Extracorporeal Membrane Oxygenation-Supported Patient Outcome Undergoing Transcatheter Aortic Valve Replacement.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

Evaluation of the Current Bacterial Pathogens and Antibiogram of Chronic Suppurative Otitis Media in Adults.

To determine the bacterial pathogens in chronic suppurative otitis media (CSOM) & the antibiotic susceptibility patterns of isolates among patients. A total of 400 patients clinically diagnosed with CSOM were interviewed &middle-ear effusion samples were collected using sterile swabs. All bacterial isolates were identified by conventional microbiological methods. Antibiotic susceptibility patterns of the isolates were determined by Kirby-Bauer disc diffusion. Pseudomonas aeruginosa (30.25%) were the most prevalent bacteria isolated, followed by S. aureus (MSSA) (18.5%) & MRSA (8.25%). The most effective antibiotic for treatment of bacterial CSOM was amikacin & ciprofloxacin. Statistical analysis showed no significant difference in bacterial infestations among CSOM patients & the antimicrobial susceptibility patterns of the bacterial isolates based on age (p > 0.05). The importance of a continuous & annual evaluation of bacteriological profile & antibiotic susceptibility patterns in CSOM patients is highlighted in our study.

Do physicians know when to refer patients for genetic testing?

Primary care physicians (PCPs) are commonly approached with concerns involving patient genetics. This is a challenge because most PCPs lack expertise in genetic testing compared to their genetic counselor counterparts. Currently, the recommended best practice is to refer patients for genetic testing based on cancer-related family history questionnaires with a genetic counseling referral to discuss their results and any implications. However, the extent to which PCPs are using these questionnaires for this purpose remains poorly understood. In this cross-sectional study, PCPs were presented with the American Cancer Society's seven recommended family history questions to determine the percentage who consider each to be an indicator for referral to a genetics specialist. Questionnaires were completed by 88 of 260 attending PCPs at a national primary care review conference. The main outcome was the percentage of PCPs who identified each question as a trigger for genetic testing. Secondary outcomes included correlations with years of practice, genetics training, and methods used to obtain patient family history. Only two of the seven questions were considered triggers by most PCPs (range, 76-83%). The remaining five had lower percentages (range, 22-55%). Years of practice did not influence the number of triggers identified (Spearman correlation coefficient test: r = 0.05, p = 0.68). Few PCPs (3.4%) felt they had good to excellent genetics training during residency. Only 44.3% had genetics specialists available for referral. Overall, low percentages of PCPs consider the American Cancer Society questions to be triggers for genetic testing referrals. Furthermore, many do not have a genetics specialist or counselor available for referral. Addressing these concerns may help PCPs understand the basics of genetic testing and use standardized questionnaires to make appropriate referrals to genetic specialists, thereby reducing inappropriate referrals and improving appointment access to this precious resource for those who truly need it.

Sleep scoring in rodents: Criteria, automatic approaches and outstanding issues.

There is nothing we spend as much time on in our lives as we do sleeping, which makes it even more surprising that we currently do not know why we need to sleep. Most of the research addressing this question is performed in rodents to allow for invasive, mechanistic approaches. However, in contrast to human sleep, we currently do not have shared and agreed upon standards on sleep states in rodents. In this article, we present an overview on sleep stages in humans and rodents and a historical perspective on the development of automatic sleep scoring systems in rodents. Further, we highlight specific issues in rodent sleep that also call into question some of the standards used in human sleep research.

A deep learning framework for inference of single-trial neural population dynamics from calcium imaging with subframe temporal resolution.

In many areas of the brain, neural populations act as a coordinated network whose state is tied to behavior on a millisecond timescale. Two-photon (2p) calcium imaging is a powerful tool to probe such network-scale phenomena. However, estimating the network state and dynamics from 2p measurements has proven challenging because of noise, inherent nonlinearities and limitations on temporal resolution. Here we describe Recurrent Autoencoder for Discovering Imaged Calcium Latents (RADICaL), a deep learning method to overcome these limitations at the population level. RADICaL extends methods that exploit dynamics in spiking activity for application to deconvolved calcium signals, whose statistics and temporal dynamics are quite distinct from electrophysiologically recorded spikes. It incorporates a new network training strategy that capitalizes on the timing of 2p sampling to recover network dynamics with high temporal precision. In synthetic tests, RADICaL infers the network state more accurately than previous methods, particularly for high-frequency components. In 2p recordings from sensorimotor areas in mice performing a forelimb reach task, RADICaL infers network state with close correspondence to single-trial variations in behavior and maintains high-quality inference even when neuronal populations are substantially reduced.

