Violent Hiccups: An Infrequent Cause of Bradyarrhythmias

A hiccup, or singultus, results from a sudden, simultaneous, vigorous contraction of the diaphragm and inspiratory muscles, accompanied by closure of the glottis. Hiccups can be associated with bradyarrhythmias. The mechanism of this phenomenon is likely hiccup-induced Valsalva maneuver and increased parasympathetic tone. We present a case of a patient with violent hiccups producing a bradyarrhythmia

Correlation between fracture surface morphology and toughness in Zr-based bulk metallic glasses

Fracture surfaces of Zr-based bulk metallic glasses of various compositions tested in the as-cast and annealed conditions were analyzed using scanning electron microscopy. The tougher samples have shown highly jagged patterns at the beginning stage of crack propagation, and the length and roughness of this jagged pattern correlate well with the measured fracture toughness values. These jagged patterns, the main source of energy dissipation in the sample, are attributed to the formation of shear bands inside the sample. This observation provides strong evidence of significant “plastic zone” screening at the crack tip

Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

BackgroundTranscatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR.MethodsRecords for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost.ResultsOf the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses.ConclusionConscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia

Validation of a Predictive Model for Survival in Patients With Advanced Cancer: Secondary Analysis of RTOG 9714.

BackgroundThe objective of this study was to validate a simple predictive model for survival of patients with advanced cancer.MethodsPrevious studies with training and validation datasets developed a model predicting survival of patients referred for palliative radiotherapy using three readily available factors: primary cancer site, site of metastases and Karnofsky performance score (KPS). This predictive model was used in the current study, where each factor was assigned a value proportional to its prognostic weight and the sum of the weighted scores for each patient was survival prediction score (SPS). Patients were also classified according to their number of risk factors (NRF). Three risk groups were established. The Radiation Therapy and Oncology Group (RTOG) 9714 data was used to provide an additional external validation set comprised of patients treated among multiple institutions with appropriate statistical tests.ResultsThe RTOG external validation set comprised of 908 patients treated at 66 different radiation facilities from 1998 to 2002. The SPS method classified all patients into the low-risk group. Based on the NRF, two distinct risk groups with significantly different survival estimates were identified. The ability to predict survival was similar to that of the training and previous validation datasets for both the SPS and NRF methods.ConclusionsThe three variable NRF model is preferred because of its relative simplicity

The NuSTAR Extragalactic Surveys: unveiling rare, buried AGNs and detecting the contributors to the peak of the Cosmic X-ray Background

We report on the results of active galactic nuclei (AGNs) detection by NuSTAR performed in three extragalactic survey fields (COSMOS, UDS, ECDFS) in three hard bands, namely H1 (8-16 keV), H2 (16-24 keV) and VH (35-55 keV). The aggregated area of the surveys is $\sim 2.7$ deg$^2$. While a large number of sources is detected in the H1 band (72 at the $97\%$ level of reliability), the H2 band directly probing close to the peak of the Cosmic X-ray Background (CXB) returns four significant detections, and two tentative, although not significant, detections are found in the VH band. All the sources detected above 16 keV are also detected at lower energies. We compute the integral number counts for sources in such bands, which show broad consistency with population synthesis models of the CXB. We furthermore identify two Compton-thick AGNs, one in the COSMOS field, associated with a hard and faint Chandra source, and one in the UDS field, never detected in the X-ray band before. Both sources are at the same redshift $z \sim 1.25$, which shifts their Compton-hump into the H1 band, and were previously missed in the usually employed NuSTAR bands, confirming the potential of using the H1 band to discover obscured AGNs at $z > 1$ in deep surveys.Comment: 12 pages, 5 figures, accepted for publication in The Astrophysical Journa

Mechanical circulatory support in acute myocardial infarction and cardiogenic shock: Challenges and importance of randomized control trials

BACKGROUND: Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality. METHODS: We provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States. RESULTS: Well powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent. CONCLUSIONS: With growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken

Regional Climate Model Intercomparison Project for Asia

Improving the simulation of regional climate change is one of the high-priority areas of climate study because regional information is needed for climate change impact assessments. Such information is especially important for the region covered by the East Asian monsoon where there is high variability in both space and time. To this end, the Regional Climate Model Intercomparison Project (RMIP) for Asia has been established to evaluate and improve regional climate model (RCM) simulations of the monsoon climate. RMIP operates under joint support of the Asia–Pacific Network for Global Change Research (APN), the Global Change System for Analysis, Research and Training (START), the Chinese Academy of Sciences, and several projects of participating nations. The project currently involves 10 research groups from Australia, China, Japan, South Korea, and the United States, as well as scientists from India, Italy, Mongolia, North Korea, and Russia. RMIP has three simulation phases: March 1997–August 1998, which covers a full annual cycle and extremes in monsoon behavior; January 1989–December 1998, which examines simulated climatology; and a regional climate change scenario, involving nesting with a global model. This paper is a brief report of RMIP goals, implementation design, and some initial results from the first phase studies