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Introduction: Sida fallax (Malvaceae) is the most widespread and variable taxon of Malvaceae in the Hawaiian Islands, growing with a diversity of morphological forms in different habitats including Midway Atoll, Nihoa, and all the main islands. Morphological variation exists within and among populations. The study aimed to investigate the genetic variation within and among populations from various habitats and geographic locations throughout the Hawaiian range of S. fallax. Methods: A total of 124 samples, with up to five samples per population where possible, were collected from 26 populations across six of the main Hawaiian Islands (Kaua'i, O'ahu, Maui, Moloka'i, Lana'i, and Hawai'i) and Nihoa in the Northwestern Hawaiian Islands. The sampling strategy encompassed collecting populations from different habitats and geographic locations, including coastal and mountain ecotypes, with many intermediate morphological forms. Multiplexed ISSR genotyping by sequencing (MIG-seq) was used to detect single nucleotide polymorphisms (SNP) and genetic differences among individuals and populations were evaluated using PCO analyses. Results: The relationship of FST with the geographical distance between the populations was assessed using the Mantel test. The results showed that populations on a single island were more closely related to each other and to populations on islands within their respective groups than they were to populations on other islands. Discussion: The overall genetic relationships among islands were, to a large extent, predictive based on island position within the chain and, to a lesser extent, within island topography.
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Background The REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) randomized trial demonstrated that a 3-month transitional, tailored, progressive, multidomain physical rehabilitation intervention improves physical function, frailty, depression, and health-related quality of life among older adults with acute decompensated heart failure. Whether there is differential intervention efficacy by race is unknown. Methods and Results In this prespecified analysis, differential intervention effects by race were explored at 3 months for physical function (Short Physical Performance Battery [primary outcome], 6-Minute Walk Distance), cognition, depression, frailty, health-related quality of life (Kansas City Cardiomyopathy Questionnaire, EuroQoL 5-Dimension-5-Level Questionnaire) and at 6 months for hospitalizations and death. Significance level for interactions was P≤0.1. Participants (N=337, 97% of trial population) self-identified in near equal proportions as either Black (48%) or White (52%). The Short Physical Performance Battery intervention effect size was large, with values of 1.3 (95% CI, 0.4-2.1; P=0.003]) and 1.6 (95% CI, 0.8-2.4; P<0.001) in Black and White participants, respectively, and without significant interaction by race (P=0.56). Beneficial effects were also demonstrated in 6-Minute Walk Distance, gait speed, and health-related quality of life scores without significant interactions by race. There was an association between intervention and reduced all-cause rehospitalizations in White participants (rate ratio, 0.73 [95% CI, 0.55-0.98]; P=0.034) that appears attenuated in Black participants (rate ratio, 1.06 [95% CI, 0.81-1.41]; P=0.66; interaction P=0.067). Conclusions The intervention produced similarly large improvements in physical function and health-related quality of life in both older Black and White patients with acute decompensated heart failure. A future study powered to determine how the intervention impacts clinical events is required. REGISTRATION URL: https://www.clinicaltrials.gov. Identifier: NCT02196038.
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Fragilidad , Insuficiencia Cardíaca , Humanos , Anciano , Calidad de Vida , Hospitalización , Readmisión del PacienteRESUMEN
BACKGROUND: The manner in which heuristics and biases influence clinical decision-making has not been fully investigated and the methods previously used have been rudimentary. AIMS: Two studies were conducted to design and test a trial-based methodology to assess the influence of heuristics and biases; specifically, with a focus on how practitioners make decisions about suitability for therapy, treatment fidelity and treatment continuation in psychological services. METHOD: Study 1 (N=12) used a qualitative design to develop two clinical vignette-based tasks that had the aim of triggering heuristics and biases during clinical decision making. Study 2 (N=133) then used a randomized crossover experimental design and involved psychological wellbeing practitioners (PWPs) working in the Improving Access to Psychological Therapies (IAPT) programme in England. Vignettes evoked heuristics (anchoring and halo effects) and biased responses away from normative decisions. Participants completed validated measures of decision-making style. The two decision-making tasks from the vignettes yielded a clinical decision score (CDS; higher scores being more consistent with normative/unbiased decisions). RESULTS: Experimental manipulations used to evoke heuristics did not significantly bias CDS. Decision-making style was not consistently associated with CDS. Clinical decisions were generally normative, although with some variability. CONCLUSIONS: Clinical decision-making can be 'noisy' (i.e. variable across practitioners and occasions), but there was little evidence that this variability was systematically influenced by anchoring and halo effects in a stepped-care context.
