Heart Failure in a Patient With Metastatic Well-Differentiated Neuroendocrine Tumor.

Patients with neuroendocrine malignancy with liver metastases are at risk for carcinoid heart disease which, if left unchecked, can lead to heart failure. This case study demonstrates a clinical situation in which an advanced practitioner performed a thorough workup consisting of lab work and imaging studies, including echocardiogram, cardiac MRI, and dotatate PET/CT, as well as outside record review and comprehensive physical exam. Early detection, intervention, and control of disease are paramount to prevent potentially life-limiting carcinoid heart disease.

Where and with whom does a brief social-belonging intervention promote progress in college?

A promising way to mitigate inequality is by addressing students' worries about belonging. But where and with whom is this social-belonging intervention effective? Here we report a team-science randomized controlled experiment with 26,911 students at 22 diverse institutions. Results showed that the social-belonging intervention, administered online before college (in under 30 minutes), increased the rate at which students completed the first year as full-time students, especially among students in groups that had historically progressed at lower rates. The college context also mattered: The intervention was effective only when students' groups were afforded opportunities to belong. This study develops methods for understanding how student identities and contexts interact with interventions. It also shows that a low-cost, scalable intervention generalizes its effects to 749 4-year institutions in the United States.

Quality improvement approach to increasing respiratory therapist driven teach back style asthma education.

OBJECTIVE: Asthma is a common chronic medical condition that can require treatment with multiple inhaled medications. Our quality improvement group established a standard asthma teaching protocol with respiratory therapists utilizing the teach back method. We aimed to increase the percentage of pulmonary asthma clinic visits receiving this education from a baseline of 42.7% in 2016 to 80% by December 2019. METHODS: Multiple interventions were put in place and data was collected monthly from the electronic medical record system. Data was recorded in statistical process control charts using a p chart. Nelson's established rules for determining special versus common cause variation were used. RESULTS: Over the three-year project the percentage of asthma clinic visits receiving the standardized respiratory therapist driven teach back asthma education increased to 82.3%. CONCLUSION: Utilizing a standardized approach, it's possible to deliver standardized asthma education in a busy pulmonary clinic.

Temporal trends in routine predischarge pulse oximetry screening: 6 years' experience in a UK regional neonatal unit.

OBJECTIVES: To evaluate the continued impact of pulse oximetry screening (POS) in a regional neonatal unit (NNU) and identify trends in screening outcomes in comparison with our previous experience. DESIGN: Retrospective review of admissions between April 2013 and March 2019 (the current study) and comparison with previously published data (the 2014 study). PATIENTS: All infants >34 weeks completed gestation admitted to NNU as a result of positive POS. OUTCOME MEASURES: Indication for admission, diagnosis, investigations and management. RESULTS: There were 49 375 livebirths and 253 NNU admissions as a result of positive POS (0.5% of livebirths; compared with 0.8% in 2014). 247/253 (97.6%) of those admitted had a significant diagnosis requiring medical intervention (compared with 79% in 2014) and the proportion of healthy babies (with transitional circulation) admitted decreased from 21% to 2.4%.22 (9%) babies admitted as a result of a positive POS were found to have a previously undiagnosed congenital heart defect (CHD) of which eight were critical CHDs (CCHDs). This accounted for 73% of all undiagnosed CCHD undergoing POS. The antenatal detection rate of CCHD was 75% compared with 46% in 2014. No baby died or collapsed on the postnatal ward during the study period. The proportion of babies with CCHD identified before discharge improved from 94% to 99%. CONCLUSIONS: Routine POS, in addition to antenatal screening and postnatal examination, continues to contribute to the improvement of our overall CCHD detection rates. We have demonstrated an overall reduction in the admission of healthy babies and therefore workload following a positive test.

Novel compound heterozygous TTN variants as a cause of severe neonatal congenital contracture syndrome without cardiac involvement diagnosed with rapid trio exome sequencing.

