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Background and Objective: Myasthenia gravis (MG) is an immune-mediated disorder that can sometimes present acutely with a focal neurological deficit and thus mimic a cerebrovascular event. The objective of this study was to describe the clinical characteristics in a large cohort of patients who were initially misdiagnosed with an acute vascular event and later diagnosed with MG. Methods: This is a retrospective chart review of patients who were initially diagnosed with an acute cerebrovascular event but subsequently found to have MG. The chart review was done for the period from January 2013 to December 2017, and patients with at least one-year follow-up included. Data are reported as means ± SEM, and the results reported using prevalence rates. Results: Twenty-one patients met our inclusion criteria. Among them, 13 (61.9%) were female with a mean age of 56.7 ± 4.07 years. Ten were MGFA class 3a; seven were MGFA class 2b, 3 were MGFA 3b. Eighteen patients were acetylcholine receptor antibody positive; one was MuSK positive, and the rest two seronegative. Slurred speech (8 patients, 38.1%) was the most common symptom that resulted in misdiagnosis, followed by hemibody weakness (7 patients, 33.3%) and dysphagia (3, 14.3%). Smoking (12, 57.1%) and hypertension (11, 52.4%) were common risk factors for cerebrovascular disease. Small vessel disease was suspected the most common etiology (15, 71.4%) of the vascular event. Ten patients had received thrombolytic therapy, and 16 patients were on antiplatelets. 4 patients who presented recurrent symptoms placed on anticoagulants. Conclusion: Acute presentation of bulbar symptoms and hemibody weakness resulted in the misdiagnosis of MG.

Purpose To assess the safety of needle electromyography in patients on non-vitamin K oral anticoagulants (NOACs) compared with warfarin. Methods A retrospective chart review was done in patients who underwent needle electromyography studies while they were using warfarin and NOACs. After the needle electromyography, all the patients were monitored for 2 hours and ultrasound of high-risk muscle groups was done. The complications were classified based on the International Society on Thrombosis and Hemostasis definitions. Results Fifty-eight patients were included: 29 were using NOACs and the other 29 were on warfarin. The mean age was 59.33 ± 16 years. Hemorrhagic complications from needle electromyography were noted in 9 patients: 7 (77.7%) NOACs and 2 (22.3%) warfarin. Among them, 6 patients (66.6%) met the diagnostic criteria for Clinically Relevant Non-Major Bleeding criteria proposed by International Society on Thrombosis and Hemostasis and 3 patients (33.4%) had an asymptomatic hematoma on ultrasound evaluation. A total of 267 muscles were tested and only 9 (3.3%) muscles had hemorrhagic complications. One patient (rivaroxaban) had acute bleeding requiring pressure bandage, five patients (two apixaban, two rivaroxaban, and one warfarin) had clinical hematoma that required ice packs, and three patients (two rivaroxaban and one warfarin) had a hematoma on ultrasound of deep muscles. Conclusions Patients on NOACs had minimal risk of clinically relevant hemorrhagic complications, and the risk is not significantly different from those on warfarin.

Background Free text in electronic health records (EHR) may contain additional phenotypic information beyond structured (coded) information. For major health events – heart attack and death – there is a lack of studies evaluating the extent to which free text in the primary care record might add information. Our objectives were to describe the contribution of free text in primary care to the recording of information about myocardial infarction (MI), including subtype, left ventricular function, laboratory results and symptoms; and recording of cause of death. We used the CALIBER EHR research platform which contains primary care data from the Clinical Practice Research Datalink (CPRD) linked to hospital admission data, the MINAP registry of acute coronary syndromes and the death registry. In CALIBER we randomly selected 2000 patients with MI and 1800 deaths. We implemented a rule-based natural language engine, the Freetext Matching Algorithm, on site at CPRD to analyse free text in the primary care record without raw data being released to researchers. We analysed text recorded within 90 days before or 90 days after the MI, and on or after the date of death. Results We extracted 10,927 diagnoses, 3658 test results, 3313 statements of negation, and 850 suspected diagnoses from the myocardial infarction patients. Inclusion of free text increased the recorded proportion of patients with chest pain in the week prior to MI from 19 to 27%, and differentiated between MI subtypes in a quarter more patients than structured data alone. Cause of death was incompletely recorded in primary care; in 36% the cause was in coded data and in 21% it was in free text. Only 47% of patients had exactly the same cause of death in primary care and the death registry, but this did not differ between coded and free text causes of death. Conclusions Among patients who suffer MI or die, unstructured free text in primary care records contains much information that is potentially useful for research such as symptoms, investigation results and specific diagnoses. Access to large scale unstructured data in electronic health records (millions of patients) might yield important insights.

