The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study.

BACKGROUND: This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS). METHODS: First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS. RESULTS: PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019). CONCLUSIONS: The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.

Novel modified endoscopic mucosal resection of large GI lesions (> 20 mm) using an external additional working channel (AWC) may improve R0 resection rate: initial clinical experience.

BACKGROUND: En-bloc resection of large, flat dysplastic mucosal lesions of the luminal GI tract can be challenging. In order to improve the efficacy of resection for lesions ≥2 cm and to optimize R0 resection rates of lesions suspected of harboring high-grade dysplasia or early adenocarcinoma, a novel grasp and snare EMR technique utilizing a novel over the scope additional accessory channel, termed EMR Plus (EMR+), was developed. The aim of this pilot study is to describe the early safety and efficacy data from the first in human clinical cases. METHODS: A novel external over-the-scope additional working channel (AWC) (Ovesco, Tuebingen, Germany) was utilized for the EMR+ procedure, allowing a second endoscopic device to be used through the AWC while using otherwise standard endoscopic equipment. The EMR+ technique allows tissue retraction and a degree of triangulation during endoscopic resection. We performed EMR+ procedure in 6 patients between 02/2018-12/2018 for lesions in the upper and lower GI tract. RESULTS: The EMR+ technique utilizing the AWC was performed successfully in 6 resection procedures of the upper and/or lower GI tract in 6 patients in 2 endoscopy centers. All resections were performed successfully with the EMR+ technique, all achieving an R0 resection. No severe adverse events occurred in any of the procedures. CONCLUSIONS: The EMR+ technique, utilizing an additional working channel, had an acceptable safety and efficacy profile in this preliminary study demonstrating it's first use in humans. This technique may allow an additional option to providers to remove complex, large mucosal-based lesions in the GI tract using standard endoscopic equipment and a novel AWC device.

Wheat-dependent exercise-induced anaphylaxis.

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare, but potentially severe food allergy exclusively occurring when wheat ingestion is accompanied by augmenting cofactors. It is clinically characterized by anaphylactic reactions ranging from urticaria and angioedema to dyspnoea, hypotension, collapse, and shock. WDEIA usually develops after ingestion of wheat products followed by physical exercise. Other cofactors are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, alcohol, and infections. The precise mechanisms of WDEIA remain unclear; exercise and other cofactors might increase gastrointestinal allergen permeability and osmolality, redistribute blood flow, or lower the threshold for IgE-mediated mast cell degranulation. Among wheat proteins, ω5-gliadin and high-molecular-weight glutenin subunits have been reported to be the major allergens. In some patients, WDEIA has been discussed to be caused by epicutaneous sensitization with hydrolysed wheat gluten included in cosmetics. Diagnosis is made based on the patient's history in combination with allergy skin testing, determination of wheat-specific IgE serum antibodies, basophil activation test, histamine release test, and/or exercise challenge test. Acute treatment includes application of adrenaline or antihistamines. The most reliable prophylaxis of WDEIA is a gluten-free diet. In less severe cases, a strict limitation of wheat ingestion before exercise and avoidance of other cofactors may be sufficient.

Vision in the common bed bug Cimex lectularius L. (Hemiptera: Cimicidae): eye morphology and spectral sensitivity.

Bed bugs as pests of public health importance recently experienced a resurgence in populations throughout the U.S. and other countries. Consequently, recent research efforts have focused on improving understanding of bed bug physiology and behaviour to improve management. While few studies have investigated the visual capabilities of bed bugs, the present study focused specifically on eye morphology and spectral sensitivity. A 3-D imaging technique was used to document bed bug eye morphology from the first instar through adult and revealed morphological characteristics that differentiate the common bed bug from the tropical bed bug as well as sex-specific differences. Electrophysiological measurements were used to evaluate the spectral sensitivity of adult bed bugs. Male bed bugs were more responsive than females at some wavelengths. Electrophysiological studies provided evidence for at least one photoreceptor with a spectral sensitivity curve peak in the green (λmax 520 nm) region of the spectrum. The broadened long wavelength portion of the spectral sensitivity curve may potentially indicate another photoreceptor in the yellow-green (λmax 550 nm) portion of the spectrum or screening pigments. Understanding more about bed bug visual biology is vital for designing traps, which are an important component of integrated bed bug management.

