Acute Aortic Syndrome in a patient with COVID-19.

The global effects of the COVID-19 pandemic make it of the utmost importance to comprehend its mechanisms and define strategies for the most effective approach possible. The SARS-CoV-2 virus can be responsible for the induction of a hypercoagulable state, which can trigger vascular phenomena of venous etiology, specifically deep venous thrombosis or pulmonary embolism. Arterial thrombotic events associated with COVID-19 have also been described in the medical literature, although less frequently. In this paper the authors report the case of a 66-year-old man who was diagnosed with an Acute Aortic Syndrome, specifically an intramural thrombus on the aortic arch, while he was still infected with the virus. Anticoagulation with low weight molecular heparin was initiated and the patient was admitted at the Internal Medicine ward for a conservative therapeutic approach. The thrombus remained stable on a serial imaging evaluation; therefore, the patient was discharged with oral anticoagulation with subsequent follow-up in the outpatient clinic. This case describes a rare and potentially serious complication of COVID-19, which highlights how broad its clinical spectrum can be, affecting systems other than the pulmonary.

Serial viral load analysis by DDPCR to evaluate FNC efficacy and safety in the treatment of mild cases of COVID-19.

Introduction: The SARS-CoV-2 outbreak has threatened the human population globally as the numbers of reinfection cases even after large-scale vaccination. Trials have been carried out to find drugs effective in fighting the disease, as COVID-19 is being considered a treatable disease only after we have antivirals. A clinical candidate originally developed for HIV treatment, AZVUDINE (FNC), is a promising drug in the treatment of COVID-19. Methods: To predict the clinical outcome of COVID-19, we examined the course of viral load, every 48 h, by RT-PCR, and disease severity using an antiviral drug, FNC, with 281 participants. A randomized clinical trial was performed to evaluate the efficacy of FNC added to standard treatment, compared with placebo group added to standard treatment, for patients with mild COVID-19. RT-qPCR and ddPCR were applied to estimate the viral load in samples from patients. Also, the clinical improvement was evaluated as well as the liver and kidney function. Results and discussion: Notably, the FNC treatment in the mild COVID-19 patients may shorten the time of the nucleic acid negative conversion (NANC) versus placebo group. In addition, the FNC was effective in reducing the viral load of these participants. The present clinical trial results showed that the FNC accelerate the elimination of the virus in and could reduce treatment time of mild patients and save a lot of medical resources, making it a strong candidate for the outpatient and home treatment of COVID-19. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT05033145, identifier NCT05033145.

Hypometabolic strategy and glucose metabolism maintenance of Aedes aegypti egg desiccation.

The mosquito Aedes aegypti is vector of several viruses including yellow fever virus, dengue virus chikungunya virus and Zika virus. One of the major problems involving these diseases transmission is that A. aegypti embryos are resistant to desiccation at the end of embryogenesis, surviving and remaining viable for several months inside the egg. Therefore, a fine metabolism control is essential to support these organisms throughout this period of resistance. The carbohydrate metabolism has been shown to be of great importance during arthropod embryogenesis, changing dramatically in order to promote growth and differentiation and in periods of resistance. This study investigated fundamental aspects of glucose metabolism in three stages of A. aegypti egg development: pre-desiccated, desiccated, and rehydrated. The activities of regulatory enzymes in carbohydrate metabolism such as pyruvate kinase, hexokinase and glucose 6-phosphate dehydrogenase were evaluated. We show that these activities were reduced in A. aegypti desiccated eggs, suggesting a decreased activity of glycolytic and pentose phosphate pathway. In contrast, gluconeogenesis increased in desiccated eggs, which uses protein as substrate to synthesize glucose. Accordingly, protein amount decreased during this stage, while glucose levels increased. Glycogen content, a major carbohydrate reserve in mosquitoes, was evaluated and shown to be lower in desiccated and rehydrated eggs, indicating it was used to supply energy metabolism. We observed a reactivation of carbohydrate catabolism and an increased gluconeogenesis after rehydration, suggesting that controlling glucose metabolism was essential not only to survive the period of desiccation, but also for subsequent larvae hatch. Taken together, these results contribute to a better understanding of metabolism regulation in A. aegypti eggs during desiccation periods. Such regulatory mechanisms enable higher survival rate and consequently promote virus transmission by these important disease vectors, making them interesting subjects in the search for novel control methods.