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Toma de Decisiones Clínicas , Heurística , Humanos , Inglaterra , Sesgo , Toma de DecisionesRESUMEN
OBJECTIVES: To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. METHODS: We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. RESULTS: Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. CONCLUSIONS: MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
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Apendicitis , Femenino , Embarazo , Humanos , Adulto , Niño , Apendicitis/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Tomografía Computarizada por Rayos X/métodos , Enfermedad Aguda , Sensibilidad y Especificidad , AbdomenRESUMEN
BACKGROUND: Volitional physical activity level is predictive of a variety of health outcomes, but has not been examined in patients recently hospitalized for acute decompensated HF (ADHF). METHODS: Ten to 14 days after index hospitalization for ADHF, 93 participants wore a wrist-mounted triaxial accelerometer (ActiGraph GT3X+) to objectively quantify sedentary behavior, light physical activity, and moderate-to-vigorous physical activity. Levels were compared to 2 groups of age-matched NHANES participants: healthy and chronic, stable HF. The relationship between physical activity levels and physical function [Short Physical Performance Battery (SPPB)], HF-specific quality-of-life (QOL) [Kansas City Cardiomyopathy Questionnaire (KCCQ)], and cognition [Montreal Cognitive Assessment (MOCA)] were examined. RESULTS: ADHF participants accumulated a median 1,008 (IQR 896, 1,109) minutes of sedentary time, 88 (57, 139) minutes of light physical activity, and 10 (6, 25) minutes of moderate-to-vigorous physical activity per day. Sedentary time, light physical activity, or moderate-to-vigorous activity did not differ by sex or EF subtype. ADHF participants spent only 9% of awake time nonsedentary, compared to 34% and 27% for healthy adults and adults with chronic, stable HF, respectively. Among ADHF participants, SPPB, KCCQ, and MOCA scores did not differ among quartiles of total physical activity. CONCLUSIONS: Older patients recently hospitalized for ADHF have very low levels of physical activity and high levels of sedentary time, both of which may be potential targets for interventions in this high-risk population. Physical activity level was not significantly associated with objectively measured physical function, QOL, or cognition, suggesting that this measure provides independent information regarding the patient experience of living with HF. TRIAL REGISTRATION: NCT02196038, https://clinicaltrials.gov/ct2/show/NCT02196038.
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Insuficiencia Cardíaca , Calidad de Vida , Adulto , Anciano , Humanos , Cognición , Ejercicio Físico , Encuestas Nutricionales , Masculino , FemeninoRESUMEN
Background: Chemical meningitis, a subtype of aseptic meningitis, as a complication of posterior fossa surgery is not a rare complication. However, the description of a severe protracted course following the surgical resection of an epidermoid cyst has not been described in the current literature. Chemical meningitis is thought to be associated with a hyperreactive inflammatory response, mediated in part by interleukin (IL)-10, IL-1ß, and tumor necrosis factor-α, to the postoperative keratin debris from the spontaneous leakage or surgical release of epidermoid contents into subarachnoid spaces, which ultimately can result in patient symptoms of meningitis and hydrocephalus. Often, this remains mild and the recommended management includes a short course administration of corticosteroids. Case Description: The authors report such a case in a patient who underwent a redoresection for a fourth ventricular epidermoid cyst. Postoperatively, the patient returned several times with symptoms of meningitis and hydrocephalus requiring multiple hospitalizations in the ensuing months. The patient required emergent cerebrospinal fluid diversion, further posterior fossa exploration and an extended high-dose corticosteroid treatment regimen. Conclusion: The authors summarize the current understanding of the biochemical processes involved for the rare presentation of postoperative chemical meningitis.