High-flow oxygen therapy in cluster headache patients has no significant effect on nociception specific blink reflex parameters: a pilot study.

BACKGROUND: The exact pathophysiology of cluster headache is unclear. We examined the influence of interneurons on the trigemino-facial reflex arch and the effect of oxygen, by using the nociception specific blink reflex parameters. FINDINGS: There is no significant effect of oxygen, immediately and over time, on the nociception specific blink reflex parameters in ten male patients during the active phase of cluster headache, outside attacks. Also, there is no significant difference between the symptomatic and asymptomatic side. None of the subjects experienced a cluster headache attack during study participation. We therefore present the collected data as reference values of nociception specific trigeminal stimulation and the effect of oxygen on nociception specific blink reflex parameters. CONCLUSION: The nociception specific blink reflex seems not a suitable instrument for exploring the pathophysiology of cluster headache.

Climbing Ability of the Common Bed Bug (Hemiptera: Cimicidae).

Little is known about what factors influence the climbing ability of bed bugs, Cimex lectularius L. (Hemiptera: Cimicidae), in relation to the various surfaces they encounter. We examined how sex, time since last fed, and what surfaces the bed bugs were in contact with affected their climbing performance. The effects of sex and time since fed were tested by counting the number of bed bugs able to climb a 45° slope. The pulling force was recorded using an analytical balance technique that captured the sequential vertical pulling force output of bed bugs attached to various surfaces. Recently fed female bed bugs were found to have the most difficulty in climbing smooth surfaces in comparison with males. This difference can be explained by the larger weight gained from bloodmeals by female bed bugs. A variety of vertical pulling forces were observed on surfaces ranging from sandpaper to talc powder-covered glass. For surfaces not treated with talc powder, bed bugs generated the least amount of vertical pulling force from synthetically created 0.6-µm plastron surfaces. This vast range in the ability of bed bugs to grip onto various surfaces may have implications on limiting bed bugs dispersal and hitchhiking behaviors.

Neutron capture cross section of unstable 63Ni: implications for stellar nucleosynthesis.

The 63Ni(n,γ) cross section has been measured for the first time at the neutron time-of-flight facility n_TOF at CERN from thermal neutron energies up to 200 keV. In total, capture kernels of 12 (new) resonances were determined. Maxwellian averaged cross sections were calculated for thermal energies from kT=5-100 keV with uncertainties around 20%. Stellar model calculations for a 25M⊙ star show that the new data have a significant effect on the s-process production of 63Cu, 64Ni, and 64Zn in massive stars, allowing stronger constraints on the Cu yields from explosive nucleosynthesis in the subsequent supernova.

Is isolated aphasia a typical presentation of presumed cardioembolic transient ischemic attack or stroke?