Perception of dental students towards the online method of dental education during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has changed the education system drastically. The shift from traditional learning to online mode during the quarantine period affected dental education substantially. The present study aimed to determine the impact of online learning on dental education and the potential challenges being faced by the dental students. METHODS: An online survey-based questionnaire was distributed to 103 BDS students and feedback was recorded. RESULTS: The study yielded a response rate of 57% comprising of female(56%)and male(44%) respondents. The participants were categorized into two groups with age brackets of 22 years& above. Majority of the female students (86.2%) were more inclined towards offline learning than male students (57.8%) (p = 0.001). More predilection for offline mode was observed in 83% of the students (>22 years of age) than 66.1%students (<22 years) (p = 0.05).BDS 1st (59.6%),2nd (74.1%) 3rd (93.8%)& 4th year (100%) students preferred offline mode for exams (p = 0.005). Most of the students (77.7%) including male (86.7%) and female (70.6%) (p = 0.05) strongly disagreed to continue E-learning in future. The students (<22 years) (98.2%) were more accessible to the internet than students (>22 years) (93.2%) (p = 0.02). The students (>22 years) found more difficulty in using different online platforms (87.2%) than students (<22 years) i.e., 69.6% (p = 0.03).BDS 3rd and 4th year (100%) appeared for the exams in greater numbers than BDS 1st year (76.6%) and 2nd year (92.6%) (p = 0.02). CONCLUSION: Online learning had a detrimental impact on dental education. The students agreed that online mode cannot substitute conventional face-to-face learning.

Comparison of a Focused Family Cancer History Questionnaire to Family History Documentation in the Electronic Medical Record.

INTRODUCTION: Family health history can be a valuable indicator of risk to develop certain cancers. Unfortunately, patient self-reported family history often contains inaccuracies, which might change recommendations for cancer screening. We endeavored to understand the difference between a patient's self-reported family history and their electronic medical record (EMR) family history. One aim of this study was to determine if family history information contained in the EMR differs from patient-reported family history collected using a focused questionnaire. METHODS: We created the Hereditary Cancer Questionnaire (HCQ) based on current guidelines and distributed to 314 patients in the Department of Family Medicine waiting room June 20 to August 1, 2018. The survey queried patients about specific cancers within their biological family to assess their risk of an inherited cancer syndrome. We used the questionnaire responses as a baseline when comparing family histories in the medical record. RESULTS: Agreement between the EMR and the questionnaire data decreased as the patients' risk for familial cancer increased. Meaning that the more significant a patient's family cancer history, the less likely it was to be recorded accurately and consistently in the EMR. Patients with low-risk levels, or fewer instances of cancer in the family, had more consistencies between the EMR and the questionnaire. CONCLUSIONS: Given that physicians often make recommendations on incomplete information that is in the EMR, patients might not receive individualized preventive care based on a more complete family cancer history. This is especially true for individuals with more complicated and significant family history of cancer. An improved method of collecting family history, including increasing patient engagement, may help to decrease this disparity.

Prevalence of Asymptomatic Bacteriuria and Antimicrobial Resistance Profile among Pregnant Females in a Tertiary Care Hospital.

BACKGROUND AND OBJECTIVES: Urinary tract infection (UTI) is the most common clinical finding during pregnancy, and if it is asymptomatic bacteriuria (ASB), it can progress to pyelonephritis, leading to further complications. The present study aims to know the prevalence of ASB in pregnant females and the antimicrobial resistance pattern in our hospital setup. MATERIALS AND METHODS: A total of 552 urine samples were collected from pregnant females (with no symptoms of UTI) both attending outpatient department and admitted in the wards of obstetrics and gynecology department. Urine culture was performed on blood agar, MacConkey agar, and UTI chromogenic agar. Antibiotic sensitivity test was done using Kirby-Bauer disc diffusion method, and the results were interpreted. RESULTS: The prevalence rate of ASB in pregnant females was 17.4%. It was common in the age group of 25-33 years (60.4%). The infection rate was higher in the second trimester (43.7%) compared to the third (29.2%) and first (27.1%) trimester. Multiparity (60.4%) was a common finding in ASB during pregnancy. There was a significant finding of previous history of UTI (22.9%) and anemia (58.3%) associated with ASB in pregnant females. Escherichia coli (39.2%) was the most common microorganism isolated followed by Staphylococcus aureus (34.3%), Enterococcus faecalis (14.7%), Klebsiella (4.9%), coagulase-negative Staphylococcus spp. (2.9%), and Citrobacter and Acinetobacter (1.9%). Most sensitive drugs to be given in ASB during pregnancy were nitrofurantoin and fosfomycin. CONCLUSION: It was emphasized that urine culture should be done in early antenatal visit as routine screening to identify ASB in pregnant females as it can prevent fetal and maternal complications.

