High-Degree Heart Block During Noncardiac Surgery Soon After Transcatheter Aortic Valve Replacement: A Case Report.

Patients undergoing transcatheter aortic valve replacement (TAVR) as a bridge to noncardiac surgery have improved outcomes. Older clinical trials concluded no increased risk of performing noncardiac surgery within 30 days of the TAVR procedure. Emerging evidence suggests patients with preexisting conduction abnormalities may require additional intervention to proceed safely with noncardiac surgery. More data are needed to clarify this clinical situation, especially for the anesthesiologist whose job is to mitigate risk for these patients. We present a patient who received a TAVR and suffered associated complications during subsequent surgery. We further discuss preventative measures and perioperative considerations for this patient population.

Investigating the Potential Double-Edged Score of Immigration-Related Stress, Discrimination, and Mental Health Access.

Prior work has suggested that discrimination and immigration-related stress may impede mental health care seeking and utilization among Latinx populations. These effects may be more nuanced as both discrimination and immigration-related stress may increase symptomology, particularly post-traumatic stress disorder (PTSD) and depression. Both symptoms may, in turn, prompt attempts to seek care. The current study examined the direct effects of discrimination and immigration-related stress on care access, as well as potentially indirect effects with PTSD and depression symptoms as mediators. Interviews and online surveys were completed with 234 Latinx residents of the Midwest, assessing everyday discrimination, discrimination in healthcare, PTSD symptoms, depression symptoms, current mental health utilization, and previous unsuccessful attempts to seek care. Direct effects of discrimination and immigration-related stress were largely unrelated to care access variables. Discrimination in healthcare settings predicted both unsuccessful attempts to seek care and current use, but this effect was positive. The indirect effect was largely supported, but only for PTSD symptoms and not depression. Results indicate that further investigation is necessary to understand the direct effects of discrimination on care access. Further, discrimination and immigration-related stress may indirectly prompt attempts to seek mental health care.

Development of a fast and sensitive RT-qPCR assay based on SYBR® green for diagnostic and quantification of Avian Nephritis Virus (ANV) in chickens affected with enteric disease.

BACKGROUND: Enteric viruses are among the most prominent etiological agents of Runting-Stunting Syndrome (RSS). The Avian Nephritis Virus (ANV) is an astrovirus associated with enteric diseases in poultry, whose early diagnosis is essential for maintaining a good poultry breeding environment. ANV is an RNA virus that rapidly mutates, except for some conserved regions such as ORF1b. Therefore, the approach of a diagnostic method based on fast-RT-qPCR using SYBR® Green that focuses on the amplification of a fragment of ORF1b is presented as a feasible alternative for the diagnosis of this viral agent. In this study, the proposed assay showed a standard curve with an efficiency of 103.8% and a LoD and LoQ of 1 gene viral copies. The assay was specific to amplify the ORF 1b gene, and no amplification was shown from other viral genomes or in the negative controls. 200 enteric (feces) samples from chickens (broilers) and laying hens with signs of RSS from Ecuadorian poultry flocks were examined to validate the proposed method. RESULTS: Using our method, 164 positive results were obtained out of the total number of samples run, while the presence of viral RNA was detected in samples collected from one day to 44 weeks old in both avian lines. CONCLUSIONS: Our study presents a novel, rapid, robust, and sensitive molecular assay capable of detecting and quantifying even low copy numbers of the ANV in commercial birds, therefore introducing a handy tool in the early diagnosis of ANV in enteric disease outbreaks in poultry.

High Performance of a Dominant/X-Linked Gene Panel in Patients with Neurodevelopmental Disorders.

Neurodevelopmental disorders (NDDs) affect 2-5% of the population and approximately 50% of cases are due to genetic factors. Since de novo pathogenic variants account for the majority of cases, a gene panel including 460 dominant and X-linked genes was designed and applied to 398 patients affected by intellectual disability (ID)/global developmental delay (GDD) and/or autism (ASD). Pathogenic variants were identified in 83 different genes showing the high genetic heterogeneity of NDDs. A molecular diagnosis was established in 28.6% of patients after high-depth sequencing and stringent variant filtering. Compared to other available gene panel solutions for NDD molecular diagnosis, our panel has a higher diagnostic yield for both ID/GDD and ASD. As reported previously, a significantly higher diagnostic yield was observed: (i) in patients affected by ID/GDD compared to those affected only by ASD, and (ii) in females despite the higher proportion of males among our patients. No differences in diagnostic rates were found between patients affected by different levels of ID severity. Interestingly, patients harboring pathogenic variants presented different phenotypic features, suggesting that deep phenotypic profiling may help in predicting the presence of a pathogenic variant. Despite the high performance of our panel, whole exome-sequencing (WES) approaches may represent a more robust solution. For this reason, we propose the list of genes included in our customized gene panel and the variant filtering procedure presented here as a first-tier approach for the molecular diagnosis of NDDs in WES studies.

