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Cushing syndrome results from supraphysiological exposure to glucocorticoids and is associated with significant morbidity and mortality. The pathogenesis includes administration of corticosteroids (exogenous Cushing syndrome) or autonomous cortisol overproduction, whether or not ACTH-dependent (endogenous Cushing syndrome). An early diagnosis of Cushing syndrome is warranted; however, in clinical practice, it is very challenging partly because of resemblance with other common conditions (ie, pseudo-Cushing syndrome). Initial workup should start with excluding local and systemic corticosteroid use. First-line screening tests including the 1-mg dexamethasone suppression test, 24-hour urinary free cortisol excretion, and late-night salivary cortisol measurement should be performed to screen for endogenous Cushing syndrome. Scalp-hair cortisol/cortisone analysis helps in the assessment of long-term glucocorticoid exposure as well as in detection of transient periods of hypercortisolism as observed in cyclical Cushing syndrome. Interpretation of results can be difficult because of individual patient characteristics and hence requires awareness of test limitations. Once endogenous Cushing syndrome is established, measurement of plasma ACTH concentrations differentiates between ACTH-dependent (80%-85%) or ACTH-independent (15%-20%) causes. Further assessment with different imaging modalities and dynamic biochemical testing including bilateral inferior petrosal sinus sampling helps further pinpoint the cause of Cushing’s syndrome. In this issue of “Approach to the patient,” the diagnostic workup of Cushing syndrome is discussed with answering the questions when to screen, how to screen, and how to differentiate the different causes. In this respect, the latest developments in biochemical and imaging techniques are discussed as well.

Objectives Few studies have assessed the role of socioeconomic health care disparities in skull base pathologies. We compared the clinical history and outcomes of pituitary tumors at private and public hospitals to delineate whether health care disparities exist in pituitary tumor surgery. Methods We reviewed the records of patients who underwent transsphenoidal pituitary tumor resection at NYU Langone Health and Bellevue Hospital. Seventy-two consecutive patients were identified from each hospital. The primary outcome was time-to-surgery from initial recommendation. Secondary outcomes included postoperative diabetes insipidus, cerebrospinal fluid (CSF) leak, and gross total resection. Results Of 144 patients, 23 (32%) public hospital patients and 24 (33%) private hospital patients had functional adenomas (p = 0.29). Mean ages for public and private hospital patients were 46.5 and 51.1 years, respectively (p = 0.06). Private hospital patients more often identified as white (p Conclusion Significant socioeconomic differences exist among patients undergoing pituitary surgery at our institution's hospitals. Public hospital patients more often required emergency surgery, developed diabetes insipidus, and underwent subtotal tumor resection. Identifying these differences is an imperative initial step in improving the care of our patients.

Purpose: High levels of human immunodeficiency virus (HIV) prevalence and inconsistent condom use among transgender women in India highlight the need for additional effective HIV prevention methods like preexposure prophylaxis (PrEP). We examined the extent of and factors influencing willingness to use PrEP among trans women in India. Methods: Between June and August 2017, we conducted a cross-sectional survey among 360 trans women recruited through community-based organizations in six cities. We assessed PrEP knowledge, condom use, attitudes toward PrEP (after providing information on PrEP), preferences in PrEP pricing and access venues, discrimination experiences, and the likelihood of using PrEP. Logistic regression analyses were conducted. Results: Participants' median age was 26 years; 50.7% had not completed high school, and 24.8% engaged in sex work. Only 17.1% reported having heard of PrEP before the survey, and 80.6% reported that they would definitely use PrEP. Trans women in sex work had 28 times higher odds of reporting willingness to use PrEP than those not in sex work (adjusted odds ratio [aOR]=28.9, 95% confidence interval [CI]=8.79–95.16, p

The presence of Sidis, Indians of African descent, in India today is concentrated in the states of Gujarat and Karnataka. In this essay, we focus on the Sidis of Gujarat, and their oral narratives,...

Transgenders (TGs) are highly affected by HIV with high prevalence of 3.14% in India. Since 2017, targeted preventive efforts have been initiated by the government and HIV-infected TGs are being provided the antiretroviral (ART) treatment. Information on the primary HIV drug resistance is crucial for appropriate treatment selection to curb further spread of HIV in this population. In this study, we analyzed HIV-1 pol gene sequences from 36 TGs for presence of drug resistance mutations. To our knowledge, this first study from India reports high-level primary drug resistance (13.8%) among the TG population. Mutations M184V, A98G, K103N, G190A, and Y318F associated with resistance to nucleoside reverse transcriptase inhibitor and non-nucleoside reverse transcriptase inhibitors were observed. All pol gene sequences revealed HIV-1 subtype C in all study TG. High-level HIV-1 drug resistance warrant nationwide larger studies on TGs to understand the level of primary ART drug resistance among this population.

