Hemoparasite occurrence and hematological/serum chemistry variations in Podocnemis vogli turtles: A comparative analysis between wild-residing infected specimens and captive non-infected counterparts.

Reptiles show a high occurrence of hemoparasites in the wild; however, little is known about the impact of such infections on their hosts' physiology and health status. Podocnemis vogli is an ancient turtle distributed in South America, frequently infected by blood parasites. Specifically, we analyzed the hematological and serum chemistry parameters of 78 wild turtles. We compared these values with those obtained from non-infected turtles of the same species in ex-situ conditions, considering factors such as sex and coinfections. Two orders of hemoparasites were detected under microscopic analyses: Adelorina, represented by Haemogregarina sp. (98.72 ± 0.28%), and Haemosporida, represented by Haemocystidium sp. (30.77 ± 1.16%), the latter genus being always in coinfection with Haemogregarina. Significant differences were observed in 20 parameters between infected (free living) and uninfected (living in captivity) turtles. The ALP, PCV, Hb, and MCV were significantly different by sex; albumin, cholesterol, creatinine, percentage of heterophils, lymphocytes, and basophils differed in coinfection. This is the first report of reference intervals of P. vogli in the wild and the first study comparing hematological and blood biochemistry values between hemoparasite-infected and uninfected P. vogli turtles. However, the limited knowledge of these parameters in wild reptiles and the wide range of interval values makes it difficult to determine any significant impact on turtle health. Nevertheless, this study highlights the need for more in-depth research to explore the potential effects of blood parasite infections on turtles, including immune response and coevolution studies.

Effect of a texture-modified and controlled bolus volume diet on all-cause mortality in older persons with oropharyngeal dysphagia: Secondary analysis of a randomized controlled trial.

BACKGROUND: Oropharyngeal dysphagia (OD) is common among older adults. Some studies have evaluated the efficacy of a texture-modified diet on mortality but with short-term follow-up. We aimed to evaluate the effect of a texture-modified diet and controlled bolus volume on all-cause mortality after 12 months in older persons with OD. METHODS: This secondary analysis of a randomized clinical trial included patients aged ≥60 years with a diagnosis of OD. They were concurrently and randomly assigned to receive either a texture-modified food diet and controlled bolus volume (intervention group) or standard treatment (control group) with 12 months of follow-up. Secondary outcomes were oral intake, weight, handgrip strength, phase angle, and aspiration pneumonia. Kaplan-Meier analysis and the Cox proportional hazards model were used for mortality analysis. RESULTS: A total of 127 participants (intervention group: 64 and control group: 63) were recruited, with a mean age of 76 years. The probability of all-cause mortality was significantly lower in the intervention group (n = 8, 12%) than in the control group (n = 18, 29%) (hazard ratio = 0.36 [95% CI = 0.16-0.86]; P = 0.01). There were 5 (7.9%) and 10 (16.1%) aspiration pneumonia events in the intervention and control groups, respectively (not significant) in 12 months of follow-up. Changes were observed in protein consumption (P = 0.01), body weight (P = 0.04), body mass index (P = 0.004), handgrip strength (P = 0.02), and phase angle (P = 0.04) between the treatment groups. CONCLUSION: Compared with the standard treatment, the dietary intervention improved efficacy by limiting nutrition complications, aspiration pneumonia, and all-cause mortality.

Evaluation of the Effects of Atorvastatin and N-Acetyl Cysteine on Platelet Counts in Patients with Primary Immune Thrombocytopenia: An Exploratory Clinical Trial.

