Spine Bracing: When to Utilize-A Narrative Review.

Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.

Media and technology usage and attitudes in emergency department patients.

Introduction: Digital health technologies are increasingly being used in emergency medicine, many of which utilize smartphones and computers. Patient willingness to use these modalities is an important factor in successful implementation. Therefore, this study aimed to assess emergency department (ED) patients' use of and attitudes towards technology. Methods: This was a pooled sub-analysis of ED patients (≥18 years old) that were enrolled in two studies evaluating the ED patient experience in response to novel technological interventions. Participants completed the Media and Technology Usage and Attitudes Scale (MTUAS) that assessed computer and smartphone ownership; frequency of use of phone calls, texting, email, and smartphones; and anxiety and dependence attitudes on these technologies. Results: One hundred and forty-four participants completed the survey. Mean age was 47.2 years (SD 17.94); 61.8% were female; and 61.1% were white. There was high usage of smartphones (93.1%) and computers (74.3%). Participants most frequently used phone calling and texting and least commonly used email. Participants had a positive attitude (mean 3.9/5, SD 0.68) towards the use of these technologies. Discussion: ED patients reported high ownership of smartphones and computers, had a positive attitude towards their use, and had varying frequency with which they used different technologies. Future studies can use this information to inform the development of digital health interventions that utilize technologies that patients find most acceptable.

Novel MSH6 mutation predicted metastasis in eyelid and periocular squamous cell carcinoma.

BACKGROUND: Our previous research revealed the relative local aggressiveness of eyelid and periocular squamous cell carcinoma (EPSCC), but its distinct genetic characteristics involved remain unknown. OBJECTIVES: We conducted this study based on next-generation sequencing to identify the genetic distinctiveness of EPSCC and damaging mutations for possible aetiology and poor prognosis. METHODS: We performed sequencing using a 556-gene panel (SmartOnco) in 48 EPSCCs. Cox hazards model was applied to explore mutated genes that increase the risk of metastasis and death. Pathogenesis of the mutations was predicted by sequence alignment algorithms. RESULTS: The most commonly mutated genes were KMT2C (N = 17, 35%), LRP1B (N = 14, 29%), KMT2D (N = 12, 25%), PTCH1 (N = 10, 21%) and TP53 (N = 10, 21%). DNA mismatch repair (MMR) genes (42%) like MSH6 (19%) and MLH3 (12%) were among the most frequently mutated genes. Cell cycle regulators including TP53 (21%) and CDKN2A (10%) were less frequently mutated than in other squamous cell carcinomas (SCCs). Ultraviolet exposure, MMR deficiency and ageing were the main aetiology. Of note, KMT2C has a deleterious mutation hotspot. Patients burdened with MSH6 mutation has a higher risk of overall metastasis (P = 0.045, HR = 5.165) and nodal metastasis (P = 0.022, HR = 14.038). Moreover, a hotspot mutation MSH6E52A brought an even higher risk of nodal metastasis (P = 0.011, HR = 18.745). CONCLUSIONS: EPSCCs displayed a unique mutation profile from cutaneous SCCs and mucosal SCCs. We have identified novel damaging mutations in epigenetic regulators like KMT2C boosted early onset of EPSCCs in addition to UVR, ageing or MMR deficiency. And malfunction of MMR genes worsened prognosis.

Winner Winner Turkey Dinner! An Empirical Approach to Measuring Palatability and Satisfaction with Emergency Department Turkey Sandwiches.

Introduction: Despite their popularity in many EDs, little is known regarding perceptions of turkey sandwiches among patients. Given the importance of turkey sandwiches as a form of nutrition provided in EDs, we sought to quantify the composition and taste of ED turkey sandwiches through a quantitative assessment of turkey sandwiches by ED staff. Methods: This was a blinded observational study performed at a tertiary, urban academic medical center in Boston, MA. We collected ED turkey sandwiches up to 48 hours prior to study days from 4 emergency departments in the Boston area (2 community hospitals and 2 academic medical centers). We enrolled ED physicians, nurses, physician assistants, and staff who were exposed to four sandwiches in a random fashion. Participants were asked to assess sandwiches on a Likert scale of 1 to 5 on a variety of factors including, nutritional value "goodness", smell "olfactory", texture "bite", ingredient distribution "balance", appearance "look", and flavor "edibility" to produce a composite score for sandwich quality (GOBBLE score). Next, participants were asked standardized questions surrounding suitability for consumption and nutrition on a 10 point Likert scale. We calculated mean scores and measured differences using t-tests. Results: We enrolled 22 participants over the study period. Twenty-one participants completed all measures. GOBBLE scores were calculated and averaged for sandwiches. A One-way ANOVA test was performed to measure statistically significant differences between mean GOBBLE scores (p<0.05) with a post hoc Tukey HSD procedure used to assess for statistically significant difference for pairwise comparison. A significant difference (p=0.009) was noted between the 4 sandwiches being compared, with a single site outperforming the others. Aggregating for academic and community sites demonstrated no statistically significant difference (p=0.08). Sandwiches in general were not considered healthy or palatable by study subjects. Conclusion: Despite out-performance by a single ED, there is no significant difference in the quality of sandwiches provided to patients in EDs between academic and community hospitals. ED turkey sandwiches do not appear to be food items that are viewed as healthy or recommended to patients by ED staff who participated in this study.

