Search

Objectives: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital., Design: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals., Setting: An urban safety-net hospital ICU., Patients: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search., Interventions: None., Measurements and Main Results: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories., Conclusions: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models., Competing Interests: Dr. Caruso received funding from Senior Whole Health, Magellan Health, and Boston Medical Center Health Plan Senior Care Options Plan. Dr. Ieong’s institution received funding from Alexion Pharmaceuticals and the National Institutes of Health. Dr. Lowe received funding from Gi Reviewers. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background and Aims: Portal pressure can be used to identify patients with chronic liver disease who have progressed to cirrhosis. Portal pressure can also provide accurate prognostication for patients with cirrhosis. However, there are no practical means for assessment of portal pressure. Although it is well established that the gastric mucosal blood supply increases in patients with cirrhosis, this has been difficult to quantify reproducibly. Our group has developed a novel spectroscopic technology called spatially resolved subdiffuse reflectance spectroscopy (SRSRS), which enables quantification of mucosal microcirculation. We aim to ascertain if quantification of the gastric mucosal microcirculation with SRSRS correlates with clinical evidence of portal hypertension., Methods: Patients undergoing EGD for clinical indications had 10 measurements taken in the endoscopically normal gastric fundus via SRSRS probe to assess the microcirculation. Cases were defined as patients with cirrhosis (n = 18), and controls were those without evidence of liver disease (n = 18); this was corroborated with transient elastography., Results: The blood volume fraction (P = .06) and subdiffuse reflectance (P = .02) from a shallow depth in the gastric fundus were higher in patients with cirrhosis than those without. These markers were combined to yield an overall optical marker that can differentiate patients with cirrhosis from controls with a sensitivity of 72% and specificity of 94% (area under receiver operating curve, 0.82)., Conclusions: Spectroscopic quantification of gastric fundal mucosal microcirculation is a promising surrogate of clinical correlates of portal hypertension. This approach may represent a less-intrusive surrogate biomarker for liver disease prognostication and potentially response to therapy., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Effective lecturing stimulates learning, creates a verbal history for our profession, and is a central basis for evaluating academic promotion. Unfortunately, few resources exist in the medical literature to guide the academician toward success as an effective lecturer. Using evidence-based principles, this review fosters adult learning in academic venues by incorporating the latest innovations in educational theory for both online and traditional teaching. The novice or advanced academic teacher will be guided toward critical self-evaluation of current teaching practices and encouraged to replace ineffective methods with ones more likely to be both rewarding and rewarded. By introducing literature-based learning techniques, emphasizing audience targeting, truncating content to an appropriate level of detail, effectively linking images and text, and accepting the brevity of learners' attentiveness, we show that the audience, not the speaker, is the primary educational focus., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2021.)

Purpose: To report surgical and corneal clarity scores (CCSs) of corneo-limbo-conjunctival transpositions (CLCTs) in a large number of canine cases., Methods: Retrospective review of records that underwent CLCT to repair deep ulcers or perforations between 2002 and 2018. Signalment, concurrent eye disease, additional procedures, pathogenesis, medication, graft orientation, follow-up, and CCSs were recorded., Results: 418 eyes of 399 dogs were included. Brachycephalics were most commonly affected, comprising 325/418 (77.75%) of the eyes. The most commonly affected breeds were Pugs, Shih Tzus, Cavalier King Charles Spaniels, and French Bulldogs, with 116/418 (27.75%), 64/418 (15.31%), 34/418 (8.13%), and 34/418 (8.13%) ulcerated eyes, respectively. Mean age at surgery was 5.5 years (range 59 days-17.7 years), and median follow-up time was 100 days (range 3 days-7.64 years). The most common etiopathogenesis was spontaneous ulceration in 205/418 eyes (49.04%) of which 191 (93.17%) occurred in brachycephalics. Primary keratoconjunctivitis sicca affected 122/418 eyes (29.19%) and injury 39/418 eyes (9.33%). Mean ulcer width was 3.5 mm (0.5-10 mm). Success rate was 97.13% (406/418 eyes). Failure end points recorded included no menace response, secondary glaucoma, and endophthalmitis. Pre-existing perforation was found in 101/418 (24.16%) of the eyes and significantly increased failure rate (P < .001). The median CCS was G3 (G0-G4), which was lower for Pugs (G2). Graft orientation affected CCS, but did not reach statistical significance., Conclusion: The high success rate and CCS for CLCT in dogs make it a good technique to treat deep ulcers but a less desirable outcome is anticipated when treating perforations and Pugs., (© 2020 American College of Veterinary Ophthalmologists.)