Objective: We aimed to evaluate the efficacy of the combination of atorvastatin and N-acetyl cysteine in increasing platelet counts in patients with immune thrombocytopenia who were resistant to steroid therapy or had a relapse after treatment. Material and Methods: The patients included in this study received oral treatment of atorvastatin at a dose of 40 mg daily and N-acetyl cysteine at a dose of 400 mg every 8 h. The desired treatment duration was 12 months, but we included patients who completed at least 1 month of treatment in the analysis. The platelet counts were measured prior to the administration of the study treatment and in the first, third, sixth, and twelfth months of treatment (if available). A p value < 0.05 was considered statistically significant. Results: We included 15 patients who met our inclusion criteria. For the total treatment duration, the global response was 60% (nine patients); eight patients (53.3%) had a complete response and one patient (6.7%) had a partial response. Six patients (40%) were considered as having undergone treatment failure. Of the responder group, five patients maintained a complete response after treatment (55.5%), three patients maintained a partial response (33.3%), and one patient (11.1%) lost their response to the treatment. All of the patients in the responder group had significant increases in their platelet counts after treatment (p < 0.05). Conclusion: This study provides evidence of a possible treatment option for patients with primary immune thrombocytopenia. However, further studies are needed.

Guía de Práctica Clínica para el diagnóstico temprano y la referencia oportuna del cáncer de pulmón.

OBJETIVO: Proporcionar recomendaciones para la detección temprana de pacientes con alto riesgo de desarrollar cáncer de pulmón (CP) en el primer nivel de atención y su referencia oportuna. Material y métodos. Se realizó una búsqueda detallada de la evidencia científica disponible para responder las preguntas de investigación clínica y se utilizó el Panel Delphi modificado para lograr un consenso entre expertos. RESULTADOS: Se generaron 14 recomendaciones siguiendo los estándares de una GPC. Conclusión. El CP representa un problema de salud pública en México; por ello, esta guía establece recomendaciones que apoyan la toma de decisiones sobre la detección precoz y la referencia de pacientes con sospecha de CP en el primer nivel de atención.

Phase angle and overhydration are associated with post-extubating dysphagia in patients with COVID-19 discharged from the ICU.

BACKGROUND: Few studies have evaluated the prevalence of post-extubation dysphagia and associated factors in patients with coronavirus disease 2019 (COVID-19) . Our study assessed the prevalence of post-extubation dysphagia and body composition in patients with COVID-19 discharged from an intensive care unit (ICU). METHODS: A prospective cohort study was performed in post-ICU extubated patients with acute respiratory distress syndrome related to COVID-19 in two referral hospitals. A total of 112 patients were evaluated and included; swallowing assessment and bioelectrical impedance analysis (BIA) were performed after extubation and discharge from the ICU. To identify associations between dysphagia, lower phase angle (PhA) (<4.8°) and hydration (extracellular water/total body water < 0.390) logistic and linear regression analyses were conducted. RESULTS: The incidence of post-extubation dysphagia was 41% (n = 46). From these, 65% (n = 30) had severe swallowing impairment. Overhydration and PhA were significantly different in patients with dysphagia, and segmental hydration in the trunk and legs was higher than in arms. PhA <4.8° (odds ratio [OR], 12.2; 95% CI, 4.3-34.1; P < .05) and overhydration measured by BIA (OR, 9.1; 95% CI, 3.4-24.5; P < .05) were associated with post-extubation dysphagia in multivariate analysis. PhA (<4.8°) was associated with a lower rate of swallowing recovery at hospital discharge (log-rank test = 0.007). CONCLUSIONS: A high incidence of post-extubation dysphagia was found in patients with COVID-19. Low PhA and overhydration were associated with the presence of dysphagia. Lower PhA was an independent factor for swallowing recovery at discharge.

Disseminated atypical mycobacterial infection in an allogeneic stem cell transplant recipient.

Nontuberculous mycobacteria are pathogens with diverse manifestations in immunocompromised hosts. The lesser-known Mycobacterium haemophilum usually causes cutaneous infection. Diagnosis is challenging but is aided by molecular testing and multidisciplinary communication. We present an immunocompromised patient with disseminated cutaneous mycobacterial infection with digital tenosynovitis.

Patient Reported Outcome Measure in Atopic Dermatitis Patients Treated with Dupilumab: 52-Weeks Results.