Optimizing fiber and protein levels in diet of lactating Murrah buffaloes to ameliorate heat stress: Effect on physiological status and production performance.

The objective of study was to assess the outcome of feeding six total mixed rations (TMR), differing in NDF and protein content, for their synergistic effect on ameliorating heat load of lactating Murrah buffaloes evident through improved physiological and production performance. Thirty six lactating Murrah buffaloes (587 ± 12.3, MY 9 ± 2.2, Parity 2.5 ± 1.5) were arranged in a 3 × 2 factorial design with three levels of dietary NDF (30, 34.5 and 37% dietary NDF) and two levels of metabolizable protein (MP; 7.0% and 8.4%). Buffaloes were fed either of six dietary treatments: 30%NDF; 7.0% MP (CF1, as recommended), 34.5%NDF; 7.0% MP (MF1), 37%NDF; 7.0% MP (HF1), 30%NDF; 8.4% MP (CF2), 34.5%NDF; 8.4% MP (MF2) and 37%NDF; 8.4% MP (HF2). TMR offered with maize silage and respective concentrate for 90 days feeding trial. Fortnightly feed samples and weekly milk samples collection was done for analyses. Metabolic trial conducted in mid of experiment for estimating nutrient digestibility. Throughout the trial, THI level (79.7-83.8) denoted that buffaloes were exposed to stressful environment. Higher MP in diet reduced pulse rate in buffaloes as compared with lower MP diet. Rectal temperature was lower in Murrah buffaloes fed MF2 diet whereas; minimum breathing rate was recorded for high protein fed group. The MF2 diet increased dry matter intake (kg/d) by 2.7%, milk yield (kg/d) by 8.3% and feed efficiency (milk/DMI) by 7.2% as compared with CF1 group indicating reduced heat load. Increase in protein intake along with improved protein digestibility in MF2 group was recorded. Measured 6%FCM and ECM (kg/d), milk fat (%) and total solid (%) were higher in MF2 treatment group. Results revealed that 34.5% NDF and 8.4% MP have a positive influence on amelioration of heat stress in present experimental conditions.

Professionalism and inter-communication skills (ICS): a multi-site validity study assessing proficiency in core competencies and milestones in medical learners.

BACKGROUND: Interpersonal and Communication Skills (ICS) and Professionalism milestones are challenging to evaluate during medical training. Paucity in proficiency, direction and validity evidence of assessment tools of these milestones warrants further research. We validated the reliability of the previously-piloted Instrument for Communication skills and Professionalism Assessment (InCoPrA) in medical learners. METHODS: This validity approach was guided by the rigorous Kane's Framework. Faculty-raters and standardized patients (SPs) used their respective InCoPrA sub-component to assess distinctive domains pertinent to ICS and Professionalism through multiple expert-built simulated-scenarios comparable to usual care. Evaluations included; inter-rater reliability of the faculty total score; the correlation between the total score by the SPs; and the average of the total score by two-faculty members. Participants were surveyed regarding acceptability, realism, and applicability of this experience. RESULTS: Eighty trainees and 25 faculty-raters from five medical residency training sites participated. ICC of the total score between faculty-raters was generally moderate (ICC range 0.44-0.58). There was on average a moderate linear relationship between the SPs and faculty total scores (Pearson correlations range 0.23-0.44). Majority of participants ascertained receiving a meaningful, immediate, and comprehensive patient-faculty feedback. CONCLUSIONS: This work substantiated that InCoPrA was a reliable, standardized, evidence-based, and user-friendly assessment tool for ICS and Professionalism milestones. Validating InCoPrA showed generally-moderate agreeability and high acceptability. Using InCoPrA also promoted engaging all stakeholders in medical education and training-faculty, learners, and SPs-using simulation-media as pathway for comprehensive feedback of milestones growth.

Decoding the small size challenges of mini-tablets for enhanced dose flexibility and micro-dosing.

