS the emergency physician identified SA. This was confirmed by computed tomography (CT) scan. The patient was then successfully managed non-operatively using antibiotics. Conclusions Despite its rarity, it is feasible to diagnose SA using PoCUS, as patients presenting with right lower quadrant pain and history of appendectomy are at risk for delayed diagnosis, perforation, and poor outcome. PoCUS may reduce time to diagnosis, time to definitive operative or non-operative management, and minimize morbidity.

Introduction Echocardiography is commonly performed in the evaluation of patients with pulmonary hypertension (PH). The report summary often serves to guide the future evaluation of these patients. Our aim was to explore the relationship between the echocardiography reports of patients with PH and referral to a PH specialty clinic. Methods A random sample of 500 echocardiographic reports of patients with an estimated right ventricular systolic pressure (RVSP) greater than 40 mm Hg between 2006 and 2014 was selected from the institutional database of a single academic center. Referral to the PH clinic was determined by evaluating the electronic medical record. Univariate and multivariate logistic regression analyses were performed to identify characteristics associated with referral. Results Pulmonary hypertension was mentioned in 31% of the report summaries, and only 4.6% were referred to the PH clinic. Variables associated with referral were younger age, indication for echocardiography, higher right atrial and ventricular (RV) systolic pressures, RV dilatation, mention of PH in the summary, and higher left ventricular ejection fraction. Mention of PH in the summary was the variable most strongly associated with referral (adjusted odds ratio 4.6, 95% CI 1.5-14.2). Conclusion Pulmonary hypertension was infrequently mentioned in the summary of echocardiography reports of patients with RVSP >40 mm Hg. Referral to the PH clinic was rare but occurred more often following the mention of PH in the summary. Explicit mention of the presence of PH in the echocardiography report summary may facilitate referral to a specialty clinic and allow more comprehensive evaluation of PH.

Objective: To review the use of nondihydropyridine calcium channel blockers (non-DHP CCBs) for the treatment of proteinuria in diabetic and nondiabetic kidney disease. Data Sources: A search using PubMed and MEDLINE, Scopus, and Google Scholar was performed from 1964 through February 2019 using the following search terms alone or in combination: verapamil, diltiazem, non-dihydropyridine calcium channel blocker, proteinuria, albuminuria, microalbuminuria, kidney disease, renal disease. Study Selection and Data Extraction: All prospective English-language trials examining one or more non-DHP CCB for the treatment of proteinuria were evaluated. Data Synthesis: A total of 13 clinical trials examining the use of non-DHP CCBs to treat proteinuria alone or in combination with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) were included in the evaluation. Most studies evaluated patients with macroalbuminuria secondary to diabetes and hypertension. Verapamil was the most common agent studied. Non-DHP CCBs were effective in reducing proteinuria in diabetic kidney disease but did not reduce renal or cardiovascular outcomes in the one trial that evaluated clinical end points. They were generally well tolerated, with the most common adverse effect reported being constipation. Relevance to Patient Care and Clinical Practice: This review evaluates and summarizes the available evidence on non-DHP CCBs for treatment of proteinuria in patients with existing kidney disease. Conclusion: Non-DHP CCBs may be a reasonable therapeutic option for patients with diabetic kidney disease and persistent proteinuria despite maximum doses of ACE inhibitors or ARBs. Additionally, they may be reasonable alternatives to ACE inhibitors or ARBs if a contraindication or intolerance exists.

Purpose: To develop a care process model for the delivery of peptide receptor radionuclide therapy (PRRT) with lutetium-177 (177Lu)-Dotatate for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Methods: A multidisciplinary, structured PRRT process model was established. Over the last 9 months, meetings were held bi-weekly to discuss the logistics of clinical trials. Meetings are still held regularly at the Mayo Clinic Florida to discuss plans regarding commercially available PRRT treatments. The process model has evolved as we have treated patients on both clinical trials and commercial treatments. Results: An effective process model was formulated. We had 5 patients on our Expanded Access Program (EAP) clinical trial. Our ability to be a part of the EAP allowed us to understand the mechanics of how to treat these patients, and what was involved before it became commercially available. Since commercial availability of the 177Lu-Dotatate, more than 50 treatments (>20 patients) have already been completed, with several new patients getting started on treatment every week. Our nuclear medicine department receives continual requests to schedule new patients for PRRT. This can be attributed to our streamlined approach in delivering PRRT to our patients. Conclusion: A thorough procedural approach was formulated to provide patients with PRRT. Experiences and challenges led to refinement, which has allowed the process to advance. This development could lead to better patient outcomes, treatment efficiency, and a reference standard for other institutions trying to develop this at their location.

