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Hypertension is one of the most prevalent medical disorders in the world and is associated with significant cerebrovascular and cardiovascular morbidity. Pre-bout blood pressure (BP) elevation is extremely common, and ringside physicians must accurately assess the accompanying risk of adverse cerebrovascular and cardiovascular events in the decision to allow participation in combat sports. It is strongly recommended that a ringside physician consider disqualifying a combat sports athlete with severe pre-bout hypertension (systolic BP ≥160 mm Hg and/or diastolic BP ≥100 mm Hg, or stage 2 hypertension in children when indexed by gender, age, and height) from that bout, if it persists despite rest and repeated measurement with accurate equipment. This recommendation is congruent with that of the American College of Sports Medicine, the American College of Cardiology, and the American Heart Association, which recommend non-clearance for sports or exercise testing when BP exceeds those thresholds. Severely elevated BP, as defined above, confers markedly increased risk of morbidity and mortality. Exercise further raises BP markedly. The combination of severely elevated blood pressure and cranial trauma during combat sports is a risk factor for intracranial hemorrhage with a direct impact on the morbidity and mortality associated with ringside combat sports events. Combat sports athletes with SBP ≥130 or DBP ≥90 - and their coaches and families, if available and the athlete consents - should be educated on the causes of hypertension, its acute and chronic risks, and the possible future implications for bout clearance, and the athletes should be referred for evaluation and management.

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BACKGROUND: Management of ascites-related symptoms in home hospice and palliative care patients can be challenging. Ultrasound-guided paracentesis is a standard intervention for this indication, but generally requires transfer to a hospital or outpatient interventional-radiology (IR) setting; thus, such interventions are often not practical or attainable for home hospice and palliative care patients. OBJECTIVE: To describe a mobile, in-home service that provides home-based palliative paracentesis (HBPP) as an interventional palliative option for patients with distressing symptoms related to ascites. DESIGN: Retrospective case series. Setting/Subjects: Thirty patients with ascites, confirmed by portable bedside ultrasound, who underwent HBPP at their residence. RESULTS: Thirty-three patients were referred for HBPP for symptomatic abdominal distention from March 1, 2019 to March 1, 2020. Thirty (91%) patients had ultrasound-confirmed ascites and received HBPP. All 30, verbalized appreciable symptom relief post-intervention. There were no reported post-procedural complications. CONCLUSION: Home-based palliative paracentesis is a safe, effective, and convenient intervention for hospice and palliative care patients with symptomatic ascites.

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BACKGROUND: Symptomatic pleural effusions create discomfort and are a frequent cause of hospitalization. Ultrasound-guided thoracentesis is a key palliative intervention to assist in the management of this vulnerable population. Our institution has created a multidisciplinary transitional care program to address the needs of those discharged from the hospital with chronic complex conditions, including symptomatic pleural effusions. METHODS: This case series was performed in a transitional care clinic between May 8, 2017, and December 11, 2018. Eight unique patients with symptomatic pleural effusions were referred to our clinic posthospital discharge and treated with ultrasound-guided thoracentesis. A retrospective review was performed to assess procedure details, complications, and follow-up emergency department visits or hospital readmissions. Additionally, cost comparison data were obtained from the hospital financial system. RESULTS: Of the 8 unique patients, 15 thoracenteses were performed over the 19-month period in the transitional care clinic. The median age of the cohort was 56 years old (range: 39-92 years). All patients reported an immediate relief of symptoms (dyspnea and/ or pain) and no procedural complications. The total cost of performing an ultrasound-guided thoracentesis in the transitional care clinic was 61.8% that of performing the procedure in the hospital (US$537.61 vs US$869.65). CONCLUSION: All 8 patients experienced an immediate relief in pleural effusion-related symptoms following thoracentesis. Our experience helps reveal the safety, efficacy, and cost-efficiency of ultrasound-guided thoracentesis in providing symptom management for patients with pleural effusions in a transitional care clinic.

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BACKGROUND: Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. METHODS: We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. RESULTS: Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. CONCLUSION: Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.

