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Objective: To assess the short- and long-term safety and efficacy of oral flecainide therapy in patients with symptomatic tachycardia and an extranodal accessory pathway.Design: Open-label, uncontrolled trial with a mean follow-up of 24 months.Setting: Referral-based, teaching medical center.Patients: Sixty-three patients with symptomatic tachycardia and an extranodal accessory pathway.Interventions: Patients had electrophysiologic testing before and after the initiation of oral flecainide therapy and were followed long-term for the presence of symptoms, new physical limitations, and adverse effects of therapy.Measurements and Main Results: Flecainide therapy prevented or slowed (324 +/- 59 ms to 398 +/- 55 ms; P less than 0.001) inducible sustained atrioventricular reciprocating tachycardia in 44 of 63 patients (70%). Of the 44 patients discharged from the hospital, 33 (75%) have continued to receive flecainide therapy and have shown no adverse effects (mean follow-up, 24 +/- 10 months). Adverse cardiac reactions (proarrhythmia or sinus node suppression) attributable to flecainide occurred in 11 of 63 patients (17%); in 9 (82%) of these 11 patients, events were detected during either in-hospital monitoring or the electrophysiologic study done before discharge. Structural heart disease was detected by two-dimensional echocardiography in 8 of 11 patients who had adverse cardiac events and in 6 of 52 patients who did not have such events (P less than 0.001). Isoproterenol reversed the effects of flecainide therapy in 11 of 21 patients; 7 of the 11 patients had spontaneous clinical recurrences of tachycardia or palpitations during the follow-up period, but these symptoms occurred in only 1 of 10 patients who did not show isoproterenol-induced reversal (P = 0.02).Conclusions: Oral flecainide therapy was effective in 33 of 63 patients who had tachycardia and an extranodal accessory connection. Hospital monitoring during initial therapy is recommended, and flecainide should be used with caution, if at all, in patients with structural heart disease. An isoproterenol challenge appears to be helpful in predicting late recurrence of tachycardia. [ABSTRACT FROM AUTHOR]

Purpose: Mechanical thrombectomy for the treatment of deep vein thrombosis (DVT) is being increasingly utilized to reduce symptoms and prevent postthrombotic syndrome (PTS), but more data on clinical outcomes are needed. Mechanical thrombectomy was studied in the ClotTriever Outcomes (CLOUT) registry with 6-month full analysis outcomes reported herein., Materials and Methods: The CLOUT registry is a prospective, all-comer study that enrolled 500 lower extremity DVT patients across 43 US sites treated with mechanical thrombectomy using the ClotTriever System. Core-lab assessed Marder scores and physician-assessed venous patency by duplex ultrasound, PTS assessment using Villalta score, venous symptom severity, pain, and quality of life scores through 6 months were analyzed. Adverse events were identified and independently adjudicated., Results: All-cause mortality at 30 days was 0.9%, and 8.6% of subjects experienced a serious adverse event (SAE) within the first 30 days, 1 of which (0.2%) was device related. SAE rethrombosis/residual thrombus incidence was 4.8% at 30 days and 8.0% at 6 months. Between baseline and 6 months, venous flow increased from 27.2% to 92.5% of limbs (P < 0.0001), and venous compressibility improved from 28.0% to 91.8% (P < 0.0001), while median Villalta scores improved from 9.0 at baseline to 1.0 at 6 months (P < 0.0001). Significant improvements in venous symptom severity, pain, and quality of life were also demonstrated. Outcomes from iliofemoral and isolated femoral-popliteal segments showed similar improvements., Conclusion: Outcomes from the CLOUT study, a large prospective registry for DVT, indicate that mechanical thrombectomy is safe and demonstrates significant improvement in symptoms and health status through 6 months. Level of Evidence 3: Non-randomized controlled cohort/follow-up study., (© 2023. The Author(s).)

