Comparison of transjugular intrahepatic portosystemic shunt with covered stent and balloon-occluded retrograde transvenous obliteration in managing isolated gastric varices

OBJECTIVE: Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience. MATERIALS AND METHODS: We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups. RESULTS: There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months. CONCLUSION: BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy

Reducing Perineal Tears: The Effect of Pushing Methods and Length of 2nd Stage of Labor

Objective: To evaluate the current literature evidence for the effects of either instructed or spontaneous pushing on perineal laceration incidence during delivery and the duration of second stage of labor. Background: Lacerations (tears) of the perineum are common among women during delivery, increasing pain, infection risk, and other problems for women. Furthermore, prolonged second stage of labor has been shown a risk factor for lacerations. Pushing methods could have an effect on the incidence of lacerations and duration of second stage of labor. Methods: Thorough search of online databases for the highest levels of evidence relating to the topic within the last 5 years. Results: Spontaneous pushing versus instructed pushing method may decrease laceration incidence, according to limited evidence; however, other studies do not find this effect to be statistically significant. In addition, spontaneous pushing results in longer second stage of labor, having a possible indirect effect on laceration incidence. Conclusion: Since no evidence strongly supports either pushing method as beneficial for decreasing lacerations, further research on this topic seems warranted. For now, either method may be accepted for use in current medical practice

Impact of a brief faculty training to improve patient-centered communication while using electronic health records

Objective Despite rapid EHR adoption, few faculty receive training in how to implement patient-centered communication skills while using computers in exam rooms. We piloted a patient-centered EHR use training to address this issue. Methods Faculty received four hours of training at Cleveland Clinic and a condensed 90-minute version at the University of Chicago. Both included a lecture and a Group-Objective Structured Clinical Exam (GOSCE) experience. Direct observations of 10 faculty in their clinical practices were performed pre- and post-workshop. Results Thirty participants (94%) completed a post-workshop evaluation assessing knowledge, attitude, and skills. Faculty reported that training was important, relevant, and should be required for all providers; no differences were found between longer versus shorter training. Participants in the longer training reported higher GOSCE efficacy, however shorter workshop participants agreed more with the statement that they had gained new knowledge. Faculty improved their patient-centered EHR use skills in clinical practice on post- versus pre-workshop ratings using a validated direct-observation rating tool. Conclusion A brief lecture and GOSCE can be effective in training busy faculty on patient-centered EHR use skills. Practice Implications Faculty training on patient-centered EHR skills can enhance patient-doctor communication and promotes positive role modeling of these skills to learners

Development and initial testing of the self‐care of chronic illness inventory

Aim The aim was to develop and psychometrically test the self‐care of chronic illness Inventory, a generic measure of self‐care. Background Existing measures of self‐care are disease‐specific or behaviour‐specific; no generic measure of self‐care exists. Design Cross‐sectional survey. Methods We developed a 20‐item self‐report instrument based on the Middle Range Theory of Self‐Care of Chronic Illness, with three separate scales measuring Self‐Care Maintenance, Self‐Care Monitoring, and Self‐Care Management. Each of the three scales is scored separately and standardized 0–100 with higher scores indicating better self‐care. After demonstrating content validity, psychometric testing was conducted in a convenience sample of 407 adults (enrolled from inpatient and outpatient settings at five sites in the United States and ResearchMatch.org). Dimensionality testing with confirmatory factor analysis preceded reliability testing. Results The Self‐Care Maintenance scale (eight items, two dimensions: illness‐related and health‐promoting behaviour) fit well when tested with a two‐factor confirmatory model. The Self‐Care Monitoring scale (five items, single factor) fitted well. The Self‐Care Management scale (seven items, two factors: autonomous and consulting behaviour), when tested with a two‐factor confirmatory model, fitted adequately. A simultaneous confirmatory factor analysis on the combined set of items supported the more general model. Conclusion The self‐care of chronic illness inventory is adequate in reliability and validity. We suggest further testing in diverse populations of patients with chronic illnesses

Elevated Depressive Symptoms and Incident Stroke in Hispanic, African-American, and White Older Americans

Although depressive symptoms have been linked to stroke, most research has been in relatively ethnically homogeneous, predominantly white, samples. Using the United States based Health and Retirement Study, we compared the relationships between elevated depressive symptoms and incident first stroke for Hispanic, black, or white/other participants (N = 18,648) and estimated the corresponding Population Attributable Fractions. The prevalence of elevated depressive symptoms was higher in blacks (27%) and Hispanics (33%) than whites/others (18%). Elevated depressive symptoms prospectively predicted stroke risk in the whites/other group (HR = 1.53; 95% CI: 1.36–1.73) and among blacks (HR = 1.31; 95% CI: 1.05–1.65). The HR was similar but only marginally statistically significant among Hispanics (HR = 1.33; 95% CI: 0.92–1.91). The Population Attributable Fraction, indicating the percent of first strokes that would be prevented if the incident stroke rate in those with elevated depressive symptoms was the same as the rate for those without depressive symptoms, was 8.3% for whites/others, 7.8% for blacks, and 10.3% for Hispanics

Water Enables Efficient CO2 Capture from Natural Gas Flue Emissions in an Oxidation-Resistant Diamine-Appended Metal-Organic Framework.