Background: The objective of the study was to evaluate the practice patterns of controlled ovarian stimulation (COS) in patients who underwent in vitro-fertilization and embryo transfer (IVF-ET) or intracytoplasmic sperm injection (ICSI).Methods: In REAL-COS (REAL-world observational study to capture practice pattern of COS in IVF-ET/ ICSI cycle) study, data was collected by 138 clinicians across India between April 2021 and March 2022 in a retrospective manner.Results: Data of 1651 subfertility female patients were evaluated. The mean (SD) age was 31.8 (3.9) years and majority (77.8%) of the patients were aged

The pituitary gland in concurrence with the hypothalamus regulates key physiologic processes in the body, including growth, reproduction, metabolism, and water homeostasis. Hypersecretion of trophic hormones, usually due to hormonally active pituitary tumors, causes unique clinical syndromes that can have systemic complications that lead to significant morbidity and mortality. This chapter will provide an overview of the hormone excess syndromes that result from the hypersecretion of prolactin (prolactinomas), adrenocorticotropic hormone (Cushing’s syndrome), growth hormone (acromegaly), thyroid-stimulating hormone (TSHoma), and gonadotropins from the anterior pituitary. Inappropriate hypersecretion of antidiuretic hormone (syndrome of inappropriate antidiuretic hormone) from the posterior pituitary will also be discussed. The focus of this chapter will be on the clinical presentation, diagnosis, and management of each of these syndromes.

Purpose: The treatment priority in management of Temporomandibular Joint (TMJ) pain is directed towards the causative factor along with symptomatic treatment. In this process many times psychological aspect is overlooked. Hence with this pilot study, importance of psychological aspect of Temporomandibular Joint Disorder (TMD) is emphasised. Methods and Material: 15 patients suffering from pain in TMD region who qualify under myalgia pain in DC/TMD Axis I category were selected. Patients were divided into 3 groups; Ibuprofen, placebo and occlusal splint with 5 patients in each group. Pain assessment was done at the first visit, 7th day visit and 14th day visit using a VAS scale. Statistical Analysis Used: Friedman Test was applied to determine overall relief from pain in the three groups. Wilcoxon sign rank test evaluated pain relief between each time interval. Kruskal Wallis Test compared different groups for relief from pain at each time interval. Key Finding: Wilcoxon sign rank test showed a significant pain relief in all three groups from I day to I follow up day and I day to II follow up day. However Pain relief from I follow up to II follow up day was significant only in placebo group. Conclusions: Management of TMD myalgia requires a comprehensive understanding of physical and psychological aspect. This will aid us in formulating a treatment plan comprising pharmacotherapy, placebo or physical therapy or combination of any of these.

Delirium is a common symptom in patients admitted to our hospital with COVID-19, and in cases of hyperactive delirium we have frequently observed behaviors that pose a significant risk of disease transmission to health care providers. Managing this symptom has emerged as an important challenge, as our local health care system has been strained by providers becoming sick or quarantined. Preventative and non-pharmacologic interventions remain critical for managing delirium in such patients, though occasionally pharmacologic treatment is required. When use of an antipsychotic medication is indicated, we recommend that providers consider foregoing the lowest common dose and instead start with the next incrementally higher dose to more quickly and reliably ensure the safety of both patients and providers. We do not recommend initiating prophylactic treatment or escalating doses in a manner that conflicts with currently accepted guidelines without carefully considering the risks and benefits

Background: Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. Objectives: To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. Design: Systematic review. Study Selection: English-language articles analyzing multicomponent palliative care interventions. Outcomes Measured: Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). Results: Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. Conclusions: While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.

The world’s population is increasingly older. Much attention has been paid to this phenomenon in recent years, especially in developed countries. In 2011, the first of the baby boomers began to reach 65. By 2030 an estimated 20% of the population of adults age 80 and above will have tripled.

In the era of evidence based dentistry, a well-documented consolidated data about improvements in dentistry is a necessity. Concentrated growth factor (CGF) is an emerging trend in periodontology and now in implant dentistry. Various studies have been published in the literature evaluating the effect of CGF on implant osseointegration, implant stability, survival rate, sinus augmentation, and peri-implant defects. However, no systematic review has yet been documented. The present systematic review, being first of its kind, aimed to evaluate the potential outcomes of employing CGF in implant treatment. A literature search was carried out in PubMed and Google scholar for articles published between 2001 and 2019, with various keywords such as "CGF," "dental implant," "bone regeneration," "CGF," and "osseointegration." The screening of studies was done according to PRISMA guidelines. A total of eleven studies were included in this review. Majority of the included studies pointed toward the beneficial effects of CGF in implant treatment. CGF was seen to promote osseointegration and enhance bone regeneration. Although more clinical studies are required to validate the potential merits of CGF in the long run, the preliminary results seem promising.