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@#International borders to Vanuatu closed on 23 March 2020 due to the global COVID-19 pandemic. In May–July 2020, the Government of Vanuatu focused on the safe and timely return of citizens and residents while ensuring Vanuatu remained COVID-19 free. Under Phase 1 of repatriation, between 27 May and 23 June 2020, 1522 people arrived in the capital, Port Vila, and were placed in compulsory government-mandated 14-day quarantine in 15 hotels. Pre-arrival health operations included collection of repatriate information, quarantine facility assessments, training for personnel supporting the process, and tabletop and functional exercises with live scenario simulations. During quarantine, health monitoring, mental health assessments and psychosocial support were provided. All repatriates completed 14 days of quarantine. One person developed symptoms consistent with COVID-19 during quarantine but tested negative. Overall health operations were considered a success despite logistical and resource challenges. Lessons learnt were documented during a health sector after-action review held on 22 July 2020. Key recommendations for improvement were to obtain timely receipt of repatriate information before travel, limit the number of repatriates received and avoid the mixing of “travel cohorts”, ensure sufficient human resources are available to support operations while maintaining other essential services, establish a command and control structure for health operations, develop training packages and deliver them to all personnel supporting operations, and coordinate better with other sectors to ensure health aspects are considered. These recommendations were applied to further improve health operations for subsequent repatriation and quarantine, with Phase 2 commencing on 1 August 2020.
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Infecciones por Coronavirus , Pandemias , Neumonía Viral , Triaje , Betacoronavirus , COVID-19 , Humanos , SARS-CoV-2 , Ultrasonografía IntervencionalRESUMEN
We present the case of a patient with recurrent sigmoid neovaginal prolapse treated with a modified Altemeier procedure for rectal prolapse, which has not been previously described in the literature.Our case highlights the difficulty in treating patients with intestinal neovaginal prolapse due to their complex abdominal surgical history, altered anatomy, and goals of care.
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Colon Sigmoide/cirugía , Procedimientos de Cirugía Plástica/métodos , Prolapso Uterino/cirugía , Vagina/cirugía , Femenino , Humanos , Persona de Mediana Edad , Rabdomiosarcoma/cirugíaRESUMEN
Despite recent popularity of wrist-worn accelerometers for assessing free-living physical behaviours, there is a lack of user-friendly methods to characterize physical activity from a wrist-worn ActiGraph accelerometer. Participants in this study completed a laboratory protocol and/or 3-8 hours of directly observed free-living (criterion measure of activity intensity) while wearing ActiGraph GT9X Link accelerometers on the right hip and non-dominant wrist. All laboratory data (n = 36) and 11 participants' free-living data were used to develop vector magnitude count cut-points (counts/min) for activity intensity for the wrist-worn accelerometer, and 12 participants' free-living data were used to cross-validate cut-point accuracy. The cut-points were: <2,860 counts/min (sedentary); 2,860-3,940 counts/min (light); and ≥3,941counts/min (moderate-to-vigorous (MVPA)). These cut-points had an accuracy of 70.8% for assessing free-living activity intensity, whereas Sasaki/Freedson cut-points for the hip accelerometer had an accuracy of 77.1%, and Hildebrand Euclidean Norm Minus One (ENMO) cut-points for the wrist accelerometer had an accuracy of 75.2%. While accuracy was higher for a hip-worn accelerometer and for ENMO wrist cut-points, the high wear compliance of wrist accelerometers shown in past work and the ease of use of count-based analysis methods may justify use of these developed cut-points until more accurate, equally usable methods can be developed.