This report focuses on a case of severe congenital myopathy with arthrogryposis without cardiac involvement due to compound heterozygous variants in the TTN gene. The proband presented with severe axial hypotonia, arthrogryposis and severe respiratory insufficiency with ventilator dependence. Electromyogram was abnormal with absent motor responses but preserved sensory nerve responses. Rapid gene-agnostic trio exome sequencing detected novel compound heterozygous variants in the TTN gene. One variant is a truncating frameshift located in the meta-transcript only exon 195. The other variant is a nonsense variant in exon 327 which affects all recognised post-natal transcripts apart from one. This case presents with a severe phenotype and adds to the expanding known variants associated with autosomal recessive titinopathy. It also demonstrates the utility of rapid trio exome sequencing when used early in the clinical course.

Improving Discourse following Traumatic Brain Injury: A Tale of Two Treatments.

Persons with traumatic brain injury (TBI) often present with discourse-level deficits that affect functional communication. These deficits are not thought to be primarily linguistic in nature but instead are thought to arise from the interaction of linguistic and cognitive processes. Discourse processing treatment (DPT) is a discourse-based treatment protocol which targets discourse deficits frequently seen in TBI. Attention Process Training-2 (APT-2) is a published treatment protocol which targets four levels of attention. The purpose of this article is to investigate the effectiveness of DPT and APT-2 in improving discourse production and cognition in adults with TBI. Our results suggest that DPT results in greater improvement in discourse informativeness and coherence, but the combination of DPT and APT-2 resulted in greater generalization to untrained stimuli. Both DPT and APT-2 appear to have some potential to improve cognition, but there was intersubject variability with regard to which treatment is more effective.

Growing Roots: A Newcomer Nutrition Program Designed Using Action Research Methods.

Many newcomers to Canada struggle with food insecurity and the health impacts of dietary acculturation. "Growing Roots" is a newcomer nutrition program designed through a community development approach to help immigrants and refugees adapt positively to the Canadian food environment. This qualitative action research project documented the development, implementation and impacts of the program in an inner city neighbourhood of Winnipeg, Manitoba, Canada. Data was collected through oral questionnaires and interviews. Impacts included: 1) Healthy adaptation to the Canadian foodscape; 2) Enhanced nutrition knowledge and behaviours; 3) Improvements to food security status; and 4) Enhanced social networks.

Respiratory Depression Following Ambulatory Urogynecologic Procedures: A Retrospective Analysis.

OBJECTIVE: To assess the rate of postanesthesia respiratory depression (RD) and test for potential associations with clinical characteristics of patients undergoing urogynecologic procedures at ambulatory surgical centers (ASCs). Postanesthesia RD is poorly characterized for patients undergoing urogynecologic procedures in ASCs. PATIENTS AND METHODS: Health records of adult patients undergoing urogynecologic procedures at an ASC from July 1, 2010, through December 31, 2015, were abstracted. Cases complicated by RD were identified, and analyses of risk factors were performed with generalized estimating equations (GEE). RESULTS: During the study time frame, 9105 patients underwent 9141 procedures, of which RD complicated 221 cases (mean [95% confidence interval (CI)] complication rate per 100 cases, 2.4 [2.1-2.8]). Risk increased with advancing age, male sex, obstructive sleep apnea (OSA), morbid obesity, and use of volatile anesthetics and airway secured. Patients with RD had longer anesthesia recovery (median [interquartile range], 135 [110-166] vs 105 [80-138] minutes; P<.001). Within 48 postprocedural hours, 290 ED visits or hospitalizations occurred, but this risk was not increased by RD (adjusted odds ratio [95% CI], 0.62 [0.30-1.26]; P=.12). CONCLUSION: Postanesthesia RD after ambulatory urogynecologic procedures delay anesthesia recovery but are not associated with later complications. Patients with OSA or having other conditions related to OSA, or both, are at higher risk for RD.

Discourse-based treatment in mild traumatic brain injury.