Introduction and Hypothesis: Intracranial Atherosclerotic Stenosis (ICAS) is associated with 8-10% of all strokes in the U.S. Although there is evidence in the Asian population that inflammation plays a role in ICAS, it has not been shown in the U.S. population. We hypothesized that midlife sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is associated with late-life ICAS in the U.S. population. Methods: The Atherosclerosis Risk in Communities (ARIC) study recruited participants from four U.S. communities between 1987-1989. In the ancillary Dental ARIC study, dentate subjects from ARIC undergoing full-mouth examination also had blood samples obtained to measure the serum inflammatory marker, hs-CRP (1996-1998). High sensitivity ELISA assay that had been validated against nephelometry, was used to measure hs-CRP. Of this cohort, a subset (N=909) underwent high resolution 3T magnetic resonance angiogram at a follow-up visit (2011-2013). All images were analyzed in a centralized lab and ICAS was graded as no stenosis/3 mg/l), and ICAS. Results: A total of 909 subjects (mean age 62±6, 45% male, 81% Caucasian and 19% African-American), underwent assessment of hs-CRP and ICAS. Compared with the reference group (hs-CRP 50% ICAS, on univariate (Crude OR 1.3 95% CI: 0.9-2.0) or multivariable analysis (Adjusted OR 1.3, 95% CI: 0.9-2.0). Elevated hs-CRP (>3mg/l) was significantly associated with >50% ICAS in both univariate (Crude OR 1.6, 95% CI:1.1-2.3) and adjusted model (Adjusted OR 1.6, 95% CI:1.1-2.4). Conclusions: In this US population-based community study, we report a significant and independent association between inflammatory marker hs-CRP and ICAS. Further studies are required to test if anti-inflammatory drugs or diet prevents ICAS.

Introduction and Hypothesis: Approximately a third of stroke/TIA events occur in patients taking daily Aspirin. We studied the comparative effectiveness of FDA approved antiplatelet agents (Aspirin, Clopidogrel, and Aspirin-dipyridamole or ASA+DP) in prevention of recurrent vascular events in stroke/TIA patients on Aspirin. Methods: Consecutive patients identified as having stroke or TIA were screened and enrolled into this prospective longitudinal registry. Patients on dual antiplatelet therapy or oral anticoagulants were excluded. Patient’s etiological stroke subtype, medication history, medication compliance and Aspirin Platelet Function Test were assessed at baseline. Changes in antiplatelet regimen including Aspirin dose, Clopidogrel, ASA+DP, changes in statin therapy were recorded. Follow up 6 and 12 month phone visits were conducted to assess primary outcomes (stroke/TIA, MI, death), adjudicated by chart review. Results: A total of 183 subjects (mean age 68+12, 58% males, 50% white, 44% African-American) were enrolled over a 24 month period on Aspirin. Majority (63%) had ischemic stroke (NIHSS: 0-21) and remaining (37%) had TIA (ABCD 2 : 2-7). Ischemic strokes were attributed to penetrating artery disease (41%), large artery atherosclerosis (35%), other/undetermined (18%), and cardiogenic (6%). After 12-months, 4.9% of participants on Clopidogrel, 15.1% of participants on aspirin and 35.3% of participants on ASA+DP had a primary outcome (p=0.006), depicted in the Kaplan-Meier curve. Changes in Aspirin dose from 81mg to 325mg or statin therapy regimen did not appear to impact primary outcome. Conclusions: This study shows a significant difference in secondary vascular event within 12 months of stroke/TIA on Aspirin, with effectiveness recorded in the order: Clopidogrel>Aspirin>ASA+DP. A larger randomized pragmatic trial may help ascertain this finding and clarify if specific subtype benefit from specific antiplatelet agent. Figure

