A case series on treatment of central and branch retinal artery occlusion with intravenous tenecteplase: Tenecteplase for retinal artery occlusions.

OBJECTIVES: Central and branch retinal artery occlusions are disabling ischemic strokes of the retina for which established acute treatments are lacking. This is the first published report of the use of intravenous tenecteplase (TNK) for retinal artery occlusion, in which we describe the clinical course of four patients with central retinal artery occlusion (CRAO) and one patient with branch retinal artery occlusion (BRAO). MATERIALS AND METHODS: Patients were retrospectively recruited to the study from two stroke centers. Clinical course was determined from review of electronic medical records. The primary outcomes of interest were short and long term complications as well as visual acuity at presentation and at any subsequent follow up. RESULTS: There were no hemorrhagic complications. None of the four patients with CRAO experienced functional visual recovery (defined as improvement to 20/100 or better). The patient with BRAO had functional visual recovery. CONCLUSIONS: Intravenous TNK may be a safe and reasonable treatment for CRAO and BRAO.

An interpretable multi-task system for clinically applicable COVID-19 diagnosis using CXR.

BACKGROUND: With the emergence of continuously mutating variants of coronavirus, it is urgent to develop a deep learning model for automatic COVID-19 diagnosis at early stages from chest X-ray images. Since laboratory testing is time-consuming and requires trained laboratory personal, diagnosis using chest X-ray (CXR) is a befitting option. OBJECTIVE: In this study, we proposed an interpretable multi-task system for automatic lung detection and COVID-19 screening in chest X-rays to find an alternate method of testing which are reliable, fast and easily accessible, and able to generate interpretable predictions that are strongly correlated with radiological findings. METHODS: The proposed system consists of image preprocessing and an unsupervised machine learning (UML) algorithm for lung region detection, as well as a truncated CNN model based on deep transfer learning (DTL) to classify chest X-rays into three classes of COVID-19, pneumonia, and normal. The Grad-CAM technique was applied to create class-specific heatmap images in order to establish trust in the medical AI system. RESULTS: Experiments were performed with 15,884 frontal CXR images to show that the proposed system achieves an accuracy of 91.94% in a test dataset with 2,680 images including a sensitivity of 94.48% on COVID-19 cases, a specificity of 88.46% on normal cases, and a precision of 88.01% on pneumonia cases. Our system also produced state-of-the-art outcomes with a sensitivity of 97.40% on public test data and 88.23% on a previously unseen clinical data (1,000 cases) for binary classification of COVID-19-positive and COVID-19-negative films. CONCLUSION: Our automatic computerized evaluation for grading lung infections exhibited sensitivity comparable to that of radiologist interpretation in clinical applicability. Therefore, the proposed solution can be used as one element of patient evaluation along with gold-standard clinical and laboratory testing.

Antipsychotic-Induced Movement Disorder: Screening via Telemental Health.

BACKGROUND: The purpose of this brief report is to make clinical and research recommendations to advance current knowledge and practices related to the assessment of antipsychotic drug-induced movement disorders (DIMDs) via live interactive videoconferencing. MATERIALS AND METHODS: The authors provide an overview of the frequent neurological side effects of antipsychotic drugs and review relevant telemedicine research. DIMD prevention is critical, but these disorders remain underdetected and under-reported. Although there are not yet formal recommendations for specific screening tools or screening frequency, baseline and annual assessments are generally agreed-upon minimums. As DIMD awareness increases and more specific guidelines are developed to steer assessments, telemental health may aid practitioners in efficiently and regularly monitoring onset and severity. Research shows that videoconferencing can be used for effective psychiatric treatments and assessment, with at least one study validating the use of videoconference assessment for a subset of movement disorders. RESULTS AND CONCLUSIONS: Clinical recommendations include developing practice-level protocols and procedures that include regular DIMD assessment (either in-person or via telemedicine) for the full spectrum of possible movement disorders for all patients taking antipsychotic medications. Research and evaluation recommendations include replicating and expanding upon the existing study using videoconferencing to assess movement disorder symptoms, using asynchronous telemental health assessments of DIMDs, and pilot-testing facial and movement recognition software to allow for clinical comparison of patients' movement patterns over time.

