Reflex syncope in the setting of deglutition: A case report

Background: Deglutition syncope was first identified by Thomas Spens in 1793 as a rare form of neurally-mediated transient loss of consciousness secondary to an atypical vasovagal reflex during swallow-induced esophageal dilation. Due to the lack of validated diagnosing criteria, detailed history is imperative to guide timely evaluation and management.Case: A 58-year-old male with a past medical history of bipolar disorder, PTSD, anxiety, cocaine and methamphetamine use presented after a syncopal episode. He reported multiple syncopal episodes over the past five years associated with swallowing. During the most recent incident, the patient reported consuming food when he started feeling fullness in his throat, associated with lightheadedness and diaphoresis prior to a syncope episode. Patient's ED course was unremarkable with stable vitals without orthostasis, negative troponin, chest radiography and ECG. Patient was admitted for further syncope work up.Decision-making: Modified barium swallow study and CT chest were performed to evaluate dysphagia and anatomical abnormality, which revealed mild esophageal reflux and normal anatomy respectively. The patient was allowed to eat. He was placed on continuous telemetry. Patient had several witnessed syncopal events while eating. Corresponding telemetry strips demonstrated bradycardia with a low of 10 bpm along with a 3 second pause.Echocardiogram revealed EF of 35-40% with no significant structural abnormalities. Left heart catheterization revealed normal coronaries. Given his symptomatic bradycardia associated with swallowing, a permanent pacemaker device was suggested as the definitive treatment. Patient requested time to consider the decision, but ultimately decided to leave the hospital against medical advice.Conclusion: This case demonstrates the broad differential for syncope and lack of validated diagnostic criteria for situational syncope. We have excluded esophageal and structural pathology. Patient's symptoms were corresponding to telemetry findings. His psychiatric illness and substance dependence made management challenging, but detailed history and high clinical suspicion guided our diagnosis

Use of superlatives in news articles on cardiac drugs

Background: Superlatives are exaggerated expressions that are often used by writers to inflate the benefit of drugs and medical devices. News articles containing superlatives have the potential to mislead consumers' and health care providers' perception of a drug's effectiveness or its potential harm. The primary objective of this study is to evaluate the presence of superlatives in news articles covering drugs in the field of cardiology.Methods: We searched Google News for news articles published over a four-day period (September 1, 2019 to September 5th, 2019). The following superlative terms were searched: breakthrough, game changer, miracle, cure, home run, revolutionary, transformative, life- saving, groundbreaking, and marvel. Articles were reviewed and data was extracted for all news articles in a duplicate, blinded fashion.Results: Twenty-three unique news articles were included in our study which contained 29 instances of superlative use. Ten drugs from 7 drug classes were associated with superlative use. The most common drug associated with superlative use was Inclisiran, a PCSK9 Inhibitor, with 15 instances in 10 articles. Over a quarter of the drugs in this study did not have FDA Approval (3/11).Conclusion: We demonstrated that superlatives are commonly used in news articles covering a variety of cardiovascular medications. Superlatives have the potential to influence a reader's opinion of a specific drug and its relation to current medical care. We provide recommendations that readers exercise caution when reading news articles containing this sensational style of writing

Study protocol for the Anesthesiology Control Tower—Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: A pilot randomized controlled trial in intraoperative telemedicine [version 1; referees: 2 approved]

Background: Each year, over 300 million people undergo surgical procedures worldwide. Despite efforts to improve outcomes, postoperative morbidity and mortality are common. Many patients experience complications as a result of either medical error or failure to adhere to established clinical practice guidelines. This protocol describes a clinical trial comparing a telemedicine-based decision support system, the Anesthesiology Control Tower (ACT), with enhanced standard intraoperative care. Methods: This study is a pragmatic, comparative effectiveness trial that will randomize approximately 12,000 adult surgical patients on an operating room (OR) level to a control or to an intervention group. All OR clinicians will have access to decision support software within the OR as a part of enhanced standard intraoperative care. The ACT will monitor patients in both groups and will provide additional support to the clinicians assigned to intervention ORs. Primary outcomes include blood glucose management and temperature management. Secondary outcomes will include surrogate, clinical, and economic outcomes, such as incidence of intraoperative hypotension, postoperative respiratory compromise, acute kidney injury, delirium, and volatile anesthetic utilization. Ethics and dissemination: The ACTFAST-3 study has been approved by the Human Resource Protection Office (HRPO) at Washington University in St. Louis and is registered at clinicaltrials.gov (NCT02830126). Recruitment for this protocol began in April 2017 and will end in December 2018. Dissemination of the findings of this study will occur via presentations at academic conferences, journal publications, and educational materials

