Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study.

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

Popliteal pseudoaneurysm in a young patient with multiple hereditary exostosis.

Multiple hereditary exostosis is an osteogenic disorder that causes outgrowths of cartilaginous bone tumors that are associated with adjacent neurovascular compressive injuries. We present the case of an adolescent male with multiple hereditary exostosis complicated by popliteal pseudoaneurysm formation who underwent excision of the osteochondroma and vein patch angioplasty repair of the artery. We highlight the rare association between this genetic disease and subsequent vascular complications and review the available literature of arterial complications of this disease.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis.

PURPOSE: To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. METHODS: We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. MAIN FINDINGS: Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). PRINCIPAL CONCLUSIONS: Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.

Carpal Tunnel Syndrome: Pathophysiology and Comprehensive Guidelines for Clinical Evaluation and Treatment.

In carpal tunnel syndrome (CTS), the median nerve is compressed at the level of the carpal tunnel in the wrist. This entrapment manifests as unpleasant symptoms, such as burning, tingling, or numbness in the palm that extends to the fingers. As the disease progresses, afflicted individuals also report decreased grip strength accompanied by hand weakness and restricted movement. The first half of this review elaborates on CTS pathology by providing readers with a comprehensive understanding of the etiology, relevant anatomy, and disease mechanism. CTS is considered the most common entrapment neuropathy, affecting around 3-6% of the adult population. Further, CTS prevalence has seen a dramatic increase in the last few decades paralleling the growth of everyday technology usage. Despite how common it is to have CTS, it can be quite challenging for physicians to make a definite diagnosis due to differentials that present with overlapping symptoms. Even more difficult can be deciding on a course of treatment that is the most effective and considerate of patient needs. Thus arises the need for clear clinical direction, and hence we end with a discussion around such guidelines that serve as a starting point toward effective diagnoses and patient treatment.

Systematic overexpression of genes encoded by mycobacteriophage Waterfoul reveals novel inhibitors of mycobacterial growth.

Bacteriophages represent an enormous reservoir of novel genes, many of which are unrelated to existing entries in public databases and cannot be assigned a predicted function. Characterization of these genes can provide important insights into the intricacies of phage-host interactions and may offer new strategies to manipulate bacterial growth and behavior. Overexpression is a useful tool in the study of gene-mediated effects, and we describe here the construction of a plasmid-based overexpression library of a complete set of genes for Waterfoul, a mycobacteriophage closely related to those infecting clinically important strains of Mycobacterium tuberculosis and/or Mycobacterium abscessus. The arrayed Waterfoul gene library was systematically screened in a plate-based cytotoxicity assay, identifying a diverse set of 32 Waterfoul gene products capable of inhibiting the growth of the host Mycobacterium smegmatis and providing a first look at the frequency and distribution of cytotoxic products encoded within a single mycobacteriophage genome. Several of these Waterfoul gene products were observed to confer potent anti-mycobacterial effects, making them interesting candidates for follow-up mechanistic studies.

An Analysis of Epidemiological Factors in Heart Failure Outcomes.

Background Various socioeconomic and demographic factors play a role in determining treatment outcomes across numerous conditions. Different studies have shown that certain demographic factors, such as income status, directly correlate with treatment outcomes. In this study, we analyze the effect of some of these variables, namely, insurance and age, on various endpoints, including length of stay and discharge status, among heart failure patients. Methodology The data used in this project were retrieved from the HealthCare Utilization Project. We sorted the data by insurance, age, length of stay, and discharge status. To compare discharge status between different insurance types and age groups, we used Stata to compute odds ratios and 95% confidence intervals. To compare the length of stay among different age groups and insurance types, we conducted an unpaired two-tailed Student's t-test. Results Across all age groups, we found that younger patients with heart failure are more likely to discharge against medical advice compared to older patients. The average length of stay for heart failure patients was the same across all age groups except those 85 and older. Moreover, patients with a lower socioeconomic status, as determined by insurance type, were more likely to discharge against medical advice and less likely to die within hospitals. Conclusions Our results speak to the socioeconomic inequalities seen in medicine today. Studies have shown that those with a lower socioeconomic status tend to have worse outcomes across various conditions. Our analysis shows this phenomenon holds true for heart failure as well. In addition, our study helps to determine which groups are at higher risk of making medical decisions, such as discharging against medical advice, that will negatively affect their condition. Identifying these high-risk groups is a key first step to counteracting such behavior.

Genomic Sequence and Characteristics of EmiRose, a Bacteriophage Isolated on Corynebacterium flavescens.

Bacteriophage EmiRose is a siphovirus infecting Corynebacterium flavescens. The EmiRose genome is 37,431 bp long and composed of 47 protein-coding genes. Based on gene content similarity, EmiRose is not closely related to any previously sequenced bacteriophages in the actinobacteriophage database to date, including other corynebacteriophages. EmiRose is classified as a singleton.

Single cell transcriptomics reveals unique metabolic profiles of ependymoma subgroups.