Objectives: Quantify the relationship between district policy permitting in-person instruction and educational outcomes during the 2020 to 2021 academic year for kindergarten through eighth grade students., Methods: An ecological, repeated cross-sectional analysis of grade-level proficiency of students enrolled in public school districts in North Carolina (n = 115 school districts) was conducted. Univariate and multivariate analyses were performed to evaluate the association between the proportion of the school year a district spent in-person and 2020 to 2021 end-of-year student proficiency in the district. We then fit a multivariable linear regression model, weighted by district size, and adjusted for district-level 2018 to 2019 proficiency and district-level factors (rural or urban, area deprivation)., Results: Compared to 2018 to 2019, there was a 12.1% decrease (95% confidence interval [CI]: 16.8-19.3) in mathematics and an 18.1% decrease (95% CI: 10.8-13.4) in reading proficiency across the state at the end of 2020 to 2021. Compared to a district that remained entirely remote for the 2020 to 2021 school year, a district offering full in-person instruction had 12% (95% CI: 11%-12.9%) and 4.1% (95% CI: 3.5%-4.8%) more students achieve grade-level proficiency in mathematics and reading, respectively. In-person instruction was associated with greater increases in mathematics proficiency than reading, and greater increases in elementary-level students' proficiency than middle school-level., Conclusions: The proportion of students achieving grade-level proficiency in 2020 to 2021 fell below prepandemic levels at each evaluated time point in the academic year. Increased time spent in-person by a school district was associated with an increased proportion of students achieving grade-level end-of-grade proficiency in both mathematics and reading., (Copyright © 2023 by the American Academy of Pediatrics.)

A 7-month-old male North Island brown kiwi ( Apteryx mantelli ) was transferred from a European zoological park to a North American private aviary. The bird appeared clinically normal upon arrival, but within 30 days, it developed clinical disease signs of sneezing, stridor, and increased respiratory effort. Upon examination a 1-mm yellow plaque was identified on the glottis. After 14 days of empiric treatment with enrofloxacin, meloxicam, and itraconazole, on repeat examination, the glottal plaque had increased in size to a 7-mm-diameter friable mass attached to the right laryngeal cartilage and was partially obstructing the airway. Initially, 80% of the mass was manually dislodged, but within 4 days the tissue mass had again enlarged to approximately 3 mm × 4 mm × 4 mm, prompting surgical excision. On histopathologic examination, the mass was identified as a benign salivary gland adenoma without clear margins. Approximately 3 years postexcision, there is no evidence of tumor regrowth. The successful excision of a benign salivary tumor described in this report will serve as a valuable guide for future cases of similar neoplasms diagnosed in the oral cavity of kiwis and other avian species.

Functionalized tryptamines are targets of interest for development as small molecule therapeutics. The ring opening of aziridines with indoles is a powerful method for tryptamine synthesis where isomer formation can be controlled. 3,5-Dinitrobenzoyl (DNB)-protected aziridines undergo regioselective, enantiospecific ring opening to produce β-substituted tryptamines for a series of indoles. Attack at the more substituted aziridine carbon occurs in an S N 2-like fashion to generate DNB-tryptamine products as synthetic precursors.

N-Acylaziridines are important starting materials for the synthesis of chiral amine derivatives. The traditional methods for producing these activated aziridines have significant drawbacks. The gram scale synthesis of N-acylaziridines by deprotection of N-tosylaziridines and reprotection with N-hydroxysuccinimide derivatives is described. Mono- and disubstituted aziridines perform well, with complete retention of stereochemical purity. The consistently moderate yields are linked to the N-tosylaziridine deprotection step, while acylation with N-hydroxysuccinimide derivatives is highly efficient.

Background: To date, insertable cardiac monitors (ICM) have been implanted in the hospital without critical evaluation of other potential settings. Providing alternatives to in-hospital insertion may increase access to ICM, decrease waiting times for patients awaiting diagnosis, and reduce hospital resources., Methods: This was a prospective, non-randomized, clinical trial involving nine clinical sites throughout the United States designed to assess the feasibility of ICM implants in a non-hospital setting. Other than the Reveal® ICM, implant supplies and techniques were left to physician discretion in patients who met indications. Patients were followed up to 90 days post-implant. The primary objective was to characterize the number of procedure-related adverse events that required surgical intervention within 90 days., Results: Sixty-five patients were implanted at nine out-of-hospital sites. The insertion procedure was well tolerated by all patients. There were no deaths, systemic infections or endocarditis. There were two (3%) procedure-related adverse events requiring device explant and four (6%) adverse events not requiring explant. ICM use led to 16 diagnoses (24.6%) with 9 patients proceeding to alternate cardiac device implants during the course of the 90-day follow up., Conclusion: Out-of-hospital ICM insertion can be accomplished with comparable procedural safety and represents a reasonable alternative to the in-hospital setting. CLINICALTRIALS.GOV REGISTRATION NUMBER: NCT01168427.

