Distal subgaleal-peritoneal shunt migration into the abdominal wall with subsequent formation of a pre-peritoneal pseudocyst: a rare complication.

Distal ventriculo-peritoneal shunt migration and extra-peritoneal CSF pseudocyst formation are unusual complications of shunt placement. We present a 65-year-old-female who received a subgaleal-peritoneal shunt to decompress a post-surgical subgaleal fluid collection. Eight weeks later, shunt series showed tight coiling of the distal catheter, and operative exploration found the distal shunt tip to have migrated superficial to the rectus sheath, where it had become encapsulated in a pre-peritoneal CSF pseudocyst. Migration of the distal catheter into the abdominal wall was likely due to local inflammation of the inner surface of the abdomen, with pressure from intestinal peristaltic movements and intra-abdominal pressure, and continued inflammation at the distal catheter tip may have caused formation of a pre-peritoneal CSF pseudocystic dilatation. To date, this is the first reported case of distal shunt migration into the abdominal wall with subsequent formation of an extra-peritoneal pseudocyst and represents a rare event in the surgical management of peritoneal shunts

Spatial heterogeneity of land cover response to climatic change in the Nilgiri highlands (southern India) since the Last Glacial Maximum

25 pagesFourteen hillslope soil profiles were sampled under natural vegetation (i.e., grassland or forest) and plantations in the Nilgiri highlands, southern India. Delta 13C ratios were measured at different depths and 14C ages determined for six profiles. In these highland soils where the turnover rate of organic matter is extremely low, the Δ13C ratios of entire soil profiles have recorded signatures of past land cover. By correlating the data with results previously obtained from peat bogs and with knowledge concerning the history of human settlement, we distinguish three contrasting trajectories of palaeoenvironmental history and landscape change since the Last Glacial Maximum. In the central Nilgiris, between 18 and 10 ka BP, forest expansion occurred due to the conjunction of a wetter climate (the maximum of southwest monsoon-related humidity occurring at ca. 11 ka BP) and higher temperatures; since 10 ka BP, the reversal towards grassland vegetation is attributed to drier conditions. In the western Nilgiris, where strong southwest monsoon winds permanently restrict forest patches to sheltered valley sites, steady but limited expansion of forest from 18 ka BP to the present is recorded and attributed to rising temperatures. The southern and eastern Nilgiris, where the northeast monsoon contributes 20% of the annual rainfall, are the less sensitive to fluctuations in the southwest monsoon. In these areas, rapid and extensive expansion of forest occurred mainly as a consequence of higher temperatures from 18 ka BP to the present. Massive deforestation by Badaga cultivators and Europeans planters followed after the 16th century AD. As a result, and in contrast with the western Nilgiris where the land cover mosaic has remained remarkably stable in the last 18 ka BP, the current landscape differs sharply from the land cover pattern detected by the soil record

HUBUNGAN PENGETAHUAN DAN PERILAKU MEROKOK ANGGOTA KELUARGA DENGAN KEJADIAN ISPA DI DESA BASAAN 1 WILAYAH KERJA PUSKESMAS KECAMATAN RATATOTOK

Penyakit ISPA (Infeksi Saluran Pernapasan Akut) merupakan salah satu penyakit infeksi yang menular pada pernapasan dan merupakan penyakit infeksi yang masih menjadi isu kesehatan global disemuah Negara. Berdasarkan hasil (Riskesdas, 2013) Infeksi saluran pernapasan akut disebabkan oleh virus atau bakteri, diawali dengan panas disertai salah satu atau lebih gejala : tenggorokan sakit/nyeri menelan, pilek batuk kering atau berdahak. Tujuan penelitian ini untuk menganalisis hubungan pengetahuan dan perilaku merokok anggota keluarga dengan kejadian ISPA di Desa Basaan 1 wilayah kerja Puskesmas Kecamatan Ratatotok Jenis penelitian ini adalah analitik dengan pendekatan Cross sectional yaitu menganalisis hubungan pengetahuan dan perilaku merokok anggota keluarga dengan kejadian ISPA di Desa Basaan 1 wilayah kerja Puskesmas Kecamatan Ratatatotok sebanyak 91 responden yang menjadi subjek sesuai dengan kriteria inklusi. Uji statistic dengan Chi Square dengan tingkat kemaknaan = 0,05 Hasil penelitian menunjukan ada hubungan antara pengetahuan dan perilaku merokok anggota keluarga dengan kejadian ISPA diperoleh = 0,05 p value 0,009 sedangkan perilaku merokok anggota keluarga diperoleh hasil = 0,05 p value 0,05 artinya ada hubungan dengn kejadian ISPA  Kesimpulan hasil penelitian membuktikan bahwa ada hubungn antara pengetahuan dan perilaku merokok anggota keluarga dengan kejadian ISPA