Wartime toxicology: the spectre of chemical and radiological warfare in Ukraine.

The unprovoked invasion of Ukraine by the Russian Federation has resulted in the largest humanitarian crisis in Europe since World War II. As fighting intensifies throughout Ukraine, there is an increasing concern that the Russian Federation may consider the direct use of chemical or radiological weapons against military personnel and civilians in Ukraine. Despite prohibition of chemical weapons from the Chemical Weapons Convention of 1997, recent evidence has demonstrated that state actors will continue to use these agents as weapons of war and terror, despite publicly denying their use. We review chemical weapons produced and used by the Russian Federation (or its allies) to identify plausible risks in the Russian war in Ukraine. We also provide rapid assessment and treatment guidelines to recognize and manage these acute exposures.

Severe colchicine poisoning treated successfully with kidney replacement therapy and plasmapheresis: a case report.

Colchicine is commonly prescribed for treatment of inflammatory conditions but has a narrow therapeutic window and dangerous toxicity profile. Here we describe a case of survival after massive unintentional colchicine overdose treated with plasmapheresis and renal replacement therapy. A 37 year old male with history of pericarditis presented to the Emergency Department with a chief complaint of nausea, vomiting, and diarrhea after unintentionally ingesting 36 mg of colchicine 17 h prior to arrival. An initial colchicine concentration resulted at 5.1 ng/mL (30 h post-ingestion) and peaked at 12 ng/mL (40 h post-ingestion). He was treated with continuous kidney replacement therapy (CKRT) beginning on his first day of hospitalization and with plasmapheresis on hospital days two through four. The patient's course was complicated by multiorgan failure including coagulopathy, respiratory failure, neuropathy, renal failure, pancytopenia, and heart failure. He was discharged to inpatient rehabilitation on hospital day 24. On clinical follow up four months after discharge the patient was found to have no significant persistent morbidity related to colchicine overdose.

Comparison of radiation dose, contrast enhancement and image quality of prospective ECG-Gated CT coronary angiography: Single versus dual source CT.

INTRODUCTION: The updated National Institute of Clinical Excellence (NICE) guidelines of 2017 state that new generation cardiac CT scanners (Aquilion ONE, Brilliance iCT, Discovery CT750 HD and Somatom Definition Flash) are recommended as an option for first-line imaging of the coronary arteries in people with suspected stable coronary artery disease (with an estimated likelihood of coronary artery disease of 10-29%) in whom imaging with earlier generation CT scanners is difficult. New generation cardiac CT scanners are also recommended as an option for first-line evaluation of disease progression, to establish need for revascularisation in people with known coronary artery disease in whom imaging with earlier generation CT scanners is difficult. CT scanning might not be necessary in situations in which immediate revascularisation is being considered. The European Society of Cardiology 2019 clinical practice guidelines recommend non-invasive functional imaging for myocardial ischaemia or coronary CT angiography (CTA) as the initial test to diagnose CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone. Given increased computed tomography coronary angiogram (CTCA) utilisation, radiation dose, contrast enhancement and image quality of prospective ECG-gated CTCA between 256-slice single-source and 192x2-slice dual-source CT scanners were retrospectively evaluated. METHODS: Prospectively gated CTCA data from 63 patients on a 256-slice CT (group A) and 71 patients on a 192x2-slice dual source CT (group B) from January to December 2016 were retrospectively evaluated respectively. Scanner-reported dose length product values were used with a conversion factor (k = 0.014 mSv/mGy x cm) to estimate effective dose. Contrast enhancement was assessed with mean CT attenuation at selected regions of interest on axial coronary images. Image quality of the coronary arteries was assessed by a 4-point grading score (1 = non-diagnostic, 4 = excellent image quality). RESULTS: The radiation doses in group B were significantly lower than group A (3.68 + 2.13 mSv versus 4.81 + 1.56 mSv, p < 0.001). There were no significant differences in contrast enhancement in the left coronary artery, proximal right coronary artery and left ventricular wall for both groups. Vessel image quality scores for group B were higher than group A (right coronary artery (RCA): 3.2 + 0.7 versus 2.4 + 0.7, p < 0.001; left anterior descending (LAD) artery: 3.0 + 0.8 vs 2.5 + 0.6, p < 0.001; left circumflex (LCx) artery: 3.3 + 0.7 vs 2.6 + 0.6, p < 0.001). Coronary artery contour scores for group B were significantly higher than group A (RCA: 3.2 + 0.8 versus 2.3 + 0.7, p < 0.001; LAD: 3.0 + 0.7 versus 2.4 + 0.6, p < 0.001; LCx: 3.3 + 0.6 versus 2.5 + 0.6, p < 0.001). CONCLUSION: Prospective ECG-gated CTCA performed on 192x2-slice CT results in better image quality and lower radiation dose than 256-slice CT. There were no significant differences in contrast enhancement in left main coronary artery (LMCA), proximal RCA and left ventricular wall in both groups. IMPLICATIONS FOR PRACTICE: In institutions with both 256-slice and 192x2-slice CT scanners, we recommend that CTCAs be preferentially performed using the 192x2-slice CT scanner.