Field-induced magnetic states in holmium tetraboride

A study of the zero field and field induced magnetic states of the frustrated rare earth tetraboride HoB4 has been carried out using single crystal neutron diffraction complemented by magnetization measurements. In zero field, HoB4 shows magnetic phase transitions at TN1 = 7.1 K to an incommensurate state with a propagation vector (delta, delta, delta'), where delta = 0.02 and delta' = 0.43 and at TN2 = 5.7 K to a noncollinear commensurate antiferromagnetic structure. Polarized neutron diffraction measurements in zero field have revealed that the incommensurate reflections, albeit much reduced in intensity, persist down to 1.5 K despite antiferromagnetic ordering at 5.7 K. At lower temperatures, application of a magnetic field along the c axis initially re-establishes the incommensurate phase as the dominant magnetic state in a narrow field range, just prior to HoB4 ordering with an up-up-down ferrimagnetic structure characterized by the (h k 1/3)-type reflections between 18 and 24 kOe. This field range is marked by the previously reported M/M-sat = 1 3 magnetization plateau, which we also see in our magnetization measurements. The region between 21 and 33 kOe is characterized by the increase in the intensity of the antiferromagnetic reflections, such as (100), the maximum of which coincides with the appearance of the narrow magnetization plateau with M/M-sat approximate to 3/5. Further increase of the magnetic field results in the stabilization of a polarized state above 33 kOe, while the incommensurate reflections are clearly present in all fields up to 59 kOe. We propose the H-T phase diagram of HoB4 for the H parallel to c containing both stationary and transitionary magnetic phases which overlap and show significant history dependence

Preoperative falls predict postoperative falls, functional decline, and surgical complications

AbstractBackgroundFalls are common and linked to morbidity. Our objectives were to characterize postoperative falls, and determine whether preoperative falls independently predicted postoperative falls (primary outcome), functional dependence, quality of life, complications, and readmission.MethodsThis prospective cohort study included 7982 unselected patients undergoing elective surgery. Data were collected from the medical record, a baseline survey, and follow-up surveys approximately 30days and one year after surgery.ResultsFall rates (per 100 person-years) peaked at 175 (hospitalization), declined to 140 (30-day survey), and then to 97 (one-year survey). After controlling for confounders, a history of one, two, and ≥three preoperative falls predicted postoperative falls at 30days (adjusted odds ratios [aOR] 2.3, 3.6, 5.5) and one year (aOR 2.3, 3.4, 6.9). One, two, and ≥three falls predicted functional decline at 30days (aOR 1.2, 2.4, 2.4) and one year (aOR 1.3, 1.5, 3.2), along with in-hospital complications (aOR 1.2, 1.3, 2.0). Fall history predicted adverse outcomes better than commonly-used metrics, but did not predict quality of life deterioration or readmission.ConclusionsFalls are common after surgery, and preoperative falls herald postoperative falls and other adverse outcomes. A history of preoperative falls should be routinely ascertained

Magnetic correlations in the triangular antiferromagnet FeGa2 S4

The crystal structure and magnetic correlations in triangular antiferromagnet FeGa2S4 are studied by x-ray diffraction, magnetic susceptibility, neutron diffraction, and neutron inelastic scattering. We report significant mixing at the cation sites and disentangle magnetic properties dominated by major and minor magnetic sites. The magnetic short-range correlations at 0.77Å-1 correspond to the major sites and being static at base temperature they evolve into dynamic correlations around 30-50 K. The minor sites contribute to the magnetic peak at 0.6Å-1, which vanishes at 5.5 K. Our analytical studies of triangular lattice models with bilinear and biquadratic terms provide the ratios between exchanges for the proposed ordering vectors. The modeling of the inelastic neutron spectrum within linear spin-wave theory results in the set of exchange couplings J1=1.7,J2=0.9,J3=0.8meV for the bilinear Heisenberg Hamiltonian. However, not all features of the excitation spectrum are explained with this model.Fil: Guratinder, K.. Universidad de Ginebra; SuizaFil: Schmidt, M.. Max-Planck-Institut für Chemische Physik fester Stoffe; AlemaniaFil: Walker, H. C.. Rutherford Appleton Laboratory; Reino UnidoFil: Bewley, R.. Rutherford Appleton Laboratory; Reino UnidoFil: Wörle, M.. Laboratorium für Anorganische Chemie; SuizaFil: Cabra, Daniel Carlos. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Física de Líquidos y Sistemas Biológicos. Universidad Nacional de La Plata. Facultad de Ciencias Exactas. Instituto de Física de Líquidos y Sistemas Biológicos; ArgentinaFil: Osorio, Santiago Antonio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Unidad Ejecutora Instituto de Nanociencia y Nanotecnología. Unidad Ejecutora Instituto de Nanociencia y Nanotecnología - Nodo Bariloche | Comisión Nacional de Energía Atómica. Unidad Ejecutora Instituto de Nanociencia y Nanotecnología. Unidad Ejecutora Instituto de Nanociencia y Nanotecnología - Nodo Bariloche; ArgentinaFil: Villalba, Maria Luisa. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Física de Líquidos y Sistemas Biológicos. Universidad Nacional de La Plata. Facultad de Ciencias Exactas. Instituto de Física de Líquidos y Sistemas Biológicos; ArgentinaFil: Madsen, A. K.. Paul Scherrer Institute; SuizaFil: Keller, L.. Paul Scherrer Institute; SuizaFil: Wildes, A.. Institut Laue Langevin; FranciaFil: Puphal, P.. Institut Laue Langevin; FranciaFil: Cervellino, A.. Institut Laue Langevin; FranciaFil: Rüegg, Ch.. Universidad de Ginebra; SuizaFil: Zaharko, O.. Universidad de Ginebra; Suiz