BACKGROUND: Individuals with traumatic brain injury (TBI) present with numerous discourse deficits associated with impairments to the linguistic system and other cognitive systems. Individuals with TBI may produce discourse that is lacking important information and poorly organized, as well as containing numerous coherence disrupting elements. Yet there are few studies directly addressing discourse deficits in individuals with TBI to guide clinicians. AIMS: The purpose of the study was to determine if discourse processing treatment improved the discourse production in individual with TBI. Aims of the study included determining if the discourse processing treatment improved completeness and informativeness in TBI discourse samples. METHODS & PROCEDURES: The study included three participants with mild-to-moderate TBI. The study utilized an A-B with maintenance design that incorporated components of functional practice, structured cues in the form of comprehension questions and story guide, and meta-cognitive and meta-linguistic processes. Discourse samples were obtained for baseline, treatment, and maintenance one-week and one-month post treatment. Stimuli included 12 sequential pictures, as well as a single picture and a recount probe. OUTCOMES & RESULTS: All participants demonstrated small gains in completeness and informativeness for treated items, and 2 of 3 participants demonstrated a medium therapeutic effect for untreated stimuli. Participants also produced discourse with fewer errors for both treated and untreated stimuli after treatment with no therapeutic effect to a small effect for the generalization stimuli. CONCLUSIONS: The study demonstrated that the discourse processing treatment is capable of producing small therapeutic effects that persisted one-month post treatment in adults with mild-to-moderate TBI.

Working Memory in Aphasia: Considering Discourse Processing and Treatment Implications.

Evidence suggests that persons with aphasia (PWAs) present with working memory impairments that affect a variety of language tasks. Most of these studies have focused on the phonological loop component of working memory and little attention has been paid to the episodic buffer component. The episodic buffer, as a limited capacity, multimodal system that binds and integrates information from the phonological loop, visuospatial sketchpad, and long-term memory would likely be involved in discourse processing. The purposes of this article were to (1) review discourse level deficits associated with aphasia, (2) describe how a deficit at the level of the episodic buffer could cause such deficits, (3) to review discourse treatment approaches for PWAs, and (4) present preliminary results from a novel discourse treatment study for PWAs.

Lexical Ambiguity Resolution Using Discourse Contexts in Persons With and Without Aphasia.

Purpose: The purpose of this study was to investigate the ability of persons with aphasia (PWA) to resolve different types of ambiguous words (homophones, metaphors, and metonyms) in discourse contexts. Method: Six PWA and 10 controls listened to short discourses that biased either the dominant (more frequent) or subordinate (less frequent) version of an ambiguous word as well as nonsense (filler) discourses. Participants then indicated whether or not the final sentence, which contained the ambiguity, made sense in the discourse. Data for both accuracy and reaction time were collected. Results: There was no significant Group × Word Type × Frequency interaction in the reaction time data. In the accuracy analysis, there was a significant Group × Frequency × Word Type interaction, which appeared to be driven by the PWA's relative accuracy with subordinate homophones and relative inaccuracy with subordinate metaphors. Conclusions: These results suggest that PWA were able to use discourse contexts to resolve subordinate versions of literal ambiguous words but have difficulty resolving metaphoric ambiguous words. Further investigations should be done to clarify how much context PWA require to successfully resolve lexical ambiguities.

Global coherence during discourse production in adults: a review of the literature.

BACKGROUND: Global coherence is a metric of expressive language performance that represents the speaker's ability to initiate, plan and maintain a topic of discussion. Studies indicate that disruptions of global coherence can occur during the ageing process and following neurological disease or injury. However, little is known about the specific impact that the ageing process, disease or injury has on global coherence during discourse production. AIMS: To review the literature on global coherence in adult populations and assess the impact that age, disease or injury has on global coherence during expressive language tasks. METHODS & PROCEDURES: We completed an in-depth search of Medline and PyschInfo (1990-2014) to identify studies of global coherence in adult populations. We identified studies that included a comparison group and utilized a measure of global coherence during expressive language production among adults. OUTCOMES & RESULTS: Twenty studies comprised of 692 study participants who met inclusion criteria were identified for the review of the literature. Studies included participants without neurological impairments and individuals with aphasia, traumatic brain injury, dementia, generalized memory impairment and other neurological conditions. Study results indicated global coherence is an expressive language skill that is influenced by the ageing process and neurological disease or injury. CONCLUSIONS & IMPLICATIONS: Although evidence indicated that global coherence is negatively influenced by ageing and neurological disease/injury, the heterogeneity of study populations, measurement tools and study designs were limiting factors in determining the exact nature by which these factors impact the skill of global coherence.

