Splinter

Splinter “Do what you need to,” I said. As though this was extracting an arrowhead buried in flesh, not a sliver of wood from a pinky. She my officemate, colleague, friend. But not – it occurred to me as she started to probe – a surgeon. Probably hadn’t fingered a forceps in years. What I warn my patients against every day – not wise to compromise with convenience. I had no fear of pain. A dozen tours in the OR, years of drawing blood – we learn to distance, numb ourselves. Numb ourselves, that is, to the pain of another – my pinky should have taken itself to Urgent Care. Maybe there was hurt, but I never noticed. All I recall is a flood of sweetness, a drowsy warmth, as when the world is about to go dark. Sometimes as we’re falling we hear a voice calling in the distance. “Oh, shit – going vagal,” this one said. It sounded like mine

Time

Time My index finger was reaching for  the up button on the elevator  when the voice sounded above,  Code Blue Tower 8. Code Blue Tower 8. I broke for the stairs.    They were getting the paddles in place;  the First Year with the floppy hair, Ethan,  pumping the chest; the Night Float, Emily, manning an Ambu-Bag; Jamie, the Resident, running the code.   I dared a look at the face –  Ken, with whom I’d traded jokes  for twenty years – Ken, whom I’d told  yesterday his time was coming –  he’d be back home, maybe two days.   Clear! barked Jamie. Hands backed away, motion suspended. A very long second. The shape on the bed gave a shudder. Then Jamie’s voice: Excellent, a rhythm.   A rhythm – but no pulse. Hands were pumping again,  counting, squeezing in air.  The spark was there on the screen –  life, dancing across it –  but none of the tiny muscles  in the heart were listening.    Epi. Atropine. Thirty minutes.  Ethan looked up at Jamie, she  shot a glance at me. Someone  had to say it – and first  right of refusal to the guy  with gray hair.   A power none of us wished for –  a power none of us have –  but the world pretends.   I felt my head move up and down. Jamie’s eyes found the clock –  7:44 AM, she said. Time

Sugar alcohol provides imaging contrast in cancer detection

Clinical imaging is widely used to detect, characterize and stage cancers in addition to monitoring the therapeutic progress. Magnetic resonance imaging (MRI) aided by contrast agents utilizes the differential relaxivity property of water to distinguish between tumorous and normal tissue. Here, we describe an MRI contrast method for the detection of cancer using a sugar alcohol, maltitol, a common low caloric sugar substitute that exploits the chemical exchange saturation transfer (CEST) property of the labile hydroxyl group protons on maltitol (malCEST). In vitro studies pointed toward concentration and pH-dependent CEST effect peaking at 1?ppm downfield to the water resonance. Studies with control rats showed that intravenously injected maltitol does not cross the intact blood-brain barrier (BBB). In glioma carrying rats, administration of maltitol resulted in the elevation of CEST contrast in the tumor region only owing to permeable BBB. These preliminary results show that this method may lead to the development of maltitol and other sugar alcohol derivatives as MRI contrast agents for a variety of preclinical imaging applications

Adolescent Female Text Messaging Preferences to Prevent Pregnancy After an Emergency Department Visit: A Qualitative Analysis

Background: Over 15 million adolescents use the emergency department (ED) each year in the United States. Adolescent females who use the ED for medical care have been found to be at high risk for unintended pregnancy. Given that adolescents represent the largest users of text messaging and are receptive to receiving text messages related to their sexual health, the ED visit represents an opportunity for intervention. Objective: The aim of this qualitative study was to explore interest in and preferences for the content, frequency, and timing of an ED-based text message intervention to prevent pregnancy for adolescent females. Methods: We conducted semistructured, open-ended interviews in one urban ED in the United States with adolescent females aged 14-19 years. Eligible subjects were adolescents who were sexually active in the past 3 months, presented to the ED for a reproductive health complaint, owned a mobile phone, and did not use effective contraception. Using an interview guide, enrollment continued until saturation of key themes. The investigators designed sample text messages using the Health Beliefs Model and participants viewed these on a mobile phone. The team recorded, transcribed, and coded interviews based on thematic analysis using the qualitative analysis software NVivo and Excel. Results: Participants (n=14) were predominantly Hispanic (13/14; 93%), insured (13/14; 93%), ED users in the past year (12/14; 86%), and frequent text users (10/14; 71% had sent or received >30 texts per day). All were interested in receiving text messages from the ED about pregnancy prevention, favoring messages that were “brief,” “professional,” and “nonaccusatory.” Respondents favored texts with links to websites, repeated information regarding places to receive “confidential” care, and focused information on contraception options and misconceptions. Preferences for text message frequency varied from daily to monthly, with random hours of delivery to maintain “surprise.” No participant feared that text messages would violate her privacy. Conclusions: Adolescent female patients at high pregnancy risk are interested in ED-based pregnancy prevention provided by texting. Understanding preferences for the content, frequency, and timing of messages can guide in designing future interventions in the ED