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

Introduction Various thrombectomy devices promise high rates of recanalization and reduction of disability. A recent meta-analysis of the Solitaire device demonstrated its utility as safe and effective in revascularization of large vessel occlusions. The present analysis seeks to determine if good clinical outcome can similarly be achieved by the 3D Revascularization Device for patients with small score infarcts (ASPECTS 8-10). Methods The 3D trial sought to evaluate the safety and efficacy of the 3D Revascularization Device as compared to the Penumbra System alone in acute stroke intervention. Subjects meeting the per protocol study criteria and presenting with small core infarcts were included in the present analysis. Notwithstanding similarities in baseline characteristics between the 3D ASPECTS 8–10 patients compared to the Campbell cohort (Table I), only patients with small core infarcts were considered for the present analysis. Study outcome on the reduction of disability, defined as mRS 0-2 at 90 days, were compared with the Campbell Solitaire meta-analysis. Results In total, 105 of 198 patients met the study criteria. While ASPECTS 8-10 data could not be determined for the Campbell cohort, the median NIHSS (3D: 17 [IQR 12–21] vs Campbell: 17 [IQR 13–20] and ASPECTS (3D: 9 [IQR 8–10] vs 9 [IQR 7–10] scores were similar. Reduction of disability (mRS 0-2) data for available trials within the Campbell meta-analysis was extrapolated to evaluated to yield a weighted outcome of 57.7% at 90 days for ASPECTS 8–10 patients treated with the Solitaire device (Table II). Similarly, patients treated with the 3D Revascularization Device demonstrated comparable clinical outcomes, mRS 0–2 in 52.5% (figure 1). Conclusion Utility of the 3D Revascularization Device with the Penumbra System can achieve favorable long term clinical outcome similar to the use of Solitaire. Disclosures: A. Siddiqui: 2; C; Codman, Medtronic, Guide Point Global Consulting, Penumbra, Stryker, Microvention, W. L. Gore & Associates, Three Rivers Medical, Inc., Corindus, Inc., Amnis Therapeutics, Ltd.,CereVasc, LLC. D. Frei: 2; C; Penumbra, Inc., Codman, Microvention, Stryker, Siemens. 4; C; Penumbra, Inc. A. Yoo: 1; C; Neuravi, Inc., Penumbra, Inc.. J. Kirmani: None. O. Zaidat: 2; C; Penumbra, Inc.. D. Lopes: None. A. Turk: 1; C; Penumbra, Inc., Microvention, Stryker, Covidien, Medina Medical. D. Heck: 1; C; Penumbra, Inc.. 2; C; Stryker. B. Mason: None. D. Haussen: None. E. Levy: None. S. Mehta: None. M. Lazzaro: None. M. Chen: None. A. Dorfler: 1; C; Penumbra, Inc.. C. Derdeyn: None. L. Schwamm: None. D. Langer: None. R. Nogueira: None.

Substantial agreement has been achieved on research priorities in palliative care over the past 15 years, as evidenced by consensus conferences and systematic reviews. Despite the presence of a widely endorsed research agenda, however, addressing the gaps in scientific knowledge has progressed slowly, suggesting that researchers face significant obstacles to conducting high-quality research on the most pressing topics in the field.To systematically identify barriers to improved and expanded palliative care research as reported by researchers.Semistructured telephone interviews to solicit barriers to research in palliative care.A purposive, interdisciplinary sample of 61 leading researchers in palliative care.Interviews were transcribed and analyzed using standard qualitative methods.Respondents named five barriers impeding progress: (1) funding, (2) institutional capacity, (3) researcher workforce, (4) challenges related to the topic and population (e.g., attrition, heightened human subjects protections), and (5) public and professional misunderstanding of palliative care and aversion to topics related to serious illness and end-of-life.Research in palliative care is being held back by significant barriers that require the attention of institutions and funders. The consensus within the interdisciplinary sample indicates that concentrated effort to address barriers related to funding and researcher workforce could facilitate progress on established research priorities. More research is needed on viable strategies for overcoming the identified barriers.

This qualitative investigation explored access to and use of gender transition services by hijras and other male-to-female transgender people in the public and private hospitals in 7 Indian cities. We conducted 7 focus groups (n = 42 participants) and 30 in-depth interviews with a purposive sample of hijras/transpeople and 22 key informant interviews with service providers. Findings reveal a near-absence of gender transition services in public hospitals. Lack of free sex reassignment surgery (SRS) in public hospitals and the prohibitive cost of SRS in private hospitals seem to be the key reasons behind why some hijras/transpeople go to unqualified medical practitioners for surgery or undergo Dai Nirvan, a traditional but risky method of removing male genitalia practiced within the hijra communities. Similarly, unwillingness among qualified medical practitioners to prescribe hormone therapy compels many hijras/transpeople to self-administer hormones. The lack of national guidelines on gender tran...

Background: Coil embolization of wide-neck cerebral aneurysms frequently requires stent or balloon assistance. Such approaches to coil embolization increase the procedural complexity, adding risk and cost. Objective: To describe a series of coil embolization procedures performed using a single-balloon microcatheter to treat wide-neck aneurysms and establish the safety, feasibility and efficacy of this technique. Methods: A retrospective review was performed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, Mass., USA) was used as a single-balloon microcatheter for aneurysm coil embolization at two institutions. Clinical, demographic and angiographic data were obtained, and aneurysm volumes as well as packing densities (PD) were calculated. Results: Eight cerebral aneurysms were treated using this technique. Six of these were unruptured. The aneurysms had an average neck diameter of 3.7 mm, and the maximum dimension ranged from 5 to 11 mm, with a mean of 7.5 mm. The mean aspect ratio was 2.07. The mean volume of the aneurysms was 180.38 mm3. The average PD achieved in these 8 aneurysms was 41.79%. Complete occlusion with coil embolization [Raymond-Roy Occlusion Classification (RROC) 1] was achieved in all cases except one, where a small residual was left deliberately and the occlusion grade was RROC 2. There were no intraprocedural complications. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of a single-balloon microcatheter technique in coil embolization of wide-neck cerebral aneurysms. This technique may be used to achieve a high PD, comparable to that obtained with stent-assisted coiling or coiling alone, while avoiding permanent stent placement and potentially reducing thromboembolic complications.