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Acelerometría/instrumentación , Acelerometría/estadística & datos numéricos , Ejercicio Físico/fisiología , Monitores de Ejercicio/estadística & datos numéricos , Acelerometría/métodos , Adolescente , Adulto , Anciano , Análisis de Datos , Cadera , Humanos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Conducta Sedentaria , Muñeca , Adulto JovenAsunto(s)
Betacoronavirus , Infecciones por Coronavirus/diagnóstico por imagen , Servicios Médicos de Urgencia/métodos , Neumonía Viral/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Triaje/métodos , Ultrasonografía Intervencional/métodos , COVID-19 , Infecciones por Coronavirus/prevención & control , Servicios Médicos de Urgencia/tendencias , Humanos , Pandemias/prevención & control , Neumonía Viral/prevención & control , SARS-CoV-2 , Tomografía Computarizada por Rayos X/tendencias , Triaje/tendencias , Ultrasonografía Intervencional/tendenciasRESUMEN
Healthcare-acquired infections (HAIs) contribute to maternal and neonatal morbidity and mortality, especially in low- and middle-income countries (LMICs). Deficient environmental health (EH) conditions and infection prevention and control (IPC) practices in healthcare facilities (HCFs) contribute to the spread of HAIs, but microbial sampling of sources of contamination is rarely conducted nor reported in low-resource settings. The purpose of this study was to assess EH conditions and IPC practices in Malawian HCFs and evaluate how EH deficiencies contribute to pathogen exposures and HAIs, and to provide recommendations to inform improvements in EH conditions using a mixed-methods approach. Thirty-one maternity wards in government-run HCFs were surveyed in the three regions of Malawi. Questionnaires were administered in parallel with structured observations of EH conditions and IPC practices and microbial testing of water sources and facility surfaces. Results indicated significant associations between IPC practices and microbial contamination. Facilities where separate wards were not available for mothers and newborns with infections and where linens were not used for patients during healthcare services were more likely to have delivery tables with surface contamination (relative risk = 2.23; 1.49, 3.34). E. coli was detected in water samples from seven (23%) HCFs. Our results suggest that Malawian maternity wards could reduce microbial contamination, and potentially reduce the occurrence of HAIs, by improving EH conditions and IPC practices. HCF staff can use the simple, low-cost EH monitoring methods used in this study to incorporate microbial monitoring of EH conditions and IPC practices in HCFs in low-resource settings.
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Escherichia coli , Maternidades , Control de Infecciones , Infecciones , Descontaminación , Monitoreo del Ambiente , Femenino , Humanos , Recién Nacido , Malaui , EmbarazoRESUMEN
BACKGROUND AND OBJECTIVES: Primary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short-term outcomes, and five-year survival of patients undergoing nonpalliative surgery for PCL. METHODS: We performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis. RESULTS: We identified 2153 patients. Median patient age was 68. Diffuse large B-cell lymphoma accounted for 57% of tumors. 30- and 90-Day mortality were high (5.6% and 11.1%, respectively). Thirty-nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5-year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07-1.51; P = .01). CONCLUSIONS: Patients undergoing surgery for PCL have high rates of margin positivity and high short-term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.
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Neoplasias del Colon/mortalidad , Neoplasias del Colon/cirugía , Linfoma/mortalidad , Linfoma/cirugía , Anciano , Anciano de 80 o más Años , Macrodatos , Quimioterapia Adyuvante , Estudios de Cohortes , Neoplasias del Colon/tratamiento farmacológico , Neoplasias del Colon/patología , Femenino , Humanos , Estimación de Kaplan-Meier , Linfoma/tratamiento farmacológico , Linfoma/patología , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Linfoma de Células B Grandes Difuso/mortalidad , Linfoma de Células B Grandes Difuso/patología , Linfoma de Células B Grandes Difuso/cirugía , Linfoma no Hodgkin/tratamiento farmacológico , Linfoma no Hodgkin/mortalidad , Linfoma no Hodgkin/patología , Linfoma no Hodgkin/cirugía , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Radioterapia Adyuvante , Estudios RetrospectivosAsunto(s)
Cardiomegalia/microbiología , Endocarditis Bacteriana/microbiología , Enfermedades de las Válvulas Cardíacas/microbiología , Infecciones Estreptocócicas/microbiología , Adulto , Cardiomegalia/diagnóstico por imagen , Diagnóstico Diferencial , Endocarditis Bacteriana/diagnóstico por imagen , Resultado Fatal , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Infecciones Estreptocócicas/diagnóstico por imagen , Streptococcus mutans/aislamiento & purificación , Abuso de Sustancias por Vía Intravenosa/complicaciones , Tomografía Computarizada por Rayos X , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/microbiologíaRESUMEN
