Crossbow Bolt Injury to the Heart

Case summary A 33-year-old woman was transferred from an outside hospital with a penetrating injury to her right chest. The patient was shot with a crossbow with the entry site to the right breast/chest and a transmediastinal trajectory. She was intubated prior to arrival due to difficulty breathing. Her vital signs remained stable and within normal limits, with good breath sounds, and no evidence of pneumothorax on chest X-ray. The tip of the bolt was palpable at the patient’s left midaxillary line. Chest X-ray in trauma bay showed the transmediastinal trajectory, and the bolt appeared to have a field point (not a broadhead point) (figure 1). A CT of the chest was obtained to assist with surgical planning. Images showed the bolt penetrating the right chest, right ventricle and inferior aspect of the left ventricular muscle, through the stomach, and ending near the tip of the spleen with a fracture of the left seventh ri

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock

BACKGROUND: Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). METHODS: All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI. RESULTS: Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55-0.75). There were no differences in other secondary outcomes between groups. CONCLUSION: ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6 patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival

Social Media in Virtual Marketing: Antecedents to Electronic Word of Mouth Communication

Social media usage in the world and especially in Pakistan has a high growth due to which it (social media) has a potential of becoming an effective marketing tool. Despite its compar-atively low cost and significance, marketers are not effectively utilizing social media. Thus the aim of this study is to measure the influence (effect) of four social variables: social capital, trust, homophily and interpersonal influence on electronic word of mouth (eWOM) communi-cation. The sample size for the study is 300 and preselected enumerator's collected the data from the leading shopping malls of the city. Although the scales and measures adopted for this study have been earlier validated in oth-er countries, however the same were re-ascertained on the present set of data. After prelimi-nary analysis including normality and validity the overall model was tested through Structural Equation Model (SEM). This was carried out in two stages - initially CFA for all the constructs was ascertained which was followed by CFA of the overall model. Developed conceptual framework was empirically tested on the present set of data in Pa-kistan which adequately explained consumer attitudinal behavior towards electronic word of mouth (eWOM) communication. Three hypotheses failed to be rejected and one was rejected. Trust was found to be the strongest predictor of electronic word of mouth (eWOM) communi-cation, followed by homophily and social capital. Interpersonal influence has no relationship with electronic word of mouth (eWOM) communication. The results were consistent to earlier literature. Implication for markers was drawn from the results.Keywords: eWOM, social capital, trust, homophily and interpersonal influence, social medi

Pyrolysis: A Sustainable Way to Generate Energy from Waste

Lignocellulosic biomass is a potentially more valuable renewable resource that can be utilized effusively as a chief source of heat for cooking and can correspondingly subsidize the production of electricity, heat, biofuels and chemicals including solid fuel like char or carbon. Lignocellulosic residues are mixed and burnt with coal to generate electricity. Presently, crude oil is replaced by bioethanol and biodiesel produced from biomass substrate. Some special class of chemicals can be derived from biomass that can subsequently replace the usage of non‐renewable resources of oil and coal. Pyrolysis of woody biomass to obtain pyroliginous acid was started hundreds of years ago, which has versatile applications. The range of products that can be derived from biomass is huge, prompting extent of research using different types of thermal conversion technologies, including pyrolysis, gasification, torrefaction, anaerobic digestion and hydrothermal processing. This chapter provides insights about the stages of reaction during pyrolysis and the outcome of reaction conditions on the products. Technical development and adjustment of process condition can offer a suitable environmentally benign scheme to increase the energy density of the lignocellulosic residues

Long-term protection against HBV chronic carriage of Gambian adolescents vaccinated in infancy and immune response in HBV booster trial in adolescence.

BACKGROUND: Chronic infection with hepatitis B virus (HBV) arising in childhood is associated with hepatocellular carcinoma in adult life. Between 1986 and 1990, approximately 120,000 Gambian newborns were enrolled in a randomised controlled trial to assess the effectiveness of infant HBV vaccination on the prevention of hepatocellular carcinoma in adulthood. These children are now in adolescence and approaching adulthood, when the onset of sexual activity may challenge their hepatitis B immunity. Thus a booster dose in adolescence could be important to maintain long-term protection. METHODS: Fifteen years after the start of the HBV infant vaccination study, 492 vaccinated and 424 unvaccinated children were identified to determine vaccine efficacy against infection and carriage in adolescence. At the same time, 297 of the 492 infant-vaccinated subjects were randomly offered a booster dose of HBV vaccine. Anti-HBs was measured before the booster, and two weeks and 1 year afterwards (ISRCTN71271385). RESULTS: Vaccine efficacy 15 years after vaccination was 67.0% against infection as manifest by anti-HBc positivity (95% CI 58.2-74.6%), and 96.6% against HBsAg carriage (95% CI 91.5-100%). 31.2% of participants had detectable anti-HBs with a GMC of 32 IU/l. For 168 boosted participants GMC anti-HBs responses were 38 IU/l prior to vaccination, 524 IU/l two weeks after boosting, and 101 IU/l after 1 year. CONCLUSIONS: HBV vaccination in infants confers very good protection against carriage up to 15 years of age, although a large proportion of vaccinated subjects did not have detectable anti-HBs at this age. The response to boosting persisted for at least a year. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN71271385