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Most nonplatinum group metal (non-PGM) catalysts for polymer electrolyte fuel cell cathodes have so far been limited to iron(cobalt)/nitrogen/carbon [Fe(Co)/N/C] composites owing to their high activity in both half-cell and single-cell cathode processes. Group IV and V metal oxides, another class of non-PGM catalysts, are stable in acidic media; however, their activities have been mostly evaluated for half-cells, with no single-cell performances comparable to those of Fe/N/C composites reported to date. Herein, we report successful syntheses of zirconium oxynitride catalysts on multiwalled carbon nanotubes, which show the highest oxygen reduction reaction activity among oxide-based catalysts. The single-cell performance of these catalysts reached 10 mA cm-2 at 0.9 V, being comparable to that of state-of-the-art Fe/N/C catalysts. This new record opens up a new pathway for reaching the year 2020 target set by the U.S. Department of Energy, that is, 44 mA cm-2 at 0.9 V.

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Titanium oxides crystals are widely used in a variety of fields, but little has been reported on the functionalities of noncrystalline intermediates formed in their structural transformation. We measured the oxygen reduction reaction activity of titanium oxide nanoparticles heat-treated for a different time and found that the activity abruptly increased at a certain time of the treatment. We analyzed their structures by using X-ray pair distribution functions with the help of high-resolution transmission electron microscopy and X-ray photoelectron spectroscopy and ascertained that the abrupt increase in the activity corresponded to a structural transformation from a reduced lepidocrocite-type layered titanate to a disordered structure consisting of domains of brookite-like TiO6 octahedral linkages. The further treatment transformed these brookite-like domains into another phase having more edge-sharing sites like the TiO-type cubic structure. This finding would position noncrystalline, disordered structure as a possible origin of the catalytic activity, though nanocrystalline rutile particles might be also considered as the origin.

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OBJECTIVES: Our aim was to investigate the clini- cal effects of levofloxacin (LVFX) administered intravenously to patients with pulmonary tuberculosis. METHODS: We studied 65 patients hospitalized at The National Hospital Organization Tokyo National Hospital between January 2010 and December 2012. The patients did not have human immunodeficiency virus (HIV) infection, and received anti-tuberculous drugs intravenously due to the inability to receive drugs orally. RESULTS: Twenty-seven patients were intravenously treated with isoniazid (INH), streptomycin (SM) and LVFX (HLS), and 38 patients were treated with INH and SM (HS). For both groups, mean age was very high (80.6±15.0 years, HLS group; 81.0± 12.1 years, HS group) and serum albumin levels were low (2.0 ± 0.62 mg/dl and 2.1 ± 0.42 mg/dl, respectively). Most patients were administered oxygen (81.5%, HLS; 78.9 %, HS). In radiological findings, most patients had bilateral (92.6%, HLS; 92.1%, HS) and widely spread (55.6%, HLS; 57.9%, HS) shadows. No significant differences were found between both groups in terms of the above data, except for sex. Almost 70% of all patients died; 51.9% of patients in the HLS group and 50.0% of those in the HS group died of tuberculosis, while 18.5% of patients in the HLS group and 18.4% of those in the HS group died of the other diseases. There were no significant differences in the causes of death and the survival rates of both groups. CONCLUSION: Patients with pulmonary tuberculosis who were administered intravenous drugs were elderly and in poor general health. As such, mortality of these patients was very high. In this study, no clinical effects were found in the patients administered intravenous LVFX with INH and SM compared with patients treated with INH and SM.

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BACKGROUND: Despite a variety of national efforts to improve transitions of care for patients at risk for rehospitalization, 30-day rehospitalization rates for patients with heart failure have remained largely unchanged. METHODS: This is a retrospective review of 73 patients enrolled in our hospital-based, physican-directed Heart Failure Transitional Care Program (HFTCP). This study evaluated the 30- and 90- day readmission rates before and after enrollment in the program. The Transitionalist's services focused on bedside consultation prior to hospital discharge, follow-up home visits within 72 hours of discharge, frequent follow-up phone calls, disease-specific education, outpatient intravenous diuretic therapy, and around-the-clock telephone access to the Transitionalist. RESULTS: The pre-enrollment 30-day readmission rates for acute decompensated heart failure (ADHF) and all-cause readmission was 26.0% and 28.8%, respectively, while the post-enrollment rates for ADHF and all-cause readmission were 4.1% (P < 0.001) and 8.2% (P = 0.002), respectively. The pre-enrollment 90-day all-cause and ADHF readmission rates were 69.8%, and 58.9% respectively, while the post-enrollment rates for all-cause and ADHF were 27.3% (P < 0.001) and 16.4% (P < 0.001) respectively. CONCLUSIONS: Our physician-implemented HFTCP reduced rehospitalization risk for patients enrolled in the program. This program may serve as a model to assist other hospital systems to reduce readmission rates of patients with HF.