Background Thrombolysis for acute ischemic stroke (AIS) in children is yet to be proven efficacious, and there is limited information about its safety in large pediatric samples. Here we evaluate the safety outcomes associated with thrombolysis in children as well as the trend of hospital utilization over the past decade in the United States. Methods A cohort of children with acute ischemic stroke was identified from the Kids' Inpatient Database for the years 1998-2009. Acute ischemic stroke was identified by the International Classification of Diseases-9 clinical classification software codes (109 and 110). Multivariate logistic regression analyses were used to assess covariates associated with outcomes of hospital mortality and intracerebral hemorrhage. The Cochran-Armitage test was employed for linear trend of discrete variables. Results In this analysis, 9257 children were admitted with the diagnosis of acute ischemic stroke; only 67 (0.7%) received thrombolysis. Thrombolysis-treated children were older than the rest of the cohort (13.1 ± 7.3 vs 8.18 ± 7.5; P P P = 0.06) and intracerebral hemorrhage (2.99% vs 0.77%; P = 0.08) in the thrombolysis group. Adjusted analysis showed that intracerebral hemorrhage is predictive of a higher hospital mortality (odds ratio 3.43; 95% confidence interval 1.89-6.22), whereas thrombolysis was not (odds ratio 1.78; 95% confidence interval 0.86-3.64). The overall rate of thrombolysis per 3 years intervals had increased from 5.2 to 9.7 per 1000 children with acute ischemic stroke ( P = 0.02). This increase was mainly seen in non-children hospitals ( P = 0.01). Conclusion Thrombolysis for acute ischemic stroke is infrequently used in children. There is a trend toward higher risks of intracerebral hemorrhage and hospital mortality, although these risks are as low as those reported in adult population. The hospitals' utilization of thrombolysis in children has increased during the study period.

Parag Goyal,1 Madeline R Sterling,2 Ashley N Beecy,2 John T Ruffino,2 Sonal S Mehta,3 Erica C Jones,1 Mark S Lachs,3 Evelyn M Horn1 1Division of Cardiology, Department of Medicine, 2Department of Medicine, 3Division of Geriatrics, Department of Medicine, Weill Cornell Medicine, New York, NY,USA Objectives: Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge.Patients and methods: This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014. Patient demographics, administrative data, clinical parameters, echocardiographic indices, and scheduled postdischarge outpatient follow-up appointments were collected.Results: Of the 796 patients hospitalized for heart failure, just over half of the cohort had a scheduled follow-up appointment upon discharge. Follow-up appointments were less likely among patients who were white and had heart failure with preserved ejection fraction and more likely among patients with Medicaid and chronic obstructive pulmonary disease. In an adjusted multivariable regression model, age ≥65 years was inversely associated with a scheduled follow-up appointment upon hospital discharge, despite higher rates of several cardiovascular and noncardiovascular comorbidities.Conclusion: Just half of the patients discharged home following a hospitalization for heart failure had a follow-up appointment scheduled, representing a missed opportunity to provide a recommended care transition intervention. Despite a greater burden of both cardiovascular and noncardiovascular comorbidities, older adults (age ≥65years) were less likely to have a follow-up appointment scheduled upon discharge compared with younger adults, revealing a disparity that warrants further investigation. Keywords: appointments, patient readmission, ageism, heart failure&nbsp

Sentiment analysis is the process of identifying people's point of view and its impact on them. It determines whether apiece of writing is positive, negative, or neutral. Now-a-days one of the most common tool for sharing opinion is the Internet. This opinion may be different moods of people or reviews about products and so on. People share their views on social-networking websites which proves to be an important source of information. Twitter is one of the most popular social networking website where people post their opinion in the form of tweets. The proposed onto-fuzzy logic system provides a new approach where it uses hash tag level sentiment classification of tweets along with fuzzy logic. Sentiment analysis done with fuzzy logic will help any person to take effective decision according to the product or service of their interest.

