The role of pleural fluid lactate dehydrogenase-to-adenosine deaminase ratio in differentiating the etiology of pleural effusions.

Exudative pleural effusion includes tuberculous pleural effusion (TPE), parapneumonic pleural effusion (PPE), and malignant pleural effusion (MPE). An elevated pleural fluid adenosine deaminase (ADA) typically implies TPE, but the rule may not apply to every individual case. Recent studies proposed that the pleural fluid lactate dehydrogenase (LDH)-to-ADA ratio showed a higher diagnostic power than pleural fluid ADA alone in differentiating the etiology of pleural effusion. Hence, we aimed to investigate the performance of pleural fluid LDH-to-ADA ratio as a biomarker in assistance with the diagnosis of TPE, PPE, and MPE. All patients who underwent thoracentesis for the first time with a pleural fluid ADA >40 U/L were included in this retrospective study. The clinical data including pleural fluid ADA and LDH-to-ADA ratio were analyzed. A total of 311 patients were enrolled during the study interval. The pleural fluid LDH-to-ADA ratio <14.2 (sensitivity: 74.2%; specificity: 90.4%) favored TPE, while the pleural fluid LDH-to-ADA ratio >14.5 (sensitivity: 79.9%; specificity: 78.5%) favored PPE. Besides, the pleural fluid LDH-to-ADA ratio >46.7 (sensitivity: 56.3%; specificity: 78.3%) favored MPE owing to primary lung cancers. In conclusion, the pleural fluid LDH-to-ADA ratio was an effective indicator in differentiating the etiology of pleural effusions in the cases of high ADA level in the pleural fluid.

Use of Contrast Medium Volume to Guide Prophylactic Hydration to Prevent Acute Kidney Injury After Contrast Administration: A Meta-Analysis.

OBJECTIVE. The purpose of this study was to determine whether contrast medium volume and method of administration and baseline estimated glomerular filtration rate influence the efficacy of prophylactic hydration for prevention of acute kidney injury after contrast administration. MATERIALS AND METHODS. An online search of PubMed conducted on August 25, 2017, produced a total of 697 studies. After the reports were reviewed, nine were included in this study. The extracted data on all patients in these studies were separated into a group that received prophylactic hydration and a group that did not. The following three parameters were used for subgroup analysis: contrast medium volume, contrast administration method, and baseline estimated glomerular filtration rate. The t test was performed, and study-level odds ratios with 95% CIs and p values were calculated. Tests of heterogeneity were conducted. RESULTS. When the volume of contrast agent administered exceeded 100 mL, hydration was beneficial in the prevention of contrast-induced acute kidney injury (odds ratio, 0.546). If the volume was less than 100 mL, hydration had no efficacy in preventing contrast-induced acute kidney injury (odds ratio, 0.917). Administration route and baseline estimated glomerular filtration rate exerted no effect on the efficacy of prophylactic hydration. CONCLUSION. For patients who receive less than 100 mL of contrast medium, the prevalent practice for contrast-enhanced CT studies, prophylactic hydration may not be necessary, regardless of the estimated glomerular filtration rate or route of contrast administration. For patients undergoing procedures requiring administration of large volumes of contrast medium, however, hydration is recommended to prevent contrast-induced acute kidney injury.

Hypoglycemic encephalopathy mimicking acute ischemic stroke in clinical presentation and magnetic resonance imaging: a case report.

BACKGROUND: The imaging findings of hypoglycemic encephalopathy can be considerably similar to those of ischemic infarction or toxic leukoencephalopathy. We demonstrated unusual magnetic resonance (MR) imaging features of hypoglycemic encephalopathy which can be confused with other pathology both on imaging and acute clinical presentation. The diffusion-weighted imaging (DWI) and apparent diffusion coefficients (ADC) map findings in our case further supports the hypothesis of hypoglycemia-induced "excitotoxic injury" of glial cells and myelin sheath that might protect neuron axons from intracellular edema and irreversible damage. CASE PRESENTATION: A 72-year-old woman presented with poor appetite and was initially drowsy at home; the symptoms progressed to loss of consciousness accompanied by mild incontinence. The initial glucose level was 44 mg/dL, but no nausea, vomiting, fever, or cold sweating was reported. Physical examination after intravenous glucose supplementation revealed the absence of focal neurological signs, facial palsy, and tongue or eye deviations. The images obtained 24 h after symptoms onset revealed symmetrical hyperintensities on DWI (b-value: 1000) associated with hypointensities on ADC map along the corticospinal tract, from the levels of the cerebral peduncle and the posterior limbs of the internal capsule to the level of the corona radiata, which may mimic the imaging findings of acute ischemic infarction or amyotrophic lateral sclerosis. The patient received sliding-scale insulin therapy and rehabilitation, and she recovered consciousness without motor function deficits after 1 month. Moreover, repeat DWI and ADC map showed the complete disappearance of the lesions. CONCLUSIONS: In the phenomenon of excitotoxic injury, axons could be protected from intracellular edema and irreversible damage, which may explain the reversible clinical symptoms and imaging abnormality after controlling for blood glucose because of the preserved motor axon. The diagnosis of acute symptomatic hypoglycemic encephalopathy through clinical and imaging features can be challenging. It is crucial to differentiate it from ischemic encephalopathy since the management and clinical outcome are different.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