Dupilumab is used to treat atopic dermatitis (AD) patients who have proven to be refractory to previous treatments. The aim of this study was to assess evolution and patient reported outcome measures in adult patients with moderate-to-severe AD treated with dupilumab in routine clinical practice. The outcomes were evaluated and registered at baseline and weeks 16, 40 and 52. The variables evaluated were: disease severity, pruritus, stressful life events, difficulty to sleep, anxiety and depression, quality of life, satisfaction, adherence to the treatment, efficacy and safety. Eleven patients were recruited between 14 Nov 2017 and 16 Jan 2018. Demographic variables: 90% Caucasian, 82% women. Clinical variables: Mean duration of AD = 17.7 (±12.8), 91% had severe disease severity. At baseline, SCORAD median (range) score = 69.2 (34.8-89.2); itch was reported by 100% of patients; itch visual analogue scale median (range) was 9 (6-10); HADS median (range) total score = 13 (5-21); DLQI mean score = 16 (2-27); EQ-5D-3L median (range) = 57 (30-99). At week-52 there was a significant reduction of SCORAD scores median (range) = 4.3 (0-17.1), HADS total score median (range) = 2 (0-10) and improved quality of life EQ-5D-3L median (range) = 89 (92-60). This study confirms that dupilumab, used for 52-weeks under routine clinical practice, maintains the improved atopic dermatitis signs and symptoms obtained at week 16, with a good safety profile.

Body composition by bioelectrical impedance, muscle strength, and nutritional risk in oropharyngeal dysphagia patients.

INTRODUCTION: Introduction: oropharyngeal dysphagia (OD) has complications such as malnutrition and dehydration. Body composition is an important factor for nutritional status. Objective: to evaluate the presence of cachexia, phase angle, muscle strength, and nutritional risk according to the type of feeding regimen tolerated by patients, determined with the volume-viscosity swallow test (V-VST). Methods: this cross-sectional study included hospitalized adults of both sexes with a diagnosis of OD established by the Eating Assessment Tool and V-VST. Nutritional risk status was assesed using the Nutritional Risk Screening-2002 tool. Phase angle and cachexia were determined through bioelectrical impedance vector analysis (BIVA), and functional capacity through handgrip strength (HGS) and anthropometric parameters. Results: seventy-nine patients with a median age of 73 years (56-79 yrs) were included; 79.9 % of patients were categorized at nutritional risk. According to the V-VST, 27 (34.2 %) patients tolerated nectar viscosity; 27 (34.2 %) belonged to the spoon-thick and 25 (31.6 %) to the exclusive tube feeding groups. In the exclusive tube feeding group a lower phase angle (3.7° ± 0.9) and lower HGS of 9 kg (5-15) were observed in comparison to the nectar and spoon-thick groups (in both, 4.6° ± 1.1, p = 0.005), which featured 20 kg (16-31) and 19 kg (14-26), respectively (p = 0.03). Conclusion: nutritional risk was present in 79.9 % of the study population. BIVA allows to evaluate the integrity of muscle mass and tissue hydration, both related to phase angle. A lower phase angle and HGS were observed in the exclusive tube feeding group. These factors are considered important for prognosis.

INTRODUCCIÓN: Introducción: la disfagia orofaríngea (DO) tiene complicaciones tales como la desnutrición y la deshidratación. La composición corporal es un factor importante en el estado nutricional. Objetivo: evaluar la presencia de caquexia, el ángulo de fase (AF), la fuerza muscular y el riesgo nutricional según el tipo de alimentación tolerado por los pacientes de acuerdo con la prueba de exploración clínica del volumen-viscosidad (MECV-V). Material y métodos: estudio transversal de pacientes hospitalizados, con DO determinada por el tamiz Eating Assessment Tool y la MECV-V. El riesgo nutricional se evaluó con la herramienta Nutritional Risk Screening-2002. La composición corporal se determinó mediante impedancia eléctrica y la fuerza de prensión por dinamometría, entre otros parámetros antropométricos. Resultados: se incluyeron 79 pacientes con una mediana de edad de 73 años (56-79 años). El 79,9 % de los pacientes presentaban riesgo nutricional. Según el MECV-V, 27 (34,2 %) toleraron la viscosidad néctar y 27 (34,2 %) la viscosidad puré, y 25 (31,6 %) requirieron alimentación exclusiva por sonda. En el grupo de alimentación por sonda se observaron un AF menor (3,7° ± 0,9) y una fuerza de presión más baja de 9 kg (5-15) en comparación con los grupos de néctar y puré (en los dos parámetros: 4,6° ± 1,1, p = 0,005), con 20 kg (16-31) y 19 kg (14-26) (p = 0,03), respectivamente. Conclusión: la impedancia eléctrica permite evaluar la integridad y la hidratación de los tejidos, ambas relacionadas con el AF. Se observó que el AF y la fuerza de prensión fueron menores en el grupo con nutrición exclusiva por sonda. Estos factores se consideran importantes para el pronóstico de estos pacientes.