Kinetic resolution of N-acylaziridines by nucleophilic ring opening was achieved with (R)-BINOL as the chiral modifier under boron-catalyzed conditions (see scheme; Ar=3,5-dinitrophenyl). The consumed enantiomer of aziridine can be further converted to an enantioenriched 1,2-chloroamide with recovery of (R)-BINOL., (Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Long-term follow-up studies of children conducted during the K-12 school years suggest that problems associated with TBI tend to persist or worsen as children progress through school. A critical issue in service delivery for students with TBI is the significant discrepancy between the incidence of TBI and the identification of children with TBI for special education services. The purpose of this study was to examine factors that influence identification and service practices for students with TBI. Parents of 56 youth with TBI completed a questionnaire and interview about the hospital-school transition and educational services provided within the first year of school re-entry. A subsample participated in a concurrent qualitative study. Results document that 25% of the sample were identified for formal services (via individual education plan or 504 plan) while over 41% received informal supports (e.g., schedule change, extra time on tests). Results from chi-square and logistic regression analyses suggest that injury severity and hospital-school transition services (e.g., written or verbal communication between hospital and school) were related to the provision of formal special education or 504 services. A critical factor contributing to the identification of students with TBI for special education is the link between hospital and school.

In a cytostat, a continuous culture is monitored and controlled by an automated flow cytometer system, based on the determination of the cell concentration and the single cell property distribution of the growing cell population. The growing culture can be maintained at steady state even at such low cell concentrations that the bioreactor medium composition is negligibly changed by the few cells. Therefore, the cell environment is precisely defined by the feed composition since products of cell growth are not present in significant amounts. Effects on cell growth of nutrients, of toxic compounds such as drugs, or of products made by the cells, if added to the feed medium, can be readily isolated. Using the cytostat, it is shown here that ethanol assumes the triggering function for the increase in cell size in Saccharomyces cerevisiae normally only seen at critical growth rates above critical cell densities. This suggests that ethanol assumes a quorum sensing function on cell growth when a critical cell density is reached.

Objective: Evidence suggests that the neuropathology of Huntington's disease, a neuropsychiatric disorder due to a mutation on chromosome 4, results from excessive activation of glutamate-gated ion channels, which kills neurons by oxidative stress. Therefore, the authors hypothesized that alpha-tocopherol, which reduces oxyradical damage to cell membranes, might slow the course of Huntington's disease., Method: A prospective, double-blind; placebo-controlled study of high-dose d-alpha-tocopherol treatment was carried out with a cohort of 73 patients with Huntington's disease who were randomly assigned to either d-alpha-tocopherol or placebo. Patients were monitored for changes in neurologic and neuropsychologic symptoms., Results: Treatment with d-alpha-tocopherol had no effect on neurologic and neuropsychiatric symptoms in the treatment group overall. However, post hoc analysis revealed a significant selective therapeutic effect on neurologic symptoms for patients early in the course of the disorder., Conclusions: Antioxidant therapy may slow the rate of motor decline early in the course of Huntington's disease.

This paper assesses the needs of high- and low-income caregivers shortly after the traumatic brain injury of their child. The Family Needs Questionnaire [1], developed to assess the priorities and satisfaction of needs among family members, was administered to 49 caregivers. Surprisingly, caregivers from both groups displayed similar patterns of priorities and rated their most important needs as met. Caregivers' most important needs included clear information, therapy input, and understanding from professionals and classroom teachers. Personal needs, family support, and future patient-related concerns were devalued by both groups. These results are discussed as having implications for identification of high-risk families, treatment goals, and community reintegration needs.

A retrospective chart review of 62 children aged 2 to 18.5 years admitted over a 4-year period to a brain injury rehabilitation unit was performed. Glasgow Coma Scales were not always recorded at the referring institutions, but all but three of the children in the series experienced a period of unresponsiveness to the environment for a period of at least one hour. Available Glasgow Coma scores at the time of injury ranged from 3 to 13. Maximum coma duration was 3 months. All children received an audiological evaluation. Sixteen per cent of the children had conductive hearing losses, 13% had sensorineural hearing loss, and 16% had central auditory processing problems. Three of these children were found to have combined losses, one with both conductive and sensorineural hearing loss, and two with sensorineural hearing loss and central auditory processing problems. Of the five patients with the most severe injuries and prolonged comas, none had hearing deficits. Twenty-five of the 62 patients, or 40%, had hearing deficits, of which 15 are known to persist.