Supported by increasingly available reserves, natural gas is achieving greater adoption as a cleaner-burning alternative to coal in the power sector. As a result, carbon capture and sequestration from natural gas-fired power plants is an attractive strategy to mitigate global anthropogenic CO2 emissions. However, the separation of CO2 from other components in the flue streams of gas-fired power plants is particularly challenging due to the low CO2 partial pressure (∼40 mbar), which necessitates that candidate separation materials bind CO2 strongly at low partial pressures (≤4 mbar) to capture ≥90% of the emitted CO2. High partial pressures of O2 (120 mbar) and water (80 mbar) in these flue streams have also presented significant barriers to the deployment of new technologies for CO2 capture from gas-fired power plants. Here, we demonstrate that functionalization of the metal-organic framework Mg2(dobpdc) (dobpdc4- = 4,4'-dioxidobiphenyl-3,3'-dicarboxylate) with the cyclic diamine 2-(aminomethyl)piperidine (2-ampd) produces an adsorbent that is capable of ≥90% CO2 capture from a humid natural gas flue emission stream, as confirmed by breakthrough measurements. This material captures CO2 by a cooperative mechanism that enables access to a large CO2 cycling capacity with a small temperature swing (2.4 mmol CO2/g with ΔT = 100 °C). Significantly, multicomponent adsorption experiments, infrared spectroscopy, magic angle spinning solid-state NMR spectroscopy, and van der Waals-corrected density functional theory studies suggest that water enhances CO2 capture in 2-ampd-Mg2(dobpdc) through hydrogen-bonding interactions with the carbamate groups of the ammonium carbamate chains formed upon CO2 adsorption, thereby increasing the thermodynamic driving force for CO2 binding. In light of the exceptional thermal and oxidative stability of 2-ampd-Mg2(dobpdc), its high CO2 adsorption capacity, and its high CO2 capture rate from a simulated natural gas flue emission stream, this material is one of the most promising adsorbents to date for this important separation

Molecular Epidemiology of Escherichia coli Producing CTX-M and pAmpC β-Lactamases from Dairy Farms Identifies a Dominant Plasmid Encoding CTX-M-32 but No Evidence for Transmission to Humans in the Same Geographical Region

Third-generation cephalosporin resistance (3GC-R) in Escherichia coli is a rising problem in human and farmed-animal populations. We conducted whole-genome sequencing analysis of 138 representative 3GC-R isolates previously collected from dairy farms in southwest England and confirmed by PCR to carry acquired 3GC-R genes. This analysis identified bla(CTX-M) (131 isolates encoding CTX-M-1, -14, -15, -and 32 and the novel variant CTX-M-214), bla(CMY-2) (6 isolates), and bla(DHA-1) (1 isolate). A highly conserved plasmid was identified in 73 isolates, representing 27 E. coli sequence types. This novel ∼220-kb IncHI2 plasmid carrying bla(CTX-M-32) was sequenced to closure and designated pMOO-32. It was found experimentally to be stable in cattle and human transconjugant E. coli even in the absence of selective pressure and was found by multiplex PCR to be present on 26 study farms representing a remarkable range of transmission over 1,500 square kilometers. However, the plasmid was not found among human urinary E. coli isolates we recently characterized from people living in the same geographical location, collected in parallel with farm sampling. There were close relatives of two bla(CTX-M) plasmids circulating among eight human and two cattle isolates, and a closely related bla(CMY-2) plasmid was found in one cattle and one human isolate. However, phylogenetic evidence of recent sharing of 3GC-R strains between farms and humans in the same region was not found. IMPORTANCE Third-generation cephalosporins (3GCs) are critically important antibacterials, and 3GC resistance (3GC-R) threatens human health, particularly in the context of opportunistic pathogens such as Escherichia coli. There is some evidence for zoonotic transmission of 3GC-R E. coli through food, but little work has been done examining possible transmission via interaction of people with the local near-farm environment. We characterized acquired 3GC-R E. coli found on dairy farms in a geographically restricted region of the United Kingdom and compared these with E. coli from people living in the same region, collected in parallel. While there is strong evidence for recent farm-to-farm transmission of 3GC-R strains and plasmids—including one epidemic plasmid that has a remarkable capacity to be transmitted—there was no evidence that 3GC-R E. coli found on study farms had a significant impact on circulating 3GC-R E. coli strains or plasmids in the local human population

Modeling shear waves through a viscoelastic medium induced by acoustic radiation force

In this study, a finite element model of a tissue-mimicking, viscoelastic phantom with a stiffer cylindrical inclusion subjected to an acoustic radiation force (ARF) is presented, and the resulting shear waves through the heterogeneous media are simulated, analyzed, and compared with experimental data. Six different models for the ARF were considered and compared. Each study used the same finite element model, but applied the following: (1) full radiation push; (2) focal region push; (3) single element focal point source; or (4) various thresholds of the full radiation push. For each case, displacements at discrete locations were determined and compared. The finite element simulation results for the full radiation push matched well with the experimental data with respect to replicating the shear wave speed and attenuation in the peak displacements through the background medium and inclusion, but did not illustrate comparable recovery after the peak displacements. As a result of this study, it has been shown that a focal region or point source push is not adequate to accurately model the effects of the full radiation push, but thresholding the full push can produce comparable results and reduce computation time