Medical specialties

Independent indices (height, body mass index, a body shape index, and hip index) derived from basic anthropometrics have been found to be powerful predictors of mortality hazard, especially when the attributable risks are summed over these indices to give an anthropometric risk index (ARI). The metabolic syndrome (MS) is defined based on the co-occurrence of anthropometric, clinical, and laboratory criteria and is also widely employed for evaluating disease risk. Here, we investigate correlations between ARI and MS in a general population sample, the United States Third National Health and Nutrition Examination Survey. Baseline values of ARI and MS were also evaluated for their association with mortality over approximately 20 years of follow-up. ARI was found to be positively correlated with each component of MS, suggesting connections between the two entities as measures of cardiometabolic risk. ARI and MS were both significant predictors of mortality hazard. Although the associati...

The history of ascorbic acid (AA) and cancer has been marked with controversy. Clinical studies evaluating AA in cancer outcome continue to the present day. However, the wealth of data suggesting that AA may be highly beneficial in addressing cancer-associated inflammation, particularly progression to systemic inflammatory response syndrome (SIRS) and multi organ failure (MOF), has been largely overlooked. Patients with advanced cancer are generally deficient in AA. Once these patients develop septic symptoms, a further decrease in ascorbic acid levels occurs. Given the known role of ascorbate in: a) maintaining endothelial and suppression of inflammatory markers; b) protection from sepsis in animal models; and c) direct antineoplastic effects, we propose the use of ascorbate as an adjuvant to existing modalities in the treatment and prevention of cancer-associated sepsis.

Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems. General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes...

Awareness correlated with pass/fail rate (p o 0.004, B ¼ 0.66, exp(B) ¼ 1.935), which means that an increasing Internal Role Awareness score increases the likelihood of a passing score. The NN was able to be trained to predict ABSITE performance with surprising accuracy for both junior and senior residents. CONCLUSION: Behavioral, motivational, and acumen characteristics can be useful to identify residents "at risk" for substandard performance on the ABSITE. Armed with this information, PDs have the opportunity to intervene proactively to offer these residents a greater chance for success. The NN was capable of developing a model that explained performance on the examination for both the junior and the senior examinations. Subsequent testing is needed to determine if the NN is a good predictive tool for performance on this examination. ( J Surg ]:]]]-]]].

Key links in the chain of survival for the management of severe sepsis and septic shock are early identification and comprehensive resuscitation of high-risk patients. 1 Multiple studies have shown that the first 6 hours of early sepsis management are especially important from a diagnostic, pathogenic, and therapeutic perspective, and that steps taken during this period can have a significant impact on outcome. This period applies to the 700,000 cases per year of sepsis presenting to emergency departments and an equal number of patients on general hospital inpatient floors and intensive care units (ICUs) 8 in the United States. The recognition of this critical period and the robust outcome benefit realized in previous studies provides the rationale for adopting early resuscitation as a distinct intervention. 9 Sepsis joins trauma, stroke, and acute myocardial infarction in having ''golden hours,'' representing a critical opportunity early on in the course of disease for actions that offer the most benefit. The hemodynamic picture of sepsis represents a continuum from clinically stable disease to circulatory insufficiency resulting from hypovolemia, myocardial depression, increased metabolic rate, vasoregulatory-perfusion abnormalities leading to inflammation, and cytopathic tissue hypoxia. Emanuel P. Rivers receives research support from the National Institute of Allergy and Infectious Disease, and from Hutchinson Technologies. In the last 2 years, he has performed as a consultant, delivered lectures, or served as a panelist for Biosite, Edwards Lifesciences, Elan, and