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BACKGROUND: This study investigated the trend of phone calls in the Banner Good Samaritan Medical Center (BGSMC) Heart Failure Transitional Care Program (HFTCP). The primary goal of the HFTCP is to reduce 30-Day readmissions for heart failure patients by using a multi-pronged approach. METHODS: This study included 104 patients in the HFTCP discharged over a 51-week period who had around-the-clock telephone access to the Transitionalist. Cellular phone records were reviewed. This study evaluated the length and timing of calls. RESULTS: A total of 4398 telephone calls were recorded of which 39% were inbound and 61% were outbound. This averaged to 86 calls per week. During the "Weekday Daytime" period, Eighty-five percent of the totals calls were made. There were 229 calls during the "Weekday Nights" period with 1.5 inbound calls per week. The "Total Weekend" calls were 10.2% of the total calls which equated to a weekly average of 8.8. CONCLUSIONS: Our experience is that direct, physician-patient telephone contact is feasible with a panel of around 100 HF patients for one provider. If the proper financial reimbursements are provided, physicians may be apt to participate in similar transitional care programs. Likewise, third party payers will benefit from the reduction in unnecessary emergency room visits and hospitalizations.

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We present a case series of seven patients with an established diagnosis of heart failure enrolled in a transitional care program that were treated with intravenous diuretic therapy in the outpatient setting. The patients presented in this cases series were treated due to the development of decompensated heart failure within 30 days of their discharge from our hospital. All seven patients stated that they would have originally presented to the emergency department for their symptoms, but consented to alternative treatment by a transitional care physician, or transitionalist. These patients with decompensated heart failure (four male and three female) with a median age of 55 years (24 - 84 years) were evaluated and treated from November 2011 to March 2012. Of the seven patients, four presented with decompensated systolic heart failure (three with diastolic). All seven patients were treated with an intravenous diuretic for hypervolemia in our outpatient infusion room. All of the patients experienced relief of their dyspnea the day of diuretic administration or the following day. No adverse effects or emergency department transfers occurred as a result of outpatient intravenous diuretic therapy. Through the use of outpatient intravenous diuretic therapy, we have avoided the need for emergency department visits and potential hospitalization in select patients with decompensated heart failure. Based on our preliminary findings, the clinical efficacy of this approach to the treatment of heart failure decompensation is not only due to the pharmacologic effectiveness of intravenous diuretics, but also due to the bidirectional open line of communication that exists between transitionalist and patients in the program. The direct telephone access that patients have to the transitionalist allows for close post-hospitalization monitoring and facilitates timely evaluation and treatment when acute issues arise. The added benefit of our particular transitional care program is that we have an alternate venue in the hospital where our transitional care patients can be treated for heart failure decompensation (our outpatient infusion room), thus, enabling us to avoid emergency department transfers and possible hospital admissions. Further investigation of this therapy in a non-emergency department setting is warranted as our experience with this treatment modality is limited to the case series presented.

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OBJECTIVE: To report a case of levator ani syndrome (LAS) that was successfully treated with cyclobenzaprine. CASE SUMMARY: A 26-year-old male presented with a 3-week history of severe, intermittent, aching anorectal pain that would last for 30-60 minutes per episode and occurred between 1 and 3 times per day. The pain was aggravated by squatting, with no alleviating factors. Physical examination revealed no prostate tenderness, lesions, hemorrhoids, or fissures and rectal tone was intact. The patient had moderate posterior rectal tenderness. After a standard workup, he was diagnosed with LAS and treated with oral cyclobenzaprine 5 mg 3 times daily for 7 days. The patient experienced resolution of his symptoms after 3 days of treatment and remained symptom-free 6 months after completion of therapy. The only reported adverse effect was mild drowsiness, which resolved after discontinuation of the cyclobenzaprine. DISCUSSION: A review of the literature via StatRef (April 1965-December 2011), Ovid (April 1965-December 2011), and MEDLINE (April 1965-December 2011) reveals that existing treatment options for LAS have been limited to levator massage, sitz baths, nonsteroidal antiinflammatory drugs, diazepam, biofeed-back, botulinum toxin, steroid injections, and electrogalvanic stimulation, all of which offer minimal support. Cyclobenzaprine is a muscle relaxant; however, its mechanism of action is unclear. It is thought to influence the α and γ motor neurons in the central nervous system, which leads to the attenuation of muscle spasm. To our knowledge, cyclobenzaprine has not been reported as a treatment for LAS. In our patient, however, the clinical efficacy of cyclobenzaprine was clearly apparent. CONCLUSIONS: Cyclobenzaprine effectively treated our patient's LAS. Given that cyclobenzaprine is safe, inexpensive, and shown to be effective in our case study, we believe it warrants further investigation as a first-line treatment option for LAS.