BACKGROUND: Previous studies have suggested that patients with a transient ischemic attack (TIA) or minor ischemic stroke and isolated aphasia should be carefully screened for a potential cardiac source of embolism. Most of these publications, however, were case reports or small-series. The purpose of this study was to assess the relationship between isolated aphasia and atrial fibrillation (AF) as the cause of presumed cardioembolic TIA or stroke within the setting of 2 large multicenter trials. METHODS: The frequency of isolated aphasia was compared between patients with a TIA or minor ischemic stroke either with AF [European Atrial Fibrillation Trial (EAFT), n = 1,001] or without AF [Dutch TIA Trial (DTT), n = 3,150]. We analyzed data with univariable and multivariable logistic regression. Isolated aphasia was defined as aphasia without dysarthria, visual-field defects or motor or sensory deficits of the arm, leg or face. Because dysarthria can be difficult to detect in aphasic patients, a second analysis was done without excluding dysarthric patients. In a third analysis, we excluded patients with a symptomatic lacunar infarct from the DTT, as these patients were overrepresented due to the exclusion of patients with AF. Subgroup analysis was performed for patients presenting with TIA and minor stroke. RESULTS: Of 4,151 patients, 210 (5.1%) had isolated aphasia, 109 from the EAFT and 101 from the DTT, crude odds ratio (OR) 3.69, 95% confidence interval (CI) 2.79-4.89. Patients with isolated aphasia were older (mean age 70.3 vs. 66.8 years, p < 0.01), more often female (OR 1.87, 95% CI 1.41-2.46), and more often had diabetes (OR 1.73, 95% CI 1.16-2.59) and hypercholesterolemia (OR 1.83, 95% CI 1.11-3.03) than those without aphasia. After simultaneous adjustment for age, sex, diabetes and hypercholesterolemia, patients with isolated aphasia still had AF more often than patients without isolated aphasia (adjusted OR 2.94, 95% CI 2.16-4.01). Both after inclusion of patients with dysarthria in the group of patients with isolated aphasia and after exclusion of patients with a symptomatic lacunar infarct, essentially the results remained the same. Patients presenting with isolated aphasia due to a TIA tended to have AF more often than patients with a minor ischemic stroke. CONCLUSIONS: Isolated aphasia is an independent sign of AF in patients with a TIA or minor ischemic stroke. Careful cardiac screening seems warranted in patients with isolated aphasia, as secondary prevention is different in patients with a cardiac source of embolism.

Potential population growth and harmful effects on humans from bed bug populations exposed to different feeding regimes.

Effects of host availability and feeding period on bed bugs, Cimex lectularius (L.) (Hemiptera: Cimicidae), were measured. Population growth and the potential harmful effect of bed bug populations on human hosts were modelled. Bloodmeal sizes were affected by both feeding length and frequency, with >2-fold difference between insects fed daily or weekly. Blood consumption increased >2-fold between bed bugs fed occasionally and often, and 1.5-fold between occasional and daily feeding. Bed bugs fed more often than once a week, potentially every 2-4 days. Egg production was associated with nutrition, being strongly correlated with blood consumption in the previous week. Bed bug populations can grow under different feeding regimes and are hard to control with <80% mortality. Bed bugs can survive and grow even in locations with a limited blood supply, where bed bug persistence may be important for the continual spread of populations. Persistence in non-traditional locations and a potential association with human pathogens increase the health risks of bed bugs. Potential blood loss as a result of a bed bug can have serious consequences because uncontrolled populations can reach harmful levels in 3-8 months. The reproduction potential of bed bug populations suggests serious consequences to human health and the need for efficacious control measures.

How to diagnose and treat a patient without human immunodeficiency virus infection having Pneumocystis jirovecii pneumonia?

BACKGROUND: Pneumocystis jirovecii pneumonia (PCP) incidence is increasing in patients without HIV infection. In contrast to PCP in patients infected with HIV, diagnosis is often delayed and illness is associated with increased mortality. OBJECTIVES: To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options for PCP in patients without HIV infection. SOURCES: Web-based literature review on PCP for trials, meta-analyses, and systematic reviews using PubMed. The restriction to the English language was applied. CONTENT: Common underlying conditions in patients without HIV infection having PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant, and previous corticosteroid exposure. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Patients without HIV infection who have PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms and radiological as well as mycological features. Results of immunofluorescence microscopy from bronchoalveolar lavage, PCR testing, and computed tomography imaging as well as the evaluation of clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS: Although the number of patients with immunosuppression due to causes different from HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of patients without HIV infection, rapid onset of symptoms, a more complex course, and a high mortality rate are recorded. Therefore, the time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provides clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.