[Colocación de sondas nasogástricas en pacientes con COVID-19: ¿debemos preocuparnos por el riesgo de producción de aerosoles?]

A finales de 2019, en Wuhan, China, se reportaron numerosos casos de neumonía comunitaria causada por un virus, llamado coronavirus tipo 2 asociado a síndrome respiratorio agudo grave (SARS-CoV-2). En octubre de 2020 rebasamos la preocupante cifra de 34 millones de casos en todo el mundo, con más de 1 millón de decesos. Se han hecho múltiples comparaciones con otras pandemias por coronavirus, y el impacto de la actual es cada vez más desolador.

A Case Report of a Cutaneous Mucinous Reaction Associated with Erlotinib Therapy Used in the Treatment of Metastatic Tonsillar Sinus Squamous Cell Carcinoma.

Cutaneous mucinoses are a diverse group of diseases that are occasionally seen in the context of an adverse drug reaction. We report the case of a 59-year-old male who presented with an asymptomatic, acneiform rash on his forehead, scalp, nose, upper chest, and upper back that had developed after treatment with erlotinib therapy used in the treatment of metastatic tonsillar sinus squamous cell carcinoma. Biopsy of these lesions demonstrated atypical histology that had features of both follicular mucinosis and myxedema. This histologic phenomenon is a rare drug reaction that has not previously been described in association with erlotinib.

Design and implementation of modified-texture diet in older adults with oropharyngeal dysphagia: a randomized controlled trial.

BACKGROUND/OBJECTIVES: Oropharyngeal dysphagia (OD) is a common problem in elderly population that negatively affects the oral intake and body composition resulting in clinical complications as malnutrition and dehydration. The aim of this study was to design, implement, and evaluate the effect of texture-modified foods and thickened drinks diet, with nectar or pudding viscosity and controlled bolus volume in older adults with OD on body composition and oral intake. SUBJECTS/METHODS: Randomized clinical trial, simple blind. Patients ≥ 65 years, admitted at a national institute, who had a confirmed diagnosis of OD were included. A texture-modified foods and thickened drinks diet, with nectar or pudding viscosity and controlled bolus volume, was compared to isocaloric standard treatment for 12 weeks. Body composition was evaluated by bioelectrical impedance, muscular functionality was evaluated by handgrip strength, and daily energy and protein intake by 24-h recall and evaluated by Food Processor Nutrition Analysis® software. RESULTS: Twenty participants were included per group, with mean age 76 years. After 12 weeks, the consumption of energy (29 ± 10 to 40 ± 15 kcal/kg, p = 0.009) and protein (1.3 ± 0.6 to 1.8 ± 0.7 g/kg, p = 0.03), as well as phase angle (4.4 ± 1.8 to 5.5 ± 2.5°, p = 0.05), body weight (56 ± 10 to 60 ± 10 kg, p < 0.001), and handgrip strength (18 ± 11 to 21 ± 13 kg, p = 0.004) increased in the intervention group. In control group there were no changes. CONCLUSIONS: The dietary intervention improved oral intake, weight, handgrip strength, and phase angle, which can prevent or limit the nutritional complications associated with the OD.

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial.