Wingless/int-1induced secreted protein-1: a new biomarker for renal fibrosis.

This study aimed to detect the expression of Wnt-induced secreted protein-1 (WISP-1) in renal fibrosis (RF) and to clarify the underlying mechanism. An in vivo mousee model of unilateral ureteral obstruction (UUO) and in vitro model of fibrosis on renal tubular epithelial NRK52E cells after transforming growth factor-ß1 (TGF-ß1) stimulation were used. Quantitative real-time PCR (qRT-PCR), Western blot (WB), and immunohistochemistry were used to detect WISP-1 and fibrosis markers, including the expression of fibronectin (FN), collagen I (Col I), collagen IV (Col IV), and α-smooth muscle actin (α-SMA). In vitro experiments showed that the expression of WISP-1 and fibrosis markers FN, Col I, Col IV, and α-SMA in rat renal tubular epithelial cells were significantly higher than that in the control group after 48 h of TGF-ß1 stimulation. In vivo experiments showed that the expressions of WISP-1 and fibrosis markers FN, Col I, Col IV, and α-SMA in the obstructed kidney of UUO animal models were significantly increased in mRNA and protein levels compared to normal mice. This study showed that WISP-1 may be an essential cytokine that promotes renal fibrosis, being involved in the development of renal fibrosis.

Traumatic pedestrian and bicyclist injuries associated with intoxication.

BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.

[Epidemiological characteristics of COVID-19 monitoring cases in Yinzhou district based on health big data platform].

Objective: To understand the epidemiological characteristics of COVID-19 monitoring cases in Yinzhou district based on health big data platform to provide evidence for the construction of COVID-19 monitoring system. Methods: Data on Yinzhou COVID-19 daily surveillance were collected. Information on patients' population classification, epidemiological history, COVID-19 nucleic acid detection rate, positive detection rate and confirmed cases monitoring detection rate were analyzed. Results: Among the 1 595 COVID-19 monitoring cases, 79.94% were community population and 20.06% were key population. The verification rate of monitoring cases was 100.00%. The total percentage of epidemiological history related to Wuhan city or Hubei province was 6.27% in total, and was 2.12% in community population and 22.81% in key population (P<0.001). The total COVID-19 nucleic acid detection rate was 18.24% (291/1 595), and 53.00% in those with epidemiological history and 15.92% in those without (P<0.001).The total positive detection rate was 1.72% (5/291) and the confirmed cases monitoring detection rate was 0.31% (5/1 595). The time interval from the first visit to the first nucleic acid detection of the confirmed monitoring cases and other confirmed cases was statistically insignificant (P>0.05). Conclusions: The monitoring system of COVID-19 based on the health big data platform was working well but the confirmed cases monitoring detection rate need to be improved.

Chloroquine, hydroxychloroquine and COVID-19.