Abrupt change in radiation-width distribution for 147Sm neutron resonances.

We obtained the total radiation widths of s-wave resonances through an R-matrix analysis of (147)Sm(n,γ) cross sections. Distributions of these widths differ markedly for resonances below and above E(n)=300 eV, which is in stark contrast to long-established theory. We show that this change, as well as a similar change in the neutron-width distribution reported previously, is reflected in abrupt increases in both the average (147)Sm(n,γ) cross section and fluctuations about the average near 300 eV. Such effects could have important consequences for applications such as nuclear astrophysics and nuclear criticality safety.

Behavioral and physiological response of Musca domestica to colored visual targets.

A better understanding of the visual attraction of house flies to colors and patterns is needed to improve fly trap performance. This study combined physiological responses measured with electroretinogram studies of the house fly's compound eyes and ocelli with behavioral attraction of flies to reflective colors and patterns in light tunnel assays. Compound eye and ocellar electroretinogram responses to reflected light were similar, with the largest responses to white and blue followed by yellow, red, green, and black. However, data from light tunnel behavioral assays showed that flies were attracted to white and blue light but were repelled by yellow. The addition of a black line pattern enhanced the attractiveness of blue visual targets, whereas yellow lines decreased attractiveness. Sensory input from the compound eye and the ocellus seems to be integrated to direct fly behavior. There is a direct correlation of house fly attractiveness to visual targets and the intensity of electrophysiological response, except for the yellow targets, which repel flies despite of intense electrophysiological response.

149Sm(n,α)146Nd cross sections in the MeV region.

We have measured the (149)Sm(n,α)(146)Nd cross section at 4.5, 5.0, 5.5, 6.0, and 6.5 MeV. Measurements were performed at the 4.5 MV Van de Graaff accelerator of Peking University with monoenergetic neutrons produced via the (2)H(d,n)(3)He reaction using a deuterium gas target. Alpha particles were detected with a double-section gridded ionization chamber having two back-to-back (149)Sm(2)O(3) samples attached to the common cathode. Absolute neutron flux was measured using a small (238)U fission chamber and monitored by a BF(3) long counter. These are the first reported cross sections for this reaction at these energies, except at 6.0 eV, where our new data are in good agreement with our earlier result. The present results help to much better constrain the (149)Sm(n,α)(146)Nd cross section in a region where its energy dependence is changing fairly rapidly and there are large differences between evaluated nuclear data libraries.

A case study of Megaselia scalaris (Diptera: Phoridae) causing ocular myiasis in a western hognose snake.

Late instar larvae of the scuttle fly, Megaselia scalaris Loew, were found near the right eye of a live captive-reared western hognose snake, Heterodon nasicus Baird and Girard. Dissection and removal of the snake's dorsal cranial bones revealed tissue degradation of the infected eye, the optic nerve, and the brain case; we suggest that these factors contributed to the death of this snake. This case study further demonstrates the opportunistic behavior of M. scalaris.

Control of Cimex lectularius using heat combined with dichlorvos resin strips.

Successful management of the bed bug, Cimex lectularius L. (Hemiptera: Cimicidae), is difficult because of its pesticide resistance, which can allow a reduction in population, but not elimination. We evaluated the effect of heat and/or air circulation on the efficacy of dichlorvos resin strips in the control of bed bugs. Treatments were performed in unoccupied dormitory rooms and consisted of dichlorvos resin strips containing 18.6% active ingredient, the same strips + fan, and strips + fan + heat. The mortality of recently fed bed bugs and weight loss of the dichlorvos strips were evaluated over 7 days. Dichlorvos resin strips killed bed bugs and eggs in just over 7 days. The addition of a fan or a fan + heat decreased time to 100% mortality to 3 days and 36 h, respectively. Eggs located in treated rooms did not hatch. Resin strips in the strips + fan treatment and the strips + fan + heat treatment volatilized 10 and 70 times, respectively, faster than strips in the strips-only treatment. The addition of heat in treatments with dichlorvos resin strips enhances the overall efficacy of the volatile insecticide and reduces the time required to eliminate live bed bugs and eggs.