Effects of acepromazine or methadone on midazolam-induced behavioral reactions in dogs.

This study evaluated whether acepromazine or methadone reduced behavioral parameters, overall excitement, and activity associated with midazolam administration to healthy dogs. Dogs received midazolam (M) alone [M: 0.25 mg/kg body weight (BW)] or with methadone (MM) (MM: 0.75 mg/kg BW) or acepromazine (MA) (MA: 0.03 mg/kg BW) or saline (S) solution alone, all intramuscularly. Two blinded observers evaluated behavioral parameters using video recordings 30 min before and after injection of drugs. Accelerometery was used to evaluate "total activity counts" (TAC) at baseline and post-treatment. Post-treatment excitement scores were significantly higher in M and MA compared to baseline, M and MM compared to S, and M compared to MA. Behavioral parameters showed significantly higher proportions of "pacing" post-treatment in all groups receiving midazolam, and "restlessness," "chewing/licking," and "sniffing" in M. No significant differences were found for TAC at baseline and post-treatment. Midazolam-induced paradoxical behavioral changes (excitation, panting, pacing, restlessness, licking/chewing, and vocalization) were not prevented by acepromazine or methadone in healthy dogs.

Effets de l'acépromazine ou de la méthadone sur les réactions comportementales induites par le midazolam chez les chiens. Cette étude a évalué si l'acépromazine ou la méthadone réduisait les paramètres comportementaux, le niveau d'excitation général et l'activité associée à l'administration de midazolam chez des chiens en santé. Les chiens ont reçu le midazolam (M) seul (M : 0,25 mg/kg poids corporel [PC]) ou avec de la méthadone (MM) (MM : 0,75 mg/kg PC) ou de l'acépromazine (MA) (MA : 0,03 mg/kg PC) ou une solution saline (S) seule, tous administrés par voie intramusculaire. Deux observateurs à l'aveugle ont évalué les paramètres comportementaux à l'aide d'enregistrements vidéo 30 minutes avant et après l'injection des médicaments. Un accéléromètre a été utilisé pour évaluer les «numérations de l'activité totale¼ (NAT) comme données de référence et après le traitement. Les notes d'excitation après le traitement étaient significativement supérieures pour M et MA comparativement aux données de référence, M et MM comparativement à S et M comparativement à MA. Les paramètres comportementaux ont montré des proportions significativement supérieures de «va-et-vient¼ après le traitement dans tous les groupes qui avaient reçu midazolam et une «agitation¼, de «mastication et léchage¼ et de «reniflement¼ dans M. Aucune différence significative n'a été constatée pour NAT aux données de référence et après le traitement. Les changements comportementaux paradoxes induits par le midazolam (excitation, halètement, va-et-vient, agitation, lèchage et mastication et vocalisation) n'ont pas été prévenus par l'acépromazine ni la méthadone chez les chiens en santé.(Traduit par Isabelle Vallières).

Persistent enhancement of functional MRI responsiveness to sensory stimulation following repeated seizures.

PURPOSE: Neural reorganization and interictal behavioral anomalies have been documented in people with epilepsy and in animal seizure models. Alterations in behavior could be due to somatosensory dysfunction. This study was designed to determine whether seizures can lead to changes in somatosensory representations and whether those changes are persistent. METHODS: Twice-daily seizures were elicited by delivering 1 s of electrical stimulation through carbon fiber electrodes implanted in both the corpus callosum and sensorimotor neocortex of young adult male Long-Evans rats until a total of 20 seizures were elicited. Either 1-3 days or 3-5 weeks following the last seizure, functional magnetic resonance imaging (MRI) was used to image the brain during electrical stimulation of each forepaw independently. KEY FINDINGS: Forepaw stimulation in control rats resulted in a focused and contralateral fMRI signal in the somatosensory neocortex. Rats that had repeated seizures had a 151% increase in the number of voxels activated in the contralateral hemisphere 1-3 days after the last seizure and a 166% increase at 3-5 weeks after the last seizure. The number of voxels activated in response to forepaw stimulation was positively correlated with the duration of the longest seizure experienced by each rat. The intensity of the activated voxels was not significantly increased at either time interval from the last seizure. SIGNIFICANCE: The increased area of activation in somatosensory cortex, which is persistent at 3-5 weeks, is consistent with previous observations of larger motor maps following seizures. Seizure-induced changes in the functioning of sensory cortex may also contribute to interictal behavioral anomalies.