The purpose of the Risk Assessment toolkit is to depict how organizations can manage risks associated with projects, systems, applications and departments. Before an organization can use the toolkit as described here, they will need to complete the administrative side of risk management. This includes formulating policies, completing SWOT analysis on each proposed asset, project feasibility analysis and they must complete asset valuations. Once, that is completed the organization will move on to the assessment phase. In the assessment phase an organization will utilize the toolkit to discover the impact that the risk will have on their organization and they will be provided a summary of the impacts of each risk. Next, the organization will need to complete the alleviation process. In the alleviation process the organization will review what options they have, what remediation techniques they can perform, and they will continue to monitor major assets. Once an organization completes these three methods of risk management multiple times, their organization will experience significantly less risks and increased capabilities.

Smart-city intersections will play a crucial role in automated traffic management and improvement in pedestrian safety in cities of the future. They will (i) aggregate data from in-vehicle and infrastructure sensors; (ii) process the data by taking advantage of low-latency high-bandwidth communications, edge-cloud computing, and AI-based detection and tracking of objects; and (iii) provide intelligent feedback and input to control systems. The Cloud Enhanced Open Software Defined Mobile Wireless Testbed for City-Scale Deployment (COSMOS) enables research on technologies supporting smart cities. In this paper, we provide results of experiments using bird's eye cameras to detect and track vehicles and pedestrians from the COSMOS pilot site. We assess the capabilities for real-time computation, and detection and tracking accuracy - by evaluating and customizing a selection of video pre-processing and deep-learning algorithms. Distinct issues that are associated with the difference in scale for bird's eye view of pedestrians vs. cars are explored and addressed: the best multiple-object tracking accuracies (MOTA) for cars are around 73.2, and around 2.8 for pedestrians. The real-time goal of 30 frames-per-second - i.e., a total of 33.3 ms of latency for object detection for vehicles will be reachable once the processing time is improved roughly by a factor of three.

When looking at eating beyond physical nourishment, British anthropologist Mary Douglas (1921-2007) defined food as a cultural system, or code that communicates not only biological information, but social structure and meaning. What can a study of food and faith teach us, as scholars of religion, that we might not otherwise know? This article outlines thematic and pedagogical approaches to teaching food and religion through the lens of five semesters of teaching this course to undergraduate and graduate students. In it, I explore the topics of Food memory and community; Food and scripture; Food, gender and race; and Stewardship and Charity, thinking about spiritual and physical nourishment in the world's major religious traditions.

Monitoring youth treatments requires outcome instruments sensitive to change. The Y-OQ and the Y-OQ-SR measure behavioral change during psychological treatment. The focus of this study was to compare treatment progress of youth in studies using the Youth Outcome Questionnaire (YOQ) or the Youth Outcome Questionnaire Self Report (YOQSR) in wilderness and non-wilderness treatment programs. Seventy-six manuscripts were examined. Inclusion criteria were (a) contained a version of the YOQ, (b) implemented mental health treatment, (c) contained sufficient data to obtain an effect size, and (d) had at least two data points (e.g., intake and termination). The final number of studies included for the Y-OQ was 15 and for the Y-OQ-SR was 11. Random effects model results, for studies using the YOQ, indicated a large (Cohen in Psychol Bull 112(1):155, 1992) effect size (g = .98, 95 % CIs [.71, 1.26]). The YOQ-SR results also indicated a large effect size (g = .80, 95 % CIs [.63, .96]). Treatment setting demonstrated a difference between wilderness and non-wilderness programs. For the Y-OQ (parent/guardian observation) effect sizes were higher for wilderness programs Qbetween = 91.82, df = 1, p