Anomalous fluctuations of s-wave reduced neutron widths of 192,194Pt resonances.

We obtained an unprecedentedly large number of s-wave neutron widths through R-matrix analysis of neutron cross-section measurements on enriched Pt samples. Careful analysis of these data rejects the validity of the Porter-Thomas distribution with a statistical significance of at least 99.997%.

Acoustic indicators for targeted detection of stored product and urban insect pests by inexpensive infrared, acoustic, and vibrational detection of movement.

Crawling and scraping activity of three stored-product pests, Sitophilus oryzae (L.) (Coleoptera: Curculionidae), Tribolium castaneum (Herbst) (Coleoptera: Tenebrionidae), and Stegobium paniceum (L.) (Coleoptera: Anobiidae), and two urban pests, Blattella germanica (L.) (Blattodea: Blattellidae) and Cimex lectularius L. (Hemiptera: Cimicidae), were monitored individually by infrared sensors, microphones, and a piezoelectric sensor in a small arena to evaluate effects of insect locomotory behavior and size on the ability of an inexpensively constructed instrument to detect insects and distinguish among different species. Adults of all species could be detected when crawling or scraping. The smallest insects in the study, first-fourth-instar C. lectularius nymphs, could not be detected easily when crawling, but could be detected when scraping. Sound and vibration sensors detected brief, 3-10-ms impulses from all tested species, often grouped in distinctive trains (bursts), typical of impulses in previous acoustic detection experiments. To consider the potential for targeting or focusing detection on particular species of interest, indicators were developed to assess the likelihood of detection of C. lectularius. Statistically significant differences were found between C. lectularius and other species in distributions of three measured variables: infrared signal durations, sound impulse-burst durations, and sound pressure levels (energy) of impulses that best matched an averaged spectrum (profile) of scraping behavior. Thus, there is potential that signals collected by an inexpensive, polymodal-sensor instrument could be used in automated trapping systems to detect a targeted species, 0.1 mg or larger, in environments where servicing of traps is difficult or when timeliness of trapping information is important.

The diagnostic value of provocative clinical tests in ulnar neuropathy at the elbow is marginal.

BACKGROUND: Provocative clinical tests are often performed in the diagnosis of ulnar neuropathy at the elbow (UNE) although the evidence for the usefulness of these tests is limited. The aim of this study was to determine the diagnostic value of provocative clinical tests in the diagnosis of UNE in a relevant spectrum of patients and controls. METHODS: A prospective cohort study was performed in consecutive patients clinically suspected of having UNE. All patients underwent a neurological examination and four commonly used provocative clinical tests (Tinel's test, flexion compression test, palpating for local ulnar nerve tenderness and nerve thickening). Subsequently, in all patients a reference standard test comprising electrophysiological studies and neurosonography was independently assessed. RESULTS: 192 eligible patients completed the study protocol. UNE was diagnosed in 137 and an alternative diagnosis was made in 55 patients. The sensitivity, specificity, and positive and negative predictive values were as follows: Tinel's test 62%, 53%, 77% and 30%; flexion compression test 61%, 40%, 72% and 29%; palpating for nerve thickening 28%, 87%, 84% and 33%; and palpating for nerve tenderness 32%, 80%, 80% and 32%. Logistic regression and receiver operating characteristic curves showed that the added value of one or more provocative tests over routine clinical examination is minimal. CONCLUSION: The diagnostic value of provocative clinical tests in UNE is poor.

Intensive care management of influenza-associated pulmonary aspergillosis.