Larger cortical motor maps after seizures.

Expansion of motor maps occurs in both clinical populations with epilepsy and in experimental models of epilepsy when the frontal lobes are involved. We have previously shown that the forelimb area of the motor cortex undergoes extensive enlargement after seizures, although the extent to which many movement representation areas are altered is not clear. Here we hypothesize that movement representations in addition to the forelimb area will be enlarged after cortical seizures. To test our hypotheses, Long Evans Hooded rats received 20 sessions of callosal (or sham) kindling, and then were subjected to intracortical microstimulation to map several movement representations including the jaw, neck, forelimb, hindlimb, trunk and tail. We found significantly larger total map areas of several movement representations, including movements that could be evoked more posterior than they are in control rats. We also show the presence of more multiple movement sites and lower movement thresholds in kindled rats, suggesting that movements not only overlap and share cortical territory after seizures, but become present in formerly non-responsive sites as they become detectable with our intracortical microstimulation methodology. In summary, several motor map areas become larger after seizures, which may contribute to the interictal motor disturbances that have been documented in patients with epilepsy.

Cortical kindling induces elevated levels of AMPA and GABA receptor subunit mRNA within the amygdala/piriform region and is associated with behavioral changes in the rat.

Cortical kindling causes alterations within the motor cortex and results in long-standing motor deficits. Less attention has been directed to other regions that also participate in the epileptiform activity. We examined if cortical kindling could induce changes in excitatory and inhibitory receptor subunit mRNA in the amygdala/piriform regions and if such changes are associated with behavioral deficits. After cortical kindling, amygdala/piriform regions were dissected to analyze mRNA levels of NMDA, AMPA, and GABA receptor subunits using reverse transcription polymerase chain reaction, or rats were subjected to a series of behavioral tests. Kindled rats had significantly greater amounts of GluR1 and GluR2 AMPA receptor mRNA, and alpha1 and alpha2 GABA receptor subunit mRNA, compared with sham controls, which was associated with greater anxiety-like behaviors in the elevated plus maze and reduced freezing behaviors in the fear conditioning task. In summary, cortical kindling produces dynamic receptor subunit changes in regions in addition to the seizure focus.

Functional brain mapping at 9.4T using a new MRI-compatible electrode chronically implanted in rats.

There is a need for acute and chronic stimulation of the brain within the MRI for studies of epilepsy, as well as deep brain stimulation for movement and behavioral disorders. This work describes the production and characteristics of carbon fiber-based electrodes for acute and chronic stimulation in the brain. Increasing MRI field strengths are making it increasingly difficult to introduce foreign objects without a susceptibility artifact. We describe the production of, and the characteristics of carbon fiber-based electrodes. These are biocompatible and can be implanted for chronic studies. We show the use of these electrodes at 9.4T for studying functional activation. Data are presented showing regional connectivity. Activation not only occurs near the electrode, but at sites distant and often contralateral to the electrode. In addition, there were sites showing strong negative activation to stimulation both with direct stimulation and during a kindling-associated seizure.

Motor maps, seizures, and behaviour.

Atypically organised motor maps have been described in some people with epilepsy and we have modelled this in rats. Our goal is to more fully understand the mechanisms responsible for seizure-induced functional brain reorganisation and to reverse their effects. Here we present an overview of the relationship between neocortical motor maps, seizures, and interictal behaviour. To begin we summarise the observations of atypical motor maps with epilepsy and in animal models following experimentally induced seizures. Our novel experiments have established that motor map expansion is linked to a functional alteration of motor behaviour. Evidence for some of the putative brain mechanisms responsible for motor map size is discussed. Our successes reversing seizure-induced map expansion by two different methods are also briefly reviewed. Lastly, unanswered questions for possible future experimentation are posed.