Extended resection for seizure control of pure motor strip focal cortical dysplasia during awake craniotomy: illustrative case.

BACKGROUND: Focal cortical dysplasias (FCD) represent highly intrinsically epileptogenic lesions that require complete resection for seizure control. Resection of pure motor strip FCD can be challenging. Effective control of postoperative seizures is crucial and extending the boundaries of resection in an eloquent zone remains controversial. OBSERVATIONS: The authors report a 52-year-old right-handed male with refractory epilepsy. The seizure phenotype was a focal crisis with preserved awareness and a clonic motor onset of right-hemibody. Epilepsy surgery protocol demonstrated a left pure motor strip FCD and a full-awake resective procedure with motor brain mapping was performed. Further resection of surgical boundaries monitoring function along intraoperative motor tasks with no direct electrical stimulation corroborated by intraoperative-neuromonitorization was completed as the final part of the surgery. In the follow-up period of 3-years, the patient has an Engel-IB seizure-control with mild distal lower limb palsy and no gate compromise. LESSONS: This report represents one of the few cases with pure motor strip FCD resection. In a scenario similar to this case, the authors consider that this variation can be useful to improve seizure control and the quality of life of these patients by extending the resection of a more extensive epileptogenic zone minimizing functional damage.

Immigrant and U.S.-born migrant farmworkers: Dual paths to discrimination-related health outcomes.

Research with immigrant Latino populations often point to findings that immigrants tend to evidence better health outcomes than nonimmigrants. When exploring differences based on nativity, comparisons often end with just comparing these two groups. Exploring these variables alone may oversimplify the shared and unique paths of risk and resilience between these groups. Experimental research shows that discrimination is often directed toward immigrants, but U.S.-born Latinos report more frequent exposure. We sought to address this by examining two distinct pathways by which discrimination leads to negative health. A sample of 240 Latino migrant farmworkers completed questionnaires regarding immigration-related fears, discrimination, physical and mental health, demographics, and other outcomes. While U.S.-born participants reported similar or worse outcomes across health measures, the pathways to these outcomes appeared to differ between the two groups, with immigration-related fears accounting for substantial portions of these health outcomes, especially in the dual paths with discrimination (p values < .05). Simply comparing Latino groups across U.S. nativity may paper over important differences in how they arrive at those health outcomes, including that immigration-related concerns may exacerbate exposure to and severity of discrimination, which in turn leads to negative health outcomes. On the other hand, discrimination itself may account for numerous negative health outcomes more directly for U.S.-born Latinos. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examining recipient and provider perceptions of mental health treatments and written exposure therapy for posttraumatic stress disorder with a Spanish-speaking sample.

Treatments of Posttraumatic Stress Disorder (PTSD) often evidence high rates of dropout, ranging from 25% to 40%, among English-speaking samples. Written Exposure Therapy (WET), a novel manualized treatment for PTSD, evidences lower dropout rates and noninferiority to CPT, one of the most efficacious interventions for PTSD. Spanish-speaking Latinxs often experience greater dropout and barriers to care. WET appears promising for this population, but acceptability and perceived barriers to WET have not been examined among Spanish-speaking Latinxs. The present study assessed perceptions and acceptability of a Spanish-language version of WET among Spanish-speaking Latinxs who scored greater than 45 on the Spanish-language version of the PCL-IV, indicating likely PTSD (n = 20) and providers (n = 12). Participants completed a mixed-methods interview regarding reasons they/clients would not want to receive the treatment, why they/clients would want to receive the treatment, potential solutions for any identified barriers, and reasons for not seeking mental health services generally. Providers, but not potential recipients, identified low literacy as a barrier for WET. Providers and potential recipients identified time as a barrier to WET and other mental health services, but the time reduction was perceived as a potential facilitator of WET. Results also suggest no specific cultural barriers were identified for WET (e.g., provider cultural competency) and that Spanish WET may reduce time-related barriers and is perceived as effective and acceptable among Spanish-speaking Latinxs. Additional work is needed to expand the reach of the intervention, given that mental health services were often perceived as untrustworthy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factors associated with smoking in low-income persons with and without chronic illness.