Patients with stricturing or penetrating Crohn\u27s disease phenotypes report high disease burden and treatment needs

BACKGROUND: Crohn\u27s disease (CD) is a chronic autoimmune disease in which inflammation can progress to complications of stricturing and/or penetrating disease. Real-world data on burden of complicated CD phenotypes are limited. METHODS: We analyzed cross-sectional data from the SPARC IBD (Study of a Prospective Adult Research Cohort with Inflammatory Bowel Disease) registry from 2016 to 2020. Four mutually exclusive phenotype cohorts were created: inflammatory CD (CD-I), complicated CD (stricturing CD, penetrating CD, and stricturing and penetrating CD [CD-SP]). Statistical analyses were performed using CD-I as the reference. RESULTS: A total of 1557 patients were identified: CD-I (n = 674, 43.3%), stricturing CD (n = 457, 29.4%), penetrating CD (n = 166, 10.7%), and CD-SP (n = 260, 16.7%). Patients with complicated phenotypes reported significantly greater use of tumor necrosis factor inhibitors (84.2%-86.7% vs 66.0%; P \u3c .001) and corticosteroids (75.3%-82.7% vs 68.0%; P \u3c .001). Patients with CD-SP reported significantly more aphthous ulcer (15.4% vs 10.5%; P \u3c .05), erythema nodosum (6.5% vs 3.6%; P \u3c .05), inflammatory bowel disease-related arthropathy (25.8% vs 17.2%; P \u3c .01), liquid stools (24.2% vs 9.3%; P \u3c .001), nocturnal fecal incontinence (10.8% vs 2.5%; P \u3c .001), and CD-related surgery (77.7% vs 12.2%; P \u3c .001). CONCLUSIONS: Patients with complicated CD phenotypes reported higher rates of active CD-related luminal and extraintestinal manifestations, and underwent more surgeries, despite being more likely to have received biologics than those with CD-I. The potential for early recognition and management of CD-I to prevent progression to complicated phenotypes should be explored in longitudinal studies

Congestive Heart Failure Leads to Prolongation of the PR Interval and Atrioventricular Junction Enlargement and Ion Channel Remodelling in the Rabbit.

Heart failure is a major killer worldwide. Atrioventricular conduction block is common in heart failure; it is associated with worse outcomes and can lead to syncope and bradycardic death. We examine the effect of heart failure on anatomical and ion channel remodelling in the rabbit atrioventricular junction (AVJ). Heart failure was induced in New Zealand rabbits by disruption of the aortic valve and banding of the abdominal aorta resulting in volume and pressure overload. Laser micro-dissection and real-time polymerase chain reaction (RT-PCR) were employed to investigate the effects of heart failure on ion channel remodelling in four regions of the rabbit AVJ and in septal tissues. Investigation of the AVJ anatomy was performed using micro-computed tomography (micro-CT). Heart failure animals developed first degree heart block. Heart failure caused ventricular myocardial volume increase with a 35% elongation of the AVJ. There was downregulation of HCN1 and Cx43 mRNA transcripts across all regions and downregulation of Cav1.3 in the transitional tissue. Cx40 mRNA was significantly downregulated in the atrial septum and AVJ tissues but not in the ventricular septum. mRNA abundance for ANP, CLCN2 and Navβ1 was increased with heart failure; Nav1.1 was increased in the inferior nodal extension/compact node area. Heart failure in the rabbit leads to prolongation of the PR interval and this is accompanied by downregulation of HCN1, Cav1.3, Cx40 and Cx43 mRNAs and anatomical enlargement of the entire heart and AVJ

Arrhythmogenic gene remodelling in elderly patients with type 2 diabetes with aortic stenosis and normal left ventricular ejection fraction