BACKGROUND: The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer. MATERIALS AND METHODS: Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed. RESULTS: The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001). CONCLUSION: CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations. IMPLICATIONS FOR PRACTICE: Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.

Telemedicine in the management of non-acute headaches: A prospective, open-labelled non-inferiority, randomised clinical trial.

Objectives We determined headache patients' satisfaction with telemedicine and assessed how telemedicine influenced headache burden, compliance with diagnosis and treatment, and need for follow-up consultations. Methods During 2.5 years, patients from Northern Norway referred with non-acute headaches for a specialist consultation at Tromsø University Hospital were consecutively randomised to either telemedicine or traditional visits. Baseline data were recorded and compared to data from a three-month follow-up questionnaire (see Supplementary material). The following were evaluated: (1) satisfaction with the consultation; (2) headache status; subjective improvement, average pain intensity, treatment, headache days per month, and Headache Impact Test (HIT-6); and (3) treatment compliance and follow-up visits. Results Out of 402 consultations, 348 (86.6%) answered the questionnaire. Satisfaction was similar in the telemedicine and the traditional group (88.8% vs. 92.3%; p = 0.35). Subgroup analyses were not prespecified, but there were no differences in satisfaction among females, migraineurs, rural patients and urban patients. Improvement from baseline after three months was reported equally in the telemedicine and the traditional groups. There were also no differences in treatment compliance, but rural telemedicine patients had less-frequent headache visits at three months' follow-up (28.9% vs. 48.7%, p = 0.002). Conclusion Telemedicine is non-inferior to traditional consultations in patient satisfaction, specialist evaluation, and treatment of non-acute headaches. ClinicalTrials.gov ID: NCT02270177.

Photophobia and Seasonal Variation of Migraine in a Subarctic Population.

OBJECTIVE: To investigate associations between photophobia and seasonal variation of migraine. METHODS: In this cross-sectional study, migraineurs consecutively recruited were referred to a specialist center located above the Arctic Circle at 68-71 degrees North during a 2.5-year period. Data were obtained through a structured interview. RESULTS: In total, 302 migraineurs with a mean (±SD) age of 35.5 (±12.6) years were included. Patients who reported seasonal variation of migraine (n = 90; 29.8%) also reported more often interictal photophobia than the others (61/90, 67.8% vs 92/212, 43.4%, P < .0001). Patients reported sunlight or other bright light to trigger migraine attacks in 74.4% with seasonal migraine (SM) compared with 40.6% in patients with non-seasonal migraine (NSM) (P < .0001), but there were similar frequencies of attacks reported to be triggered by sleep, menstruation, and other precipitating factors. After adjusting for migraine with aura, migraine disability, chronic migraine, interictal photophobia, and insomnia, sunlight or other bright light, photophobia was still associated with SM (OR; 3.47, CI [95%]; 1.83-6.59, P < .0001). CONCLUSIONS: Migraineurs in a subarctic area reporting seasonal variation of attack frequency also report increased interictal photophobia independent of other clinical factors. Chronobiological mechanisms and/or increased activity in the visual system may be responsible for this phenomenon.

Lectin-like bacteriocins from Pseudomonas spp. utilise D-rhamnose containing lipopolysaccharide as a cellular receptor.