Objective The aim of this study was to compare the functional results of 2 different procedure types, medical or surgical used in treating native joint septic arthritis. Methods In this cohort study, we reviewed the clinical registries of patients admitted to a single third-level hospital with the diagnosis of septic arthritis during the period of January 1, 2008, to January 31, 2016. Results A total of 63 cases of septic arthritis were identified in which the initial approach for 49 patients was medical (arthrocentesis), whereas the initial approach for 14 patients was surgical (arthroscopy or arthrotomy). Of the 49 patients who received initial medical treatment (IMT), 15 patients (30%) later required surgical treatment because of poor progress. The median age of the patients was 60 (SD, 18) years. The group who received IMT were older than those who received initial surgical treatment (median, 64 years [interquartile range {IQR}, 54–76 years], vs. 48 years [IQR, 30–60 years]). There was a larger percentage of male patients in the surgical group (78% vs. 42% [p = 0.018]). Thirty percent of the medical group had been receiving corticosteroid treatment (p = 0.018). Results of complete recovery of joint functionality showed no significant differences after 1 year (68% with MT vs. 67% with ST, p = 0.91). Both groups had similar symptom duration until diagnosis, duration of antibiotic therapy (median, 30 days [IQR, 28–49 days], vs. 29.5 days [IQR, 27–49] days), and mortality rate (3 in the medical group). Conclusions The results of the study show that initial surgical treatment in patients with native joint septic arthritis is not superior to IMT. However, half of the patients with shoulder and hip infections treated with IMT eventually required surgical intervention, suggesting that perhaps this should be the preferred initial approach in these cases.

Acute myeloid leukemia (AML) is a heterogeneous disorder characterized by a wide range of genetic defects. Cytogenetics, molecular and genomic technologies have proved to be helpful for deciphering the mutational landscape of AML and impacted clinical practice. Forty-eight new AML patients were investigated with an integrated approach, including classical and molecular cytogenetics, array-based comparative genomic hybridization and targeted next generation sequencing (NGS). Various genetic defects were identified in all the patients using our strategy. Targeted NGS revealed known pathogenic mutations as well as rare or unreported variants with deleterious predictions. The mutational screening of the normal karyotype (NK) group identified clinically relevant variants in 86.2% of the patients, in the abnormal cytogenetics group, the mutation detection rate was 87.5%. Overall, the highest mutation prevalence was observed for the NPM1 gene, followed by DNMT3A, FLT3 and NRAS. An unexpected co-occurrence of KMT2A translocation and DNMT3A-R882 was identified, alterations of these genes, which are involved in epigenetic regulation, are considered to be mutually exclusive. A microarray analysis detected CNVs in 25% of the NK AML patients. In patients with complex karyotypes, the microarray analysis made a significant contribution toward the accurate characterization of chromosomal defects. In summary, our results show that the integration of multiple investigative strategies increases the detection yield of genetic defects with potential clinical relevance.