Purpose: To describe a modified keratoleptynsis procedure, as a method of preserving central corneal function, and evaluate the outcome in vision, reduction of corneal thickness and treatment of epithelial corneal ulcers in cases with endothelial cell dysfunction., Methods: Forty-four dogs (72 eyes) were affected by progressive corneal edema, with or without ulcerative keratitis. All patients were treated with a dorsal and ventral superficial keratectomy followed by conjunctival flaps, maintaining a clear central cornea. Corneal thickness measurements were obtained via ultrasound biomicroscopy., Results: All eyes showed resolution of ocular discomfort postoperatively, with a median time to resolution of 35 days. Two years post-surgery, vision had been lost in 2 of 29 eyes (7%). From the initial population, 23 dogs (39 eyes) had follow-up evaluations of corneal thickness. The mean central corneal thickness was 1359 ± 251 μm prior to surgery. Thickening of the central cornea was observed one week after surgery to 1559 ± 263 μm. Decreased corneal thickness was reported, at 1 month, 4 months, 10 months and 2 years postoperatively (1285 ± 267 μm, 1102 ± 150 μm, 1121 ± 288 μm, 1193 ± 283 μm, respectively). All eyes showed a similar trend of increasing and then decreasing corneal thickness., Conclusions: This surgical technique provided statistically significant reduction in central corneal thickness and sustained relief of ocular pain. Reduction in corneal thickness appeared to be maintained 2 years post-surgery, and all patients remained comfortable. Superficial corneal pigmentation and fibrosis resulted in vision loss in two eyes., (© 2020 American College of Veterinary Ophthalmologists.)

This report describes the clinical presentation, diagnosis, and histopathologic features of oculodermal melanocytosis in a young dog. A 3-year-old male neutered Labrador Retriever presented with conjunctival and scleral hyperpigmentation of the right eye, with concurrent ipsilateral cutaneous hyperpigmentation involving the right side of the face. Initial skin and conjunctival biopsies revealed an accumulation of histologically benign melanocytes within the dermis and conjunctival stroma, respectively. Enucleation was elected 19 months later by the referring veterinarian due to the progression of ocular pigmentation with concurrent marked corneal lipidosis and the suspicion of a scleral mass. On gross and histopathologic examination of the globe, there was marked panuveal melanocytosis with extension into the sclera, bulbar conjunctiva, and connective tissue surrounding the optic nerve, as well as sharply demarcated ipsilateral hyperpigmentation of the facial skin. The findings are characteristic of oculodermal melanocytosis (nevus of Ota), a dermal melanocytic hamartoma presenting as cutaneous facial hyperpigmentation that corresponds to the distribution of the ophthalmic and maxillary branches of the trigeminal nerve, often with ipsilateral ocular involvement.

Background: There is little information describing the perceptions of gastroenterology fellows and attending gastroenterologists of what constitutes effective teaching of endoscopy. We sought to identify common themes regarding endoscopy training methods and their impact among fellows and attendings., Methods: Focus group exercises and surveys were conducted among fellows, about educational resources, teaching techniques and ways of improving the teaching of endoscopy. The fellows identified the 'best' teachers of endoscopy, who were interviewed regarding their training in endoscopy, their teaching methods, key points of information, and opinions on endoscopy curriculum., Results: Nineteen fellows (68%) had attended the American Society for Gastrointestinal Endoscopy First Year Fellows' Endoscopy course and found it very helpful. Thirteen fellows(46%) had exposure to an endoscopy simulator, but their median duration of use was only 1 hour. Only two out of five fellowship programs used a formal endoscopic skill assessment tool and none of the programs had an endoscopy curriculum of which the fellows were aware. Fellows reported that they learned endoscopy best by performing procedures. They also volunteered that attending gastroenterologists used variable teaching methods, and might benefit from instruction on how to teach endoscopy. Ten attending gastroenterologists (77%) had received training in advanced procedures; none received formal training on teaching endoscopy: they all felt that such training would be beneficial., Conclusions: A standardized endoscopy curriculum may be beneficial to fellows, who prefer to learn endoscopy by performing procedures-but they want explicit and specific instruction. Both those attending and the fellows thought that formal instruction for attending gastroenterologists on how to teach endoscopy would be beneficial, indicating a role for a 'teach-the-teacher' curriculum., (© The Author(s) 2016. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University.)