Clinical simulation training provides a realistic environment for students and healthcare professionals to strengthen and broaden skills and abilities. This type of learning experience creates a controlled environment in which learners may attain new skills or further develop skills that positively impact patient outcomes. Although few studies exist regarding the use of clinical simulation training and nutrition support practitioners, preliminary data following a small-bowel feeding tube (SBFT) insertion workshop for intensive care unit registered nurses and registered dietitian nutritionists showed potential use in this realm. The purpose of this paper is to provide a basic overview of clinical simulation learning, review literature related to clinical simulation in healthcare, and discuss the recent implementation of a SBFT insertion workshop incorporating clinical simulation learning.

This study examines late Victorian era Protestant church community cookbooks as moral and cultural guides written by women for women (gendered texts), and examines the domestic roles and Christian practices of women in the years before and after the turn of the twentieth century. For this project I used a sample of eleven Protestant community cookbooks published from 1881 to 1913 to serve as case studies, illuminating the late Victorian period through the words and recipes of the women who wrote them. As domestic guides, the cookbooks employ paratexts, presenting recipes for food and life in broader terms. Artwork and advertisements from the texts offer additional information about the connections between gender, domesticity and religion during the era.

As a collection of essays this volume considers the ways in which food and religion have intersected in North America, through a variety of denominational lenses. This book is both historical in it...

Jacketing of nonhuman primates (NHP) is a commonly used practice in the laboratory animal setting to support data collection with reduced direct human-to-animal interaction. NHP often wear jackets for several weeks, potentially leading to the formation of dermal lesions ranging from mild alopecia to severe full-thickness ulceration. We sought to evaluate the addition of a commercially available undershirt for primates as a possible refinement practice for our jacketed rhesus macaques. In this study, we compared the lesion count, location, and severity and differences in rectal body temperature between jacketed NHP with undershirts with those wearing the jackets alone. In both groups, most lesions (75%) were located at either the underarm or shoulder. The percentages of total lesions in the back and neck were lower in jacketed NHP that wore undershirts than in those that did not. In addition, the estimated odds of increased severity scores in jacketed NHP without undershirts was 1.80 times that for NHP that wore both jackets and undershirts. Both groups of NHP showed a significant decrease in dermal scores with time, indicating adaptation to the jackets with or without undershirts. However, there was no statistically significant decrease in lesion count, severity, or location in jacketed NHP that wore undershirts compared with those that did not.