Mini-tablets are an age appropriate dosage form for oral administration to pediatric and geriatric patients, either as individual mini-tablets or as composite dosage units. Smaller size mini-tablets than the commonly used 2 mm or larger size would offer more tailored micro-dose delivery of investigational drugs. This work demonstrated drug substance particle size, drug loading and mini-tablet size ranges to achieve acceptable quality attributes of mini-tablets. A platform formulation with 60, 80, and 100 µm (particle size D6,3) ibuprofen at 3, 14, and 25% loadings were directly compressed into 1.2, 1.5, 2, and 2.5 mm diameter mini-tablets. With an enhanced weight control approach, all the mini-tablet batches except the 1.2 mm diameter mini-tablets with 100 µm ibuprofen at 3% loading would achieve acceptable content uniformity as individual mini-tablets (USP <905> L2 criteria) and as composite dosage units of five or more mini-tablets (USP <905> L1 criteria). A dissolution method was developed and successfully utilized to evaluate the formulations herein. Small size mini-tablets, small ibuprofen particle size, and low dose (or low ibuprofen loading) enhanced the dissolution performance. In addition, hypothetical scenarios of potential dose flexibility, dose range, dose titration, and excipient burden were discussed. The results of this study provide guidance for development of smaller size mini-tablets that enable dosing as a single or composite dosage unit, reduce excipient burden and leverage dispensing technology to achieve enhanced dosing flexibility and micro-dosing.

Biopsy-proven progressive multifocal leukoencephalopathy in a renal transplant patient.

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease that affects immunocompromised hosts. Most often the disease is reported in association with leukemia, lymphoma, and AIDS. With recent advancements in immunosuppressive medications and subsequent rise in solid organ transplantations, it is becoming more prevalent in this population. Both the diagnosis and treatment of PML remains a challenge to the transplant community. The disease remains mostly underreported and undertreated. The diagnostic uncertainty in a renal transplant patient leads us to do the brain biopsy for suspicion and confirmation of PML.

Postoperative Pulmonary Edema Conundrum: A Case of Negative Pressure Pulmonary Edema.

Postobstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is an underdiagnosed entity in clinical practice and can lead to life-threatening hypoxemia. A 64-year-old male patient's perioperative course was complicated by acute hypoxemic respiratory failure, after extubation following general anesthesia, following the excision of the right vocal cord papilloma. His chest X-ray showed features of pulmonary edema, EKG showed dynamic ST-T changes in the lateral leads, and echocardiography showed evidence of regional motion abnormalities. His coronaries were normal on the immediate angiogram. He was managed with lung protective mechanical ventilation strategy, diuretics, and fluid restriction. His respiratory status improved, and trachea was extubated after 10 hours of intensive care unit (ICU) stay. The case illustrates the various differentials of immediate postoperative flash pulmonary edema and ensuing appropriate management strategy.

Correction: Novel variants in COL4A4 and COL4A5 are rare causes of FSGS in two unrelated families.

[This corrects the article DOI: 10.1038/s41439-018-0016-8.].

Novel variants in COL4A4 and COL4A5 are rare causes of FSGS in two unrelated families.

We report two female patients with focal segmental glomerulosclerosis and chronic kidney disease. The first patient was found to have a heterozygous, de novo, pathogenic variant in COL4A5 (c.141+1G>A, IVS2+1G>A), which is associated with Alport syndrome. The second patient was found to have a heterozygous, likely pathogenic variant in COL4A4 (c.2842G>T). Both these variants in COL4A5 and COL4A4 are novel, and they were detected using whole exome sequencing and gene panel testing, respectively. Additionally, we discuss the complexities of diagnosis in such cases and the benefits of using the abovementioned diagnostic approaches.

Single-Kidney Transplant on VA-ECMO While Recovering from Post-Heart-Transplant Graft Failure.

Although no consensus exists on whether extracorporeal membrane oxygenation (ECMO) support is an indication for solid-organ transplantation other than heart and lung, this practice continues to be limited. We present a case of a 55-year-old man who was placed on venoarterial ECMO (VA-ECMO) during orthotopic heart transplantation (OHT) because of acute graft failure. Twenty-four hours later, the patient underwent deceased-donor renal transplantation (DDRT) while on VA-ECMO and had no complications. On post-DDRT day 2 (post-OHT day 3), the patient was successfully decannulated from VA-ECMO and ultimately discharged home. This case highlights the potential successful use of ECMO support during solid-organ transplantation other than heart and lung and the importance of trained providers and tailored anticoagulation. To the authors' knowledge, this is the first report of perioperative ECMO use during kidney transplantation after recent heart transplantation.