Association of accompanying dyspnea with diagnosis and outcome of patients presenting with acute chest discomfort

AIM: The presence of accompanying dyspnea is routinely assessed and common in patients presenting with acute chest pain/discomfort to the emergency department (ED). We aimed to assess the association of accompanying dyspnea with differential diagnoses, diagnostic work-up and outcome. METHODS: We enrolled patients presenting to the ED with chest pain/discomfort. Final diagnoses were adjudicated by independent cardiologists using all information including cardiac imaging. The primary diagnostic endpoint was the final diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The prognostic endpoints were cardiovascular and all-cause mortality at two years. RESULTS: Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. The prevalence of ACS in patients with versus without dyspnea was comparable (MI 22.4% vs. 21.9%, p = 0.60, unstable angina 8.7% vs. 7.9%, p = 0.29). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p 99.4%. Accompanying dyspnea was an independent predictor for cardiovascular and all-cause death at two years (Hazard Ratio [HR] 1.813 [95%CI, 1.453-2.261, p < 0.01]). CONCLUSION: Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was an independent predictor for cardiovascular and all-cause death

,Anders als alle anderen Egils sagas‘: Zum Konnex von Einzelverfasserschaft und anderer Ästhetik im spätvormodernen Island

In the long-lasting Icelandic manuscript culture, the production and reception of sagas was situated in a narrative tradition characterised by the absence of notions of an author genius and a high degree of mouvance and variance: from the 13th to the 19th century Icelandic saga literature was transmitted anony-mously and in handwritten form in ever new retextualisations, accompanied by reiterating changes of medium (oral / written) and genre (prose / verse). It is therefore less the absence than the more or less sudden appearance of attributions of authorship for these kinds of texts in the course of the 18th century that is remarkable in the Icelandic case. In a first generation of Icelandic literary histories and philological treatises in this period, not only new saga narratives, but also new versions of medieval texts were ascribed to individual authors. The identification of text (versions) with authors often came along with negative assessments of the literary quality of these texts. This conjunction indicates that particular texts that do not meet the aesthetic conventions of saga literature were singled out as works of individuals and that identifiable authorship thus reflects notions of aberration from the literary tra-dition in the Icelandic case. The humanistic treatises exhibit at the same time a high awareness of and nuanced terminology for the complex processes of rewriting and plural authorship of the handwritten Icelandic narrative tradition. This chapter will discuss prominent examples of this protophilological discourse as to their reflection of and relation to Icelandic textual and literary culture in the late pre-modern period

Reparations for White supremacy? Charles W. Mills and reparative vs. distributive justice after the structural turn

Drawing on the work of Charles W. Mills and considering the case of reparations to Black Americans, this article defends the “structural turn” in the philosophical reparations scholarship. In the Black American context, the structural turn highlights the structural and institutional operations of a White supremacist political system and a long chronology of state-sponsored injustice, as opposed to enslavement as a standalone historical episode. Here, the question whether distributive justice is more appropriate than reparative justice is particularly pressing, since structural racial inequalities form part of the basis for reparations. Derrick Darby’s pragmatic argument for non-race-specific redistributive policies and Tommie Shelby’s principled defense of distributive justice are both considered, as well as the challenge to the structural turn that comes from Carlton Waterhouse’s argument for reparations for enslavement rather than “legacy of slavery” reparations

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

Introduction: Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. Methods: These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. Results: Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. Conclusions: These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies

Cortical miR-709 links glutamatergic signaling to NREM sleep EEG slow waves in an activity-dependent manner

MicroRNAs (miRNAs) are key post-transcriptional regulators of gene expression that have been implicated in a plethora of neuronal processes. Nevertheless, their role in regulating brain activity in the context of sleep has so far received little attention. To test their involvement, we deleted mature miRNAs in post-mitotic neurons at two developmental ages, i.e., in early adulthood using conditional Dicer knockout (cKO) mice and in adult mice using an inducible conditional Dicer cKO (icKO) line. In both models, electroencephalographic (EEG) activity was affected and the response to sleep deprivation (SD) altered; while the rapid-eye-movement sleep (REMS) rebound was compromised in both, the increase in EEG delta (1 to 4 Hz) power during non-REMS (NREMS) was smaller in cKO mice and larger in icKO mice compared to controls. We subsequently investigated the effects of SD on the forebrain miRNA transcriptome and found that the expression of 48 miRNAs was affected, and in particular that of the activity-dependent miR-709. In vivo inhibition of miR-709 in the brain increased EEG power during NREMS in the slow-delta (0.75 to 1.75 Hz) range, particularly after periods of prolonged wakefulness. Transcriptome analysis of primary cortical neurons in vitro revealed that miR-709 regulates genes involved in glutamatergic neurotransmission. A subset of these genes was also affected in the cortices of sleep-deprived, miR-709-inhibited mice. Our data implicate miRNAs in the regulation of EEG activity and indicate that miR-709 links neuronal activity during wakefulness to brain synchrony during sleep through the regulation of glutamatergic signaling