Three- versus four-factor prothrombin complex concentrate for the reversal of warfarin-induced bleeding

Objective: The objective of this study was to evaluate the effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) compared to 4-factor PCC (4F-PCC) in warfarin-associated bleeding. Methods: This multicenter, retrospective, cohort study analyzed data from patients admitted between May 2011 and October 2014 who received PCC for warfarin-associated bleeding. The primary outcome was the rate of international normalized ratio (INR) normalization, defined as an INR ≤1.3, after administration of 3F-PCC compared to 4F-PCC. Other variables of interest included the incidence of additional reversal agents, new thromboembolic events, and mortality. Results: A total of 134 patients were included in the analysis. The average dose of PCC administered was 24.6 ± 9.3 units/kg versus 36.3 ± 12.8 units/kg in the 3F-PCC and 4F-PCC groups, respectively, P < 0.001. Baseline INR in the 3F-PCC and 4F-PCC groups was 3.61 ± 2.3 and 6.87 ± 2.3, respectively P < 0.001. 4F-PCC had a higher rate of INR normalization at first INR check post-PCC administration compared to 3F-PCC (84.2% vs. 51.9%, P = 0.0001). Thromboembolic events, intensive care unit and hospital length of stay, and mortality were similar among both groups. Conclusion: The use of 4F-PCC leads to a more significant reduction in INR compared to 3F-PCC though no difference in mortality or length of stay was observed. Thromboembolism rates were similar among both groups

Theoretical investigation of transgastric and intraductal approaches for ultrasound-based thermal therapy of the pancreas.

BackgroundThe goal of this study was to theoretically investigate the feasibility of intraductal and transgastric approaches to ultrasound-based thermal therapy of pancreatic tumors, and to evaluate possible treatment strategies.MethodsThis study considered ultrasound applicators with 1.2 mm outer diameter tubular transducers, which are inserted into the tissue to be treated by an endoscopic approach, either via insertion through the gastric wall (transgastric) or within the pancreatic duct lumen (intraductal). 8 patient-specific, 3D, transient, biothermal and acoustic finite element models were generated to model hyperthermia (n = 2) and ablation (n = 6), using sectored (210°-270°, n = 4) and 360° (n = 4) transducers for treatment of 3.3-17.0 cm3 tumors in the head (n = 5), body (n = 2), and tail (n = 1) of the pancreas. A parametric study was performed to determine appropriate treatment parameters as a function of tissue attenuation, blood perfusion rates, and distance to sensitive anatomy.ResultsParametric studies indicated that pancreatic tumors up to 2.5 or 2.7 cm diameter can be ablated within 10 min with the transgastric and intraductal approaches, respectively. Patient-specific simulations demonstrated that 67.1-83.3% of the volumes of four sample 3.3-11.4 cm3 tumors could be ablated within 3-10 min using transgastric or intraductal approaches. 55.3-60.0% of the volume of a large 17.0 cm3 tumor could be ablated using multiple applicator positions within 20-30 min with either transgastric or intraductal approaches. 89.9-94.7% of the volume of two 4.4-11.4 cm3 tumors could be treated with intraductal hyperthermia. Sectored applicators are effective in directing acoustic output away from and preserving sensitive structures. When acoustic energy is directed towards sensitive structures, applicators should be placed at least 13.9-14.8 mm from major vessels like the aorta, 9.4-12.0 mm from other vessels, depending on the vessel size and flow rate, and 14 mm from the duodenum.ConclusionsThis study demonstrated the feasibility of generating shaped or conformal ablative or hyperthermic temperature distributions within pancreatic tumors using transgastric or intraductal ultrasound

Understanding the experiences of engaging in a community-based, physical-activity focused secondary stroke prevention program

