Photoinduced Nitroarenes as Versatile Anaerobic Oxidants for Accessing Carbonyl and Imine Derivatives.

Herein, we report a protocol for the anaerobic oxidation of alcohols, amines, aldehydes, and imines promoted by photoexcited nitroarenes. Mechanistic studies support the idea that photoexcited nitroarenes undergo double hydrogen atom transfer (HAT) steps with alcohols and amines to provide the respective ketone and imine products. In the presence of aldehydes and imines, successive HAT and oxygen atom transfer (OAT) events occur to yield carboxylic acids and amides, respectively. This transformation is amenable to a continuous-photoflow setup, which led to reduced reaction times.

Impact of COVID-19 outbreak on acute gallbladder disease in the emergency department.

OBJECTIVE: Acute gallbladder disease (AGD) is frequent in the emergency department (ED) and usually requires emergency surgery. However, only a few studies have reported the impact of COVID-19 on AGD. The goal of this study was to evaluate the time between symptom onset and surgery and the perioperative severity of AGD during the COVID-19 pandemic compared to before the era of COVID-19. METHODS: This retrospective, single-center cohort study included patients who presented to the ED with suspected AGD and who underwent emergency cholecystectomy. We designed a before-after comparative study, and the intervention was the COVID-19 outbreak. The 6-month period after the COVID-19 outbreak was defined as the post-COVID group, whereas the pre-COVID group consisted of the same period in the previous year. The primary outcome was the time from symptoms to surgery. We evaluated the time intervals between symptom onset and ED arrival and between ED arrival and surgery. The secondary outcomes were preoperative and postoperative severity indexes. RESULTS: A total of 316 patients was analyzed. The post-COVID group showed longer duration from symptom onset to ED arrival (34.0 hours vs. 15.0 hours, P<0.001) and longer time interval from ED arrival to surgery (16.2 hours vs. 10.2 hours, P<0.001) than the pre-COVID group. The overall time interval between symptom onset to surgery was longer in the post-COVID group than the pre-COVID group (71.5 hours vs. 33.5 hours, P<0.001). The post-COVID group showed higher preoperative Simplified Acute Physiology Score II scores than the pre-COVID group (20.1 vs. 18.2, P=0.045). The proportion of moderate or severe disease increased in the post-COVID group (78% vs. 65%, P=0.017). The durations of hospital stay (7.0 days vs. 5.0 days, P<0.001) and intensive care unit stay (27.1 hours vs. 10.8 hours, P=0.008) were longer in the post-COVID group than in the pre-COVID group. CONCLUSION: During the pandemic, the time interval between symptom onset to surgery was significantly increased among patients with AGD. Concomitantly, higher preoperative severity indexes and longer hospital stay were reported with a delay in emergency surgery.

Team Approach to Improving Radiologist Wellness: A Case-Based Methodology.

Radiologist wellness is important on an individual and group/institutional level and helps to promote a strong and healthy working environment, which can improve radiologist retention and engagement. This paper will discuss case examples of radiologist wellness improvements in a single academic institution over a 3-year period using the DMAIC (Define, Measure, Analyze, Improve, and Control) model. Leveraging this framework led to the implementation of reading room assistants, reduction in work-related injuries by improvements in ergonomics, and the formation of a faculty mentorship program.

Role of Ergonomic Improvements in Decreasing Repetitive Stress Injuries and Promoting Well-Being in a Radiology Department.

RATIONALE AND OBJECTIVES: To determine if ergonomic improvements in a radiology department can decrease repetitive stress injuries (RSIs), advance ergonomics knowledge, and improve well-being. MATERIALS AND METHODS: Radiologists in an academic institution were surveyed regarding physician wellness, workstations, RSIs, and ergonomics knowledge before and after interventions over 1 year. Interventions included committee formation, education, wrist pads and wireless mice, broken table and chair replacement, and cord organization. Mann-Whitney U test was used for analysis. RESULTS: Survey response was 40% preinterventions (59/147), and 42% (66/157) postinterventions. Preinterventions, of radiologists with RSI history, 17/40 (42%) reported the RSI caused symptoms which can lead to burnout, and 15/40 (37%) responded their RSI made them think about leaving their job. Twenty-three of 59 (39%) radiologists had an active RSI preinterventions. Postinterventions, 9/25 (36%) RSI resolved, 13/25 (52%) RSI improved, and 3/25 (12%) RSI did not improve. RSI improvements were attributed to ergonomic interventions in 19/25 (76%) and therapy in 2/25 (8%). Radiologists who thought their workstation was designed with well-being in mind increased from 9/59 (15%) to 52/64 (81%). The percentage of radiologists knowing little or nothing about ergonomics decreased from 15/59 (25%) to 5/64 (8%). After ergonomics interventions, more radiologists thought the administration cared about safety and ergonomics, equipment was distributed fairly, and radiologists had the ability to ask for equipment (p < .01). Fifty-three of 64 (83%) of radiologists after interventions said improving workstation ergonomic design contributed to well-being. CONCLUSION: Ergonomic improvements in radiology can decrease RSIs, advance ergonomics knowledge, and improve well-being.