New Findings What is the central question of this study? Type 2 diabetes is associated with a higher rate of ventricular arrhythmias compared with the non‐diabetic population, but the associated myocardial gene expression changes are unknown; furthermore, it is also unknown whether any changes are attributable to chronic hyperglycaemia or are a consequence of structural changes. What is the main finding and its importance? We found downregulation of left ventricular ERG gene expression and increased NCX1 gene expression in humans with type 2 diabetes compared with control patients with comparable left ventricular hypertrophy and possible myocardial fibrosis. This was associated with QT interval prolongation. Diabetes and associated chronic hyperglycaemia may therefore promote ventricular arrhythmogenesis independently of structural changes. Type 2 diabetes is associated with a higher rate of ventricular arrhythmias, and this is hypothesized to be independent of coronary artery disease or hypertension. To investigate further, we compared changes in left ventricular myocardial gene expression in type 2 diabetes patients with patients in a control group with left ventricular hypertrophy. Nine control patients and seven patients with type 2 diabetes with aortic stenosis undergoing aortic valve replacement had standard ECGs, signal‐averaged ECGs and echocardiograms before surgery. During surgery, a left ventricular biopsy was taken, and mRNA expressions for genes relevant to the cardiac action potential were estimated by RT‐PCR. Mathematical modelling of the action potential and calcium transient was undertaken using the O'Hara–Rudy model using scaled changes in gene expression. Echocardiography revealed similar values for left ventricular size, filling pressures and ejection fraction between groups. No difference was seen in positive signal‐averaged ECGs between groups, but the standard ECG demonstrated a prolonged QT interval in the diabetes group. Gene expression of KCNH2 and KCNJ3 were lower in the diabetes group, whereas KCNJ2 , KCNJ5 and SLC8A1 expression were higher. Modelling suggested that these changes would lead to prolongation of the action potential duration with generation of early after‐depolarizations secondary to a reduction in density of the rapid delayed rectifier K+ current and increased Na+–Ca2+ exchange current. These data suggest that diabetes leads to pro‐arrythmogenic changes in myocardial gene expression independently of left ventricular hypertrophy or fibrosis in an elderly population

Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.http://deepblue.lib.umich.edu/bitstream/2027.42/78267/1/1748-5908-5-26.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/2/1748-5908-5-26.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/3/1748-5908-5-26-S3.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/4/1748-5908-5-26-S2.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/5/1748-5908-5-26-S1.TIFFPeer Reviewe

Association of Maternal Perinatal SARS-CoV-2 Infection With Neonatal Outcomes During the COVID-19 Pandemic in Massachusetts

Importance: The incidence of mother-to-newborn SARS-CoV-2 transmission appears low and may be associated with biological and social factors. However, data are limited on the factors associated with neonatal clinical or viral testing outcomes. Objective: To ascertain the percentage of neonates who were born to mothers with positive SARS-CoV-2 test results during the birth hospitalization, the clinical and sociodemographic factors associated with neonatal test result positivity, and the clinical and virological outcomes for newborns during hospitalization and 30 days after discharge. Design, Setting, and Participants: This multicenter cohort study included 11 academic or community hospitals in Massachusetts and mother-neonate dyads whose delivery and discharge occurred between March 1, 2020, and July 31, 2020. Eligible dyads were identified at each participating hospital through local COVID-19 surveillance and infection control systems. Neonates were born to mothers with positive SARS-CoV-2 test results within 14 days before to 72 hours after delivery, and neonates were followed up for 30 days after birth hospital discharge. Exposures: Hypothesized maternal risk factors in neonatal test result positivity included maternal COVID-19 symptoms, vaginal delivery, rooming-in practice, Black race or Hispanic ethnicity, and zip code-derived social vulnerability index. Delivery indicated by worsening maternal COVID-19 symptoms was hypothesized to increase the risk of adverse neonatal health outcomes. Main Outcomes and Measures: Primary outcomes for neonates were (1) positive SARS-CoV-2 test results, (2) indicators of adverse health, and (3) clinical signs and viral testing. Test result positivity was defined as at least 1 positive result on a specimen obtained by nasopharyngeal swab using a polymerase chain reaction-based method. Clinical and testing data were obtained from electronic medical records of nonroutine health care visits within 30 days after hospital discharge. Results: The cohort included 255 neonates (mean [SD] gestational age at birth, 37.9 [2.6] weeks; 62 [24.3%] with low birth weight or preterm delivery) with 250 mothers (mean [SD] age, 30.4 [6.3] years; 121 [48.4%] were of Hispanic ethnicity). Of the 255 neonates who were born to mothers with SARS-CoV-2 infection, 225 (88.2%) were tested for SARS-CoV-2 and 5 (2.2%) had positive results during the birth hospitalization. High maternal social vulnerability was associated with higher likelihood of neonatal test result positivity (adjusted odds ratio, 4.95; 95% CI, 1.53-16.01; P = .008), adjusted for maternal COVID-19 symptoms, delivery mode, and rooming-in practice. Adverse outcomes during hospitalization were associated with preterm delivery indicated by worsening maternal COVID-19 symptoms. Of the 151 newborns with follow-up data, 28 had nonroutine clinical visits, 7 underwent SARS-CoV-2 testing, and 1 had a positive result. Conclusions and Relevance: The findings emphasize the importance of both biological and social factors in perinatal SARS-CoV-2 infection outcomes. Newborns exposed to SARS-CoV-2 were at risk for both direct and indirect adverse health outcomes, supporting efforts of ongoing surveillance of the virus and long-term follow-up