Prospective international validation of the Quality of Life in Myelodysplasia Scale (QUALMS).

Disease-specific measures of quality of life can improve assessment of disease-related symptoms and psychosocial sequelae. We report on the development and validation of the Quality of Life in Myelodysplasia Scale (QUALMS), a 38-item assessment tool for patients with myelodysplastic syndromes (MDS). In 2014-2015, a multi-center cohort of patients with myelodysplasia completed the QUALMS, as well as the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) and the Functional Assessment of Cancer Therapy Anemia Scale (FACT-An); a second administration was undertaken three to six months later. A total of 255 patients from the United States, Canada and Italy participated. Median age was 72 years, 56.1% were men, and the International Prognostic Scoring System distribution was 40.4% low, 42.0% intermediate-1, 13.3% intermediate-2 and 2.3% high. QUALMS scores ranged from 24 to 99 (higher scores are better), with a mean of 67.2 [standard deviation (SD)=15.2]. The measure was internally consistent (α=0.92), and moderately correlated with the multi-item QLQ-C30 scales and the FACT-An (r=-0.65 to 0.79; all P<0.001). Patients with hemoglobin of 8 g/dL or under scored lower than those with hemoglobin over 10 g/dL (61.8 vs 71.1; P<0.001), and transfusion-dependent patients scored lower than transfusion-independent patients (62.4 vs 69.7; P<0.01). Principal components analysis revealed "physical burden", "benefit-finding", and "emotional burden" subscales. There was good overall test-retest reliability among those with stable hemoglobin (r=0.81), and significant changes for patients hospitalized or with infections between administrations (both P<0.01). These data suggest the QUALMS is a valuable tool for assessing MDS-specific quality of life in the modern treatment era.

Oncologists' and cancer patients' views on whole-exome sequencing and incidental findings: results from the CanSeq study.

PURPOSE: Although targeted sequencing improves outcomes for many cancer patients, it remains uncertain how somatic and germ-line whole-exome sequencing (WES) will integrate into care. METHODS: We conducted surveys and interviews within a study of WES integration at an academic center to determine oncologists' attitudes about WES and to identify lung and colorectal cancer patients' preferences for learning WES findings. RESULTS: One-hundred sixty-seven patients (85% white, 58% female, mean age 60) and 27 oncologists (22% female) participated. Although oncologists had extensive experience ordering somatic tests (median 100/year), they had little experience ordering germ-line tests. Oncologists intended to disclose most WES results to patients but anticipated numerous challenges in using WES. Patients had moderately low levels of genetic knowledge (mean 4 correct out of 7). Most patients chose to learn results that could help select a clinical trial, pharmacogenetic and positive prognostic results, and results suggesting inherited predisposition to cancer and treatable noncancer conditions (all ≥95%). Fewer chose to receive negative prognostic results (84%) and results suggesting predisposition to untreatable noncancer conditions (85%). CONCLUSION: The majority of patients want most cancer-related and incidental WES results. Patients' low levels of genetic knowledge and oncologists' inexperience with large-scale sequencing present challenges to implementing paired WES in practice.Genet Med 18 10, 1011-1019.

The Impact of Social Media on Dissemination and Implementation of Clinical Practice Guidelines: A Longitudinal Observational Study.