Dyspnea is one of the most common symptoms in advanced cancer patients at the end of their life. It is often multifactorial with diverse malignant, nonmalignant, and cancer treatment related etiologies. Oxygen, opiates, and anxiolytics are commonly administered. Here a complex case of progressive dyspnea and its treatments in a patient with advanced pancreatic cancer is described, and its multiple potential contributing causes are identified and clinical responses evaluated. Literature review is conducted on pulmonary drug toxicity and tumor lymphangitic spread, and the role of corticosteroids in relieving dyspnea in the palliative care setting.

Introduction: Post-discharge medical follow-up among geriatric patients admitted with heart failure (HF) is especially important given high rates of multimorbidity and polypharmacy. Hypothesis: Patients admitted with HF aged ≥65 years will have a high rate of follow-up appointments (FUA) scheduled upon discharge from the hospital. Methods: We studied patients discharged home from a medicine service with principal diagnosis of HF at an academic hospital in NYC during 2013-2014. Patients discharged to hospice were excluded. We collected demographics, hospitalization characteristics, clinical indices, and FUA data by chart review. Results: . 796 unique patients were hospitalized with HF, among whom 443 (56%) had an FUA scheduled prior to discharge. Patients who did not have an FUA were older, more commonly white, and less likely to have Medicaid (Table). They had higher LVEF and higher rates of HFpEF (LVEF≥50%) compared to those with an FUA. Patients with and without an FUA were similar with respect to rates of coronary artery disease (CAD), RV dysfunction, valvular disease, atrial fibrillation/flutter (AF), and ventricular tachycardia. Patients also had similar rates of non-cardiac comorbidities irrespective of having an FUA, with the exception of COPD, which was more common among those with an FUA. Despite increased rates of CAD, AF, COPD, gastrointestinal bleeding, cancer, and cerebrovascular accidents, patients aged ≥65 years were less likely to have an FUA (52% vs. 65%, p=0.001). In multivariate analysis controlling for race, insurance, COPD, and HFpEF, age ≥65 remained independently associated with not having a scheduled FUA upon hospital discharge (OR 1.45, [1.02 to 2.05], p=0.03). Conclusions: Despite higher burden of both cardiac and non-cardiac disease, patients aged ≥65 years admitted with HF were less likely to have a follow-up appointment upon discharge. This highlights an important disparity in care of the geriatric population that must be addressed.

Despite new guidelines and nationally mandated regular assessments, managing pain in cognitively impaired patients remains a complex and challenging task. Numerous studies have focused on assessing pain in this population; however, studies of treatment are limited.The purpose of this article was to characterize assessment and pain management strategies used by providers caring for hospitalized cognitively impaired patients with acute pain, and to assess for associations between amount of opioid received and specific adverse outcomes in this patient population.Medical records of patients admitted to the Geriatrics Service or Orthopedic Service or evaluated by the Geriatrics Consult Service at an urban tertiary care hospital between September 01, 2006 and September 30, 2007 with cognitive impairment and an acute pain problem on admission were reviewed.Participants (N=100) had a mean age of 86 years (range=68-99), and were mostly female (83%) with fracture-related pain (62%). A numeric pain score was recorded in 67% of nursing assessments vs5% of physician assessments. Opioids were prescribed for 100% of the surgical patients vs 43% of the medical patients. Only 15% of patients were placed on a standing analgesic regimen. Nonpharmacological management was employed for 75% of surgical patients vs 43% of medical patients. Delirium occurred in 27% of patients, and 33% experienced an interruption of physical therapy. Neither, however, was associated with level of opioid use.Current assessment and treatment practices in acute pain management for cognitively impaired patients vary widely (to include service and provider type). Implementation of evidence-based guidelines is needed to improve patient care.

Subarachnoid hemorrhage (SAH) is a rare type of hemorrhagic stroke and frequently associated with seizure disorder. While trauma is a cause of SAH, aneurysm rupture remains the most common cause of nontraumatic SAH. Hemorrhage is classified into three distinct patterns according to blood accumulation within the cranial cavity: diffuse, perimesencephalic, and cortical convexity types. The risk of seizure is the highest among those with diffuse aneurysmal SAH. Seizure is a common complication following SAH and may lead to an increase in the morbidity and mortality; hence, the detection of seizures during the hospital course is important for early treatment and prevention. Seizures following SAH may occur at onset, early (within 2 weeks of onset) and late during the disease course. The risk of early seizures in approximately 5%, whereas late seizures may be 14?% with a mean latency of approximately 8 months from the onset of hemorrhage. The risk of seizure is particularly high among patients with poor-grade SAH (Hunt–Hess grade IV and V and Fisher grade III). Continuous electroencephalography (EEG) monitoring is useful for seizure detection among comatose patients. Advances in treatment and technology of cerebral aneurysms, improved seizure detection methods, and the advancement in neurocritical care management for SAH have led to a lesser seizure frequency, improved seizure control rate, and better clinical outcomes.