BACKGROUND: Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system. OBJECTIVES: The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days. METHODS: This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures. RESULTS: Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74-47.9) in the intervention arm. CONCLUSIONS: Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

Effectiveness of a Decision Aid in Potentially Vulnerable Patients: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial.

BACKGROUND: We test the hypotheses that use of the Chest Pain Choice (CPC) decision aid (DA) would be similarly effective in potentially vulnerable subgroups but increase knowledge more in patients with higher education and trust in physicians more in patients from racial minority groups. METHODS: This was a secondary analysis of a multicenter randomized trial in adults with chest pain potentially due to acute coronary syndrome. The trial compared an intervention group engaged in shared decision making (SDM) using CPC to a control group receiving usual care (UC). We assessed for subgroup effects based on age, sex, race, income, insurance, education, literacy, and numeracy. We dichotomized each characteristic and tested for interactions using regression models with indicators for arm assignment and study site. RESULTS: Of 898 patients (451 DA, 447 UC), over 50% were female, over one-third were black, nearly one-third had a high school education or less, and over 60% had "low" health literacy. The DA did not increase knowledge more in patients with higher education ( P for interaction = 0.06) but did increase knowledge more in the "typical" than in the "low" numeracy subgroup (10.6% v. 4.7%, absolute difference [AD] = 5.9%, P for interaction = 0.025). The DA did not significantly increase patient trust in physicians in racial minorities ( P for interaction = 0.06) but did increase trust more in patients with "low" literacy compared with those with "typical" literacy (3.7% v. -1.4%, AD = 5.1, P for interaction = 0.011). CONCLUSIONS: CPC benefited all sociodemographic groups to a similar extent, with greater knowledge transfer in patients with higher numeracy and greater physician trust in patients with "low" health literacy. Tailoring SDM interventions to patient characteristics may be necessary for optimal effectiveness.

Length-Dependent Prolongation of Force Relaxation Is Unaltered by Delay of Intracellular Calcium Decline in Early-Stage Rabbit Right Ventricular Hypertrophy.

Chronic pressure overload can result in ventricular hypertrophy and eventually diastolic dysfunction. In normal myocardium, the time from peak tension to 50% relaxation of isolated cardiac myocardium is not directly determined by the time for calcium decline. This study aims to determine whether the time for calcium decline is altered with a change in preload in early-stage hypertrophied myocardium, and whether this change in time for calcium decline alters the rate of relaxation of the myocardium. Young New Zealand white rabbits underwent a pulmonary artery banding procedure and were euthanized 10 weeks later. Twitch contractions and calibrated bis-fura-2 calcium transients were measured in isolated thin right ventricular trabeculae at optimal length and with the muscle taut. Systolic calcium, calcium transient amplitude, and time from peak tension to 50% relaxation all increased with an increase in preload for both hypertrophied and sham groups. Time for intracellular calcium decline increased both with an increase in preload and an increase in extracellular calcium concentration in hypertrophied myocardium but not in sham, while time from peak tension to 50% relaxation did not significantly change between groups under either condition. Also, time for intracellular calcium decline generally decreased with an increase in extracellular calcium for both hypertrophied and sham groups, while time from peak tension to 50% relaxation generally did not significantly change in either group. Combined, these results indicate that the mild hypertrophy significantly changes calcium handling, but does not impact on the rate of force relaxation. This implies that the rate-limiting step in force relaxation is not directly related to calcium transient decline.