BACKGROUND: Evidence-based clinical practice guidelines (CPGs) are statements that provide recommendations to optimize patient care for a specific clinical problem or question. Merely reading a guideline rarely leads to implementation of recommendations. The American Academy of Neurology (AAN) has a formal process of guideline development and dissemination. The last few years have seen a burgeoning of social media such as Facebook, Twitter, and LinkedIn, and newer methods of dissemination such as podcasts and webinars. The role of these media in guideline dissemination has not been studied. Systematic evaluation of dissemination methods and comparison of the effectiveness of newer methods with traditional methods is not available. It is also not known whether specific dissemination methods may be more effectively targeted to specific audiences. OBJECTIVE: Our aim was to (1) develop an innovative dissemination strategy by adding social media-based dissemination methods to traditional methods for the AAN clinical practice guidelines "Complementary and alternative medicine in multiple sclerosis" ("CAM in MS") and (2) evaluate whether the addition of social media outreach improves awareness of the CPG and knowledge of CPG recommendations, and affects implementation of those recommendations. METHODS: Outcomes were measured by four surveys in each of the two target populations: patients and physicians/clinicians ("physicians"). The primary outcome was the difference in participants' intent to discuss use of complementary and alternative medicine (CAM) with their physicians or patients, respectively, after novel dissemination, as compared with that after traditional dissemination. Secondary outcomes were changes in awareness of the CPG, knowledge of CPG content, and behavior regarding CAM use in multiple sclerosis (MS). RESULTS: Response rates were 25.08% (622/2480) for physicians and 43.5% (348/800) for patients. Awareness of the CPG increased after traditional dissemination (absolute difference, 95% confidence interval: physicians 36%, 95% CI 25-46, and patients 10%, 95% CI 1-11) but did not increase further after novel dissemination (physicians 0%, 95% CI -11 to 11, and patients -4%, 95% CI -6 to 14). Intent to discuss CAM also increased after traditional dissemination but did not change after novel dissemination (traditional: physicians 12%, 95% CI 2-22, and patients 19%, 95% CI 3-33; novel: physicians 11%, 95% CI -1 to -21, and patients -8%, 95% CI -22 to 8). Knowledge of CPG recommendations and behavior regarding CAM use in MS did not change after either traditional dissemination or novel dissemination. CONCLUSIONS: Social media-based dissemination methods did not confer additional benefit over print-, email-, and Internet-based methods in increasing CPG awareness and changing intent in physicians or patients. Research on audience selection, message formatting, and message delivery is required to utilize Web 2.0 technologies optimally for dissemination.

Predictors of optional immunization uptake in an urban south Indian population.

BACKGROUND: In Tamil Nadu, India, bacille Calmette-Guérin, diphtheria-tetanus-pertussis, oral poliomyelitis, hepatitis B, and measles vaccines are part of the routine immunization schedule and are available free from government health centers. All other vaccines are optional and available in the private sector at a cost to families. This study assesses immunization rates of routine and optional vaccines and examines parental attitudes toward vaccines in Pallavapuram, Tamil Nadu. METHODS: The cluster sampling method was used to estimate immunization coverage. Seven children 18 to 36 months old were selected from 30 clusters for a total sample of 210 children. Demographics and vaccination data were collected from interviews and immunization records. Predictors of vaccination status were identified with logistic regression models. In addition, 21 parents participated in semi-structured interviews regarding their attitudes toward vaccination. Interviews were analyzed qualitatively for themes. RESULTS: Eighty one percent of children were fully immunized with routine vaccines. However, only 21% received all "major" optional vaccines, defined as 3 doses of Haemophilus influenzae type b vaccine, one dose of measles, mumps, rubella vaccine, and one dose of varicella zoster virus vaccine. Birth in a private hospital (OR 5.6, 95% CI 1.3 to 22.9, P<0.01), higher income (P=0.03), and maternal completion of high school (OR 6.4, 95% CI 1.5 to 27.6, P<0.01) were significant predictors of receiving all major optional vaccines. Elucidated themes from interviews included (1) strong parental support for immunizations, (2) low concern for side effects, and (3) low uptake of optional vaccines due to high cost and lack of awareness. CONCLUSIONS: Coverage of optional vaccines is low despite positive attitudes toward immunizations. Efforts to reduce cost and increase awareness of these vaccines particularly among low-income families or to include these vaccines in the routine schedule may increase uptake and reduce morbidity and mortality from vaccine-preventable diseases.

Social and behavioral research in genomic sequencing: approaches from the Clinical Sequencing Exploratory Research Consortium Outcomes and Measures Working Group.

The routine use of genomic sequencing in clinical medicine has the potential to dramatically alter patient care and medical outcomes. To fully understand the psychosocial and behavioral impact of sequencing integration into clinical practice, it is imperative that we identify the factors that influence sequencing-related decision making and patient outcomes. In an effort to develop a collaborative and conceptually grounded approach to studying sequencing adoption, members of the National Human Genome Research Institute's Clinical Sequencing Exploratory Research Consortium formed the Outcomes and Measures Working Group. Here we highlight the priority areas of investigation and psychosocial and behavioral outcomes identified by the Working Group. We also review some of the anticipated challenges to measurement in social and behavioral research related to genomic sequencing; opportunities for instrument development; and the importance of qualitative, quantitative, and mixed-method approaches. This work represents the early, shared efforts of multiple research teams as we strive to understand individuals' experiences with genomic sequencing. The resulting body of knowledge will guide recommendations for the optimal use of sequencing in clinical practice.