Research has evidenced that regular exercise can provide physical and physiological benefits for people living with stroke. Our study aims to explore the experiences of people living with stroke when participating in a community physical activity programme. This programme was created to offer targeted physical activity and education interventions following the discharge of patients from the healthcare pathway. This qualitative study involved semi-structured interviews with 16 participants living with stroke who were recruited from individuals who had engaged with the activity programme. A reflexive thematic analysis was conducted on the data, and four overarching themes were developed: (i) Feelings of appreciation, (ii) Interactions with other patients, (iii) Positive contributions of trained instructors, and iv) Personal progress. Generally, participants reported very positive perceptions of the exercise programme, and were very grateful for the opportunity that the exercise classes provided. We hope that these findings will offer practical suggestions for healthcare providers who might develop similar activity programmes for clinical populations

Using individual tracking data to validate the predictions of species distribution models

The authors would like to thank the College of Life Sciences of Aberdeen University and Marine Scotland Science which funded CP's PhD project. Skate tagging experiments were undertaken as part of Scottish Government project SP004. We thank Ian Burrett for help in catching the fish and the other fishermen and anglers who returned tags. We thank José Manuel Gonzalez-Irusta for extracting and making available the environmental layers used as environmental covariates in the environmental suitability modelling procedure. We also thank Jason Matthiopoulos for insightful suggestions on habitat utilization metrics as well as Stephen C.F. Palmer, and three anonymous reviewers for useful suggestions to improve the clarity and quality of the manuscript.Peer reviewedPostprintPostprintPostprintPostprintPostprin

Models of human preference for learning reward functions

The utility of reinforcement learning is limited by the alignment of reward functions with the interests of human stakeholders. One promising method for alignment is to learn the reward function from human-generated preferences between pairs of trajectory segments, a type of reinforcement learning from human feedback (RLHF). These human preferences are typically assumed to be informed solely by partial return, the sum of rewards along each segment. We find this assumption to be flawed and propose modeling human preferences instead as informed by each segment's regret, a measure of a segment's deviation from optimal decision-making. Given infinitely many preferences generated according to regret, we prove that we can identify a reward function equivalent to the reward function that generated those preferences, and we prove that the previous partial return model lacks this identifiability property in multiple contexts. We empirically show that our proposed regret preference model outperforms the partial return preference model with finite training data in otherwise the same setting. Additionally, we find that our proposed regret preference model better predicts real human preferences and also learns reward functions from these preferences that lead to policies that are better human-aligned. Overall, this work establishes that the choice of preference model is impactful, and our proposed regret preference model provides an improvement upon a core assumption of recent research. We have open sourced our experimental code, the human preferences dataset we gathered, and our training and preference elicitation interfaces for gathering a such a dataset.Comment: 16 pages (40 pages with references and appendix), 23 figure

A pneumatic power harvesting ankle-foot orthosis to prevent foot-drop

<p>Abstract</p> <p>Background</p> <p>A self-contained, self-controlled, pneumatic power harvesting ankle-foot orthosis (PhAFO) to manage foot-drop was developed and tested. Foot-drop is due to a disruption of the motor control pathway and may occur in numerous pathologies such as stroke, spinal cord injury, multiple sclerosis, and cerebral palsy. The objectives for the prototype PhAFO are to provide toe clearance during swing, permit free ankle motion during stance, and harvest the needed power with an underfoot bellow pump pressurized during the stance phase of walking.</p> <p>Methods</p> <p>The PhAFO was constructed from a two-part (tibia and foot) carbon composite structure with an articulating ankle joint. Ankle motion control was accomplished through a cam-follower locking mechanism actuated via a pneumatic circuit connected to the bellow pump and embedded in the foam sole. Biomechanical performance of the prototype orthosis was assessed during multiple trials of treadmill walking of an able-bodied control subject (n = 1). Motion capture and pressure measurements were used to investigate the effect of the PhAFO on lower limb joint behavior and the capacity of the bellow pump to repeatedly generate the required pneumatic pressure for toe clearance.</p> <p>Results</p> <p>Toe clearance during swing was successfully achieved during all trials; average clearance 44 ± 5 mm. Free ankle motion was observed during stance and plantarflexion was blocked during swing. In addition, the bellow component repeatedly generated an average of 169 kPa per step of pressure during ten minutes of walking.</p> <p>Conclusion</p> <p>This study demonstrated that fluid power could be harvested with a pneumatic circuit built into an AFO, and used to operate an actuated cam-lock mechanism that controls ankle-foot motion at specific periods of the gait cycle.</p