Lectin-like bacteriocins consist of tandem monocot mannose-binding domains and display a genus-specific killing activity. Here we show that pyocin L1, a novel member of this family from Pseudomonas aeruginosa, targets susceptible strains of this species through recognition of the common polysaccharide antigen (CPA) of P. aeruginosa lipopolysaccharide that is predominantly a homopolymer of D-rhamnose. Structural and biophysical analyses show that recognition of CPA occurs through the C-terminal carbohydrate-binding domain of pyocin L1 and that this interaction is a prerequisite for bactericidal activity. Further to this, we show that the previously described lectin-like bacteriocin putidacin L1 shows a similar carbohydrate-binding specificity, indicating that oligosaccharides containing D-rhamnose and not D-mannose, as was previously thought, are the physiologically relevant ligands for this group of bacteriocins. The widespread inclusion of d-rhamnose in the lipopolysaccharide of members of the genus Pseudomonas explains the unusual genus-specific activity of the lectin-like bacteriocins.

Using size-weight relationships to estimate biomass of heavily targeted aquarium corals by Australia's coral harvest fisheries.

Coral reefs are highly threatened environs subject to ongoing unprecedented degradation as a result of anthropogenic activities. Given the existential threat to coral reef ecosystems, extractive industries that make use of coral reef resources, are facing significant public and political pressure to quantify and justify their environmental impact. In Australia, hundreds of thousands of live scleractinian (hard) corals are harvested annually directly from the wild to supply the growing international marine aquarium trade. Many of the most popular and high value aquarium corals are believed to be slow growing, which would make them particularly vulnerable to over-fishing. Corals present a number of unique challenges for fisheries management, not least of which, is the marked variation in the size of corals, which may be harvested in whole or in part. This issue is further compounded because harvest limits are typically weight-based, but there is very limited information on the standing biomass of corals in targeted stocks. Herein, we describe size-weight relationships for some of Australia's most heavily targeted coral species (Catalaphyllia jardinei, Duncanopsammia axifuga, Euphyllia glabrescens, Homophyllia cf. australis, Micromussa lordhowensis, Trachyphyllia geoffroyi), which allows estimation of standing biomass from transect surveys. This work represents an important first step in the development of ecologically sound management strategies by bridging the gap between catch reporting and stock assessments.

A 15-Year Longitudinal Study of Body Composition in Finnish Military Divers.

INTRODUCTION: Finnish military divers perform a great variety of tasks all year round, all of which require good physical health and fitness. Poor physical fitness can hinder the ability to cope with different situations. A high body fat percentage has been suggested to increase the risk of decompression sickness, whereas low muscle mass has been associated with an increased risk of musculoskeletal disorders and trauma. However, a low-fat composition may render divers vulnerable to cold and hypothermia during a dive in cold Arctic conditions. The aim of this study was to evaluate possible changes in body composition of Finnish military divers during a 15-year follow-up period (2007-2021). MATERIALS AND METHODS: We used body composition measures from military divers' fit-to-dive evaluations from the Finnish Defence Forces' Diving Medical Centre. Measurements were taken with two bioimpedance devices that function based on the electrical conductivity properties of the human body. The data from both devices were compared with Bland-Altman plots to show that the devices produced congruent data and the results from both devices could be included in the study. Possible changes in body composition were evaluated with a linear mixed model with random intercepts and slopes for each variable. RESULTS: Results from the two bioimpedance devices showed no significant differences. This allowed us to combine the results in the same data analysis. There were no apparent differences in the age of the divers between the years during the follow-up. The majority of the divers were between 25 and 30 years of age. Age correlated significantly with most measures, the clinically most significant being a higher fat percentage in older divers. However, all measures were within target values defined by the Diving Medical Centre. The divers were able to retain sufficient muscle mass in all age groups. DISCUSSION AND CONCLUSIONS: According to this study, Finnish military divers have managed to maintain a surprisingly good muscle mass in all age groups despite body composition changes due to aging in older subjects. A slight increase in fat mass can be observed with increasing age; nevertheless, the values have remained within fit-to-dive target levels. The current training routines of Finnish military divers are adequate for maintaining solid physical fitness and body composition over the course of the diving career.

Increasing densities of Pacific crown-of-thorns starfish (Acanthaster cf. solaris) at Lizard Island, northern Great Barrier Reef, resolved using a novel survey method.