RE: Advanced Breast Cancer Definitions by Staging System Examined in the Breast Cancer Surveillance Consortium

As investigators for ECOG-ACRIN’s Tomosynthesis Mammographic Imaging Screening Trial (TMIST) trial, we are writing to draw attention to conceptual issues in the outcome definitions and study population in Kerlikowske et al. (1), which limit inferences with respect to the TMIST trial

Frequency of Private Spiritual Activity and Cardiovascular Risk in Post-menopausal Women: The Women\u27s Health Initiative

Purpose: Spirituality has been associated with better cardiac autonomic balance, but its association with cardiovascular risk is not well studied. We examined whether more frequent private spiritual activity was associated with reduced cardiovascular risk in postmenopausal women enrolled in the Women’s Health Initiative Observational Study. Methods: Frequency of private spiritual activity (prayer, Bible reading, and meditation) was selfreported at year 5 of follow-up. Cardiovascular outcomes were centrally adjudicated, and cardiovascular risk was estimated from proportional hazards models. Results: Final models included 43,708 women (mean age: 68.9±7.3; median follow-up: 7.0 years) free of cardiac disease through year 5 of follow-up. In age-adjusted models private spiritual activity was associated with increased cardiovascular risk (HR: 1.16; CI 1.02, 1.31, weekly vs. never; 1.25; CI 1.11, 1.40, daily vs. never). In multivariate models adjusted for demographics, lifestyle, risk factors, and psychosocial factors, such association remained significant only in the group with daily activity (HR 1.16; CI: 1.03, 1.30). Subgroup analyses indicate this association may be driven by the presence of severe chronic diseases. Conclusion: In aging women, higher frequency of private spiritual activity was associated with increased cardiovascular risk, likely reflecting a mobilization of spiritual resources in order to cope with aging and illness

Determinants of mRNA recognition and translation regulation by Lin28

Lin28 is critical for stem cell maintenance and is also associated with advanced human malignancies. Our recent genome-wide studies mark Lin28 as a master post-transcriptional regulator of a subset of messenger RNAs important for cell growth and metabolism. However, the molecular basis underpinning the selective mRNA target regulation is unclear. Here, we provide evidence that Lin28 recognizes a unique motif in multiple target mRNAs, characterized by a small but critical ‘A’ bulge flanked by two G:C base pairs embedded in a complex secondary structure. This motif mediates Lin28-dependent stimulation of translation. As Lin28 is also known to inhibit the biogenesis of a cohort of miRNAs including let-7, we propose that Lin28 binding to different RNA types (precursor miRNAs versus mRNAs) may facilitate recruitment of different co-factors, leading to distinct regulatory outcomes. Our findings uncover a putative yet unexpected motif that may constitute a mechanistic base for the multitude of functions regulated by Lin28 in both stem cells and cancer cells

Arterial properties as determinants of left ventricular mass and fibrosis in severe aortic Stenosis : findings from ACRIN PA 4008

Background-The role of arterial load in severe aortic stenosis is increasingly recognized. However, patterns of pulsatile load and their implications in this population are unknown. We aimed to assess the relationship between the arterial properties and both (1) left ventricular remodeling and fibrosis and (2) the clinical course of patients with severe aortic stenosis undergoing aortic valve replacement (AVR). Methods and Results-We enrolled 38 participants with symptomatic severe aortic stenosis scheduled to undergo surgical AVR. Aortic root characteristic impedance, wave reflections parameters (reflection magnitude, reflected wave transit time), and myocardial extracellular mass were measured with cardiac magnetic resonance imaging and arterial tonometry Cardiac magnetic resonance imaging was repeated at 6 months in 30 participants. A reduction in cellular mass (133.6 versus 113.9 g; P=0.002) but not extracellular mass (42.3 versus 40.6 g; P=0.67) was seen after AVR. Participants with higher extracellular mass exhibited greater reflection magnitude (0.68 versus 0.54; P=0.006) and lower aortic root characteristic impedance (56.3 versus 96.9 dynes/s per cm(5); P=0.006). Reflection magnitude was a significant predictor of smaller improvement in the quality of life (Kansas City Cardiomyopathy Questionnaire score) after AVR (R=-0.51; P=0.0026). The 6-minute walk distance at 6 months after AVR was positively correlated with the reflected wave transit time (R=0.52; P=0.01). Conclusions-Consistent with animal studies, arterial wave reflections are associated with interstitial volume expansion in severe aortic stenosis and predict a smaller improvement in quality of life following AVR. Future trials should assess whether wave reflections represent a potential therapeutic target to mitigate myocardial interstitial remodeling and to improve the clinical status of this patient population