A five-year-old entire male Tibetan Terrier was referred for left-sided periorbital swelling and blepharospasm 4 days following ipsilateral maxillary tooth extraction. Examination of the left eye revealed mild exophthalmos, pain on retropulsion, and absent menace response and pupillary light reflexes. Examination of the posterior segment was not possible owing to the anterior segment pathology. Differential diagnoses considered were iatrogenic globe penetration and peribulbar abscess/cellulitis. Ocular ultrasound was consistent with a penetrating wound to the globe. Treatment with systemic prednisolone and marbofloxacin, and topical atropine sulfate 1%, prednisolone acetate, and brinzolamide was started. Marked clinical improvement allowed visual confirmation of the perforation. Oral prednisolone was tapered over the following 10 weeks. At final re-examination (10 months), the patient was visual, and fundic examination revealed an additional chorioretinal scar, most likely an exit wound that was obscured by vitreal debris on initial examinations. Neither scar was associated with retinal detachment. To the authors' knowledge, this is the first reported case of successful medical management of iatrogenic globe penetration following exodontic procedures., (© 2013 American College of Veterinary Ophthalmologists.)

Uveitis in the equine population of the UK does not appear to be as prevalent or disastrous as seen across regions of Europe and the USA. Some cases perceived to be recurrent uveitis may be poorly resolved single episodes of uveitis and care should be taken not to make the diagnosis of recurrence without ensuring effective control of the initial episode. Leptospira spp. appear to play only a minor role ERU in the UK which is probably the main reason for the prevalence of the disease being much lower compared to the USA and mainland Europe. Actual data are relatively few on the ground as far as disease surveillance in concerned. This has 2 implications. Firstly unless we are able to effectively monitor the levels of uveitic disease, it will be difficult to pick up early changes in the trend which may allow quicker intervention. Secondly, it is difficult to secure funding for further research if the prevalence of the problem is poorly defined. This may leave the UK equine population at risk should the disease profile suddenly alter for the worse.

Portal hypertension is a common complication of hepatic cirrhosis, and is responsible for much of the mortality and morbidity associated with advanced liver disease. Esophageal varices are a common occurrence, and esophageal variceal hemorrhage carries a high mortality. Endoscopic therapies have proven effective in treating active bleeding and preventing recurrence, but several pharmacological agents are useful adjuncts to endoscopy in both acute bleeding and in the primary and secondary prophylaxis of variceal hemorrhage. In acute hemorrhage, vasoconstricting agents such as vasopressin, terlipressin, somatostatin, and octreotide have been demonstrated to add benefit to endoscopic therapy. Secondary prophylaxis includes endoscopic therapy to eradicate varices, usually combined with oral beta-blockers. Primary prophylaxis is typically used in patients with medium or large varices, and consists of oral beta-blockers, at times combined with oral nitrates. This paper the reviews the pharmacological principles behind these therapies, and the clinical trial data that has led to their widespread use.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders, and the pharmacological management of GERD is a topic of intense interest given the sizeable yearly expenditure for antireflux therapies. GERD is primarily a motor disorder of the esophagus, yet pharmacological approaches directed at altering esophageal motility have been only partially effective. Antisecretory therapy is the mainstay of treatment for GERD. Both H2 receptor antagonists (H2RA) and proton pump inhibitors (PPIs) are effective in the treatment of GERD, but PPI therapy is clearly superior in the treatment of severe disease and in the healing of erosive esophagitis. A treatment schema for GERD based on presenting symptoms is outlined, promoting a stepwise approach to the appropriate use of antisecretory therapy.

Figure 3 shows an algorithm for the primary prevention of variceal hemorrhage. Pharmacologic therapy is the current standard of treatment for the primary prophylaxis of esophageal variceal bleeding. Patients with medium or large varices should be treated with a nonselective beta-blocker with the dose titrated to achieve a 25% decrement in resting heart rate or a heart rate of 55 to 60 bpm. The development of symptoms will, of course, limit the dose used. As discussed previously, these therapeutic endpoints are not well correlated with decreases in portal pressure. Measurement of the HVPG before therapy and after 3 months of therapy provides a rational approach to drug dosing. If the HVPG decreases by 20% or to less than 12 mm Hg, the medication dose will be effective in preventing hemorrhage. If, however, the HVPG is not appropriately lowered, a long-acting nitrate may be added. Patients with small varices should be observed, with endoscopic examinations every 2 years to assess progression of variceal size. Endoscopic therapy is not indicated for the primary prevention of variceal bleeding.