Recurrent population irruptions of Pacific crown-of-thorns starfish (CoTS, Acanthaster cf. solaris) are among the foremost causes of coral mortality on Australia's Great Barrier Reef (GBR). Early intervention during the initiation of new population irruptions represents the best opportunity to effectively manage this threat. However, current survey methods are not sufficiently sensitive to detect changes in CoTS densities during the early onset of population irruptions. Using scooter-assisted large area diver-based (SALAD) surveys, this study revealed increasing densities of CoTS at Lizard Island from 2019 to 2022. Inferred densities of adult CoTS (which account for distinct sets of observed feeding scars where starfish were not detected) increased from 4.90 ha-1 (± 0.85 SE) in 2019 to 17.71 ha-1 (± 2.3 SE) in 2022. A wide range of size classes were recorded suggesting that recruitment over several years is contributing to increasing densities. Importantly, the sustained density increases reported here denote that renewed CoTS population irruptions may soon become fully established at Lizard Island and more broadly in the northern GBR, especially without early intervention through effective population management.

Effects of 12-Month Training Intervention on Physical Fitness, Body Composition, and Health Markers in Finnish Navy Soldiers.

BACKGROUND: Most Western adults do not meet the recommendations for sufficient activity, and obesity is a global problem. Similar trends are also seen among Western military personnel. Many successful physical training interventions have been carried out in military environments, but the interventions have been quite short term, and the training has been supervised. Therefore, the aim of this study was to investigate the effects of a 12-month voluntary motivational training intervention among the Finnish Defence Forces' (FDF) Navy soldiers. METHODS: In total, 77 FDF Navy soldiers, serving in missile patrol boats, took part in the study. The intervention group (IG) contained 45 participants and the control group (CG) contained 32 participants. The IG was divided into four teams that carried out the intervention, while the CG took part in only the measurements. RESULTS: Most of the participants (65%) in the IG reported that they had increased their exercise volume during the intervention, but no major beneficial impacts on the physical fitness, body composition, or health markers were observed. Nevertheless, there was a clear diversity visible between the subgroups in the IG. The team that reported the most exercise had the best motivation and the most motivated team coach and also had the most improved physical fitness and body composition results. CONCLUSIONS: The present study points out that in military environments, long-term voluntary training interventions may not be as successful as short-term supervised interventions. The results also suggest that in voluntary training interventions among military personnel, the participants' motivation to exercise is a key factor when improving physical fitness.

A pilot study: effects of decreasing serum insulin with diazoxide on vitamin D levels in obese women with polycystic ovary syndrome.

INTRODUCTION: We conducted a pilot project to test the hypothesis that decreasing insulin concentrations with diazoxide would affect parameters of vitamin D in obese women with and without polycystic ovary syndrome (PCOS). MATERIALS AND METHODS: Eight obese women with PCOS and nine matched controls participated in the study. Diazoxide was administered orally 100 mg three times daily for 10 days, and parameters of vitamin D were measured at baseline and end-of-study. RESULTS: At baseline, women with polycystic ovary syndrome had significantly lower serum 25-hydroxyvitamin D (25[OH]D) levels than controls. After treatment with diazoxide, there were no significant changes in vitamin D parameters when PCOS and control women were evaluated separately. Diazoxide exhibited differential effects on 25(OH)D concentrations in PCOS as compared with normal women (P for interaction=0.045), and serum 25(OH)D levels converged after diazoxide treatment. CONCLUSIONS: Obese women with PCOS had significantly lower serum 25(OH)D levels at baseline than age- and body mass index-matched controls. Short-term administration with diazoxide seemed to have differential effects on 25(OH)D levels in PCOS as compared with control women. Further studies are necessary to confirm this finding.

Size-weight relationships for estimating harvestable biomass of Acropora corals on Australia's Great Barrier Reef.