Abstract 866 Activating mutations of FLT3, either in the form of internal tandem duplication (ITD) mutations in the juxtamembrane domain or point mutations in the kinase domain, are one of the most frequent mutations in acute myeloid leukemia (AML). AML patients with FLT3/ITD mutations have poor prognosis. Loss of the wild-type FLT3 allele is associated with even worse prognosis when compared to those FLT3/ITD AML patients with the wild-type FLT3 allele still present. Also, FLT3/ITD patients with a high mutant-to-wild-type ratio have a significantly worse outcome than FLT3/ITD patients with a lower ratio. We have previously reported that heterozygous FLT3wt/ITD “knock-in” mice develop a slowly fatal MPN. In order to study the roles wild-type FLT3 play in the development of leukemia associated with FLT3/ITD mutations, we crossed FLT3wt/ITD mice with themselves or with FLT3 “knockout” (FLT3−/−) mice to obtain hemizygous (FLT3−/ITD) or homozygous (FLT3ITD/ITD) FLT3/ITD mice. Investigating phenotypic differences among them reveals the impact of wild-type FLT3 on the development of MPN resulting from FLT3/ITD mutations, and by extension, the effect on acute leukemia. FLT3−/ITD mice, with the loss of the wild-type allele, displayed a more severe MPN, as evidenced by even larger spleen, higher white blood counts and shorter survival, compared to FLT3wt/ITD mice. FLT3ITD/ITD mice had an even severe MPN compared to the FLT3−/ITD and FLT3wt/ITD mice. Fully transformed leukemia developed in some of the FLT3ITD/ITD (7%, 9/129), but not FLT3wt/ITD or FLT3−/ITD mice, with latency ranging from 139 to 304 days. Compared to FLT3wt/ITD mice, FLT3−/ITD and FLT3ITD/ITD mice displayed a further increase in the fraction of primitive hematopoietic cells, with notable increases in ST-HSCs and MPPs. Phosphorylation of STAT5, one of the key downstream targets for constitutively activated FLT3, was increased in FLT3wt/ITD, FLT3−/ITD and FLT3ITD/ITD mice compared to the wild-type control. FLT3wt/ITD, FLT3−/ITD and FLT3ITD/ITD BM also showed increased PU.1 expression and decreased GATA-1 expression, resulting in the subsequent expansion of granulocytic/monocytic/lymphocytic progenitors and a decrease in megakaryocytic/erythrocytic progenitors. It appears that the extent of myeloproliferation in FLT3/ITD mice correlates with loss of the wild-type allele (FLT3wt/ITD vs. FLT3−/ITD) and with the dose of mutant allele (FLT3−/ITD vs. FLT3ITD/ITD). In order to further explore the potential moderating effect of wild-type FLT3 expression on FLT3/ITD-associated MPN, we transduced wild-type FLT3 (wtFLT3, with the lentiviral vector co-expressing GFP) into lineage-depleted FLT3−/ITD CD45.2 BM cells and injected them into lethally irradiated CD45.1 recipients. When injected with sorted (GFP+) BM, vector alone-transduced GFP+FLT3−/ITD BM recipients died of MPN, with a median survival of 62 days. 100% of the recipients in the other three groups, i.e., those injected with vector alone-transduced GFP+ wild-type BM, wtFLT3-transduced GFP+ wild-type BM or wtFLT3-transduced GFP+ FLT3−/ITD BM, remained viable even after the point in time at which all of the recipients in the vector alone-transduced GFP+FLT3−/ITD group died. Similarly, recipients transplanted with unselected (including GFP+ and GFP− populations) vector alone-transduced FLT3−/ITD BM also died early, with a median survival of 73 days and overt signs of MPN. The percentages of GFP+ and GFP− cells in the BM of the dying recipients were comparable to those shortly after transplantation, indicative of the similar expansion ability of the GFP+ and GFP− populations in the BM. In contrast to the wtFLT3-transduced GFP+FLT3−/ITD BM recipients, which have a very prolonged survival, recipients injected with unselected wtFLT3-transduced FLT3−/ITD BM died of MPN, with a median survival of 91 days. Interestingly, 99% of the BM cells in the BM of the dying recipients were GFP−, demonstrating a proliferative/survival advantage for the FLT3−/ITD cells that had not been successfully transduced with wild-type FLT3. These results suggest that the presence of wild-type FLT3 delays and moderates the development of MPN caused by FLT3/ITD mutations. These results suggest that loss of the wild-type allele contributes to the development of a more severe phenotype. Thus, the wild-type FLT3 allele seemingly functions as a “tumor suppressor” in leukemia harboring FLT3/ITD mutations. Disclosures: No relevant conflicts of interest to declare.

Energy production in heart muscle requires adequate nutrient supply and oxygen delivery. The bioenergetic processes of the mitochondria utilize reduced equivalents from nutrients in the form of reduced NADH and FADH2, and oxidizing equivalents from oxygen to produce proton gradients for the formation of ATP during oxidative phosphorylation. Oxygen supply to red mammalian muscle includes the involvement of two heme-containing transport/buffer proteins. Hemoglobin (Hb) in red blood cells binds and transports oxygen from lungs to tissue, while myoglobin (Mb) provides temporary oxygen storage and buffering within muscle cells. When both Hb and Mb are present, they combine to increase the apparent oxygen concentration in solution by about 50-fold. Mitochondrial cytochromes aa 3 b and c play important roles as electron carriers in the mitochondrial electron-transport chain.