Origins of the Greenland shark (Somniosus microcephalus): Impacts of ice-olation and introgression

Herein, we use genetic data from 277 sleeper sharks to perform coalescent-based modeling to test the hypothesis of early Quaternary emergence of the Greenland shark (Somniosus microcephalus) from ancestral sleeper sharks in the Canadian Arctic-Subarctic region. Our results show that morphologically cryptic somniosids S. microcephalus and Somniosus pacificus can be genetically distinguished using combined mitochondrial and nuclear DNA markers. Our data confirm the presence of genetically admixed individuals in the Canadian Arctic and sub-Arctic, and temperate Eastern Atlantic regions, suggesting introgressive hybridization upon secondary contact following the initial species divergence. Conservative substitution rates fitted to an Isolation with Migration (IM) model indicate a likely species divergence time of 2.34 Ma, using the mitochondrial sequence DNA, which in conjunction with the geographic distribution of admixtures and Pacific signatures likely indicates speciation associated with processes other than the closing of the Isthmus of Panama. This time span coincides with further planetary cooling in the early Quaternary period followed by the onset of oscillating glacial-interglacial cycles. We propose that the initial S. microcephalus–S. pacificus split, and subsequent hybridization events, were likely associated with the onset of Pleistocene glacial oscillations, whereby fluctuating sea levels constrained connectivity among Arctic oceanic basins, Arctic marginal seas, and the North Atlantic Ocean. Our data demonstrates support for the evolutionary consequences of oscillatory vicariance via transient oceanic isolation with subsequent secondary contact associated with fluctuating sea levels throughout the Quaternary period—which may serve as a model for the origins of Arctic marine fauna on a broad taxonomic scale

Protocol for the Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography (P-DROWS-E) study: A prospective observational study of delirium in elderly cardiac surgical patients

INTRODUCTION: Delirium is a potentially preventable disorder characterised by acute disturbances in attention and cognition with fluctuating severity. Postoperative delirium is associated with prolonged intensive care unit and hospital stay, cognitive decline and mortality. The development of biomarkers for tracking delirium could potentially aid in the early detection, mitigation and assessment of response to interventions. Because sleep disruption has been posited as a contributor to the development of this syndrome, expression of abnormal electroencephalography (EEG) patterns during sleep and wakefulness may be informative. Here we hypothesise that abnormal EEG patterns of sleep and wakefulness may serve as predictive and diagnostic markers for postoperative delirium. Such abnormal EEG patterns would mechanistically link disrupted thalamocortical connectivity to this important clinical syndrome. METHODS AND ANALYSIS: P-DROWS-E (Prognosticating Delirium Recovery Outcomes Using Wakefulness and Sleep Electroencephalography) is a 220-patient prospective observational study. Patient eligibility criteria include those who are English-speaking, age 60 years or older and undergoing elective cardiac surgery requiring cardiopulmonary bypass. EEG acquisition will occur 1-2 nights preoperatively, intraoperatively, and up to 7 days postoperatively. Concurrent with EEG recordings, two times per day postoperative Confusion Assessment Method (CAM) evaluations will quantify the presence and severity of delirium. EEG slow wave activity, sleep spindle density and peak frequency of the posterior dominant rhythm will be quantified. Linear mixed-effects models will be used to evaluate the relationships between delirium severity/duration and EEG measures as a function of time. ETHICS AND DISSEMINATION: P-DROWS-E is approved by the ethics board at Washington University in St. Louis. Recruitment began in October 2018. Dissemination plans include presentations at scientific conferences, scientific publications and mass media. TRIAL REGISTRATION NUMBER: NCT03291626