Although hard corals (order Scleractinia) are listed in Appendix II of the Convention for the International Trade in Endangered Species (CITES), there is significant ongoing wild harvest and international trade, mostly for the aquarium industry. Acropora corals account for the majority of aquarium corals harvested and traded, but are also extremely vulnerable to fisheries-independent threats, especially climate-induced coral bleaching. Reconciling effects of coral harvesting is complicated as harvest limits are based on weight, while there is limited data on standing biomass of Acropora from different reef environments. Here, a management-friendly methodology that allows for quantification of Acropora spp. biomass is described and demonstrated, thus providing means for the development and implementation of a rigorous sustainable harvest strategy. We establish size-weight relationships for four growth forms of Acropora spp. harvested from Australia's Great Barrier Reef, to facilitate estimates of harvestable biomass and better understand the ecological context of current weight-based harvest levels and limits. Using these relationships, and field-based sampling at 12 sites across seven distinct reefs, the estimated biomass of Acropora spp. ranges from 0.12 kg ⋅ m-2 to 4.7 kg ⋅ m-2. These estimates necessitate further consideration of catch composition and the specific abundance of individual species that are heavily harvested, and how impacts of current harvest practices interact with species-specific vulnerability to climate change and other escalating human pressures contributing to the degradation of coral reef ecosystems. This study is a crucial first step towards quantifying the ecological impacts of the fishery to develop management strategies that are underpinned by research.

Drainless thoracoscopic surgery should be avoided in primary spontaneous pneumothorax with pleural adhesion.

OBJECTIVES: Drainless thoracoscopic surgery, defined by omitting chest drain after surgery, has been demonstrated to be feasible in selected patients for pulmonary resection. However, drainless procedure for the treatment of primary spontaneous pneumothorax has raised concerns for its safety and thus has been less often reported. We aimed to share our preliminary experience regarding how to select patients with spontaneous pneumothorax for this procedure. METHODS: A retrospective study recruiting 303 consecutive patients with the diagnosis of spontaneous pneumothorax undergoing thoracoscopic surgery in our centre from August 2016 to June 2020 was done. After careful selection, the chest drain was omitted in selected patients who underwent non-intubated uniportal thoracoscopic surgery. Patients' clinical characteristics and perioperative outcomes were analysed. RESULTS: A total of 34 patients underwent drainless thoracoscopic surgery for the treatment of spontaneous pneumothorax. Pleural adhesion was noted in 9 patients during surgery, and all of them (100%) developed residual pneumothorax, among which intercostal drainage was required in 2 (22.2%) patients and ipsilateral pneumothorax recurred 3 years after surgery in 1 (11.1%) patient. Among the remaining 25 without pleural adhesion, 17 (68.0%) developed minor residual pneumothorax (P = 0.006), which all resolved spontaneously within 1-2 weeks, with no complications or recurrence during postoperative follow-up for at least 2 years. CONCLUSIONS: Drainless thoracoscopic surgery for the treatment of primary spontaneous pneumothorax is feasible but can be risky without careful patient selection. In our experience, the drainless procedure should be avoided in patients with identifiable pleural adhesion noted during surgery.

Effects of operational assessment of the 4:4 and 4:4/6:6 watch systems on sleepiness, fatigue, and stress responses during patrolling on a navy missile patrol boat.

The operation of naval vessels involves watchkeeping 24 h per day, which is globally carried out by a variety of different watch systems. In this study, the rotating 4:4 and fixed 4:4/6:6 two-section watch systems were compared in terms of sleepiness, fatigue, and stress responses. The data collection took place on a Finnish Defence Forces' (FDF) Navy missile patrol boat with 15 crew members serving as study participants. The data collection periods lasted two separate weeks (7 days, 6 nights) with the different watch systems. The subjective sleepiness of the participants was assessed before and after every watch using the Karolinska Sleepiness Scale (KSS). Stress responses were assessed daily by the recorded levels of salivary alpha-amylase (sAA), cortisol (sCor), immunoglobulin A (sIgA), and dehydroepiandrosterone (sDHEA). The participants' sustained attention, inhibitory control, and working memory were assessed daily by cognitive tests (SART, N-Back). The heart rate variability (HRV) during an orthostatic test was used as an additional daily marker to assess the amount of psychological stress of the participants. In this study, the difference regarding sleepiness and fatigue between the study weeks was most visible in the subjective KSS, which clearly favored the 4:4/6:6 system. The results of sAA and sIgA also suggested that the subjects were psychologically less stressed during the study week with the 4:4/6:6 watch system. Cognitive test results (SART, N-Back) indicated that there were overall no significant differences in the subjects' sustained attention, inhibitory control, or working memory during the study weeks or between the study weeks. The results of the HRV data during the daily orthostatic tests were inconclusive but there was some indication that the subjects were less stressed during the study week with the 4:4/6:6 watch system. In conclusion, the present study indicates that in navy surface operations: working with the fixed 4:4/6:6 watch system causes less sleepiness, fatigue, and psychological stress than working with the rotating 4:4 watch system. The study result is well in line with previous research regarding watch systems.