The prevalence of pressure ulcers in patients with spinal cord injuries has been estimated to be between 30% and 47%. Individuals with spinal cord injuries sit for a majority of the time, increasing the risk of developing pressure ulcers in the buttocks and thighs due to large internal stresses. Human body models have been developed to study the formation of pressure ulcers, yet a persistent limitation in these models has been the material properties used to represent the soft tissues in the buttocks and thighs. Specifically, soft tissue material property data have not included wheelchair users, such as those with spinal cord injuries. The goals of this research were 1) to determine the in-vivo material properties of soft tissue in the thighs and buttocks of individuals with spinal cord injuries and 2) compare these to properties obtained from able-bodied people. Results indicated that the proximal and middle thigh regions of those who had a spinal cord injury were softer than the same regions as able-bodied individuals, while the distal thigh regions were stiffer. These findings are vital because they indicate that models developed using properties from able-bodied individuals will not produce internal stress or strain magnitudes that represent individuals who have a spinal cord injury. This information suggests that models should obtain material property data sets from their desired population. Human body models must represent the population being studied if they are to inform clinical assessments and make accurate patient predictions.

This study examined the dynamics of vaccine spending and vaccine legislation in the Americas Region over the period 1980-2013. Annual vaccine expenditures from thirty-one countries were extracted from the Pan American Health Organization Revolving Fund database. Information on vaccine laws and regulations was provided by the PAHO Family, Gender, and Life Course Unit. Both time series and event history models were estimated. The results show that passing an immunization law led a representative country to increase its vaccine spending, controlling for income, infant mortality, population size, and DPT3 vaccine coverage. Countries with higher vaccine coverage were also more likely to have passed laws. Conversely, higher income countries were less likely to have vaccine laws. Vaccine legislation will likely play a similarly important role in other regions as more countries move towards immunization program ownership.

Objective To provide experience on the methods and costs for delivering a large-scale community pharmacist home visit service. Setting Independent urban community pharmacy, Buffalo, NY. Practice description Mobile Pharmacy Solutions provides traditional community pharmacy walk-in service and a suite of clinically oriented services, including outbound adherence calls linked to home delivery, payment planning, medication refill synchronization, adherence packaging, and pharmacist home visits. Pharmacist daily staffing included three dispensing pharmacists, one residency-trained pharmacist, and two postgraduate year 1 community pharmacy residents. Practice innovation A large-scale community pharmacy home visit service delivered over a 1-year period. Evaluation Pharmacist time and cost to administer the home visit service as well as home visit request sources and description of patient demographics. Results A total of 172 visits were conducted (137 initial, 35 follow-up). Patients who received a home visit averaged 9.8 ± 5.2 medications and 3.0 ± 1.6 chronic disease states. On average, a home visit required 2.0 ± 0.8 hours, which included travel time. The percentages of visits completed by pharmacists and residents were 60% and 40%, respectively. The amounts of time to complete a visit were similar. Average home visit cost including pharmacist time and travel was $119 ($147 for a pharmacist, $77 for a resident). Conclusion In this community pharmacy–based home visit service, costs are an important factor, with each pharmacist visit requiring 2 hours to complete. This experience provides a blueprint and real-world perspective for community pharmacies endeavoring to implement a home visit service and sets a foundation for future prospective trials to evaluate the impact of the service on important indicators of health and cost.

Documentation of clinical interventions by pharmacists is well recognized to be an important aspect of patient care. Because interventions by pharmacists have been shown to improve patient care and decrease healthcare costs in multiple settings,[1][1]–[7][2] schools of pharmacy should provide

The aim of this study was to analyze retrospectively the influence of different acoustic and language models in order to determine the most important effects to the clinical performance of an Estonian language-based non-commercial radiology-oriented automatic speech recognition (ASR) system. An ASR system was developed for Estonian language in radiology domain by utilizing open-source software components (Kaldi toolkit, Thrax). The ASR system was trained with the real radiology text reports and dictations collected during development phases. The final version of the ASR system was tested by 11 radiologists who dictated 219 reports in total, in spontaneous manner in a real clinical environment. The audio files collected in the final phase were used to measure the performance of different versions of the ASR system retrospectively. ASR system versions were evaluated by word error rate (WER) for each speaker and modality and by WER difference for the first and the last version of the ASR system. Total average WER for the final version throughout all material was improved from 18.4% of the first version (v1) to 5.8% of the last (v8) version which corresponds to relative improvement of 68.5%. WER improvement was strongly related to modality and radiologist. In summary, the performance of the final ASR system version was close to optimal, delivering similar results to all modalities and being independent on user, the complexity of the radiology reports, user experience, and speech characteristics.