Meaningful use: a national framework for integrated telemedicine.

INTRODUCTION: The Centers for Medicare and Medicaid Services has incentivized electronic health records (EHRs) implementation through meaningful use (MU) to improve healthcare quality and efficacy. Telemedicine is a key tool that has shown its ability to facilitate MU through technological innovation with cost savings and has shown promise in the area of integrated behavioral healthcare. The purpose of this article is to propose a model of MU to frame the incentivized implementation of an integrated telemedicine (ITM)-specific model to effect system-level change. MATERIALS AND METHODS: We reviewed the background, principles, and a justification for the ITM Model including cost issues, the development and structure of MU in the context of EHRs, the benefits of integrated behavioral healthcare and telemedicine, and the case for their combined implementation in the form of ITM. RESULTS: The model proposed, the ITM Incentive Program, parallels the current MU program and is composed of three stages. Stage 1 focuses on incentivizing current and new Medicaid providers to adapt, implement, and upgrade technology needed to conduct virtual meetings with patients and other healthcare professionals. Stage 2 is a tiered incentive system with process-focused and track metrics related to increasing the number of consultations with patients. In Stage 3, providers are encouraged to continue use of ITM by meeting thresholds for several objectives focused on clinical outcomes. Recommendations for implementing this model within a payment waiver system are discussed. CONCLUSIONS: The ITM Model offers a needed union of integrated care and telemedicine through the combination of technology, business, and clinical processes. The success of MU as a tiered incentive program for EHRs, as well as the precedent of using waiver opportunities for incentive funding repayments, sets forth a strategic framework to successful implementation of ITM to address cost issues and improve quality and access to care in the healthcare system.

A lexicon of assessment and outcome measures for telemental health.

BACKGROUND: The purpose of this document is to provide initial recommendations to telemental health (TMH) professionals for the selection of assessment and outcome measures that best reflect the impacts of mental health treatments delivered via live interactive videoconferencing. MATERIALS AND METHODS: The guidance provided here was created through an expert consensus process and is in the form of a lexicon focused on identified key TMH outcomes. RESULTS: Each lexical item is elucidated by a definition, recommendations for assessment/measurement, and additional commentary on important considerations. The lexicon is not intended as a current literature review of the field, but rather as a resource to foster increased dialogue, critical analysis, and the development of the science of TMH assessment and evaluation. The intent of this lexicon is to better unify the TMH field by providing a resource to researchers, program managers, funders, regulators and others for assessing outcomes. CONCLUSIONS: This document provides overall context for the key aspects of the lexicon.

Multi-modal learning for inpatient length of stay prediction.

Predicting inpatient length of stay (LoS) is important for hospitals aiming to improve service efficiency and enhance management capabilities. Patient medical records are strongly associated with LoS. However, due to diverse modalities, heterogeneity, and complexity of data, it becomes challenging to effectively leverage these heterogeneous data to put forth a predictive model that can accurately predict LoS. To address the challenge, this study aims to establish a novel data-fusion model, termed as DF-Mdl, to integrate heterogeneous clinical data for predicting the LoS of inpatients between hospital discharge and admission. Multi-modal data such as demographic data, clinical notes, laboratory test results, and medical images are utilized in our proposed methodology with individual "basic" sub-models separately applied to each different data modality. Specifically, a convolutional neural network (CNN) model, which we termed CRXMDL, is designed for chest X-ray (CXR) image data, two long short-term memory networks are used to extract features from long text data, and a novel attention-embedded 1D convolutional neural network is developed to extract useful information from numerical data. Finally, these basic models are integrated to form a new data-fusion model (DF-Mdl) for inpatient LoS prediction. The proposed method attains the best R2 and EVAR values of 0.6039 and 0.6042 among competitors for the LoS prediction on the Medical Information Mart for Intensive Care (MIMIC)-IV test dataset. Empirical evidence suggests better performance compared with other state-of-the-art (SOTA) methods, which demonstrates the effectiveness and feasibility of the proposed approach.