Inferior petrosal sinus sampling (IPSS) is a major advance in the medical management of Cushing’s syndrome (CS). Using this selective catheterization technique, it was possible to sample ACTH output centrally and peripherally and later even lateralize ACTH production. IPSS has continued to gain wide acceptance and now it is internationally considered the gold standard for diagnosing CD. This chapter will explain IPSS including its applications, limitations, techniques, complications, and cost-effectiveness. It behooves all physicians involved in the medical management of CS to better understand this procedure.

Cerebral venous thrombosis (CVT) is an infrequent, but increasingly recognized cause of stroke. It occurs in the setting of dehydration and hypercoagulable states and disproportionately affects women. Clinical presentations range from isolated headache to focal deficits and coma. While first-line therapy has traditionally focused on hydration and anticoagulation, endovascular treatment is increasingly effective and safe. The initial endovascular approaches focused on the infusion of thrombolytic agents, but have expanded to include mechanical disruption with a variety of devices, include the “stent-retriever” family. Suction thrombectomy has returned to favor with the advent of large inner diameter, highly navigable catheters.

A 55-year-old woman with no significant medical history presented with an acute onset severe headache. A non-enhanced CT scan of the head revealed a right cerebellar hemorrhage. Investigation for etiology of the hemorrhage included an MRI showing extensive subcortical ischemic disease and also several previous microbleeds. The MRI appearance and absence of any other etiology for hemorrhage prompted work up for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). She was found to have a guanosine to thymidine transversion at nucleotide position 1336, codon position 420, resulting in a glycine>cysteine substitution interpreted as "predicted CADASIL-associated mutation". To our knowledge, this mutation has not yet been reported in association with CADASIL.

Effective communication is essential for shared decision making with families of critically ill patients in the intensive care unit (ICU), yet there is limited evidence on effective strategies to teach these skills.The study's objective was to pilot test an educational intervention to teach internal medicine interns skills in discussing goals of care and treatment decisions with families of critically ill patients using the shared decision making framework.The intervention consisted of a PowerPoint online module followed by a four-hour workshop implemented at a retreat for medicine interns training at an urban, academic medical center.Participants (N=33) completed post-intervention questionnaires that included self-assessed skills learned, an open-ended question on the most important learning points from the workshop, and retrospective pre- and post-workshop comfort level with ICU communication skills. Participants rated their satisfaction with the workshop.Twenty-nine interns (88%) completed the questionnaires. Important self-assessed communication skills learned reflect key components of shared decision making, which include assessing the family's understanding of the patient's condition (endorsed by 100%) and obtaining an understanding of the patient/family's perspectives, values, and goals (100%). Interns reported significant improvement in their comfort level with ICU communication skills (pre 3.26, post 3.73 on a five-point scale, p=0.004). Overall satisfaction with the intervention was high (mean 4.45 on a five-point scale).The findings suggest that a brief intervention designed to teach residents communication skills in conducting goals of care and treatment discussions in the ICU is feasible and can improve their comfort level with these conversations.

Background Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. Methods Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. Results One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS ( P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital ( P = .02). Conclusion The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.

Background: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. Alternative hypothesis is a higher rate of stroke mimics (SM) among AIS treated in a non-specialized stroke centers and then transferred to comprehensive centers. Methods: Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over one academic year. Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge information were collected. We also identified those who were treated in outside facility and then transferred to the tertiary center (i.e. drip-and-ship paradigm). Comparative and adjusted analysis to identify predictors for stroke mimics was performed. Results: 120 patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = 0.0003), had a slight female preponderance (55% versus 46%; P = 0.46); and more likely to harbor a psychiatric diagnosis (45% versus 9%; P = Conclusion: Drip-and-ship paradigm and the presence of any psychiatric history predict the diagnosis of SM. None of the SM had any thrombolysis related complication and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment of AIS

Background and purpose We report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke. Methods A retrospective chart review was performed in 194 consecutive patients who underwent endovascular treatment for acute ischemic stroke between January 2006 and January 2011. No patients were excluded from treatment for elevated creatinine (Cr). Each patient received approximately 150 ml intra-arterial non-ionic low-osmolar contrast agent (Optiray 320) during the endovascular procedure. Contrast-induced nephropathy (CIN) was defined according to the Acute Kidney Injury Network criteria as a relative increase of serum Cr 50% above the baseline or an absolute increase of 0.3 mg/dl at 48 h following the endovascular procedure. Results Of 194 patients (mean age 65±14 years), 52% were women (n=100) and 25% (n=48) were diabetic. Baseline Cr levels for 191 patients ranged between 0.4 and 2.7 mg/dl. Three patients on chronic hemodialysis had baseline Cr levels ranging between 5.3 and 6.1 mg/dl. Cr was ≤1.5 mg/dl in 163 patients (84%) and ≥ 1.5 mg/dl in 31 (16%). Three of the 191 patients (1.5%) developed CIN as noted from Cr measurements between baseline and within 48 h. One patient who developed an elevated Cr level had a known history of chronic renal insufficiency (Cr > 1.5 mg/dl) and two had baseline Cr levels within the normal range. An additional CT angiogram was obtained in 44 patients, none of which developed CIN. Female gender and diabetes were not associated with a higher risk of developing CIN. Conclusions The risk of developing CIN is low among patients with acute stroke who undergo emergency endovascular treatment. Treatment of acute stroke should be performed irrespective of Cr levels.