The media have featured the antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) to treat coronavirus (COVID-19). Political leaders have touted their use and recommended availability to the public. These anti-inflammatory agents have substantial human toxicity with a narrow therapeutic window. CQ and HCQ poisoning cause myocardial depression and profound hypotension due to vasodilation. Bradycardia and ventricular escape rhythms arise from impaired myocardial automaticity and conductivity due to sodium and potassium channel blockade. With cardiotoxicity, ECGs may show widened QRS, atrioventricular heart block and QT interval prolongation. CQ may also cause seizures, often refractory to standard treatment. Of concern is pediatric poisoning, where 1-2 pills of CQ or HCQ can cause serious and potentially fatal toxicity in a toddler. The treatment of CQ/HCQ poisoning includes high-dose intravenous diazepam postulated to have positive ionotropic and antidysrhythmic properties that may antagonize the cardiotoxic effects of CQ. Infusions of epinephrine titrated to treat unstable hypotension, as well as potassium for severe hypokalemia may be required. Current scientific evidence does not support treatment or prophylactic use of these agents for COVID-19 disease. Regulatory and public health authorities recognize that CQ/HCQ may offer little clinical benefit and only add risk requiring further investigation before wider public distribution.

An instrument for measuring scintillators efficiently based on silicon photomultipliers.

An instrument used for measuring multiple scintillators' light output and energy resolution was developed. The instrument consisted of a light sensor array which was composed of 64 discrete SiPMs (Silicon Photomultipliers), a corresponding individual channel readout electronics system, and a data processing algorithm. A Teflon grid and a large interval between adjacent SiPMs were employed to eliminate the optical cross talk among scintillators. The scintillators' light output was obtained by comparing with a reference sample with known light output. Given the SiPM temperature dependency and the difference among each SiPM, a temperature offset correction algorithm and a non-uniformity correction algorithm were added to the instrument. A positioning algorithm, based on nine points, was designed to evaluate the performance of a scintillator array. Tests were performed to evaluate the instrument's performance. The uniformity of 64 channels for light output measurement was better than 98%, the stability was better than 98% when temperature varied from 15 °C to 40 °C, and the nonlinearity under 511 keV was better than 2%. This instrument was capable of selecting scintillators and evaluating the packaging technology of scintillator arrays with high efficiency and accuracy.

Incidental cardiac abnormalities on non-electrocardiogram-gated multi-detector computed tomography imaging of the thorax and abdomen.

Little attention is usually paid to the heart on non-electrocardiogram (ECG)-gated multi-detector computed tomography (MDCT) imaging of the thorax and abdomen. The current MDCT systems have fast scanning capabilities that render non-ECG-gated images with reduced cardiac motion artefacts due to greater temporal and spatial resolution. This has allowed for better evaluation of the cardiac structures. We present a pictorial review of incidental cardiac abnormalities found on MDCT imaging of the thorax and abdomen performed in our institution. We systematically describe abnormalities involving the pericardium, myocardium, cardiac valves, cardiac chambers, coronary artery and congenital heart disease. Some of these images have echocardiograph and magnetic resonance imaging correlation. The purpose of this pictorial essay is to draw attention to cardiac abnormalities found incidentally on non-ECG-gated MDCT imaging of the thorax and abdomen, which may or may not be related to the patient's symptoms.

Unusual case of unrepaired omphalocoele and uncorrected tetralogy of Fallot in a young adult.

An omphalocoele is a congenital defect that affects the development of the abdominal wall in the umbilical region, resulting in a hernial-type sac of variable size. The condition is usually diagnosed prenatally and corrected in early infancy to prevent rupture of the covering membranes, which carries a high mortality and morbidity rate. Tetralogy of Fallot is the most common cyanotic congenital heart defect during infancy that is associated with this condition. Most patients experience cyanosis at birth and die in childhood if there is no surgical intervention. Overall, it is uncommon for untreated patients with both omphalocoele and tetralogy of Fallot to survive into adulthood. We report the rare case of a 17-year-old young adult with untreated omphalocoele and uncorrected tetralogy of Fallot.

Aetiology and outcome of neonatal cholestasis in Malaysia.

INTRODUCTION: Little is known about the epidemiology, causes and outcomes of neonatal cholestasis in the Asian population beyond Japan and Taiwan. METHODS: This was a prospective, observational study on patients with neonatal cholestasis who were referred to the University of Malaya Medical Centre, Malaysia, between November 1996 and May 2004. RESULTS: Biliary atresia (BA) (29 percent) and idiopathic neonatal hepatitis (38 percent) were the two commonest causes of neonatal cholestasis (n is 146) that were referred. Out of the 39 patients (27 percent of the total) who died at the time of review, 35 succumbed to end-stage liver disease. Three of the four patients (three BA, one progressive familial intrahepatic cholestasis [PFIC]) who had a living-related liver transplant (LT) died after the surgery (two BA, one PFIC). Six (four percent) of the remaining 107 survivors had liver cirrhosis. The overall four-year survival rates for patients with native liver and LT as well as those with native liver alone for all cases of neonatal cholestasis were 72 percent and 73 percent, respectively, while the respective survival rates for BA were 38 percent and 36 percent. CONCLUSION: BA and idiopathic neonatal hepatitis are important causes of neonatal cholestasis in Malaysian infants. In Malaysia, the survival rate of patients with neonatal cholestasis, especially BA, is adversely affected by the lack of a timely LT.