Does professional orientation predict ethical sensitivities? Attitudes of paediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination.

BACKGROUND: To determine (1) whether fetal care paediatric (FCP) and maternal-fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care. METHODS: Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively). RESULTS: MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) 'the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-78.4% vs 63.5%); (2) 'the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-80.5% vs 70.2%); and (3) 'the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes. CONCLUSIONS: Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.

Overcoming challenges to develop pediatric postgraduate training programs in low- and middle-income countries.

BACKGROUND: Interest is growing in strengthening postgraduate medical education in low-income countries. The purpose of this study was to understand how postgraduate pediatric training programs are developed in countries with no or few pediatric training opportunities. The authors sought to describe and compare a purposive sample of such new programs, and identify challenges and solutions for successful program establishment and sustainability. METHODS: The authors queried national pediatric email lists and the Accreditation Council for Graduate Medical Education (ACGME) accredited pediatric residency programs in the United States to identify four pediatric training programs that met study criteria. All four programs responded to a questionnaire with quantitative and qualitative components. Qualitative responses were analyzed for themes. RESULTS: Four centers - in Kenya, Laos, Eritrea and Cambodia - met study criteria. Reported challenges to program development and sustainability centered on faculty development and retention, training in pediatric subspecialties, creating pipelines for applicants and graduates, and funding. These themes were used to develop a logic model, which provides a framework for planning, implementing and evaluating new postgraduate general pediatric training program in low-income countries. DISCUSSION: This study compares four postgraduate general pediatric training programs that were recently established and now continue to graduate pediatric residents in low-income countries. Lessons derived from these programs may help guide practice and research for other centers seeking to establish similar programs.

How are childhood thyroid nodules discovered: opportunities for improving early detection.

In a retrospective analysis of childhood thyroid nodules, 18% were radiographic incidentalomas and 41% were discovered by a clinician's palpation; 40% were discovered by patients' families. The latter group had the largest nodules and highest rates of thyroid cancer metastasis, suggesting opportunities for earlier detection through annual well-child visits.

Surgeon migration between developing countries and the United States: train, retain, and gain from brain drain.

BACKGROUND: The critical shortage of surgeons in many low- and middle-income countries (LMICs) prevents adequate responses to surgical needs, but the factors that affect surgeon migration have remained incompletely understood. The goal of this study was to examine the importance of personal, professional, and infrastructural factors on surgeon migration from LMICs to the United States. We hypothesized that the main drivers of surgeon migration can be addressed by providing adequate domestic surgical infrastructure, surgical training programs, and viable surgical career paths. METHODS: We conducted an internet-based nationwide survey of surgeons living in the US who originated from LMICs. RESULTS: 66 surgeons completed the survey. The most influential factors for primary migration were related to professional reasons (p ≤ 0.001). Nonprofessional factors, such as concern for remuneration, family, and security were significantly less important for the initial migration decisions, but adopted a more substantial role in deciding whether or not to return after training in the United States. Migration to the United States was initially considered temporary (44 %), and a majority of the surveyed surgeons have returned to their source countries in some capacity (56 %), often on multiple occasions (80 %), to contribute to clinical work, research, and education. CONCLUSIONS: This study suggests that surgically oriented medical graduates from LMICs migrate primarily for professional reasons. Initiatives to improve specialist education and surgical infrastructure in LMICs have the potential to promote retention of the surgical workforce. There may be formal ways for LMICs to gain from the international pool of relocated surgeons.

Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists.

OBJECTIVES: The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations. METHODS: We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%). RESULTS: FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001). CONCLUSIONS: Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.

Cardiac morbidity in twin-twin transfusion syndrome?

Twin-to-twin transfusion syndrome (TTTS) affects about 10% of monochorionic pregnancies and develops when uncompensated unidirectional blood flow from one twin ('donor') to the other ('recipient') causes circulatory imbalance. The cardiac effect of the underlying hypervolemia or endocrine dysregulation, or both, manifests in the recipient as echocardiographic findings of the syndrome-related cardiomyopathy. The Quintero staging system for TTTS has recently been questioned, because more refined measurement of cardiac function may improve evaluation of disease severity and prediction of outcome. Much has been done to increase survival and diminish the cardiac morbidity associated with TTTS. The purpose of this paper was to review the literature on cardiac morbidity associated this syndrome.

