Cardioverting acute atrial fibrillation and the risk of thromboembolism: not all patients are created equal

Current guidelines support the well-established clinical practice that patients who present with atrial fibrillation (AF) of less than 48 hours duration should be considered for cardioversion, even in the absence of pre-existing anticoagulation. However, with increasing evidence that short runs of AF confer significant risk of stroke, on what evidence is this 48-hour rule based and is it time to adopt a new approach? We review existing evidence and suggest a novel approach to risk stratification in this setting. Overall, the risk of thromboembolism associated with acute cardioversion of patients with AF that is estimated to be of <48 hours duration is low. However, this risk varies widely depending on patient characteristics. From existing evidence, we show that using the CHA2DS2-VASc score may allow better selection of appropriate patients in order to prevent exposing specific patient groups to an unacceptably high risk of a potentially devastating complication

Auscultating heart and breath sounds through patients’ gowns: who does this and does it matter?

Background Doctors are taught to auscultate with the stethoscope applied to the skin, but in practice may be seen applying the stethoscope to the gown. Objectives To determine how often doctors auscultate heart and breath sounds through patients’ gowns, and to assess the impact of this approach on the quality of the sounds heard. Methods A sample of doctors in the west of Scotland were sent an email in 2014 inviting them to answer an anonymous questionnaire about how they auscultated heart and breath sounds. Normal heart sounds from two subjects were recorded through skin, through skin and gown, and through skin, gown and dressing gown. These were played to doctors, unaware of the origin of each recording, who completed a questionnaire about the method and quality of the sounds they heard. Results 206 of 445 (46%) doctors completed the questionnaire. 124 (60%) stated that they listened to patients’ heart sounds, and 156 (76%) to patients’ breath sounds, through patients’ gowns. Trainees were more likely to do this compared with consultants (OR 3.39, 95% CI 1.74 to 6.65). Doctors of all grades considered this practice affected the quality of the sounds heard. 32 doctors listened to the recorded heart sounds. 23 of the 64 (36%) skin and 23 of the 64 (36%) gown recordings were identified. The majority of doctors (74%) could not differentiate between skin or gown recordings, but could tell them apart from the double layer recordings (p=0.02). Trainees were more likely to hear artefactual added sounds (p=0.04). Conclusions Many doctors listen to patients’ heart and breath sounds through hospital gowns, at least occasionally. In a short test, most doctors could not distinguish between sounds heard through a gown or skin. Further work is needed to determine the impact of this approach to auscultation on the identification of murmurs and added sounds

Chains of large gaps between primes

Let $p_n$ denote the $n$-th prime, and for any $k \geq 1$ and sufficiently large $X$, define the quantity $$G_k(X) := \max_{p_{n+k} \leq X} \min( p_{n+1}-p_n, \dots, p_{n+k}-p_{n+k-1} ),$$ which measures the occurrence of chains of $k$ consecutive large gaps of primes. Recently, with Green and Konyagin, the authors showed that $$G_1(X) \gg \frac{\log X \log \log X\log\log\log\log X}{\log \log \log X}$$ for sufficiently large $X$. In this note, we combine the arguments in that paper with the Maier matrix method to show that $$G_k(X) \gg \frac{1}{k^2} \frac{\log X \log \log X\log\log\log\log X}{\log \log \log X}$$ for any fixed $k$ and sufficiently large $X$. The implied constant is effective and independent of $k$.Comment: 16 pages, no figure

Anatomical and biomechanical traits of broiler chickens across ontogeny. Part II. Body segment inertial properties and muscle architecture of the pelvic limb

In broiler chickens, genetic success for desired production traits is often shadowed by welfare concerns related to musculoskeletal health. Whilst these concerns are clear, a viable solution is still elusive. Part of the solution lies in knowing how anatomical changes in afflicted body systems that occur across ontogeny influence standing and moving. Here, to demonstrate these changes we quantify the segment inertial properties of the whole body, trunk (legs removed) and the right pelvic limb segments of five broilers at three different age groups across development. We also consider how muscle architecture (mass, fascicle length and other properties related to mechanics) changes for selected muscles of the pelvic limb. All broilers used had no observed lameness, but we document the limb pathologies identified post mortem, since these two factors do not always correlate, as shown here. The most common leg disorders, including bacterial chondronecrosis with osteomyelitis and rotational and angular deformities of the lower limb, were observed in chickens at all developmental stages. Whole limb morphology is not uniform relative to body size, with broilers obtaining large thighs and feet between four and six weeks of age. This implies that the energetic cost of swinging the limbs is markedly increased across this growth period, perhaps contributing to reduced activity levels. Hindlimb bone length does not change during this period, which may be advantageous for increased stability despite the increased energetic costs. Increased pectoral muscle growth appears to move the centre of mass cranio-dorsally in the last two weeks of growth. This has direct consequences for locomotion (potentially greater limb muscle stresses during standing and moving). Our study is the first to measure these changes in the musculoskeletal system across growth in chickens, and reveals how artificially selected changes of the morphology of the pectoral apparatus may cause deficits in locomotion