The Effects of Individual Characteristics of the Naval Personnel on Sleepiness and Stress during Two Different Watchkeeping Schedules.

BACKGROUND: Naval service can have a significant impact on the wellbeing of seafarers, and the operation of warships is highly dependent on the personnel on board. Nevertheless, there is a lack of knowledge concerning the impact of seafarers' individual characteristics on their wellbeing in a naval environment. Therefore, the aim of this study was to investigate individual characteristics of the naval personnel that may be associated with the amount of sleepiness, fatigue and stress responses experienced during shift work and irregular working hours in a naval environment. METHODS: The study took place on a Finnish Defence Forces' Navy missile patrol boat on which 18 crewmembers served as study participants. The measurement periods lasted two separate weeks (seven days and six nights) during shift work with two different watchkeeping systems (4:4, 4:4/6:6). The onboard measurements consisted of the Karolinska Sleepiness Scale, salivary stress hormones, cognitive tests (Sustained Attention to Response Task and N-back Task) and heart rate variability. RESULTS: Participants of older ages or with a longer history in naval service were associated with a greater amount of sleepiness, fatigue and stress responses on board. On the contrary, increased physical activity and a higher level of physical fitness, especially standing long jump, were associated with a lower amount of sleepiness, fatigue and fewer stress responses. In addition, an athletic body composition together with a healthy lifestyle may be beneficial, considering the stress responses on board. CONCLUSION: The present results are well in line with the previous literature regarding shift work and irregular working hours. The results highlight the importance of regular physical activity and good physical fitness during service in the naval environment.

Is tubeless uniportal video-assisted thoracic surgery for pulmonary wedge resection a safe procedure?

OBJECTIVES: Tubeless uniportal video-assisted thoracic surgery (VATS), using a uniportal approach and non-intubated anaesthesia while avoiding postoperative chest drain insertion, for patients undergoing thoracoscopic surgery has been demonstrated to be feasible in selected cases. However, to date, the safety of the procedure has not been studied. METHODS: We reviewed consecutive patients undergoing non-intubated uniportal VATS for pulmonary wedge resection at 2 medical centres between August 2016 and October 2019. The decision to avoid chest drain insertion was made in selected candidates. For those candidates in whom a tubeless procedure was performed, postoperative chest X-rays (CXRs) were taken on the day of the surgery [operation (OP) day], on postoperative day 1 and 1-2 weeks later. The factors associated with abnormal CXR findings were studied. RESULTS: Among 135 attempts to avoid chest drain insertion, 13 (9.6%) patients ultimately required a postoperative chest drain. Among 122 patients in which a tubeless procedure was performed, 26 (21.3%) and 47 (38.5%) had abnormal CXR findings on OP day and postoperative day 1, respectively. Among them, 3 (2.5%) patients developed clinically significant abnormal CXRs and required intercostal drainage. Primary spontaneous pneumothorax was independently associated with a higher risk of postoperative abnormal CXRs. CONCLUSIONS: Tubeless uniportal VATS for pulmonary wedge resection can be safely performed in selected patients. Most patients with postoperative abnormal CXRs presented subclinical symptoms that spontaneously resolved; only 2.5% of patients with postoperative abnormal CXRs required drainage.

Effects of Beta-Blocker Titration on Glucose Homeostasis in Heart Failure.

BACKGROUND: Abnormal glucose metabolism and insulin resistance have been associated with heart failure incidence, severity, and mortality. Metabolic parameters such as hepatic glucose production may be altered by beta-adrenoceptor antagonists in patients with heart failure. OBJECTIVE: This study evaluated the effects of metoprolol or carvedilol up-titration on fasting glucose, insulin resistance and beta(2)-mediated glucose production in patients with chronic heart failure. METHODS: This was a prospective, randomized, active comparator study in 15 patients with AHA/ACC Stage C systolic dysfunction HF stable on medical therapy. Participants were randomized to metoprolol 25mg daily or carvedilol 3.125mg twice daily. Metoprolol was titrated to a target of 200mg daily, and carvedilol was titrated to 25mg twice daily over 8weeks. Insulin resistance as assessed by the homeostatic model, and terbutaline-induced glucose production (AUC(0-180)), were assessed at baseline and at 4 subsequent beta-blocker titration visits over 8 weeks. RESULTS: In all 15 patients, terbutaline-induced glucose AUC(0-180) decreased (p=0.0006) as beta-blocker doses increased. A significant reduction in glucose AUC(0-180) compared to baseline was only noted in patients taking metoprolol at 100mg daily (-2424.6 [95% CI -372.6 to -4478.4] mg/dL*min) and 200mg daily (-2437.2 [95% CI -15.1 to -4604.4] mg/dL*min), and not observed in those taking carvedilol. After beta-blocker titration, fasting glucose concentrations for the metoprolol and carvedilol groups were 86.9 (95% CI 89.8-101.6) mg/dL and 95.7 (95% CI 89.8-101.6) mg/dL, respectively (p=0.0273), adjusted for baseline values. There was no significant difference between metoprolol and carvedilol on insulin resistance. CONCLUSION: Increasing doses of beta-blockers are associated with decreased in beta2-mediated glucose production in heart failure. Metoprolol, but not carvedilol, decreases hepatic glucose production at commonly used heart failure doses.