Identification of the etiology of hypotension is essential to early appropriate management of these critically ill patients. In these patients, point-of-care ultrasound (POCUS) makes diagnostic information rapidly available. One advantage of POCUS is that it is fast. It can be performed at the bedside as soon as shock or hypotension is identified. Hemodynamically unstable patients do not have to leave the clinical setting for diagnostic testing, allowing them to be monitored appropriately. Beyond its diagnostic utility, POCUS may be used dynamically to guide treatment such as fluid administration and to guide procedures like pericardiocentesis and central access.

We present the case of a 71-year-old woman diagnosed with chronic lymphocytic leukemia who received multiple chemotherapeutic lines and evolved to acute lymphoblastic leukemia. The patient was Rai stage 0 at the time of the diagnosis and was monitored for almost 9 years. After that, the disease progressed and the patient began chemotherapy (fludarabine/cyclophosphamide combination), obtained complete remission and relapsed one year later after finishing treatment. She received multiple therapeutic regimens, accompanied by multiple infectious complications. After 8 years of evolution since she started chemotherapy, bone marrow aspirate and immunophenotyping revealed acute lymphoblastic leukemia. The occurrence of acute leukemia in CLL is rare and may arise from the same clone; however, most cases appear after patients have received chemotherapy, suggesting that they are therapy-related.

Physicians commonly use formulary medication coverage information generated by electronic heath records (EHRs) and the Epocrates mobile drug database application when making medication selection decisions. Nonformulary selections may lead to higher out-of-pocket patient costs and nonadherence with prescribed regimens. Nonformulary selections also contribute to higher overall health plan spending. However, the accuracy of these systems compared with actual insurance coverage is not known. To assess the accuracy of formulary status icons generated by an EHR system and the Epocrates mobile application for patients with Alabama Medicaid and Blue Cross Blue Shield of Alabama (BCBS), the primary insurance providers in the state of Alabama.Patients of all ages who had a chart review performed at the outpatient family medicine or pediatric clinics at the University of Alabama at Birmingham Huntsville Medical Regional Campus from May to October 2013 were included in this retrospective analysis. Patients who were not insured by either Alabama Medicaid or BCBS were excluded. Patients who did not have new medications added at the time of the visit were also excluded. For each medication prescribed, the formulary status provided in the EHR system and Epocrates was compared with the actual Medicaid and BCBS formularies published online, and the accuracy of the 2 databases was determined. A total of 1,529 medication records were analyzed. The EHR and Epocrates provided accurate formulary information for 93.1% and 89.4% of medications, respectively. Formulary information generated by the EHR was 96.3% accurate for Medicaid patients and 80.1% accurate for BCBS patients. Epocrates was 88.2% accurate for Medicaid patients and 94.4% accurate for BCBS patients. A total of 936 medication records from the pediatric clinic were analyzed, and the majority of these patients (88.4%) had Medicaid insurance. In this population, the EHR was more accurate (96.9%) than Epocrates (86.6%). Of the small number of pediatric medication records (n = 109) associated with patients who had BCBS, Epocrates was more accurate (92.7%) than the EHR (83.5%). In family medicine, 593 medication records were analyzed. Again, for Medicaid patients, the EHR was more accurate (95.3%) than Epocrates (91.5%). For those with BCBS, Epocrates was more accurate (95.3%) than the EHR (78.2%). When over-the-counter (OTC) medications (n = 232) were analyzed separately from prescription medications, it was found that overall the EHR was 90.5% accurate, and Epocrates was 41.4% accurate. It is important to note that when only prescription medications were analyzed, the accuracy rates were high (93.6% for the EHR and 98.0% for Epocrates).Formulary information generated by the EHR system and the Epocrates mobile application is a useful tool for physicians when prescribing medications, but neither source is completely accurate. Prescribers should be particularly cautious when making OTC formulary decisions using the Epocrates mobile application, since the formulary information provided for these medications was found to be the least accurate.