We tested whether two-layer method (TLM) pancreas preservation and trypsin inhibition (Pefabloc) during processing allows longer preservation while retaining or improving viable islet recovery. Non-marginal primate (Macaca nemestrina) and marginal human (ischemic or preservation-injured) pancreata were processed with a research-oriented pan technique (Seattle method). Organs were processed upon arrival (∫ Pefabloc), or after TLM or University of Wisconsin solution (UW) preservation (π Pefabloc). Islet yield, viability, and function were assessed. Pefabloc increased M. nemestrina islet yields from 9696 ∫ 1749 IE/g to 15822∫ 1332 IE/g (p ∞ 0.01). Twolayer method preservation (∞ 6 h) further increased yields, to 23 769 ∫ 2773 IE/g (vs. π Pefabloc; p ∞0.01). Similarly, Pefabloc increased marginal human islet yields from 2473 ∫ 472 IE/g to 4723∫ 1006 IE/g (p ∞ 0.04). This increase was maintained after lengthy TLM preservation (Ͼ 30 h; 4801 ∫ 1066 IE/g). We also tested the applicability of TLM preservation (23.5 ∫ 3.2 h) to the processing of marginal human pancreata by the Edmonton/Immune Tolerance Network clinical protocol. Islet yield and function approached published results of pancreata processed 4.8 ∫ 0.8 h after organ recovery (p Ω 0.06). Pefabloc, and TLM vs. UW preservation, prolonged the tolerable interval between organ recovery and islet isolation. Islet yield, viability, and functionality improved from both marginal and nonmarginal pancreata.

Objective-Heritable thrombophilias have been implicated as a potential etiology of abruption via vascular disruption at the uteroplacental interface. Polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene have been linked to vascular complications outside of pregnancy, including stroke. Given the underlying thrombotic nature of abruption, we hypothesized that polymorphisms in the MTHFR gene are associated with abruption. Study design-We examined 2 variants in MTHFR: 677C→T and 1298A→C in genomic DNA extracted from maternal blood from the New Jersey-Placental Abruption Study, an ongoing, multicenter case-control study. We identified 195 women with a clinical diagnosis of abruption (cases), and 189 controls matched on race/ethnicity and parity. We assessed allele and genotype frequencies, and their associations with abruption risk after adjusting for confounders through multivariable logistic regression analysis. Results-The wild-type allele (C) frequency of the 677C→T variant of MTHFR among cases and controls was 69.0% and 64.3%, respectively, and the wild-type allele (A) of the 1298A→C variant was 75.9% and 79.4%, respectively. Distributions of the 677C→T alleles among controls violated the Hardy-Weinberg equilibrium (P=0.007), while those of the 1298A→C alleles were in equilibrium (P=0.825). In comparison to the wild-type genotype (C/C), the homozygous mutant form (T/T) of 677C→T was not associated with abruption (OR 0.60, 95% confidence interval (CI) 0.33, 1.18). Similarly, the homozygous mutant form (C/C) of the 1298A→C polymorphism was equally distributed between cases and controls (OR 2.28, 95% CI 0.82, 6.35). Plasma homocysteine and vitamin B 12 , but not folate, concentrations were elevated in cases compared to controls among women

A child with acute lymphoblastic leukemia, spinal osteoporosis with vertebral compression fractures, and hypercalcemia appearing early in the course of the hematologic disease was followed for two and a half years. Bone mineral density (BMD), measured by single photon absorptiometry at the radial shaft, was within normal limits for age and sex. However, x-rays of vertebrae and vertebral BMD, measured by dual photon absorptiometry, showed marked demineralization. Despite leukemic remission, the spinal osteoporosis became worse and the patient required aggressive treatment for eight months. Treatment included 50 units of calcitonin subcutaneously every other day, 1,000 mg/day of oral calcium, and 3,000 IU/day of vitamin D. The back pain disappeared quickly, and laboratory controls showed a significant diminution of bone turnover. No new compression fractures occurred. Eighteen months later, the patient continued in remission and menarche had occurred. Dual photon absorptiometry reveal...

Ten years after the Accreditation Council for Graduate Medical Education's (ACGME) mandate that residency programs evaluate learners' competency, research is needed to guide efforts to meet this challenge. During an innovative residency redesign, the authors developed a process to effectively measure "competence." This particular family medicine residency admits six residents per class year and is sponsored by an academic community hospital. Our objective was to generate developmentally appropriate observable behaviors that assess competencies. Eight steps guided the development of this assessment system: (1) Generate residency-specific competencies, (2) Define residency-specific competencies, (3) Identify principles of assessment, (4) Compose and analyze narratives of excellence within each competency, (5) Distill standard statements from narratives and organize into Dreyfus levels of competence, (6) Derive observable behaviors from standard statements to directly...

Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors. To explain why primary care has not begun to integrate comprehensive cancer survivorship services. Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes...

Research and Reviews (JPCRR) is a peer-reviewed scientific journal whose mission is to communicate clinical and bench research findings, with the goal of improving the quality of human health, the care of the individual patient, and the care of populations.

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the out...