Video consultations in medication overuse headache. A randomized controlled trial.

OBJECTIVE: To test the hypothesis that the effect of video consultations is noninferior to traditional consultations in managing patients with overuse headache (MOH). MATERIALS AND METHODS: Patients were recruited from referrals to a neurological clinic. In a randomized controlled trial (RCT), headache burden measured by headache impact test (HIT-6) and frequency of headache days <15 per month and visual analogue pain scale (VAS) at baseline, 3 months and 1 year were compared between groups consulted by video- (n = 51) and traditional consultations (n = 51) in a post hoc analysis. RESULTS: The overall response rate was 74.5%. HIT-6 changed from 66.3 (SD = 4.7) to 60.0 (SD = 9.1) from baseline to 12 months in participants randomized to video consultations and from 65.8 (SD = 3.7) to 58.4 (SD = 8.3) in the group consulted traditionally (95% CI -2.3 to 6.5, p = 0.44). Frequency of headache days <15 per month at 1-year follow-up were 9 (23.1%) respectively 10 (27.0%), p = 0.60. In the video group, VAS improved by 2.3 points compared to 2.4 in the traditional group from baseline to 12 months (95% CI -1.2 to 1.2, p = 0.76). Analyses of repeated measurements comparing HIT-6 and VAS over two points of time in the two groups were insignificant. CONCLUSION: The effect of video consultations is noninferior to traditional consultations in managing MOH patients. Using video may be a good alternative in consulting patients with MOH.

Hypoxia Hangover and Flight Performance After Normobaric Hypoxia Exposure in a Hawk Simulator.

INTRODUCTION: The incidence of hypoxia-like symptoms in military aviators is on the rise. Cases can be related to On-Board Oxygen Generating System (OBOGS) malfunction, air contamination, loss of cabin pressurization, hyperventilation, or a combination of these issues simultaneously. Normobaric hypoxia training in tactical fighter simulations has been conducted in the Finnish Air Force since 2008. This training helps aviators to recognize their individual hypoxia symptoms and refreshes hypoxia emergency procedures in a realistic cockpit.METHODS: A flight mission included three set-ups and a return to base (RTB) after the third set-up. In a tactical Hawk simulator, different concentrations of oxygen were used (8%, 7%, and 6% oxygen in nitrogen) to create normobaric hypoxia exposures. During the RTB, the flight instructor evaluated the subjects' flight performance (N = 16) in order to estimate cognitive functions after hypoxia. A control flight was evaluated before or after the flight with normobaric hypoxia exposure.RESULTS: Instrumental flight rule performance during RTB decreased significantly from 4.81 to 3.63 after normobaric hypoxia and emergency procedures. Some pilots reported fatigue, headache, memory problems, and cognitive impairment as adverse effects up to 12 h after normobaric hypoxia training.DISCUSSION: Hypoxia has a significant effect on flight performance during RTB, even 10 min after hypoxia emergency procedures. Since 100% oxygen was used as emergency oxygen, as in a real aircraft, the oxygen paradox may decrease flight performance. Hypoxia training in tactical fighter simulations provides an opportunity for pilots to also understand the effects of the "hypoxia hangover" on their flight performance.Varis N, Parkkola KI, Leino TK. Hypoxia hangover and flight performance after normobaric hypoxia exposure in a Hawk simulator. Aerosp Med Hum Perform. 2019; 90(8):720-724.