A Case Report of Acute Heart Failure Due to Infective Aortic Endocarditis Diagnosed by Point-of-care Ultrasound

Introduction: Infective endocarditis (IE) is a life-threatening condition with significant morbidity and mortality, and can require surgical repair.Case Report: A 36-year-old man presented to the emergency department for worsening dyspnea and chest pain. Point-of-care echocardiography demonstrated a mobile oscillating mass on the aortic valve with poor approximation of the valve leaflets, suggesting aortic valve insufficiency secondary to IE as the cause of acute heart failure. The patient underwent emergent aortic valve replacement within 24 hours.Discussion: While point-of-care echocardiography has been well documented in identifying tricuspid vegetations, aorticvalve involvement and subsequent heart failure is less well described. Earlier recognition of aortic valve vegetations and insufficiency can expedite surgical intervention, with decreased complication rates linked to earlier antimicrobial therapy.Conclusion: This case report highlights the ability of point-of-care ultrasound to identify aortic vegetations, allowing for the earlier diagnosis and therapy

In cross-national teams, cultural differences can be an advantage

But leaders need to recognise when difference is a problem, and steer the team through the bumps, write Pamela Tremain Koch, Bradley James Koch, Tanya Menon and Oded Shenka

Soft Tissue to Hard Tissue Advancement Ratios for Mandibular Elongation Using Distraction Osteogenesis in Children

Distraction osteogenesis is extensively used for the elongation of hypoplastic mandibles in children, yet the soft tissue profile response to this is not well understood. The pre- and posttreatment lateral cephalometric radiographs of 27 pediatric patients who underwent bilateral mandibular elongation using distraction osteogenesis were analyzed retrospectively to correlate horizontal soft tissue advancement with horizontal underlying bone advancement at B point and pogonion. Horizontal advancement (in millimeters) of bone and overlying soft tissue at these points was collected from the radiographs of each patient, and linear regression analysis was performed to determine the relationship of hard to soft tissue horizontal advancement at these points. A 1:0.90 mean ratio of bone to soft tissue advancement was observed at B point/labiomental sulcus and at pogonion/soft tissue pogonion (linear regression analysis demonstrated slopes [β1 values] of 0.94 and 0.92, respectively). These ratios were consistent throughout the sample population and are highly predictive of the soft tissue response that can be anticipated. Magnitude of advancement, age, and sex of the patient had no effect on these ratios in our population. This study assists with our understanding of the soft tissue response that accompanies bony elongation during distraction osteogenesis which will allow us to more effectively treatment plan the orthodontic and surgical intervention that will optimize the patients\u27 functional and esthetic outcome

Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: A review of the National Cancer Database

For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson-Deyo comorbidity score ≥2 (OR 0.82), and high-volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non-Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high-volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival

Hormonal contraceptive use increases serum 25-hydroxyvitamin D concentrations in active, young women [abstract]

Abstract only availableMany studies have shown that the estrogen in oral hormonal contraceptives (HC) increases serum 25-hydroxyvitamin D 25(OH)D concentrations in women. As a hormone that regulates gene transcription estrogen is known to increase Vitamin-D binding protein concentrations, and therefore 25(OH)D concentrations in the blood. Furthermore, Vitamin D is a major regulator of bone metabolism and its status within the blood influences circulating levels of bone turnover markers. The objective of this study was to determine the effects of HC use on serum 25OHD concentrations and biochemical markers of bone turnover in active young females. Thirty-nine young (age 18-33 years), active (≥5 h of aerobic exercise per week) women participated (HC users, n=16; Non-users, n=23). Of the HC users, 9 were taking monophasic HC; 7 were taking triphasic HC. Fasting serum samples were taken during the early follicular phase (d2-5 of the menstrual cycle) and were analyzed for 25OHD and biochemical bone markers [bone alkaline phosphatase (BAP), N-telopeptide of collagen cross-links (NTx), parathyroid hormone (PTH) and osteocalcin (OC)] using radioimmuno assay and ELISA, respectively. Serum 25OHD was significantly greater (p=.007) and BAP significantly lower (p=.002) in HC users compared with nonusers. No differences were found between groups for NTx, PTH or osteocalcin. Serum concentrations of BAP and Vitamin D were negatively correlated (r= -.453; p=.004). We conclude that HC use is associated with increased serum 25OHD concentrations and lower circulating BAP in young active females

Reflections on the Arts, Environment, and Culture After Ten Years of The Goose

To mark the tenth anniversary of The Goose, we asked prominent ecologically-minded scholars, writers, artists, and educators from across Canada to reflect on the relationship between the arts, culture, and the environment. Their comments illuminate a wide range of triumphs and tensions, from the politics and practices of environmentalist writing and art, to the connections between the environment and matters of diversity and justice, to the past and future of ALECC (Association for Literature, Environment, and Culture in Canada), to the world of a single poem

Treatment evolution in high-risk congenital diaphragmatic hernia: ten years\u27 experience with diaphragmatic agenesis.