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

Ninety-two consecutive patients wilh obstructive sleep apnea syndrome (OSAS) were studied before and six weeks after treatment with either nasal continuous positive airway pressure (CPAP) or uvulopalatopharyngoplasty (UPPP) (n = 46 per group). Assignment of patients to treatment was based on clinical considerations and patient preference. Patients were assessed hy nocturnal polysomnography and peiformance on lhe Multiple Sleep Latency Test (MSLT) thefollowing day. Before treatment, the CPAP and UPPP groups did not differ in sleep-related respiratory disturbance, oxygenation during sleep, fragmentation of sleep, or the level of excessive daytime sleepiness indicated by the MSL T. Both treatments produced significant improvemenl on all measures. However, impi-ovement in UPPP patients was significantly less ctmsistent than that of CPAP patients. To the e.xtent that UPPP successfully reversed the respiratory disturbance (i.e.. 50% reductton in respiratory events index), sleep continuity and daytime sleepiness were improved to a degree comparable to that of patients treated with CPAP.

Objective: We conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for individuals and populations experiencing PTSD. We reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event. Results: The mean prevalence of PTSD across all studies decreases from 28.8% (range = 3.1-87.5%) at 1 month to 17.0% (range = 0.6-43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months. Conclusions: Understanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.

Research and Reviews (JPCRR) is a peer-reviewed scientific journal whose mission is to communicate clinical and bench research findings, with the goal of improving the quality of human health, the care of the individual patient, and the care of populations.

We studied behavioral factors that place intravenous drug users at risk for the acquisition and transmission of the human immunodeficiency virus (HIV) in a sample of 855 individuals not in drug treatment, living in central and southwestern Ohio. The HIV seropositivity rate for the sample was 1.5%. Three factors were significantly related to HIV infection: homeless shelter residence (odds ratio [OR] = 7.7, 95% confidence interval (CI) = 3.0-20.0), travel to northeastern HIV hyperendemic areas (OR = 5.2, 95% CI = 1.8-15.4), and recent male homosexual or bisexual behavior (OR = 11.2, 95% CI = 2.9-43.9).

For determining the implications of circulating endothelial progenitor cells (cEPCs) and cellular membrane microparticles (MPs) in diabetic stroke, levels of EPCs, EPC-MPs, and endothelium-derived MPs (EMPs) and their correlations with blood glucose concentration, cerebral microvascular density (cMVD), and ischemic damage were investigated in type 2 diabetic db/db and db/+ (wild-type control) mice. Therapeutic efficacy of EPC infusion (preincubated with MPs) was also explored. Ischemic stroke was induced by middle cerebral artery occlusion (MCAO) surgery. Ischemic damage and cMVD were determined using histological analyses. The levels of cEPCs and MPs were determined using flow cytometric analyses. EPC generation and functions were evaluated by in vitro cell cultures. Results showed the following. 1) In db/db mice, the basal level of cEPCs was less and cMVDs were lower, but the levels of circulating EPC-MPs and EMPs were more; 2) MCAO induced a larger infarct volume and less of an i...

Objective: This study was designed to identify the frequency, methods, and practices of universal assessments for domestic violence (DV) within child advocacy centers (CACs) and determine which factors are associated with CACs that conduct universal DV assessments. The study design was a cross-sectional, web-based survey distributed to executive directors of National Children's Alliance accredited or accreditation-eligible CACs. Results: Responses were received from 323 of 376 eligible CACs (86%). Twenty-nine percent of CAC directors report familiarity with current DV recommendations and 29% require annual education for staff regarding DV. Twenty-nine percent of CACs conduct "universal assessments" (defined as a CAC that assesses female caregivers for DV more than 75% of the time). The majority of CACs use face-to-face interviews to conduct assessments, often with children, family or friends present. The presence of on-site DV resources (OR = 2.85, CI 1.25-6.50) and an annual DV educational requirement (OR = 2.88, CI 1.31-6.32) are associated with assessment of female caregivers. The presence of on-site DV resources (OR = 3.97, CI 2.21-7.14) is associated with universal assessments. Conclusions: Many CAC directors are not aware of current DV recommendations and do not require annual DV training for staff. Less than one-third of CACs practice universal assessments and those that do often conduct DV assessments with methods and environments shown to be less comforting for the patient and less effective in victim identification. CACs are more likely to assess female caregivers if they have co-located DV resources and they require DV training of their staff. CACs are more likely to universally screen for DV if they have co-located DV resources. Practice implications: The presence of DV in the home has significant potential to negatively impact a child's physical and mental health as well as the ability of the caregiver to adequately protect the child. Current practice in CACs suggests a knowledge gap in this area and this study identifies an opportunity to improve the services offered to these high-risk families.