Out-of-pocket costs associated with rotavirus gastroenteritis requiring hospitalization in Malaysia.

From August 2006 to July 2007 a prospective study of out-of-pocket costs incurred by care-givers of children hospitalized for rotavirus gastroenteritis was conducted in a hospital in Malaysia. Data on caretaker out-of-pocket costs were collected from 260 children hospitalized with diarrhoea. A stool sample was collected from 198 of these children of which 46 (23%) were positive for rotavirus by latex agglutination assay. The mean (median; interquartile range) out-of-pocket cost incurred by the care-givers was US$194 (US$169; US$47-738), constituting 26% of average monthly income of the households surveyed. Major components of the cost were hospital expenses (45%) and productivity loss (37%). These findings will allow further assessment of the cost-effectiveness of any future rotavirus immunization program in Malaysia.

Contrasting fatty involvement of the right ventricle: lipoma versus lipomatous hypertrophy.

We report two rare cases of right ventricular lipomatous involvement, and discuss their contrasting diagnostic images and clinical manifestations. Case 1 is a 21-year-old Malay man who presented with recurrent syncope. Transthoracic echocardiography showed a homogeneous discrete mass attached to the right ventricular septum, occupying the right ventricular outflow tract. Cardiac magnetic resonance (MR) imaging showed features consistent with intracardiac lipoma, which was confirmed on histology, upon surgical resection. Case 2, a 73-year-old Caucasian woman, was found to have incidental lipomatous infiltration of the right ventricle on echocardiography and MR imaging. In contrast to the well-defined right ventricular lipoma seen in the first case, lipomatous involvement was manifested as a diffuse homogeneous thickening of the right ventricular free wall. Multimodality imaging allows for a complementary and detailed characterisation of lipomatous masses involving the ventricular septum.

A case of neonatal diarrhoea caused by congenital glucose-galactose malabsorption.

A five-month-old Indian girl, product of consanguineous marriage, presented with diarrhoea with an onset within two days after birth, severe malnutrition and metabolic acidosis. The diarrhoea persisted even with lactose-free formula, amino acid-based formula and glucose-containing oral rehydration solution, but stopped when fasted. She required prolonged parenteral nutrition. Fructose and glucose tolerance tests were performed, confirming the child was able to absorb and metabolize fructose but not glucose, indicating a diagnosis of glucose-galactose malabsorption. This case illustrate how simple and pertinent clinical observations and laboratory investigations is sufficient to allow a firm diagnosis to be made.

Diabetic patients with normal baseline renal function are at increased risk of developing contrast-induced nephropathy post-percutaneous coronary intervention.

INTRODUCTION: We hypothesised that diabetic patients with normal baseline renal impairment who do not receive prophylaxis before percutaneous coronary intervention (PCI) are at an increased risk of developing contrast-induced nephropathy (CIN). METHODS: We conducted a cohort study involving 839 patients who underwent PCI between 2004 and 2006, and divided them into three groups: Group A (304 diabetics with normal baseline serum creatinine [Cr] of less than 1.5 mg/dL); Group B (465 non-diabetics with normal Cr); Group C (70 patients with impaired baseline renal function with Cr more than or equal to 1.5 mg/dL). CIN prophylaxis, including oral N-acetylcysteine and saline hydration, were administered only to Group C patients. RESULTS: The median age for Groups A, B and C was 58, 56 and 64 years, respectively. The prevalence of hypertension in Groups A, B and C was 76.3, 56 and 85.7 percent, respectively. Baseline demographics were comparable among the three groups with regard to gender, left ventricular systolic function and contrast volume use. Incidences of CIN in Groups A, B and C were 8.9 percent, 4.3 percent and 4.5 percent, respectively (p-value is 0.042). The incidence of CIN in diabetic patients with a normal baseline Cr who did not receive prophylaxis (Group A) was significantly higher than in the other two groups (p-value is less than 0.001). CONCLUSION: Our findings suggest that diabetic patients, despite having a normal baseline Cr, are at an increased risk of developing CIN post-PCI. Routine prophylaxis in this cohort may be beneficial.