Composición florística y reservas de carbono en bosques ribereños en paisajes agropecuarios de la zona seca del Tolima, Colombia / Floristic composition and carbon stocks of riparian forests in agricultural landscapes in the dry zone of Tolima, Colombia

Resumen El bosque seco tropical esta amenazado por una fuerte estacionalidad y presiones antropogénicas, lo cual puede afectar su estructura y composición. El objetivo del estudio fue estimar el impacto de dos matrices agropecuarias (arrozales y pasturas) en la composición florística y el almacenamiento de carbono en bosques riparios. Se establecieron cinco parcelas de muestreo (10 x 10 m cada una) en el interior y borde de los bosques en las dos matrices en julio 2013. Se midieron todos los individuos con un diámetro a la altura del pecho (dap) ≥ 5 cm. La biomasa arriba del suelo fue estimada con un modelo alométrico general, recomendado para estos bosques. El índice de valor de importancia (IVI), la riqueza de especies y los índices de diversidad alfa fueron estimados. Fueron realizados análisis de varianza y pruebas de comparación de medias de Fisher LSD. Se registró un total de 32 familias, 21 géneros y 45 especies (29 y 33 especies para pasturas y arrozales, respectivamente) de árboles en 0.2 ha. Las especies más abundantes y más importantes ecológicamente fueron: Oxandra espintana y Calliandra sp. (520 y 241 individuos/ha y 72 y 48 % de IVI, respectivamente). Estos bosques presentaron una dominancia media de 33.9 m2/ha sin efecto estadístico (P< 0.05) de la posición del bosque ni de la matriz. La matriz del paisaje no afectó (P> 0.05) los índices de la diversidad alfa. Los árboles más grandes y el mayor carbono fueron encontrados en la matriz de pasturas en comparación con la de arrozales (14.6 vs 13.4 cm de dap y 72.9 vs 45.6 t C/ha, respectivamente). Esta investigación provee un entendimiento de la riqueza y composición arbórea y almacenamiento de carbono de bosques ribereños en dos matrices agropecuarias, lo cual podría servir para el establecimiento de sistemas silvopastoriles con especies nativas.

Abstract The tropical dry forest is a typical lowland ecosystem that is threatened by a strong seasonality and anthropogenic pressures, which can affect the forest composition and structure. The objective of this study was to estimate the impact of two agricultural matrices on the floristic composition and carbon storage in riparian forests. For this, five permanent plots (10 x 10 m each) were established and sampled in the forest interior and at the edge of two agricultural matrices (rice fields and pasture lands), in July 2013. All individuals with a diameter at breast height (dbh) ≥ 5 cm were recorded and measured, and the aboveground biomass was estimated with a general allometric model. Additionally, the importance value index (IVI), species richness and Alpha´s diversity indexes were estimated; an analysis of variance and means comparison tests of Fisher LSD were also carried out. A total of 32 families, 21 genera and 45 species (29 and 33 species in pasture lands and rice fields, respectively) of trees in 0.2 ha were recorded. The most abundant and most ecologically important species were Oxandra espintana and Calliandra sp. (520 and 241 individuals/ha and 72 and 48 % of IVI, respectively). These forests presented a mean dominance of 33.9 m2/ha with no effect (P< 0.05) of forest location or agricultural matrix. The matrix of the landscape did not affect (P> 0.05) the Alpha diversity indexes. The biggest trees and greatest carbon storage were found in forests with pasture matrices when compared to rice fields (14.6 vs 13.4 cm of dbh and 72.9 vs 45.6 t C/ha, respectively). This research provides an understanding of the tree richness and composition and carbon storage of riparian forests in two agricultural matrices, which could be a basis for the establishment of silvopastoral systems with native species.

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

OBJECTIVE:  To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. DESIGN:  Multicenter pragmatic parallel randomized controlled trial. SETTING:  Six emergency departments in the United States. PARTICIPANTS:  898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. INTERVENTIONS:  Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. RESULTS:  Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P<0.001). There were no major adverse cardiac events due to the intervention. CONCLUSIONS:  Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240.

A third case of amelia in Morelet's crocodile from the Yucatan Peninsula.

Congenital defects in crocodilians have received little interest. In the context of global change and increasing threats to biodiversity, data on birth defects occurring in wildlife could be of importance for estimating the health of species populations and their ecosystems. Herein, we report the first case of amelia (i.e. absence of limbs) in Morelet's crocodiles Crocodylus moreletii from Mexico and the third on the southern Yucatan Peninsula. The crocodile in question was a juvenile (41 cm total length) captured in July 2012 in the Río Hondo, the river that forms the border between Mexico and Belize south of the state of Quintana Roo. The prevalence of this malformation in the C. moreletii population of Río Hondo (0.35%) is similar to that reported in 2 previous cases in Belize. Several causes of birth defects in crocodilians have previously been cited in the literature. Although we do not have relevant information to elucidate this case, we discuss some plausible explanations for this birth defect.