BACKGROUND: Colorectal cancer (CRC) is one of the most common causes of cancer-related deaths worldwide. Increased expression of the molecular target, EphB4 receptor, has been observed in several cancer types. However, studies on the role of EphB4 receptor in CRC have yielded contradictory results. The aim of this study was to investigate the influence of EphB4 expression levels on CRC cell behavior and its contribution to tumor growth and vascularization. METHODS: SW480, LIM2405 and CT26 CRC cell lines were transfected with EphB4 expression vector. High EphB4 expressing cells were compared to low EphB4 expressing empty vector controls. Proliferation and migration assays as well as EphrinB2-Fc cell stimulations were conducted in vitro and subcutaneous xenografts of CRC were analyzed in vivo. RESULTS: High EphB4 expression enhanced migratory ability of these CRC cell lines in vitro and contributed to a significant increase in tumor growth and vascularization in vivo. Tumours induced with high EphB4 expressing SW480 and LIM2405 cells yielded homogenous masses densely packed with cancer cells. EphrinB2-Fc cell stimulations induced cell clustering of high EphB4 expressing SW480 and LIM2405 in vitro. CONCLUSION: These results suggest that with enhanced vascularization and an increase in migratory abilities, the high EphB4 expressing cells may be able to metastasize more readily.
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Neoplasias Colorrectales/patología , Neovascularización Patológica/metabolismo , Receptor EphB4/metabolismo , Animales , Línea Celular Tumoral , Movimiento Celular , Neoplasias Colorrectales/irrigación sanguínea , Neoplasias Colorrectales/metabolismo , Femenino , Humanos , Ratones Endogámicos NOD , Receptor EphB4/genética , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
Morbidity and falls are problematic for older people. Wearable devices are increasingly used to monitor daily activities. However, sensors often require rigid attachment to specific locations and shuffling or quiet standing may be confused with walking. Furthermore, it is unclear whether clinical gait assessments are correlated with how older people usually walk during daily life. Wavelet transformations of accelerometer and barometer data from a pendant device worn inside or outside clothing were used to identify walking (excluding shuffling or standing) by 51 older people (83 ± 4 years) during 25 min of 'free-living' activities. Accuracy was validated against annotated video. Training and testing were separated. Activities were only loosely structured including noisy data preceding pendant wearing. An electronic walkway was used for laboratory comparisons. Walking was classified (accuracy ≥97 %) with low false-positive errors (≤1.9%, κ ≥ 0.90). Median free-living cadence was lower than laboratory-assessed cadence (101 vs. 110 steps/min, p < 0.001) but correlated (r = 0.69). Free-living step time variability was significantly higher and uncorrelated with laboratory-assessed variability unless detrended. Remote gait impairment monitoring using wearable devices is feasible providing new ways to investigate morbidity and falls risk. Laboratory-assessed gait performances are correlated with free-living walks, but likely reflect the individual's 'best' performance.
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Actividades Cotidianas , Marcha/fisiología , Monitoreo Ambulatorio/instrumentación , Análisis de Ondículas , Aceleración , Anciano , Anciano de 80 o más Años , Algoritmos , Árboles de Decisión , Femenino , Humanos , MasculinoRESUMEN
Epistaxis is a very common emergency in otorhinolaryngology. Anterior ethmoidal artery ligation using an external approach is one of the surgical options in posterior epistaxis. We present, to the best of our knowledge, the first reported case of an intracerebral abscess after epistaxis treatment with ligation of the anterior ethmoidal artery using an endoscopic-assisted external approach in a 56-year-old patient. The patient presented 4 days postoperatively with an orbital cellulitis. A CT was performed and a frontobasal hypodensity was found. An additional MR tomography the next day showed a lesion suspicious for an intracerebral abscess. Despite intravenous antibiotic therapy, the lesion increased and was successfully treated by the neurosurgeons, with abscess resection over a craniotomy and frontobasal repair using a pedicled periosteal flap. Surgeons have to be aware of this rare but possibly lethal severe complication and should consider early imaging studies, especially if a periorbital cellulitis appears.