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Edaravone is a brain-penetrant free radical scavenger that is known to ameliorate postischemic neuronal dysfunction. The transcription factor Nrf2 plays an important role in the coordinated expression of stress-inducible genes. Here we examined the effects of edaravone and carnosic acid (CA), an Nrf2-inducer, on the expression of nerve growth factor (NGF) in human astrocytes exposed to hypoxia/reoxygenation. Cultured astrocytes were exposed to hypoxia for up to 4.5 h and then treated with edaravone and/or CA under normoxia (reoxygenation) for up to 72 h. Edaravone (∼1 mM) and CA (∼50 µM) treatment synergistically enhanced NGF expression. Nrf2 knockdown by siRNA and the inhibition of JNK (c-Jun N-terminal kinase) by SP600125 decreased both CA-induced NGF expression and Nrf2 nuclear accumulation and suppressed their synergistic effect on NGF expression. In contrast, the MEK (mitogen-activated protein kinase/extracellular signal-regulated kinase kinase) inhibitor U0126 suppressed the synergism without inhibiting CA-induced NGF expression. These results suggest that the synergistic effects of CA and edaravone depend, at least partially, on JNK-dependent Nrf2 accumulation (induced by CA) and on MEK-dependent pathways (induced by edaravone). We conclude that the use of edaravone and CA in combination may have therapeutic potential in the treatment of brain damage, particularly ischemia/reperfusion injury.

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BACKGROUND: Valproate sodium, a commonly used antiepileptic drug (AED), is effective for the treatment of status epilepticus and is often used as a second-line agent when other AEDs are contraindicated. Some studies have reported that infusion of valproate sodium is generally well tolerated, whereas other studies have reported various degrees of hypotension during infusion. The objective of this case report was to call attention to the potential risk of hypotension after intravenous infusion of valproate sodium. CASE SUMMARY: This was the case of a 75-year-old Hispanic man (height, 145 cm; weight, 68 kg) who developed hypotension after receiving an intravenous loading dose of valproate sodium. The patient received the loading dose 12 hours after administration of his last dose of phenytoin (300 mg daily), which had been discontinued secondary to a cutaneous drug reaction. The patient's medical history was significant for seizure disorder, a cerebrovascular accident, and controlled type 2 diabetes mellitus. He was taking glyburide 5 mg daily and aspirin 81 mg daily. At baseline, the patient's blood pressure (measured while seated, at rest, using an upper-extremity cuff) was 135/70 mm Hg. The intravenous loading dose of valproate sodium (20 mg/kg) was administered at a rate of 14 mg/min (total dose, 1280 mg over 90 min). Approximately 2.5 hours after completion of the loading dose, the patient's blood pressure decreased to 107/48 mm Hg. Because our standard operating procedure is to measure blood pressure every 4 hours after the baseline measurement, the patient's hypotension was not detected during the infusion. The next morning (22 hours after completion of the valproate sodium infusion), divalproex sodium 1000 mg orally once daily was initiated as maintenance therapy. The patient's blood pressure reached a nadir of 82/44 mm Hg. The hypotension was treated initially with intravenous fluid hydration with normal saline, but the blood pressure correction was transient using this approach. The patient remained hypotensive for 3 days. The hypotension was ultimately found to be self-limited, and the patient was asymptomatic throughout his hospital stay. The patient's Naranjo adverse drug reaction probability scale score was 6, indicating that the relationship between valproate sodium infusion and hypotension was probable. CONCLUSION: In this case report, infusion of valproate sodium at a rate of 14 mg/min was a probable cause of hypotension in a 75-year-old man.

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