This study evaluated the relative hemodynamic importance of a normal left ventricular (LV) activation sequence compared to atrioventricular (AV) synchrony with respect to systolic and diastolic function. Twelve patients with intact AV conduction and AV sequential pacemakers underwent radionuclide studies at rest and Doppler echocardiographic studies at rest and during submaximal exercise, comparing atrial demand pacing (AAI) to sequential AV sensing pacing (DDD) and ventricular demand pacing (VVI). Studies at rest were performed at a constant heart rate between pacing modes, and the exercise study was performed at a constant heart rate and work load. Cardiac output was higher during AAI than during both DDD and VVI (6.2 +/- 1 vs 5.6 +/- 1 and 5.3 +/- 1 liters/min, p less than 0.05). LV ejection fraction was likewise higher during AAI (55 +/- 12 vs 49 +/- 11 vs 51 +/- 13, p less than 0.05). VVI with or without AV synchrony was associated with a paradoxical septal motion pattern, resulting in a 25% impairment of regional septal ejection fraction. In addition, LV contraction duration was more homogenous during AAI. Peak filling rate during AAI and VVI was higher than during DDD (2.86 +/- 1 and 2.95 +/- 1 vs 2.25 +/- 1 end-diastolic volume/s; p less than 0.05). During VVI, the time to peak filling was significantly shorter than during both AAI and DDD (165 +/- 34 vs 239 +/- 99 and 224 +/- 99 ms; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Lorcainide, 100 mg twice daily was compared with placebo in 39 patients with frequent ventricular arrhythmias in a randomized double-blind crossover trial. A mean frequency of ventricular premature beats (VPBs) of at least 30 VPBs/hour was required during a drug-free period of 48 hours. Holter monitoring and a maximal symptom-limited exercise test were performed at the end of each of the 2-week double-blind treatment phase. The group averaged 350 +/- 361 (standard deviation) VPBs/hour. Lorcainide decreased the mean VPB frequency of the group by 46% (p less than 0.01), with VPB reduction beyond the expected variation in 22 of 39 patients. In 13 patients VPBs were unchanged and in 4 they increased. Eight additional patients responded during drug titration, for an overall response rate of 77% (30 of 39). Lorcainide did not significantly reduce the exercise-related VPB frequency. At 6 months 61% of patients had significant VPB suppression. Thus, lorcainide was effective in reducing the frequency and grade of spontaneous ventricular arrhythmias during short- and long-term evaluation.

Premature adrenarche (PA) or isolated growth of sexual hair in young children, is a benign condition that may initially be confused with true precocious puberty or pathologic virilizing disorders. The clinical findings, family history, and serum concentrations of dehydroepiandrosterone sulfate (DHEA-S) were compared in 24 children with PA (79% black females) seen in a 2-year period and in an age-matched control group of 17 black females. Twenty three of 24 patients, but none of the controls, had an adult-type axillary odor. There was a positive family history of PA in only three of 24 children with PA, and in one of 17 controls. The mean serum DHEA-S was significantly higher in the PA children than in the controls, but there was a broad range of concentrations (10-143 micrograms/dl), with values in 10 of 24 cases falling within the control range for age. We conclude that: (1) PA is a relatively common finding in black females between ages 3 and 8, (2) an axillary odor is almost always present in children with PA, and (3) determination of serum DHEA-S may be of some help in confirming the clinical impression of a modest increase in adrenal androgen secretion and in ruling out a more serious disorder. In most cases, however, the diagnosis of PA can be made on the basis of the history, physical examination, and lack of rapid progression over time; the use of laboratory tests to rule out a pathologic virilizing process may best be reserved for those children with very early onset, increased linear growth, or other signs of virilization.

Recent reports suggest adrenal insufficiency in critically ill patients is common. We found only one case of de novo adrenal insufficiency using admission ACTH injection in 70 selected intensive care unit (ICU) patients. Random serum cortisol levels correlated positively with illness severity in ICU patients using proven methods for assessing illness severity. Those with the highest random serum cortisol levels (greater than 60 micrograms/dl) had the greatest mortality, while those with lower random cortisol levels which stimulated to more than 18 micrograms/dl after ACTH injection had improved outcomes. Based on our results, routine screening for adrenal insufficiency in ICU patients is not warranted. If it is suspected, the cosyntropin test should be performed since low random cortisol levels (even to 5 micrograms/dl) are not diagnostic of adrenal insufficiency.