INTRODUCTION: Tobacco disparities persist among low-income smokers who seek care from safety-net clinics. Many of these patients suffer from chronic illnesses (CILs) that are associated with and exacerbated by smoking. The objective of the current study was to examine the differences between safety-net patients with and without CILs in terms of nicotine dependence and related factors (such as depression, anxiety) and self-efficacy regarding ability to abstain from smoking. METHODS: Sixty-four low-income smokers who thought about or intended to quit smoking were recruited from the San Francisco Health Network (SFHN) and assessed for CILs, nicotine dependence, depression, anxiety, and smoking abstinence self-efficacy. Four one-way analyses of variance were used to examine the difference between those with and without CIL on the latter four variables. RESULTS: The CIL group had significantly higher anxiety (CIL: 8.0 ± 5.35; non-CIL: 4.44 ± 3.48; p=0.02) and tended to have higher nicotine dependence (CIL: 5.40 ± 2.58; non-CIL: 3.88 ± 2.28; p=0.04). In the CIL group, nicotine dependence was positively correlated with anxiety [r(62)=0.39; p<0.01] and negatively correlated with smoking abstinence self-efficacy [r(62)= -0.38; p<0.01]. Both depression (Spearman's rho=0.39; p<0.01) and anxiety (Spearman's rho=0.29; p<0.05) were associated with total number of CIL categories. CONCLUSIONS: Safety-net patients who smoke and suffer from CILs may be suffering from higher levels of anxiety and have less confidence in their ability to quit smoking. Incorporating mood management and developing interventions that increase a sense of self-efficacy for refraining from smoking may be necessary to help low-income smokers quit smoking.

Development and usability of a Spanish/English smoking cessation website: lessons learned.

BACKGROUND: Smoking cessation Internet interventions have been shown to be comparable in effectiveness to the nicotine patch. The aim of this study was to develop a Spanish/English smoking cessation web app using input from low-income smokers, and to evaluate modifications to the online intervention in terms of its ability to engage smokers. METHODS: Three versions of a smoking cessation web app were developed and tested. Measures of engagement, such as completion of study registration, utilization of cigarette, mood, and craving trackers, and completion of follow-up assessments, were collected to determine whether changes in the website resulted in increased engagement. RESULTS: The third version of the website, which featured improved look-and-feel and fewer barriers to engagement, markedly increased tracker engagement from the first two versions. However, follow-up rates remained low across all three versions. CONCLUSIONS: The increase in engagement was attributed to the following modifications: A more inviting landing page with key intervention elements available immediately; an easily accessible dashboard with users' data; and tracking tools that were more user friendly. We conclude that in addition to adequate and functional elements, design principles are key factors in increasing engagement in online interventions.

Primary Care Records of Chronic-Disease Patient Adherence to Treatment.

The goal of managing adherence (AD) is to achieve better medication use by patients in order to maximize benefits and reduce risks. With the aim of improving treatment adherence by patients, we carried out a descriptive study to obtain information related to adherence management in primary care. Inclusion criteria were as follows: patients that had at least one record of any treatment adherence assessment variable. For those that had more than one recorded variable, we analyzed consistency across test results. For the comparative analysis of adherence records, patients were categorized into three groups on the basis of the healthcare unit that recorded the data: case management (CM), home care (HC), and primary care team (PCT). A total of 32,137 subjects met inclusion criteria; 79.56% of subjects were older than 65. As for the analysis of assessment records across care units, 69.73% of CM patients, 67.17% of HC patients, and 2.33% of PCT patients had adherence assessment records. CM units made a significantly greater number of records than HC units. We observed low adherence at a rate of 49.3% in the CM group, 31.91% in the HC group, and 17.58% in the PCT group. When more than one adherence variable was recorded, analysis revealed inconsistent test results or recorded variables in 9.06% of PCT cases, 14.83% of HC cases, and 20.47% of CM cases. The inconsistencies observed in records of adherence assessment and management across different care units reveal the huge variability that exists in managing and selecting a tool to assess adherence.