To investigate the role of primary and/or secondary modified radical neck dissection (MRND) in patients with medullary thyroid carcinoma (MTC), follow-up data on 43 patients operated on between 1972 and 1983 were analyzed retrospectively; patients included 16 with sporadic MTC (group 1) and 27 with multiple endocrine neoplasia type 2 (group 2). Primary surgical therapy consisted of (near-) total thyroidectomy and limited lymph node dissection; one patient in group 1 and two in group 2 underwent primary MRND. Positive nodes were found in nine patients of group 1 and in 12 of group 2. Calcitonin (CT) was raised postoperatively in 11 group 1 patients, who all died (four after additional MRND). Postoperative CT was normal in the four survivors of group 1. In group 2, post-operative CT was raised in 15 patients, including those who had MRND and in four apparently node-negative patients. Three of them underwent additional MRND, which was successful in one case. One patient in this group d...

Studies evaluating the relationship between microbes and human health at non-point source beaches are necessary for establishing criteria which would protect public health while minimizing economic burdens. The objective of this study was to evaluate water quality and daily cumulative health effects (gastrointestinal, skin, and respiratory illnesses) for bathers at a non-point source subtropical marine recreational beach in order to better understand the inter-relationships between these factors and hence improve monitoring and pollution prevention techniques. Daily composite samples were collected, during the Oceans and Human Health Beach Exposure Assessment and Characterization Health Epidemiologic Study conducted in Miami (Florida, USA) at a non-point source beach, and analyzed for several pathogens, microbial source tracking markers, indicator microbes, and environmental parameters. Analysis demonstrated that rainfall and tide were more influential, when compared to other enviro...

Background Microbial water-quality indicators, in high concentrations in sewage, are used to determine whether water is safe for recreational purposes. Recently, the use of these indicators to regulate recreational water bodies, particularly in sub/tropical recreational marine waters without known sources of sewage, has been questioned. The objectives of this study were to evaluate the risk to humans from exposure to subtropical recreational marine waters with no known point source, and the possible relationship between microbe densities and reported symptoms in human subjects with random-exposure assignment and intensive individual microbial monitoring in this environment. A total of 1303 adult regular bathers were randomly assigned to bather and non-bather groups, with subsequent follow-up for reported illness, in conjunction with extensive environmental sampling of indicator organisms (enterococci). Bathers were 1.76 times more likely to report gastrointestinal illness [95% confidence interval (CI) 0.94-3.30; P ¼ 0.07]; 4.46 times more likely to report acute febrile respiratory illness (95% CI 0.99-20.90; P ¼ 0.051) and 5.91 times more likely to report a skin illness (95% CI 2.76-12.63; P < 0.0001) relative to non-bathers. Evidence of a dose-response relationship was found between skin illnesses and increasing enterococci exposure among bathers [1.46 times (95% CI 0.97-2.21; P ¼ 0.07) per increasing log 10 unit of enterococci exposure], but not for gastrointestinal or respiratory illnesses. Conclusions This study indicated that bathers may be at increased risk of several illnesses relative to non-bathers, even in the absence of any known

Background: Varicella infection causes substantial morbidity in young adults. Most military basic trainees are 18 to 21 years old, yet the Army has no varicella vaccination policy. We therefore determined varicella susceptibility in a population of Army basic trainees, examined variables that might predict antibody status, and developed a vaccination strategies model. Methods: Fifteen-hundred ninety-five trainees completed a demographic and historical questionnaire. Varicella antibody status was determined on 1201 volunteers. These data plus information from the literature were used to construct a decision tree of vaccination strategies that was applied to the total population of Army basic trainees in 1995 (n = 65,298). Results: Fifty (4.2 percent) of 1201 soldiers were antibody negative. Trainees who lived with no or 1 sibling while growing up were most likely to be seronegative (P < 0.01). The positive predictive value of a history of varicella was 98.5 percent, whereas the negative predictive value of a negative history of varicella was 23 percent. In the vaccination strategies model, serologically testing soldiers with a negative history of varicella and vaccinating those without protective antibodies was the most cost-effective approach. Conclusions: In young adults a positive varicella history accurately predicts immunity, but verification of a negative history with antibody testing is recommended before vaccination. (