Sex education for adolescents is practically unavailable from any source in India, be it home, family members or school. Yet a majority of girls marry by the time they are 16 and boys by 18, and with marriage they become sexually active. CHETNA, an NGO in Ahmedabad, Gujarat, started to run sex education workshops in 1990 as a part of residential health camps for adolescents. In an interactive manner using role plays, games, reading materials and small group discussions, we talk about physical as well as emotional changes in adolescence, love, sex and sexuality, and gender issues. We have seen positive changes in many young people but also found that parental involvement is essential to sustain the gains made and to provide support.

Introduction: From the point of dental practice, the restoration of endodontically treated teeth has become an important aspect as it involves a range of treatment options of variable complexity. Restoring teeth with insufficient coronal tooth structure, it is always indicated to use the post to retain a core for definitive restoration. Fiber post has a modulus of elasticity in analogs to dentin structure, thus reducing the stress areas at the dowel dentin interface. However, the only material that can substantiate all these properties can be none other than dentin itself. Materials and Methodology: Three-dimensional (3D) models of the maxillary central incisor were developed incorporating all the nonlinearities. Continuum 3D elements were used in three dimensions. Maxillary central incisor was laser scanned, duplicated with the help of reverse engineering into STL format, and it was converted into 3D model for finite element analysis (FEA). For the model, fixed boundary conditions were applied at the outer bone, while 100 N static vertical occlusal loads were prescribed at 135° on the loading component of the simulated tooth. The stress distribution was evaluated using dentin and fiber post with prescribed materials, loading and boundary conditions in endontically treated teeth by 3D FEA. Results: The analysis for von Misses stress for dentin post showed that the stress in the dentin post at the cervical area was 127 MPa. The displacement in the dentin post was

Objectives: We sought to assess how rate of infarction impacts outcome in acute ischemic stroke (AIS) patients undergoing endovascular therapy Methods: With institutional approval, we conducted a retrospective chart review on consecutive patients receiving endovascular treatment for anterior circulation AIS at our centers between January 2009 and June 2011. Beside patient’s demographics, we collected data on time from stroke onset to end of endovascular procedure, site of occlusion, and recanalization described as a Thrombolysis in Myocardial Infarction (TIMI) score ≥ 2. Neuro-imaging data included the immediate pre-treatment Alberta Stroke Program Early CT Score (ASPECTS). The ASPECTS score at onset was presumed to be 10. We calculated the rate of infarction as 10-ASPECTS/hour (ΔA). Our endpoint was good outcome defined as a modified Rankin Score ≤ 2 at 90 days. These parameters were entered into univariate and multivariate analyses to determine independent predictors of outcome. Results: Our cohort included 81 patients (45 females, mean age 67±12 years, median stroke score 17, median time from stroke onset to procedure completion 440 minutes). Occlusions were found in the middle cerebral artery (MCA) M2 (11), MCA M1 (46), intracranial internal carotid artery (ICA) (10), ICA origin (2), and tandem ICA origin with intracranial ICA or MCA occlusion (12). The mean baseline ASPECTS was 9 (75 patients had ASPECTS > 7). Recanalization was observed in 50%. The mean change in ASPECTS prior to endovascular therapy was 0.47 units/hour ± 0.72 units. Three parameters predicted a good outcome: recanalization (OR 10.1, 95% CI 2.7, 38.1, p < 0.001), recanalization in the setting of a pre-treatment ASPECTS score > 8 (OR 5.8, 95% CI 1.8, 19.3, p =0.002), recanalization in the setting of a ΔA < 1 unit/hour (OR 2.7, 95% CI 1.0-7.4, p =0.043). In a multivariate analysis controlling for stroke score, ΔA < 1 units/hour still impacted outcome (OR 3.1, 95% CI 1.1-8.9, p=0.039). Conclusions: While rate of infarction may impact the final outcome in patients receiving endovascular therapy for AIS, perhaps a better marker is recanalization in patients with a pre-treatment ASPECTS > 8. Rate of infarction may still be a valuable parameter when selecting patients for this endovascular therapy, in particular those being transferred to treatment sites.