Imaging of Benign Hepatic lesions.

As abdominal imaging volumes have increased, the incidence of incidentally identified benign hepatic lesions has substantially increased. Familiarity with imaging appearances of benign hepatic tumors, both common and less commonly encountered, allows the radiologist to give an informed differential diagnosis. In addition to clinical history, awareness of imaging findings of benign hepatic lesions on ultrasound, computed tomography and magnetic resonance imaging is useful in evaluating these lesions and avoiding unnecessary diagnostic interventions or imaging surveillance.

Clinical dilemma of DKA and Covid-19 infection: A case report.

A 52-year-old man with no significant past medical history was found to have diabetic ketoacidosis (DKA) in the setting of COVID-19 infection. He presented with hyperglycemia and an anion gap metabolic acidosis, but without a clear infectious precipitant. Inflammatory markers were subsequently checked, and found to be significantly elevated, raising the suspicion for COVID-19 as a possible etiology despite the lack of typical symptoms - a rapid COVID-19 PCR test checked afterwards was found to be positive. The patient's hospital course was uncomplicated, but the case highlights the possibility of COVID-19 serving as an infectious precipitant for DKA, even when a patient is otherwise asymptomatic in terms of having COVID-19.

Application of calcium nebulization for mass exposure to an accidental hydrofluoric acid spill.

PURPOSE: To determine the long-term prevalence and characteristics of acute hydrofluoric acid (HF) exposure in 2223 patients during the first 30 months after a mass-casualty exposure, and to confirm the antidotal effect of nebulized calcium on inhalation burns caused by HF. METHODS: This observational cohort study included patients after an HF spill in the Republic of Korea on September 27, 2012; registered patients were followed until April 2015. We assessed toxic effects, distance from spill, degree of acute poisoning, and the effect of nebulized calcium in HF-exposed individuals. RESULTS: Overall, 2223 patients received emergency management or antidote therapy for 20 days. Seventy-four of 134 patients with dermal toxicity received calcium-lidocaine gel, and 368 individuals with bronchial irritation signs received calcium gluconate via nebulizer nCG. A total 377 ampoules 786 g of calcium gluconate were used in the nCG formulation. Calcium administration did not cause adverse reactions during the observation period. Long-term cohort observation showed that 120 patients (120/2233, 5.4%) returned to medical facilities for management of HF-related symptoms within 1 month; 18 persons (18/1660, 1.1%) returned 1-3 months later with chronic cough and respiratory symptoms; and 3 patients (3/1660, 0.2%) underwent medical treatment due to upper-airway toxic symptoms more than 2 years after HF exposure. CONCLUSION: Respiratory toxicity after mass exposure to an HF spill was successfully treated by calcium nebulizer. Based on our experience, detoxification processes and the amounts of antidote stocked are important when planning for future chemical disasters at the community level.

Distal Femoral Arteriovenous Fistula with Iliac Vein Thrombosis after Blunt Trauma.

A 39-year-old woman arrived at our emergency department, complaining of severe pain and swelling of her left leg. She had slipped down stairs and injured on her left leg about 3 months ago. Computed tomography angiography showed left distal superficial femoral artery's pseudoaneurysm with arteriovenous fistula and thrombotic occlusion of left common iliac vein. We decided to do endovascular intervention due to severe venous hypertension and chronic inflammation around the fistula. The femoral arteriovenous fistula was closed via stent-graft (7 mm×5, 9 mm×5 cm) deployment. The occluded left iliac vein was reopened by nitinol metal stenting (12 mm×4 cm, 14 mm×4 cm). The authors report a very rare case of femoral arteriovenous fistula combined with iliac vein thrombosis developed after a blunt trauma.

Rare Vascular Anomalies in the Femoral Triangle During Varicose Vein Surgery.