Introduction: Medical student training and experiences in nursing homes are often viewed as negative; however, long-term care services represent a growing aspect of our medical system that receives little attention in medical education. The University of New England College of Osteopathic Medicine Learning by Living Nursing Home Immersion Project accelerates students learning about older adult care and the importance of empathy. Methods: Learning by Living applies qualitative ethnographic/autobiographic research methods to answer the question: "What is it like for me to live the life of an older adult nursing home resident?" Two first year medical students (female, 25 y/o & male, 27 y/o) were "admitted" into two different nursing homes for 11 days each. The students were wheelchair reliant from their assigned diagnoses of dominant-side paralysis secondary to stroke and aspiration pneumonia; requiring standard procedures of care experienced by older adults residents with similar conditions. Data were collected in the form of journal notes for pre-fieldwork, fieldwork, and post-fieldwork and included subjective and objective reporting of observations, experiences, and resident encounters. Analyses included journal review and thematic categorization and coding through content analysis. Results: Four themes of significance intersected for the two medical students: 1) control; 2) quality of life; 3) communication; and 4) isolation. Being immersed in nursing home life provided the students with firsthand experiences of loss and challenges faced by nursing home residents. This aided students' learning about empathy and communication as key components of providing health care. Conclusion: This experience imparted knowledge to the medical students' about aging, dignity, and the importance of making meaningful connections in order to thrive. These insights provided a gateway to establish a model of patient-centered care that is comprehensive and empathic for the older adult population.

BACKGROUND: Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. METHODS: A prospective 2-year study of patients aged R18 years with thoracic trauma was conducted at a level 1 trauma center. RESULTS: Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). CONCLUSIONS: Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

BACKGROUND AND PURPOSE: Pediatric brain tumors have diverse pathologic features, which poses diagnostic challenges. Although perfusion evaluation of adult tumors is well established, hemodynamic properties are not well characterized in children. Our goal was to apply arterial spin-labeling perfusion for various pathologic types of pediatric brain tumors and evaluate the role of arterial spin-labeling in the prediction of tumor grade. Arterial spin-labeling perfusion of 54 children (mean age, 7.5 years; 33 boys and 21 girls) with treatment-naive brain tumors was retrospectively evaluated. The 3D pseudocontinuous spin-echo arterial spin-labeling technique was acquired at 3T MR imaging. Maximal relative tumor blood flow was obtained by use of the ROI method and was compared with tumor histologic features and grade. Tumors consisted of astrocytic (20), embryonal (11), ependymal (3), mixed neuronal-glial (8), choroid plexus (5), craniopharyngioma (4), and other pathologic types (3). The maximal relative tumor blood flow of high-grade tumors (grades III and IV) was significantly higher than that of low-grade tumors (grades I and II) (P Ͻ .001). There was a wider relative tumor blood flow range among high-grade tumors (2.14 Ϯ 1.78) compared with low-grade tumors (0.60 Ϯ 0.29) (P Ͻ .001). Across the cohort, relative tumor blood flow did not distinguish individual histology; however, among posterior fossa tumors, relative tumor blood flow was significantly higher for medulloblastoma compared with pilocytic astrocytoma (P ϭ .014). Characteristic arterial spin-labeling perfusion patterns were seen among diverse pathologic types of brain tumors in children. Arterial spin-labeling perfusion can be used to distinguish high-grade and low-grade tumors. ABBREVIATIONS: ASL ϭ arterial spin-labeling; DIPG ϭ diffuse intrinsic pontine glioma; DNT ϭ dysembryoplastic tumor; OPG ϭ optic pathway glioma; rTBF ϭ relative tumor blood flow; WHO ϭ World Health Organization B rain tumors are the most common solid tumors of childhood and are a leading cause of cancer deaths in children. Unlike in adults, these tumors predominate in the posterior fossa and have more heterogeneous pathologic features, including embryonal and mixed neuronal-glial types. 2 Because of their diverse histologic presentation and biologic behavior, evaluation and treatment of pediatric brain tumors remain complex. MR imaging is important in tumor diagnosis, surgical guidance, and therapeutic monitoring of brain tumors. Various PWI methods have shown clinical usefulness in adult glioma, including the use of relative maximal CBV and relative CBF from DSC-PWI to predict tumor grade and behavior. Despite abundant literature on adult brain tumors, few perfusion reports exist for pediatric brain tumors, potentially because of technical challenges. For example, the most widely available T2*-weighted DSC imaging often requires constant, high-flow contrast injection by power injectors, double-dosing, and large-bore intravenous access, which pose challenges in young children and infants. Recent studies have shown that arterial spin-labeling (ASL) may be a reliable alternative to DSC-PWI in the evaluation of tumor perfusion and can predict adult glioma grade. ASL has distinct advantages in children because of lack of contrast requirement, high SNR, labeling efficiency, and the potential for CBF quantification. Also, ASL can be repeated in cases of failed sedation or patient motion, a frequent problem in children with brain tumors.