OBJECTIVE: The objective of this study was to evaluate the impact of newer therapies on the highest risk patients with congenital diaphragmatic hernia (CDH), those with agenesis of the diaphragm. SUMMARY BACKGROUND DATA: CDH remains a significant cause of neonatal mortality. Many novel therapeutic interventions have been used in these infants. Those children with large defects or agenesis of the diaphragm have the highest mortality and morbidity. METHODS: Twenty centers from 5 countries collected data prospectively on all liveborn infants with CDH over a 10-year period. The treatment and outcomes in these patients were examined. Patients were followed until death or hospital discharge. RESULTS: A total of 1,569 patients with CDH were seen between January 1995 and December 2004 in 20 centers. A total of 218 patients (14%) had diaphragmatic agenesis and underwent repair. The overall survival for all patients was 68%, while survival was 54% in patients with agenesis. When patients with diaphragmatic agenesis from the first 2 years were compared with similar patients from the last 2 years, there was significantly less use of ECMO (75% vs. 52%) and an increased use of inhaled nitric oxide (iNO) (30% vs. 80%). There was a trend toward improved survival in patients with agenesis from 47% in the first 2 years to 59% in the last 2 years. The survivors with diaphragmatic agenesis had prolonged hospital stays compared with patients without agenesis (median, 68 vs. 30 days). For the last 2 years of the study, 36% of the patients with agenesis were discharged on tube feedings and 22% on oxygen therapy. CONCLUSIONS: There has been a change in the management of infants with CDH with less frequent use of ECMO and a greater use of iNO in high-risk patients with a potential improvement in survival. However, the mortality, hospital length of stay, and morbidity in agenesis patients remain significant

Optical Alignment of the JWST ISIM to the OTE Simulator (OSIM): Current Concept and Design Studies

The James Webb Space Telescope's (JWST) Integrated Science Instrument Module (ISIM) contains the observatory's four science instruments and their support subsystems. During alignment and test of the integrated ISIM at NASA's Goddard Space Flight Center (GSFC), the Optical'telescope element SIMulator (OSIM) will be used to optically stimulate the science instruments to verify their operation and performance. In this paper we present the design of two cryogenic alignment fixtures that will be used to determine and verify the proper alignment of OSIM to ISIM during testing at GSFC. These fixtures, the Master Alignment Target Fixture (MAW) and the ISIM Alignment Target Fixture (IATF), will provide continuous, six degree of freedom feedback to OSIM during initial ambient alignment as well as during cryogenic vacuum testing. These fixtures will allow us to position the OSIM and maintain OSIM-ISIM alignment to better than 10 microns in translation and 250 micro-radians in rotation. We will provide a brief overview of the OSIM system and calibration and we will also discuss the relevance of these fixtures in the context of the overall ISIM alignment and verification plan

Direct detection of alpha synuclein oligomers in vivo

Background: Rat models of Parkinson’s disease are widely used to elucidate the mechanisms underlying disease etiology or to investigate therapeutic approaches. Models were developed using toxins such as MPTP or 6-OHDA to specifically target dopaminergic neurons resulting in acute neuronal loss in the substantia nigra or by using viral vectors to induce the specific and gradual expression of alpha synuclein in the substantia nigra. The detection of alpha- synuclein oligomers, the presumed toxic species, in these models and others has been possible using only indirect biochemical approaches to date. Here we coinjected AAVs encoding alpha-synuclein fused to the N- or C-terminal half of VenusYFP in rat substantia nigra pars compacta and describe for the first time a novel viral vector rodent model with the unique ability to directly detect and track alpha synuclein oligomers ex vivo and in vivo. Results: Viral coinjection resulted in widespread VenusYFP signal within the nigrostriatal pathway, including cell bodies in the substantia nigra and synaptic accumulation in striatal terminals, suggestive of in vivo alpha-synuclein oligomers formation. Transduced rats showed alpha-synuclein induced dopaminergic neuron loss in the substantia nigra, the appearance of dystrophic neurites, and gliosis in the striatum. Moreover, we have applied in vivo imaging techniques in the living mouse to directly image alpha-synuclein oligomers in the cortex. Conclusion: We have developed a unique animal model that provides a tool for the Parkinson’s disease research community with which to directly detect alpha- synuclein oligomers in vivo and screen therapeutic approaches targeting alpha-synuclein oligomers

The ENIGMA Stroke Recovery Working Group: Big data neuroimaging to study brain–behavior relationships after stroke

The goal of the Enhancing Neuroimaging Genetics through Meta‐Analysis (ENIGMA) Stroke Recovery working group is to understand brain and behavior relationships using well‐powered meta‐ and mega‐analytic approaches. ENIGMA Stroke Recovery has data from over 2,100 stroke patients collected across 39 research studies and 10 countries around the world, comprising the largest multisite retrospective stroke data collaboration to date. This article outlines the efforts taken by the ENIGMA Stroke Recovery working group to develop neuroinformatics protocols and methods to manage multisite stroke brain magnetic resonance imaging, behavioral and demographics data. Specifically, the processes for scalable data intake and preprocessing, multisite data harmonization, and large‐scale stroke lesion analysis are described, and challenges unique to this type of big data collaboration in stroke research are discussed. Finally, future directions and limitations, as well as recommendations for improved data harmonization through prospective data collection and data management, are provided