OBJECTIVE: Ependymomas are biologically diverse tumors with five major genomic subgroups. However, intratumor heterogeneity continues to be poorly understood. The present study characterized the metabolic landscapes of ependymoma subgroups at the single-cell level. METHODS: Expression profiles from 11,200 ependymoma single cells derived from the five major subgroups and 7,200 ependymoma-derived non-neoplastic cells were computationally analyzed using a robust workflow to elucidate relative differences in metabolic pathway activities. RESULTS: Dimensionality reduction using metabolic expression profiles exhibited clustering corresponding to each tumor subgroup, but non-neoplastic cells exhibited no discernable differences between subgroups. From the 80 metabolic pathways examined, over 75 pathways had significantly different activity scores between ependymoma subgroups. Further analysis of metabolic heterogeneity suggests that mitochondrial oxidative phosphorylation accounts for considerable metabolic variation within tumor subgroups and non-neoplastic cells of the same cell type. Drug metabolism pathways, specifically those involving cytochromes P450, were also found to be major contributors to heterogeneity. CONCLUSIONS: Ependymoma subgroups display distinct metabolic differences as evaluated through gene expression profiles with certain pathways contributing greatly to intra-subgroup variation. These results may account for variation in tumor metabolism, treatment response, and potential targeting approaches that disrupt metabolic signalling.

Using Ethereum Smart Contracts to Store and Share COVID-19 Patient Data.

Introduction The emergence and rapid spread of the coronavirus disease 2019 (COVID-19) pandemic have revealed the limitations in current healthcare systems to handle patient records securely and transparently, and novel protocols are required to address these shortcomings. An attractive option is the use of Ethereum smart contracts to secure the storage of medical records and concomitant data logs. Ethereum is an open-source platform that can be used to construct smart contracts, which are collections of code that allow transactions under certain parameters and are self-executable. Methods The present study developed a proof-of-concept smart contract that stores COVID-19 patient data such as the patient identifier (ID), variant, chest CT grade, and significant comorbidities. A sample, fictitious patient data for the purpose of testing was configured to a private network. A smart contract was created in the Ethereum state and tested by measuring the time to insert and query patient data. Results Testing with a private, Proof of Authority (PoA) network required only 191 milliseconds and 890 MB of memory per insertion to insert 50 records while inserting 350 records required 674 milliseconds and similar memory per insertion, as memory per insertion was nearly constant with the increasing number of records inserted. Retrieving required 912 MB for a query involving all three fields and no wildcards in a 350-record database. Only 883 MB was needed to procure a similar observation from a 50-record database. Conclusion This study exemplifies the use of smart contracts for efficient retrieval/insertion of COVID-19 patient data and provides a case use of secure and efficient data logging for sensitive COVID-19 data.

Genome Sequences of Ilzat and Eleri, Two Phages Isolated Using Microbacterium foliorum NRRL B-24224.

Bacteriophages Ilzat and Eleri are newly isolated Siphoviridae infecting Microbacterium foliorum NRRL B-24224. The phage genomes are similar in length, G+C content, and architecture and share 62.9% nucleotide sequence identity.

Sentiments expressed in relation to tooth loss: a qualitative study among edentulous Saudis.

PURPOSE: The objective was to explore and gain insight into the sentiments surrounding tooth loss in a group of edentulous Saudis. MATERIALS AND METHODS: Using a qualitative methodology, 44 edentulous patients who were receiving complete denture treatment were interviewed in private, in the Arabic language. Interviews were tape recorded and semistructured, following a list of predetermined and piloted topics, but dialogue also took place, with the freedom for both interviewer and interviewee to explore areas of interest. All recordings were transcribed, translated into English, and interpreted independently by two members of the team to identify the core themes associated with tooth loss. RESULTS: The mean age of participants was 58.9 years (range 35 to 72 years), and they had been edentulous for a mean of 7.1 years (range 3 months to 22 years). The main themes related to tooth loss were unqualified acceptance, inevitability with old age, behavior changes with respect to eating comfort, aged appearance, self-responsibility, positively perceived benefits, high prosthetic expectations and reduced level of denture satisfaction, and some need for privacy. CONCLUSION: The lack of any outward indication that participants experienced bereavement suggests that outlook on life can influence the impact of tooth loss. Participants' unqualified acceptance of their edentulous fate, yet their clear need to "normalize" oral function, reflects a degree of pragmatism toward life events. The strong influence of religion in Saudi society is a possible factor in the sentiments expressed.

Influence on dimensional accuracy of volume of wash material introduced into pre-spaced putty/wash impressions.

This study compared the accuracy of stone models obtained from two-stage, pre-spaced putty/wash impressions under conditions in which known volumes of wash material were introduced during the second stage of the impression: Group I, a quantity of wash material corresponding to the space provided; Group II, double the quantity of wash material as the space provided; Group III, double the quantity of wash material, but with V-shaped vents in the putty for escape of excess material. Percentage deviations of the vertical dimensions of stone dies with respect to the master model were significantly different between Groups I and II (the latter being shorter) (p < 0.05). For horizontal dimensions, differences were less consistent, although the deviations for Groups I and II and Groups II and III, with respect to the master model, were significantly different from each other for two of the three dimensions measured (Group II inter-abutment distances were generally larger) (p < 0001 and p < 0.05, respectively). It is concluded that putty recoil, resulting from compression by excess wash material, plays a significant role in the undersizing of working dies, although the level of clinical relevance is less clear.