Economic benefits associated with the usage of generic drugs have been suggested to increase patients' adherence to their medications and to improve patients' health outcomes. However, the therapeutic equivalence of certain generic products to their branded counterparts has been questioned. Our study aims to compare the efficacy and safety of generic and branded ivabradine in adult patients with chronic heart failure with reduced ejection fraction (≤40%) (HFrEF). This was a randomized, open-label, crossover, and two-period comparative study. A total of 32 patients with HFrEF were randomized into two groups. Group A received brand ivabradine® for 12 weeks followed by generic ivabradine for the next 12 weeks. Group B received generic ivabradine for 12 weeks followed by brand ivabradine for the next 12 weeks with no washout period. The efficacy outcomes included resting heart rate (HR), New York Heart Association Functional Classification (NYHA FC), Quality of life (QoL) using Minnesota Living with Heart Failure (MLWHF), and ejection fraction (EF). After taking the drugs for the first 12 weeks, no statistically significant difference was detected in all efficacy outcomes between Group A and Group B. After crossover and taking drugs for a further 12 weeks, similar results were obtained. Only minor side effects, mainly phosphenes were observed in both products. No mortality was demonstrated in both groups. This study showed no statistically significant difference between the generic and brand ivabradine in terms of efficacy and safety. The results suggest that generic ivabradine can be a safe substitute for branded ivabradine for economic reasons.

A review of publications relating to significant advances in the specialty of Obstetrics and Gynaecology over the past four years will be discussed: topics reviewed will have an important impact on reducing maternal/fetal morbidity and mortality and should improve on woman's health care.

Objectives: To describe the types of contraception used by women attending Title X-funded clinics and a comparable group of low-income reproductive-age women at risk of unintended pregnancy. Study design: We estimated the percentage of reproductive aged (15-44 years) women using contraception, by method type and level of effectiveness in preventing pregnancy (i.e., most, moderately, and less effective), using Title X Family Planning Annual Report (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) and National Survey of Family Growth (2006Growth ( -2015) ) data. We divided most effective methods into permanent (female and male sterilization) and reversible (long-acting reversible contraceptives [LARCs]) methods. Results: Among Title X clients during 2006-2016, use of LARCs increased (3-14%); use of moderately effective methods decreased (64-54%); and use of sterilization (~2%), less effective methods (21-20%), and no method (8-7%) was unchanged. These same trends in contraceptive use were observed in a comparable group of women nationally during 2006-2015, during which LARC use increased (5-19%, pb .001); moderately effective method use decreased (60-48%, pb .001); and use of sterilization (~5%), less effective methods (19%), and no method (11-10%) was unchanged. Conclusions: The contraceptive method mix among Title X clients differs from that of low-income women at risk of unintended pregnancy nationally, but general patterns and trends are similar in the two populations. Research is needed to understand whether method use patterns among low-income women reflect their preferences, access, or the conditions of the supply environment. Implications: This study contributes to our understanding of patterns and trends in contraceptive use among two groups of reproductive-age women -Title X clients and low-income women nationally who are at risk of unintended pregnancy. The findings highlight areas for further research.