Biotypes of Central Nervous System Complications in People With Human Immunodeficiency Virus: Virology, Immunology, and Neuropathology

Despite viral suppression with antiretroviral therapy (ART), people with human immunodeficiency virus (HIV) continue to experience central nervous system (CNS) complications, primarily in the form of mild cognitive impairment and mental health disorders (eg, depression, anxiety, other neuropsychiatric problems). The multifactorial pathogenesis and heterogeneity of mechanisms likely underlying CNS complications must be addressed in the development of preventive interventions and effective treatments. The biotyping approach has previously been useful to define phenotypes of other CNS diseases based on underlying mechanisms and could be translated to the field of neuroHIV. The purpose of the Biotype Workshop series, and the Virology, Immunology and Neuropathology Working Group in particular, is to capitalize on current and new technologies and guide future research efforts using the wealth of available immunological, virologic, and neuropathological data collected from people with HIV on and off ART

2010 Solar and Space Physics Decadal Survey White Paper: Next Steps in Solar Spectral Irradiance Studies

Understanding the physical causes underlying solar spectral irradiance variations and the impact of these variations on terrestrial climate remain critical compelling challenges. On the solar side, the most fundamental unknown is the role of the “quiet-sun7 ,” a question brought into focus by spectral irradiance observations during the recent deep minimum, which show opposing trends in the infrared and ultraviolet portions of the spectrum (Harder et al. 2009). On the terrestrial side, while it is clear that the Sun played only a small role in late twentieth century warming, the signature of solar cycle variations in climate are now quite well established (Gray et al. 2010). How this coupling occurs is not fully understood, suggesting something incomplete in our understanding of the climate system. We suggest that in the coming decade, through the focused efforts outlined below, we can successfully address both of these scientific challenges and emerge with a new more complete understanding of the Sun and its influence on Earth. The essential ingredients in this effort are poised at the edge of our abilities, challenging but not risky, and take full advantage of current technological capabilities

Biofabrication of human articular cartilage: a path towards the development of a clinical treatment

Cartilage injuries cause pain and loss of function, and if severe may result in osteoarthritis (OA). 3D bioprinting is now a tangible option for the delivery of bioscaffolds capable of regenerating the deficient cartilage tissue. Our team has developed a handheld device, the Biopen, to allow in situ additive manufacturing during surgery. Given its ability to extrude in a core/shell manner, the Biopen can preserve cell viability during the biofabrication process, and it is currently the only biofabrication tool tested as a surgical instrument in a sheep model using homologous stem cells. As a necessary step toward the development of a clinically relevant protocol, we aimed to demonstrate that our handheld extrusion device can successfully be used for the biofabrication of human cartilage. Therefore, this study is a required step for the development of a surgical treatment in human patients. In this work we specifically used human adipose derived mesenchymal stem cells (hADSCs), harvested from the infrapatellar fat pad of donor patients affected by OA, to also prove that they can be utilized as the source of cells for the future clinical application. With the Biopen, we generated bioscaffolds made of hADSCs laden in gelatin methacrylate, hyaluronic acid methacrylate and cultured in the presence of chondrogenic stimuli for eight weeks in vitro. A comprehensive characterisation including gene and protein expression analyses, immunohistology, confocal microscopy, second harmonic generation, light sheet imaging, atomic force mycroscopy and mechanical unconfined compression demonstrated that our strategy resulted in human hyaline-like cartilage formation. Our in situ biofabrication approach represents an innovation with important implications for customizing cartilage repair in patients with cartilage injuries and OA