BACKGROUND: We observed several cases of rare vascular anomalies within the femoral triangle during varicose vein operations. METHODS: From among 2,093 patients who underwent stripping operations of the great saphenous vein between January 2002 and June 2016, 14 cases of rare vascular anomalies were enrolled in this study. RESULTS: Twelve cases of femoral artery and vein transposition (0.57%), 1 case of separate entrance of the great saphenous vein trunk and its tributaries (0.05%), and 1 case of separate entrance with femoral artery and vein transposition (0.05%) were observed. The preoperative diagnosis rate was 71% (10 of 14) using duplex ultrasound. In all cases of femoral artery and vein transposition, the saphenofemoral junction was located at the lateral or posterolateral side of the superficial femoral artery, corresponding to complete or incomplete transposition, respectively. Among the 12 cases of femoral artery and vein transposition, 5 cases were complete transposition and 7 cases were incomplete transposition. In 2 cases of separate entrance of the great saphenous vein trunk and its tributaries, the separated tributaries formed a common trunk before connecting to the femoral vein. CONCLUSION: The anatomy of the saphenofemoral junction may infrequently be altered in some individuals. Detailed preoperative sonographic examinations and meticulous groin dissection during the operation are necessary to prepare for unexpected anatomical variations.

Factors related to intentional and unintentional medication nonadherence in elderly patients with hypertension in rural community.

PURPOSE: We assessed medication nonadherence, categorized as intentional or unintentional, and related factors in elderly patients with hypertension, correlating the data with measurement of blood pressure as the final target of medication adherence and other possible influencing factors, such as lifestyle. PATIENTS AND METHODS: Subjects were aged ≥65 years, resided in a rural area, and were taking antihypertensive drugs. The survey was conducted in July 2014. Participants were divided into the following three groups: "Adherence", "Unintentional nonadherence", and "Intentional nonadherence". Individual cognitive components, such as necessity and concern as well as self-efficacy and other related factors, were compared according to adherence groups. The interrelationships between those factors and nonadherence were tested using structural equation modeling analysis. RESULTS: Of the 401 subjects, 182 (45.6%) were in the adherence group, 107 (26.7%) in the unintentional nonadherence group, and 112 (27.9%) in the intentional nonadherence group. Necessity and self-efficacy were found to have a significant direct influence on unintentional nonadherence behaviors (necessity ß=-0.171, P=0.019; self-efficacy ß=-0.433, P<0.001); concern was not statistically significant (ß=-0.009, P=0.909). Necessity was found to have significant direct and indirect impact on intentional nonadherence (direct ß=-0.275, P=0.002; indirect ß=-0.113, P=0.036). Self-efficacy had no significant direct effect on intentional nonadherence though it had the only significant indirect effect on intentional nonadherence (direct ß=-0.055, P=0.515; indirect ß=-0.286, P<0.001). Concern had no significant influence on intentional or on unintentional nonadherence (direct ß=0.132 0.132, P=0.151; indirect ß=-0.006, P=0.909). CONCLUSION: Unintentional nonadherence should be regularly monitored and managed because of its potential prognostic significance. Interventions addressing cognitive factors, such as beliefs about medicine or self-efficacy, are relatively difficult to implement, but are essential to improve medication adherence.

The Poisoning Information Database Covers a Large Proportion of Real Poisoning Cases in Korea.

The poisoning information database (PIDB) provides clinical toxicological information on commonly encountered toxic substances in Korea. The aim of this study was to estimate the coverage rate of the PIDB by comparing the database with the distribution of toxic substances that real poisoning patients presented to 20 emergency departments. Development of the PIDB started in 2007, and the number of toxic substances increased annually from 50 to 470 substances in 2014. We retrospectively reviewed the medical records of patients with toxic exposure who visited 20 emergency departments in Korea from January to December 2013. Identified toxic substances were classified as prescription drug, agricultural chemical, household product, animal or plant, herbal drug, or other. We calculated the coverage rate of the PIDB for both the number of poisoning cases and the kinds of toxic substances. A total of 10,887 cases of intoxication among 8,145 patients was collected. The 470 substances registered in the PIDB covered 89.3% of 8,891 identified cases related to poisoning, while the same substances only covered 45.3% of the 671 kinds of identified toxic substances. According to category, 211 prescription drugs, 58 agricultural chemicals, 28 household products, and 32 animals or plants were not covered by the PIDB. This study suggested that the PIDB covered a large proportion of real poisoning cases in Korea. However, the database should be continuously extended to provide information for even rare toxic substances.

Cross-validation and Peeling Strategies for Survival Bump Hunting using Recursive Peeling Methods.