Pharmacologic therapy for portal hypertension is effective in the treatment and prevention of hemorrhage from esophagogastric varices. Acute hemorrhage from varices can be treated with intravenous agents such as somatostatin or terlipressin, either alone or in combination with endoscopic sclerotherapy or band ligation. Intravenous octreotide has not shown effectiveness as monotherapy, but it appears to be beneficial when combined with endoscopic treatment. The prevention of rebleeding after initial hemorrhage is best accomplished with non-selective beta blockers, endoscopic band ligation of varices, or a combination of endoscopic and pharmacologic therapies. The addition of oral nitrates may further decrease rebleeding rates, but more data from randomized trials are needed. Beta blockers are currently the only agents recommended for the primary prevention of variceal hemorrhage.

To differentiate between transient (acute) and training (chronic) effects of exercise at two different intensities on blood lipids and apolipoproteins (apo), 26 hypercholesterolemic men (cholesterol = 258 mg/dl, age = 47 yr, weight = 81.9 kg) trained three times per week for 24 wk, 350 kcal/session at high (80% maximal O2 uptake, n = 12) or moderate (50% maximal O2 uptake, n = 14) intensity. Serum lipid and apolipoprotein (apo) concentrations (plasma volume adjusted) were measured before and immediately, 24, and 48 h after exercise on four different occasions corresponding to 0, 8, 16, and 24 wk of training. Data were analyzed using three-way repeated-measures multivariate analysis of variance followed by analysis of variance and Duncan's procedures (alpha = 0.05). A transient 6% rise in low-density-lipoprotein cholesterol measured before training at the 24-h time point was no longer evident after training. Triglycerides fell and total cholesterol, high-density-lipoprotein cholesterol (HDL-C), HDL3-C, apo A-I, and apo B rose 24-48 h after exercise regardless of training or intensity. Total cholesterol, HDL3-C, apo A-I, and apo B were lower and HDL2-C was higher after training than before training. Thus exercise training and a single session of exercise exert distinct and interactive effects on lipids and apolipoproteins. These results support the practice of training at least every other day to obtain optimal exercise benefits.

Twenty-six hypercholesterolemic men (mean cholesterol, 258 mg/dl; age, 47 yr; weight, 81.9 kg) completed 24 wk of cycle ergometer training (3 days/wk, 350 kcal/session) at either high (n = 12) or moderate (n = 14) intensity (80 and 50% maximal O2 uptake, respectively, randomly assigned) to test the influence of training intensity on blood lipid and apolipoprotein (apo) concentrations. All physiological, lipid, and apo measurements were completed at 0, 8, 16, and 24 wk. Lipid data were analyzed via two x four repeated-measures analysis of variance (alpha = 0.0031). Training produced a significant decrease in body weight and increase in maximal O2 uptake. No interactions between intensity and weeks of training were noted for any lipid or apo variable, and no between-group differences were significant before or throughout training. Therefore, intensity did not affect the training response. Regardless of intensity, apo AI and apo B fell 9 and 13%, respectively, by week 16 and remained lower through week 24 (P < 0.0003). Total cholesterol fell transiently (-5.5%) by week 16 (P < 0.0021) but returned to initial levels by week 24. Triglyceride, low-density-lipoprotein cholesterol, and high-density-lipoprotein (HDL) cholesterol did not change with training. In contrast, HDL2 cholesterol rose 79% above initial levels by week 8 and 82% above initial levels by week 24 (P < 0.0018); HDL3 cholesterol fell 8 and 13% over the same training intervals (P < 0.0026). These data show that changes in blood lipid and apo concentrations that accompany training in hypercholesterolemic men are not influenced by exercise intensity when caloric expenditure is held constant.

The purpose of this study was to characterize the short-term changes in blood lipid and apolipoprotein concentrations in healthy hypercholesterolemic men after high-intensity [80% maximal O2 uptake (VO2max); n = 20] or moderate-intensity (50% VO2max; n = 19) cycle ergometer exercise balanced for caloric expenditure (350 kcal). The men's age, height, weight, %fat, and VO2max were 46 +/- 2 yr, 173 +/- 7 cm, 82.7 +/- 2.2 kg, 28 +/- 1%, and 31.1 +/- 1.0 ml O2.kg-1.min-1, respectively. Blood samples were drawn before exercise, immediately after exercise, then 24 and 48 h later, and concentrations of all variables were adjusted for changes in plasma volume. Significant changes (P < 0.0016) were as follows: total and low-density lipoprotein cholesterol fell by 4% immediately after exercise and then rose by 5-8% by 48 h. Triglycerides were 18 and 15% lower at 24 and 48 h, respectively. HDL-cholesterol, high-density lipoprotein3-cholesterol, and apolipoprotein B rose 8-9% by 24 h and remained elevated. High-density lipoprotein2-cholesterol rose by 27% by 48 h after exercise, but this change was not significant. Apolipoprotein A-I did not change with exercise. The response patterns were not affected by exercise intensity. These data show that a single session of exercise performed by untrained hypercholesterolemic men alters blood lipid and apolipoprotein concentrations. Furthermore, the postexercise response patterns are not influenced by exercise intensity, as long as caloric expenditure is held constant.