Antimicrobial resistance is a growing, global public health crisis, due in large part to the overuse and misuse of antibiotics. Understanding medication allergy data and allergy reactions that are documented in electronic health records (EHRs) can help to identify opportunities to improve the quality of documentation of beta-lactam allergies, thus potentially reducing the prescribing of alternative antibiotics. Medication allergies and allergy reactions recorded in the EHR for 319 051 patients seen across 32 community health centers were reviewed. Patients with a beta-lactam allergy recorded in their EHR were identified. Free text, as well as standardized allergy and allergy reaction fields, were analyzed. Among patients, 9.1% (n = 29 095) had evidence of a beta-lactam allergy recorded in their EHR. Women, white, and non-Hispanic patients were more likely to have a documented allergy compared to men, black, and Hispanic patients. Among all patients with a documented beta-lactam alle...

for the Neonatal Kidney Collaborative BACKGROUND: Neonates with serum creatinine (SCr) rise ≥0.3 mg/dL and/or ≥50% SCr rise are more likely to die, even when controlling for confounders. These thresholds have not been tested in newborns. We hypothesized that different gestational age (GA) groups require different SCr thresholds. METHODS: Neonates in Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) with ≥1 SCr on postnatal days 1-2 and ≥1 SCr on postnatal days 3-8 were assessed. We compared the mortality predictability of SCr absolute (≥0.3 mg/dL) vs percent (≥50%) rise. Next, we determine usefulness of combining absolute with percent rise. Finally, we determined the optimal absolute, percent, and maximum SCr thresholds that provide the highest mortality area under curve (AUC) and specificity for different GA groups. RESULTS: The ≥0.3 mg/dL rise outperformed ≥50% SCr rise. Addition of percent rise did not improve mortality predictability. The optimal SCr thresholds to predict AUC and specificity were ≥0.3 and ≥0.6 mg/dL for ≤29 weeks GA, and ≥0.1 and ≥0.3 mg/dL for >29 week GA. The maximum SCr value provides great specificity. CONCLUSION: Unique SCr rise cutoffs for different GA improves outcome prediction. Percent SCr rise does not add value to the neonatal AKI definition.

Monitoring of vancomycin trough concentrations is recommended for pediatric patients in the product label and by several professional societies. However, among a network of freestanding children's hospitals vancomycin therapeutic drug monitoring (TDM) practices were reported to be highly variable. In this study, we sought to evaluate whether trends in vancomycin use and TDM changed across a large healthcare delivery system in Utah and Idaho from 2006 to 2012. Children ≤ 18 years who received ≥2 vancomycin doses were included. Overall, vancomycin TDM was performed during 5,035 (80%) of 6,259 hospital encounters, in which 85,442 doses were administered and 7,935 concentrations were obtained. Across this time period, the median trough concentration increased from 10.9 to 13.7 µg/mL (P < .001), which temporally coincided with recommendations published by the Infectious Disease Society of America that recommend targeting higher trough concentrations. Two or more abnormally low trough concentrations were accompanied by an increase in the dose 75% of the time. Similarly, ≥2 abnormally high trough concentrations were followed by a decrease in the dose 35% of the time. In aggregate, these data suggest that vancomycin TDM is commonly performed among children and the majority of abnormal trough concentrations were associated with an appropriate modification to the dosing regimen.

Introduction: Since 2010, the number of new HIV-1 cases has declined by 30% globally, however, in few countries, such as Pakistan, the cases have continued to increase, where the country witnessed a 57% increase in the number of new infections between 2010 and 2020. The HIV-1 epidemic in Pakistan is concentrated in certain high-risk groups, however, it is unknown which high-risk group has a higher likelihood of transmitting HIV-1 infections to vulnerable populations. This study aimed to apply mathematical probabilistic modeling to estimate the probability of HIV-1 transmission for different high-risk groups of Pakistan. Methodology: MATLAB software was used to conduct probabilistic modeling (chance estimation) of HIV-1 transmission for different high-risk groups of Pakistan, and also draw a comparison between Pakistan and different high- and low- HIV-1 prevalence countries. Results: Our results revealed that Pakistan overall had the lowest probability of HIV-1 transmission as compar...