Anesthesiology Resident Performance on the US Medical Licensing Examination Predicts Success on the American Board of Anesthesiology BASIC Staged Examination: An Observational Study.

BACKGROUND: Correlation has been found between the US Medical Licensing Examination (USMLE) Step 1 examination results and anesthesiology resident success on American Board of Anesthesiology (ABA) examinations. In 2014, the ABA instituted the BASIC examination at the end of the postgraduate year-2 year. We hypothesized a similar predictive value of USMLE scores on BASIC examination success. METHODS: After the Committee for the Protection of Human Subjects at UTHealth Institutional Review Board approved and waived written consent, we retrospectively evaluated USMLE Step examination performance on first-time BASIC examination success in a single academic department from 2014-2018. RESULTS: Over 5 years, 120 residents took the ABA BASIC examination and 108 (90%) passed on the first attempt. Ten of 12 first-time failures were successful on repeat examination but analyzed in the failure group. Complete data was available for 92 residents (76.7%), with absent scores primarily reflecting osteopathic graduates who completed Comprehensive Osteopathic Medical Licensing Examination of the United States level examinations rather than USMLE. In the failure cohort, all 3 USMLE examination step scores were lower (P < .02). USMLE Step 1 score independently predicted success on the BASIC examination (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17, P < .001). Although USMLE Step 2 score predicted BASIC examination success (OR 1.10, 95% CI 1.04-1.18, P = .001), this did not remain after adjustment for Step 1 score using multiple logistic regression (P = .11). In multivariable logistical regression, first clinical anesthesia in-training examination score and USMLE Step 1 score were significant for predictors of success on the BASIC exam. CONCLUSIONS: In anesthesiology residency training, our preliminary single-center data is the first to suggest that USMLE Step 1 performance could be used as a predictor of success on the recently introduced ABA BASIC Examination. These findings do not support recent action to change USMLE scoring to a pass/fail report.

Surgical and Pharmacological Outcomes in Acromegaly: Real-Life Data From the Mexican Acromegaly Registry.

CONTEXT: Acromegaly registries constitute a valuable source of therapeutic outcome information in real-life. OBJECTIVE: The objective of this work is to analyze surgical and pharmacological outcomes in the Mexican Acromegaly Registry (MAR). DESIGN AND METHODS: Data were extracted from the MAR informatic platform. Surgical remission was defined by a postoperative postglucose (GH) of less than 1 ng/mL and an insulin-like growth factor 1 (IGF-1) of less than 1.2 × upper limit of normal (ULN). Pharmacological remission was defined by a basal GH of less than 1 ng/mL and an IGF-1 of less than 1.2 × ULN. RESULTS: A total of 650 surgical outcomes were analyzed (94.6% transsphenoidal). Surgical remission was achieved in 40.15%, whereas 44.15% remained biochemically active. Persistently active disease after surgery was significantly associated with harboring an invasive macroadenoma, a basal GH of greater than 10 ng/mL, and/or an IGF-1 of greater than 2 × ULN at diagnosis on bivariate and multivariate analysis. The outcome of monotherapy with first-generation somatostatin analogs (SSAs) was evaluated in 267 patients (adjunctive in 65%), of whom 28.4% achieved remission. Persistently active disease was significantly associated with harboring an invasive macroadenoma as well as with pretreatment basal GH and IGF-1 levels of greater than 10 ng/mL and greater than 2 × ULN, respectively, on bivariate and multivariate analysis. Combined therapy with SSA and cabergoline was analyzed in 100 patients, of whom 19% achieved remission and 44% remained active; in this subset of patients, only a pretreatment IGF-1 of greater than 2 × ULN was significantly associated with persistent disease activity. CONCLUSION: Surgical and pharmacological outcomes in acromegaly are highly dependent on tumor size/invasiveness as well as on the degree of hypersomatotropinemia.

Quadratus Lumborum 2 Block as the Sole Anesthetic Technique for Open Hernia Repair in Multimorbid Patients.