This study was undertaken by the University of Calgary Sport Medicine Centre, Physical Therapy Section. Financial support for the study was provided by a grant from the BE Schurr Memorial fund and the Canadian Physiotherapy Association (Calgary District). Information on the relative strengths of the muscles that internally and externally rotate the hip is scant. The present study used a Cybex(R) 340 isokinetic dynamometer to investigate hip rotation strength in 60 normal subjects. Subjects performed maximum internal and external hip rotation movements in each of three different testing positions. Results showed that hip rotation torques were significantly dependent on testing position (p < 0.05). Highest torques were obtained using a "seated" position, while a supine position with the knee flexed produced stronger torques than a supine position with the knee extended. Within each test position, internal rotation torques exceeded external rotation torques in all but one situation (p < 0.05). These findings contradicted previous reports that external rotation was the stronger of the two movements. Overall, the results provided valuable normative data on the relative strength proportions of the hip rotation musculature. J Orthop Sports Phys Ther 1992;16(1):43-50.

This study measured oxygen uptake (VO2), minute ventilation (VE), and heart rate (HR) in a bilateral above-knee (AK) amputee and in three able-bodied controls during progressive treadmill exercise. Walking conditions for the amputee included using bilateral short-leg (SL) and long-leg (LL) prostheses. A progressive treadmill protocol to maximal capacity was used for the amputee and duplicated by the control subjects. An automated system was used to measure VO2, VE, and HR throughout exercise. Data analysis was restricted to the use of parameter averages and percentages to describe differences between experimental conditions. Maximal VO2 for the amputee averaged 23.3mL/kg-1/min-1 with the LL and 22.8mL/kg-1/min-1 with the SL prostheses, a negligible difference between conditions; however, exercise duration was 27% longer when using the SL prostheses. In addition, when averaged over the first four stages of exercise, VO2, VE, and HR were 24%, 32%, and 14% higher, respectively, when the LL prostheses were used. Treadmill walking by unimpaired controls averaged 47% and 79% more economical than walking with the SL or LL prostheses, respectively. These results demonstrate that the use of currently available AK prostheses requires significant energy expenditure, which limits their use to only the most physically fit individuals.

Subjects were tested in a cued reaction-time task wherein warning stimuli (S1) of 5-letter words or dot patterns inter-mixed across trials were briefly presented. After 2 sec a second stimulus (S2) of th same category as the S1 appeared and the subject pressed a key with the left or right hand. The right key was pressed if S2 was a synonym of S1 or if the second dot pattern was the same as the first. The left key was pressed for antonyms or different patterns. It was predicted that CNVs would be larger over the left than right hemisphere on word trials and vice-versa on pattern trials in accordance with speculations concerning hemispheric specialization. The CNV was lateralized as expected, most prominently on pattern trials. In addition a negative transient evoked by S2, and a late negative post-imperative slow wave were similarly lateralized. P300 waves were very large and largest to the S2 when it differed from S1. Factor analysis confirmed these results and indicated, in addition, that P300 was larger in the hemisphere least relevant to the task.

The effect of a high-carbohydrate meal 4 h before 105 min of exercise at 70% of maximal O2 uptake was determined in seven endurance-trained cyclists and compared with exercise following a 16-h fast. The preexercise meal produced a transient elevation of plasma insulin and blood glucose, which returned to fasting basal levels prior to the initiation of exercise. The meal also resulted in a 42% elevation (P less than 0.05) of glycogen within the vastus lateralis at the beginning of exercise. The 1st h of exercise when subjects were fed was characterized by a 13-25% decline (P less than 0.05) in blood glucose concentration, a suppression of the normal increase in plasma free fatty acids and blood glycerol, and a 45% (P less than 0.05) greater rate of carbohydrate oxidation compared with exercise when subjects were fasted. After 105 min of exercise, there were no significant differences when subjects were fed or fasted regarding blood glucose levels, rate of carbohydrate oxidation, or muscle glycogen concentration. The greater muscle glycogen utilization (97 +/- 18 vs. 64 +/- 8 mmol glucosyl units X kg-1; P less than 0.05) and carbohydrate oxidation when subjects were fed appeared to be derived from the glycogen synthesized following the meal. These results indicate that preexercise feedings alter substrate availability despite a return of plasma insulin to fasting levels prior to exercise and that these effects persist until the 2nd h of exercise.