Development of specific IgE antibodies to the oligosaccharide galactose-α-1, 3-galactose (α-gal) following tick bites has been shown to be the source of red meat allergy. In this study, we investigated the presence of α-gal in four tick species: the lone-star tick (Amblyomma americanum), the Gulf-Coast tick (Amblyomma maculatum), the American dog tick (Dermacentor variabilis), and the black-legged tick (Ixodes scapularis) by using a combination of immunoproteomic approach and, carbohydrate analysis. Anti-α-gal antibodies identified α-gal in the salivary glands of both Am. americanum and Ix. scapularis, while Am. maculatum and De. variabilis appeared to lack the carbohydrate. PNGase F treatment confirmed the deglycosylation of N-linked α-gal-containing proteins in tick salivary glands. Immunolocalization of α-gal moieties to the salivary secretory vesicles of the salivary acini also confirmed the secretory nature of α-gal-containing antigens in ticks. Am. americanum ticks were fed on human blood (lacks α-gal) using a silicone membrane system to determine the source of the α-gal. N-linked glycan analysis revealed that Am. americanum and Ix. scapularis have α-gal in their saliva and salivary glands, but Am. maculatum contains no detectable quantity. Consistent with the glycan analysis, salivary samples from Am. americanum and Ix. scapularis stimulated activation of basophils primed with plasma from α-gal allergic subjects. Together, these data support the idea that bites from certain tick species may specifically create a risk for the development of α-gal-specific IgE and hypersensitivity reactions in humans. Alpha-Gal syndrome challenges the current food allergy paradigm and broadens opportunities for future research.

We report here some results from studies carried out on Thai temporary labourers in Israel. All had come to Israel within the past year and they were young (20-35), healthy, and free of STD. All were HIV seronegative. They had very high levels of serum IgE and IgG and their TNF systems were clearly activated, as seen by the high levels of serum soluble TNF receptors type II (p75) and by the high level of surface membrane expression of these receptors on lymphocytes (table ). Serum levels of interferon-'Y were low and not different from those observed in controls (not shown). These findings indicate immune activation in this group of healthy, HIV-seronegative Thais. The pattern has some of the characteristics of activation of type 2 T-helper cells (Th2)-namely, high IgE and IgG and normal interferon-y-plus an activated TNF system which does not clearly belong to either Thl-type or Th2-type activation. We suggest that this pattern makes these individuals more susceptible to HIV infection once exposed. Observations by Maggi and colleagues3 support this nor n, which also fits in with the ideas of Clerici and Shearer4on the role ofThl/Th2 activation in HIV infection.

The locations of five random mouse genomic DNA markers and five cloned genes, including the genes for clotting factors VIII and IX (Cf-8 and Cf-9), Duchenne muscular dystrophy (Dmd), phosphoglycerate kinase-1 (P&z-I), and a-galactosidase (Ags), on the mouse X chromosome were determined by in situ hybridization. The five random DNA markers provide new genetic loci with useful restriction fragment length polymorphisms between mouse strains and species, including one locus close to the centromeric region of the mouse X chromosome. The physical map and the recombination map of these loci on the X chromosome were compared. There was good agreement in the order of loci. Relative distances between loci were consistent along the X chromosome, with the exception of the telomeric end of the long arm, where the recombination fraction observed between loci closely associated on the physical map was higher than that between similarly spaced markers located in the proximal region of the X chromosome. These results are discussed in comparison to the human X-chromosome map.

In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient&#39;s autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown. To determine the barriers and perceptions in discussion of code status by physicians. Questionnaire-based cross-sectional study. This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included. A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal...

Scholars have identified the presence of natural mentoring relationships (NMRs) as one of a set of protective factors that promote and protect the health and well-being of "at-risk" and marginalized youth. While this work has informed our understanding of the importance of NMRs for supporting youth and promoting positive development, it has only just begun to extend its inquiry focus onto the lives of same-sex attracted (SSA) youth (e.g., gay and bisexual youth). Thirty-nine in-depth interviews with self-identified gay, bisexual, and questioning (GBQ) male youth (ages 15 -22) were qualitatively analyzed for the presence, form, and function of NMRs. Results from this inquiry revealed that participants identified a diverse range of "natural mentors" and that the provision of social support was of thematic prominence in these relationships. Results from this effort are here presented. Clinical and programming implications, as well as directions for future work are discussed.

To evaluate the implementation of the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines and their perceived impact on local policies and practice. The study design was a cross-sectional survey of emergency department (ED) medical directors, or appropriate person identified by the hospital, perception of the impact of the Ohio ED Opioid Prescribing Guidelines on their departments practice. All hospitals with an ED in Ohio were contacted throughout October and November 2016. Distribution followed Dillman&#39;s Tailored Design Method, augmented with telephone recruitment. Hospital chief executive officers were contacted when necessary to encourage ED participation. Descriptive statistics were used to assess the impact of opioid prescribing policies on prescribing practices. A 92% response rate was obtained (150/163 EDs). In total, 112 (75%) of the respondents stated that their ED has an opioid prescribing policy, is adopting one or is...