Abstract 924 FLT3 is a tyrosine kinase receptor that is frequently mutated in acute myeloid leukemia (AML). The most common mutations involve either an internal tandem duplication (ITD) in the juxtamembrane domain or a point mutation in the tyrosine kinase domain (TKD). The most common TKD mutation is a D835Y mutation in which aspartic acid is mutated to tyrosine at residue 835. ITD mutations are reported in approximately 25% of adult AML and 15% of pediatric leukemia. TKD mutations occur in approximately 8–10% of both adult and pediatric leukemia. Both of these mutations constitutively activate FLT3, but only patients with an ITD mutation have a significantly poorer prognosis. Small molecule inhibitors against FLT3 are currently in clinical trials with some success, but resistance to single agent treatment frequently occurs. A better understanding of the molecular mechanisms behind the prognostic difference, between the two types of mutations and the activation, inhibition, and resistance of FLT3 will hopefully lead to more tailored treatments of leukemia. To help address some of these questions we have generated a knock-in mouse with an Aspartic acid to Tyrosine mutation at reside 838 (D838Y) which is homologous to the FLT3/D835Y mutation reported in the majority of human leukemia cases with a FLT3-TKD mutation. These mice have been compared to the mice with a FLT3-ITD mutation previously generated and characterized by the lab. Mice with either the FLT3/D838Y or FLT3-ITD mutation develop predominantly a myeloproliferative disease. Mice with the FLT3/D838Y mutation show a less aggressive phenotype when compared to mice with the FLT3/ITD mutation in terms of survival, spleen size, and histopathologic changes of the bone marrow, spleen and liver.8 weeks spleen wt (g)12 weeks spleen wt (g)wildtype0.079 g ± 0.011 (n=27)0.092 g ± 0.009 (n=5)D838Y/wt0.155 g ± 0.027 (n=21)0.184 g ± 0.027 (n=9)ITD/wt0.185 g ± 0.034 (n=12)0.267 g ± 0.052 (n=8) Flow cytometry analysis shows that bone marrow from 8–12 week old mice with the FLT3/D838Y mutation have a marginally expanded fraction of granulocytic/monocytic lineage cells in their bone marrow compared to their wildtype littermate controls, but a lower fraction when compared to age-matched FLT3/ITD mice. B cell development is significantly blocked at the late pro-B to pre-B transition in the FLT3/ITD mice, with very few cells developing into pre-B or more mature B cells (Li et al. Blood. 117(11): 3131-9). In contrast, FLT3/D838Y mice demonstrate an expansion of early and late pro-B cell populations, with a significant fraction of cells maturing beyond the pre-B stage to become mature B cells. In mice with the FLT3/D835Y mutation the long-term HSC (LT-HSC) compartment, responsible for the self-renewal and maintenance of the hematopoietic stem/progenitor cell pool, appears to have a greater than 2-fold expansion in the number of immunophenotypic LT-HSCs. This appears to be a functional expansion as the BM cells from FLT3/D835Y mice have long-term engraftment superiority compared with ITD and wildtype mice. The short term HSC and MPP compartments from both FLT3/D838Y and FLT3/ITD mice appear to be comparably expanded compared to wildtype controls. In human leukemia, FLT3/ITD signaling results in the activation of downstream targets, including STAT5, MAP kinase and AKT. Consistent with the intermediate phenotype observed, intracellular levels of phospho-Stat5 in the FLT3-D838Y mice were lower than levels measured in the FLT3-ITD mice, but higher than those of wildtype littermate controls. RT-PCR measured expression levels of FLT3 and Pim1 in lineage negative cells of D838Y mice fall between those of the wildtype and ITD mice. (Ratios: FLT3 – ITD/wt 3.7; D838Y/wt 2.5; Pim1 – ITD/wt 3.4; D838Y/wt 2.5). In summary, we have generated a knock-in mouse model with the FLT3 kinase domain D838Y mutation. The mice demonstrate a less aggressive phenotype when compared to knock-in mice with the FLT3/ITD mutation, analogous to the less aggressive AML seen in cases involving D835 mutations compared to ITD mutations. Both mouse models on the same mouse background provide a useful platform for understanding the molecular mechanisms of FLT3 mutations and for testing new therapeutic agents targeting FLT3. Disclosures: No relevant conflicts of interest to declare.