Musculoskeletal modelling of an ostrich (Struthio camelus) pelvic limb: influence of limb orientation on muscular capacity during locomotion

We developed a three-dimensional, biomechanical computer model of the 36 major pelvic limb muscle groups in an ostrich (Struthio camelus) to investigate muscle function in this, the largest of extant birds and model organism for many studies of locomotor mechanics, body size, anatomy and evolution. Combined with experimental data, we use this model to test two main hypotheses. We first query whether ostriches use limb orientations (joint angles) that optimize the moment-generating capacities of their muscles during walking or running. Next, we test whether ostriches use limb orientations at mid-stance that keep their extensor muscles near maximal, and flexor muscles near minimal, moment arms. Our two hypotheses relate to the control priorities that a large bipedal animal might evolve under biomechanical constraints to achieve more effective static weight support. We find that ostriches do not use limb orientations to optimize the moment-generating capacities or moment arms of their muscles. We infer that dynamic properties of muscles or tendons might be better candidates for locomotor optimization. Regardless, general principles explaining why species choose particular joint orientations during locomotion are lacking, raising the question of whether such general principles exist or if clades evolve different patterns (e.g., weighting of muscle force–length or force–velocity properties in selecting postures). This leaves theoretical studies of muscle moment arms estimated for extinct animals at an impasse until studies of extant taxa answer these questions. Finally, we compare our model’s results against those of two prior studies of ostrich limb muscle moment arms, finding general agreement for many muscles. Some flexor and extensor muscles exhibit self-stabilization patterns (posture-dependent switches between flexor/extensor action) that ostriches may use to coordinate their locomotion. However, some conspicuous areas of disagreement in our results illustrate some cautionary principles. Importantly, tendon-travel empirical measurements of muscle moment arms must be carefully designed to preserve 3D muscle geometry lest their accuracy suffer relative to that of anatomically realistic models. The dearth of accurate experimental measurements of 3D moment arms of muscles in birds leaves uncertainty regarding the relative accuracy of different modelling or experimental datasets such as in ostriches. Our model, however, provides a comprehensive set of 3D estimates of muscle actions in ostriches for the first time, emphasizing that avian limb mechanics are highly three-dimensional and complex, and how no muscles act purely in the sagittal plane. A comparative synthesis of experiments and models such as ours could provide powerful synthesis into how anatomy, mechanics and control interact during locomotion and how these interactions evolve. Such a framework could remove obstacles impeding the analysis of muscle function in extinct taxa

Attention model of binocular rivalry

This is the final version of the article. Available from National Academy of Sciences from the DOI in this record.When the corresponding retinal locations in the two eyes are presented with incompatible images, a stable percept gives way to perceptual alternations in which the two images compete for perceptual dominance. As perceptual experience evolves dynamically under constant external inputs, binocular rivalry has been used for studying intrinsic cortical computations and for understanding how the brain regulates competing inputs. Converging behavioral and EEG results have shown that binocular rivalry and attention are intertwined: binocular rivalry ceases when attention is diverted away from the rivalry stimuli. In addition, the competing image in one eye suppresses the target in the other eye through a pattern of gain changes similar to those induced by attention. These results require a revision of the current computational theories of binocular rivalry, in which the role of attention is ignored. Here, we provide a computational model of binocular rivalry. In the model, competition between two images in rivalry is driven by both attentional modulation and mutual inhibition, which have distinct selectivity (feature vs. eye of origin) and dynamics (relatively slow vs. relatively fast). The proposed model explains a wide range of phenomena reported in rivalry, including the three hallmarks: (i) binocular rivalry requires attention; (ii) various perceptual states emerge when the two images are swapped between the eyes multiple times per second; (iii) the dominance duration as a function of input strength follows Levelt’s propositions. With a bifurcation analysis, we identified the parameter space in which the model’s behavior was consistent with experimental results.This work was supported by NIH National Eye Institute Grants R01-EY019693 (to M.C. and D.J.H.) and R01-EY025673 (to D.J.H.). H.-H.L. was supported by NIH Grant R90DA043849. J. Rankin was supported by the Swartz Foundation

On the ratio of consecutive gaps between primes

In the present work we prove a common generalization of Maynard-Tao's recent result about consecutive bounded gaps between primes and on the Erd\H{o}s-Rankin bound about large gaps between consecutive primes. The work answers in a strong form a 60 years old problem of Erd\"os, which asked whether the ratio of two consecutive primegaps can be infinitely often arbitrarily small, and arbitrarily large, respectively