Ultrasound-guided quadratus lumborum (QL, QL1-3) blocks have been used extensively for perioperative pain control for patients undergoing abdominal procedures. These blocks provide a more widespread and longer-lasting analgesic effect compared to the transversus abdominis plane (TAP) block. While QL blocks have been used as an adjunct in multimodal postoperative pain control, they are rarely used as the sole anesthetic technique for abdominal surgeries. We report the cases of two high-risk multimorbid patients requiring urgent open umbilical hernia repairs secondary to incarceration or obstruction. Bilateral QL2 blocks were utilized as the sole anesthetic technique to reduce anesthetic risk, with positive outcomes.  Utilization of the QL2 block technique for our patients enabled avoidance of general anesthesia in these high-risk patients because of the extensive area of anesthesia they provide when compared with the TAP and QL1 block techniques. The advantages of the QL2 block for high-risk patients include immediate perioperative pain control, reduced use of muscle relaxants, reduced opioid analgesic requirement for postoperative pain management, and enhanced postoperative recovery. Disadvantages include potential for local anesthetic toxicity, neural injury, or failure of the block. While regional anesthetic techniques may be beneficial options for those patients who are not candidates for general anesthesia, more studies in which these techniques are used need to be performed to determine the widespread efficacy and adequacy of this method.

Actitudes de madres de preescolares ante la implementación de la ley de etiquetado nutricional en Chile / Attitudes of mothers of preschools in the implementation of the nutritional labeling law in Chile

Debido a los cambios en los estilos de vida y su reflejo en la prevalencia de malnutrición por exceso a nivel mundial, en Chile (2016) se aprobó la Ley sobre Composición de los Alimentos y su Publicidad. El objetivo de este estudio fue determinar las actitudes alimentarias en madres de preescolares de distinto nivel socioeconómico y el estado nutricional de sus hijos, frente a la publicidad de alimentos y bebidas a través de distintas formas de promoción comercial, así como su actitud ante la Ley 20.606. Se aplicó una encuesta validada, la cual incluye preguntas sobre las etiquetas en los envases de los alimentos. Se realizó un análisis descriptivo de las variables y se determinó si existía diferencias entre la distribución de las respuestas según NSE mediante la prueba Chi2 .Al consultar los lugares en los que han visto publicidad de alimentos, 72% de las madres refiere haberla visto en los supermercados y 48,5% en internet. Sólo 34, 8% refirió recordar algún comercial en particular, y al solicitarles que especificaran el comercial que recordaban, 45,3% nombró alguna bebida azucarada y 13,6% alguna de yogurt. Respecto a los sellos de advertencia presentes en los envases de los alimentos, 87% declaró que les gustaban o les parecían bien. Sólo 43,6% respondió que había dejado de comprar alimentos con dichos sellos. Estos resultados serán útiles para el diseño de intervenciones específicas para este importante grupo, ya que un cambio positivo en sus conductas actuales podría repercutir en la creación de hábitos saludables en sus hijos e hijas(AU)

Due to changes in lifestyles and its reflection on the worldwide prevalence of malnutrition due to excess, in Chile (2016) the Law on Food Composition and its Advertising was approved. The objective of this study was to determine the nutritional attitudes of 509 mothers of preschoolers of different socioeconomic levels and the nutritional status of their children, in front of the advertising of food and beverages through different forms of commercial promotion, as well as their attitude towards Law 20,606. A validated survey was applied, which includes questions about labels on food containers. A descriptive analysis of the variables was carried out to determine if there were differences between the distributions of the responses according to the SEL using the Chi2 test. When consulting the places where they have seen the food advertising, 72% of the mothers reported having seen it in the supermarkets and 48.5% on the internet. Only 34, 8% reported to remembering a particular commercial, and when asked to specify the commercial they remembered, 45.3% named a sugary drink and 13.6% some yogurt. Regarding the warning seals present on food containers, 87% stated that they liked them or they seemed good to them. Only 43.6% answered that they have stopped buying foods with these labels. These results will be useful for the design of specific interventions for this important group, since a positive change in their current behaviors could have an impact on the creation of healthy habits in their children(AU)

Dramatic change in cerebral oximetry during liver transplantation.

We report dramatic changes in bilateral cerebral tissue oxygenation in a patient undergoing an orthotopic liver transplant coincident with clamping and subsequent restoration of flow through the inferior vena cava. Although hemodynamic stability was maintained with low-dose vasopressor support, cardiac output was decreased, suggesting preload dependence of the measured cerebral oxygenation. Further investigation is warranted in patients with end-stage liver disease and interruption of venous return.

The New Kidney Donor Allocation System and Implications for Anesthesiologists.

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.