Effectiveness of the Chest Pain Choice decision aid in emergency department patients with low-risk chest pain: study protocol for a multicenter randomized trial.

BACKGROUND: Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization. METHODS/DESIGN: This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up. DISCUSSION: This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs. TRIAL REGISTRATION: NCT01969240.

Detailed analysis of putative genes encoding small proteins in legume genomes.

Diverse plant genome sequencing projects coupled with powerful bioinformatics tools have facilitated massive data analysis to construct specialized databases classified according to cellular function. However, there are still a considerable number of genes encoding proteins whose function has not yet been characterized. Included in this category are small proteins (SPs, 30-150 amino acids) encoded by short open reading frames (sORFs). SPs play important roles in plant physiology, growth, and development. Unfortunately, protocols focused on the genome-wide identification and characterization of sORFs are scarce or remain poorly implemented. As a result, these genes are underrepresented in many genome annotations. In this work, we exploited publicly available genome sequences of Phaseolus vulgaris, Medicago truncatula, Glycine max, and Lotus japonicus to analyze the abundance of annotated SPs in plant legumes. Our strategy to uncover bona fide sORFs at the genome level was centered in bioinformatics analysis of characteristics such as evidence of expression (transcription), presence of known protein regions or domains, and identification of orthologous genes in the genomes explored. We collected 6170, 10,461, 30,521, and 23,599 putative sORFs from P. vulgaris, G. max, M. truncatula, and L. japonicus genomes, respectively. Expressed sequence tags (ESTs) available in the DFCI Gene Index database provided evidence that ~one-third of the predicted legume sORFs are expressed. Most potential SPs have a counterpart in a different plant species and counterpart regions or domains in larger proteins. Potential functional sORFs were also classified according to a reduced set of GO categories, and the expression of 13 of them during P. vulgaris nodule ontogeny was confirmed by qPCR. This analysis provides a collection of sORFs that potentially encode for meaningful SPs, and offers the possibility of their further functional evaluation.

The positive inotropic effect of pyruvate involves an increase in myofilament calcium sensitivity.

Pyruvate is a metabolic fuel that is a potent inotropic agent. Despite its unique inotropic and antioxidant properties, the molecular mechanism of its inotropic mechanism is still largely unknown. To examine the inotropic effect of pyruvate in parallel with intracellular calcium handling under near physiological conditions, we measured pH, myofilament calcium sensitivity, developed force, and calcium transients in ultra thin rabbit heart trabeculae at 37 °C loaded iontophoretically with the calcium indicator bis-fura-2. By contrasting conditions of control versus sarcoplasmic reticulum block (with either cyclopiazonic acid and ryanodine or with thapsigargin) we were able to characterize and isolate the effects of pyruvate on sarcoplasmic reticulum calcium handling and developed force. A potassium contracture technique was subsequently utilized to assess the force-calcium relationship and thus the myofilament calcium sensitivity. Pyruvate consistently increased developed force whether or not the sarcoplasmic reticulum was blocked (16.8±3.5 to 24.5±5.1 vs. 6.9±2.6 to 12.5±4.4 mN/mm(2), non-blocked vs. blocked sarcoplasmic reticulum respectively, p<0.001, n = 9). Furthermore, the sensitizing effect of pyruvate on the myofilaments was demonstrated by potassium contractures (EC50 at baseline versus 20 minutes of pyruvate infusion (peak force development) was 701±94 vs. 445±65 nM, p<0.01, n = 6). This study is the first to demonstrate that a leftward shift in myofilament calcium sensitivity is an important mediator of the inotropic effect of pyruvate. This finding can have important implications for future development of therapeutic strategies in the management of heart failure.