We introduce a framework to build a survival/risk bump hunting model with a censored time-to-event response. Our Survival Bump Hunting (SBH) method is based on a recursive peeling procedure that uses a specific survival peeling criterion derived from non/semi-parametric statistics such as the hazards-ratio, the log-rank test or the Nelson--Aalen estimator. To optimize the tuning parameter of the model and validate it, we introduce an objective function based on survival or prediction-error statistics, such as the log-rank test and the concordance error rate. We also describe two alternative cross-validation techniques adapted to the joint task of decision-rule making by recursive peeling and survival estimation. Numerical analyses show the importance of replicated cross-validation and the differences between criteria and techniques in both low and high-dimensional settings. Although several non-parametric survival models exist, none addresses the problem of directly identifying local extrema. We show how SBH efficiently estimates extreme survival/risk subgroups unlike other models. This provides an insight into the behavior of commonly used models and suggests alternatives to be adopted in practice. Finally, our SBH framework was applied to a clinical dataset. In it, we identified subsets of patients characterized by clinical and demographic covariates with a distinct extreme survival outcome, for which tailored medical interventions could be made. An R package PRIMsrc (Patient Rule Induction Method in Survival, Regression and Classification settings) is available on CRAN (Comprehensive R Archive Network) and GitHub.

R package PRIMsrc: Bump Hunting by Patient Rule Induction Method for Survival, Regression and Classification.

PRIMsrc is a novel implementation of a non-parametric bump hunting procedure, based on the Patient Rule Induction Method (PRIM), offering a unified treatment of outcome variables, including censored time-to-event (Survival), continuous (Regression) and discrete (Classification) responses. To fit the model, it uses a recursive peeling procedure with specific peeling criteria and stopping rules depending on the response. To validate the model, it provides an objective function based on prediction-error or other specific statistic, as well as two alternative cross-validation techniques, adapted to the task of decision-rule making and estimation in the three types of settings. PRIMsrc comes as an open source R package, including at this point: (i) a main function for fitting a Survival Bump Hunting model with various options allowing cross-validated model selection to control model size (#covariates) and model complexity (#peeling steps) and generation of cross-validated end-point estimates; (ii) parallel computing; (iii) various S3-generic and specific plotting functions for data visualization, diagnostic, prediction, summary and display of results. It is available on CRAN and GitHub.

Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP.

OBJECTIVE: To report a case of severe rebound thrombocytopenia after temporary discontinuation of romiplostim during splenectomy in the context of refractory immune (idiopathic) thrombocytopenic purpura (ITP). CASE SUMMARY: A 65-year-old man with a history of severe refractory ITP failing multiple treatments was considered for romiplostim therapy. He was initiated on 1 µg/kg and titrated upward to 4 µg/kg to elevate and stabilize his platelet levels prior to splenectomy. On day 74 of his clinical course, his platelets increased to 434 × 10(9)/L, and his scheduled dose of romiplostim was withheld on day 75 for fear of romiplostim-induced postsplenectomy rebound thrombocytosis. On day 78, his platelets dropped precipitously to 9 × 10(9)/L, and he experienced multiple episodes of epistaxis. He was reinitiated at 5 µg/kg and soon recovered. He later missed a scheduled dose of romiplostim, and his platelets fell to 23 × 10(9)/L. After resuming romiplostim at 8 µg/kg, his platelets continued to recover. DISCUSSION: Romiplostim, a thrombopoietin mimetic is directly regulated by megakaryocytes and existing circulating platelets via a negative feedback mechanism. This explains the theoretical risk of rapid clearance of romiplostim caused by an increased platelet pool. Clinically, alternative causes of his severe postoperative thrombocytopenia were considered and deemed unlikely. The rebound effect was observed after romiplostim was withdrawn on 2 occasions, and platelet counts improved after restarting romiplostim. The Naranjo Adverse Drug Reaction Probability Score of 7 suggests a probable adverse drug reaction. CONCLUSION: Physicians using romiplostim as a bridge to splenectomy should be cautious about withholding a scheduled dose around the time of surgery.

Cross-Validation of Survival Bump Hunting by Recursive Peeling Methods.

We introduce a survival/risk bump hunting framework to build a bump hunting model with a possibly censored time-to-event type of response and to validate model estimates. First, we describe the use of adequate survival peeling criteria to build a survival/risk bump hunting model based on recursive peeling methods. Our method called "Patient Recursive Survival Peeling" is a rule-induction method that makes use of specific peeling criteria such as hazard ratio or log-rank statistics. Second, to validate our model estimates and improve survival prediction accuracy, we describe a resampling-based validation technique specifically designed for the joint task of decision rule making by recursive peeling (i.e. decision-box) and survival estimation. This alternative technique, called "combined" cross-validation is done by combining test samples over the cross-validation loops, a design allowing for bump hunting by recursive peeling in a survival setting. We provide empirical results showing the importance of cross-validation and replication.