Why are monozygotic twins different?

Although popularly designated as "identical", monozygotic (MZ) twins are rarely identical. Much has been speculated on the origin of MZ twins and several theories have been proposed. Post-fertilization events, such as chromosomal mosaicism, skewed X-inactivation and imprinting mechanisms, as well as other epigenetic mechanisms are responsible for the differences between MZ twins. Numerous discordant MZ twins have been reported including discordance for lateral asymmetry, major malformation, growth and intrauterine death of the co-twin. This discrepancy may have long-term implications on complex diseases and their predisposition, organ transplantation and interpretation of twin-based studies. We reviewed the genotypic and phenotypic differences between MZ twins and discuss their main causes.

Beyond muscles: unexplored parts of men's body image.

Thus far the study of men's body image has been largely restricted to the dimensions of adiposity and muscularity. The aim of this study was to investigate in a systematic way multiple aspects of men's body images, in particular, head hair, body hair, height and penis size, in addition to body weight and muscularity. Questionnaires were completed online by 200 heterosexual men. It was found that men were dissatisfied with all six aspects of their bodies, and worried primarily about body weight, penis size and height. In addition, aspects of weight, muscularity, height and penis size, but not head or body hair, were related to overall appearance self-esteem. It was concluded that men's body image is both multi-faceted and complex.

Hair today, gone tomorrow: a comparison of body hair removal practices in gay and heterosexual men.

Although hairlessness is rapidly becoming a component of the ideal male body, little research has examined men's concerns about their body hair or their hair removal practices. Samples of gay and heterosexual men completed questionnaires that assessed whether they had ever removed their back, buttock or pubic hair, the frequency with which they did so, the methods used and their self-reported reasons for removing this hair, as well as their level of appearance investment. Results indicated that many gay and heterosexual men remove their back, buttock and pubic hair regularly and that their primary reason for doing so is to maintain or improve their appearance. The frequency of hair removal was also associated with the motivational salience component of appearance investment. The findings offer further support to the premise that gay and heterosexual men exhibit similar body image concerns.

Feeding and eating behaviors in children with autism and typically developing children.

Mothers of children aged 2-12 years completed an exhaustive questionnaire assessing feeding and eating behaviors for both themselves and their children with autism, and typically developing siblings of children with Autism Spectrum Disorder (where available), or typically developing children with no sibling with a disability. Results indicate that children with autism were only marginally more likely to exhibit picky eating behavior (overall style) than their siblings or matched typically developing children. Rates of ritualistic feeding behaviors were equivalent in all groups of children although children with autism were more likely to be currently exhibiting problematic eating and feeding behaviors. The implications of these results for the treatment of feeding difficulties exhibited by children with autism will be discussed.

Those speedos become them: the role of self-objectification in gay and heterosexual men's body image.

Objectification Theory proposes that membership in sexually objectifying Western societies gradually socializes women to adopt an observer's perspective on their physical self. This leads to negative consequences, including body shame and restricted eating behavior. The authors extend this framework to investigate a subgroup of men, namely gay men, who also exist in a subculture that emphasizes and values physical appearance. Study 1 investigated trait differences in self-objectification and body image among gay and heterosexual men. Analyses indicated that gay men scored higher on self-objectification, body shame, body dissatisfaction, and drive for thinness. In Study 2, the authors experimentally manipulated state self-objectification and found that for gay men, increasing state self-objectification resulted in greater body shame and dissatisfaction and more restrained eating. Together, these results offer strong support to Objectification Theory as a useful framework from within which to view the experience of gay men.

"Ugh! That's disgusting!": Identification of the characteristics of foods underlying rejections based on disgust.

Previous research has demonstrated that individuals' beliefs about the disgusting properties of foods play a central role in predicting willingness to eat novel foods of either animal or non-animal origin (Martins & Pliner, in press). The present study aimed to identify what characteristics of foods make individuals perceive them as disgusting. In this study, participants read a set of scenarios designed to depict potentially disgusting foods; participants in Sample 1 rated the perceived disgustingness of the foods while participants in Sample 2 rated the foods on a variety of attributes relevant to theoretical conceptions of disgust. Multidimensional scaling revealed two dimensions, aversive textural properties of the foods and reminders of livingness/animalness, that accounted for most of the variability in ratings of perceived disgustingness of the foods depicted in the scenarios. Implications for our current conceptualization of disgust are examined.