BACKGROUND: Severe pulmonary infections are among the most common reasons for admission to intensive care units (ICU). Within the last decade, increasing reports of severe influenza pneumonia resulting in acute respiratory distress syndrome (ARDS) complicated by Aspergillus infection were published. OBJECTIVES: To provide a comprehensive review of management of influenza-associated pulmonary aspergillosis in patients with ARDS. SOURCES: Review of the literature pertaining to severe influenza-associated pulmonary aspergillosis. PubMed database was searched for publications from the database inception to January 2019. CONTENT: In patients with lower respiratory symptoms, development of respiratory insufficiency should trigger rapid and thorough clinical evaluation, in particular in cases of suspected ARDS, including electrocardiography and echocardiography to exclude cardiac dysfunction, arrhythmias and ischaemia. Bronchoalveolar lavage should obtain lower respiratory tract samples for galactomannan assay, direct microscopy, culture, and bacterial, fungal and viral PCR. In case of positive Aspergillus testing, chest CT is the imaging modality of choice. If influenza pneumonia is diagnosed, neuraminidase inhibitors are the preferred approved drugs. When invasive aspergillosis is confirmed, first-line therapy consists of isavuconazole or voriconazole. Isavuconazole is an alternative in case of intolerance to voriconazole, drug-drug interactions, renal impairment, or if a spectrum of activity including the majority of Mucorales is desired. Primary anti-mould prophylaxis with posaconazole is recommended in haematology patients at high-risk. It may be considered in newly diagnosed influenza and ARDS, but ideally in clinical trials. IMPLICATIONS: The rising reports of influenza-associated pulmonary aspergillosis in patients with ARDS, who are otherwise not considered at risk for fungal pneumonia demands heightened clinical awareness. Tracheobronchitis and Aspergillus in respiratory tract samples should prompt suspicion of invasive fungal infection and further work-up. The management algorithm should comprise bronchoalveolar lavage, CT imaging, sophisticated ventilator-management, rescue extracorporeal membrane oxygenation, and antifungal and antiviral therapy. To decrease the burden of influenza-related illness, vaccination is of utmost importance, specifically in patients with co-morbidities.

Morbidity and mortality of candidaemia in Europe: an epidemiologic meta-analysis.

OBJECTIVES: Candidaemia is a serious hazard to hospitalized patients, but European epidemiological data are restricted to national studies focusing on Northern Europe, population-based surveillance programmes or studies conducted in distinct local areas. The aim was to provide current data on the overall burden and epidemiological development of candidaemia in Europe. METHODS: A Web of Knowledge™ search was carried out from January 2000 to February 2019. Appropriate data were collected on total cases, study duration, incidence, species distribution and/or mortality rates. Meta-analysis was performed to pool individual studies. Heterogeneity was examined using the I2 statistic. Calculations of pooled incidence and mortality rates, subgroup analysis by geographical origin, study period and scenarios were carried out. Daily candidaemia incidence and mortality rates in Europe were extrapolated. Systematic review and meta-analysis were used to determine incidence and mortality of candidaemia in the UN European region. Complete datasets were categorized into population-based and hospital-based epidemiological studies and were analysed separately. Subgroup analyses were performed for geographic distributions and time-dependent developments. RESULTS: In population-based studies, 43 799 cases of candidaemia were diagnosed in 1 885 271 885 person-years, revealing an overall pooled incidence rate of 3.88/100 000. The highest pooled incidence rate was observed in intensive care units (5.5/1000 admissions, Day 30 mortality rate 37%), followed by tertiary care centres (0.96/1000 admissions, pooled Day 30 mortality rate 38%) and the mixed group of teaching and general hospitals (0.52/1000 admissions, pooled Day 30 mortality rate 37%). European incidence of candidaemia was extrapolated to approximately 79 cases per day, of which an estimated 29 patients might have fatal outcome at Day 30. CONCLUSIONS: Pooled incidence rates, species distribution and outcome of candidaemia differ considerably between clinical groups, European regions and over time. We observed an increasing overall pooled incidence rate of candidaemia and a higher proportion of Candida spp. other than C. albicans in the current decade in population-based data.