Seasonality and outbreak of a predominant Streptococcus pneumoniae serotype 1 clone from The Gambia: Expansion of ST217 hypervirulent clonal complex in West Africa

BACKGROUND: Streptococcus pneumoniae serotype 1 causes > 20% of invasive disease, among all age groups combined, in The Gambia. In contrast, it is rarely detected in carriage studies. This study compares the molecular epidemiology of S. pneumoniae serotype 1 causing invasive disease in The Gambia between 1996 and 2005 to those carried in the nasopharynx between 2004 and 2006. RESULTS: A total of 127 invasive and 36 nasopharyngeal carriage serotype 1 isolates were recovered from individuals of all age groups and were analyzed by serotyping, antibiotic susceptibility testing and MLST. MLST analysis revealed 23 different sequence types (STs), 18 of which were novel. The most prevalent clone among the 163 isolates was ST618 (70.5%), followed by ST3575 (7.4%), ST2084 (2.5%) and ST612 (2.5%). A single ST (ST618), previously shown to belong to the ST217 hypervirulent clonal complex, was frequent among carriage (61.1%) and invasive (72.7%) serotype 1 isolates. ST618 causing both paediatric and adult disease peaked annually in the hot dry season and caused outbreak in 1997 and 2002. CONCLUSION: For over a decade, isolates of ST618 have been the dominant lineage among serotype 1 carriage and disease isolates circulating in the Gambia. This lineage shows similar epidemiological features to those of the meningococcus in the African meningitis belt being able to cause outbreaks of disease

Malignant Precursor Cells Pre-Exist in Human Breast DCIS and Require Autophagy for Survival

BACKGROUND: While it is accepted that a majority of invasive breast cancer progresses from a ductal carcinoma in situ (DCIS) precursor stage, very little is known about the factors that promote survival of DCIS neoplastic cells within the hypoxic, nutrient deprived intraductal microenvironment. METHODOLOGY AND PRINCIPAL FINDINGS: We examined the hypothesis that fresh human DCIS lesions contain pre-existing carcinoma precursor cells. We characterized these cells by full genome molecular cytogenetics (Illumina HumanCytoSNP profile), and signal pathway profiling (Reverse Phase Protein Microarray, 59 endpoints), and demonstrated that autophagy is required for survival and anchorage independent growth of the cytogenetically abnormal tumorigenic DCIS cells. Ex vivo organoid culture of fresh human DCIS lesions, without enzymatic treatment or sorting, induced the emergence of neoplastic epithelial cells exhibiting the following characteristics: a) spontaneous generation of hundreds of spheroids and duct-like 3-D structures in culture within 2-4 weeks; b) tumorigenicity in NOD/SCID mice; c) cytogenetically abnormal (copy number loss or gain in chromosomes including 1, 5, 6, 8, 13, 17) compared to the normal karyotype of the non-neoplastic cells in the source patient's breast tissue; d) in vitro migration and invasion of autologous breast stroma; and e) up-regulation of signal pathways linked to, and components of, cellular autophagy. Multiple autophagy markers were present in the patient's original DCIS lesion and the mouse xenograft. We tested whether autophagy was necessary for survival of cytogenetically abnormal DCIS cells. The lysosomotropic inhibitor (chloroquine phosphate) of autophagy completely suppressed the generation of DCIS spheroids/3-D structures, suppressed ex vivo invasion of autologous stroma, induced apoptosis, suppressed autophagy associated proteins including Atg5, AKT/PI3 Kinase and mTOR, eliminated cytogenetically abnormal spheroid forming cells from the organ culture, and abrogated xenograft tumor formation. CONCLUSIONS: Cytogenetically abnormal spheroid forming, tumorigenic, and invasive neoplastic epithelial cells pre-exist in human DCIS and require cellular autophagy for survival

What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research