Cerebral hemodynamic changes after wartime traumatic brain injury.

Traumatic brain injury (TBI) is associated with the severest casualties from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). From October 1, 2008, the U.S. Army Medical Department initiated a transcranial Doppler (TCD) ultrasound service for TBI; included patients were retrospectively evaluated for TCD-determined incidence of post-traumatic cerebral vasospasm and intracranial hypertension after wartime TBI. Ninety patients were investigated with daily TCD studies and a comprehensive TCD protocol, and published diagnostic criteria for vasospasm and increased intracranial pressure (ICP) were applied. TCD signs of mild, moderate, and severe vasospasms were observed in 37%, 22%, and 12% of patients, respectively. TCD signs of intracranial hypertension were recorded in 62.2%; 5 patients (4.5%) underwent transluminal angioplasty for post-traumatic clinical vasospasm treatment, and 16 (14.4%) had cranioplasty. These findings demonstrate that cerebral arterial spasm and intracranial hypertension are frequent and significant complications of combat TBI; therefore, daily TCD monitoring is recommended for their recognition and subsequent management.

Time-to-event modeling for hospital length of stay prediction for COVID-19 patients.

Providing timely patient care while maintaining optimal resource utilization is one of the central operational challenges hospitals have been facing throughout the pandemic. Hospital length of stay (LOS) is an important indicator of hospital efficiency, quality of patient care, and operational resilience. Numerous researchers have developed regression or classification models to predict LOS. However, conventional models suffer from the lack of capability to make use of typically censored clinical data. We propose to use time-to-event modeling techniques, also known as survival analysis, to predict the LOS for patients based on individualized information collected from multiple sources. The performance of six proposed survival models is evaluated and compared based on clinical data from COVID-19 patients.

Thbs1 induces lethal cardiac atrophy through PERK-ATF4 regulated autophagy.

The thrombospondin (Thbs) family of secreted matricellular proteins are stress- and injury-induced mediators of cellular attachment dynamics and extracellular matrix protein production. Here we show that Thbs1, but not Thbs2, Thbs3 or Thbs4, induces lethal cardiac atrophy when overexpressed. Mechanistically, Thbs1 binds and activates the endoplasmic reticulum stress effector PERK, inducing its downstream transcription factor ATF4 and causing lethal autophagy-mediated cardiac atrophy. Antithetically, Thbs1-/- mice develop greater cardiac hypertrophy with pressure overload stimulation and show reduced fasting-induced atrophy. Deletion of Thbs1 effectors/receptors, including ATF6α, CD36 or CD47 does not diminish Thbs1-dependent cardiac atrophy. However, deletion of the gene encoding PERK in Thbs1 transgenic mice blunts the induction of ATF4 and autophagy, and largely corrects the lethal cardiac atrophy. Finally, overexpression of PERK or ATF4 using AAV9 gene-transfer similarly promotes cardiac atrophy and lethality. Hence, we identified Thbs1-mediated PERK-eIF2α-ATF4-induced autophagy as a critical regulator of cardiomyocyte size in the stressed heart.

University of Texas Medical Branch telemedicine disaster response and recovery: lessons learned from hurricane Ike.

Despite previous efforts and expenditure of tremendous resources on creating and simulating disaster response scenarios, true disaster response, specifically for healthcare, has been inadequate. In addition, none of the >200 local and statewide telemedicine programs in the United States has ever responded to a large-scale disaster, let alone, experienced one directly. Based on its experience with hurricanes Rita and, most recently, Ike, the University of Texas Medical Branch (UTMB) experienced its most challenging trials. Although there were significant disruptions to a majority of UTMB's physical and operational infrastructures, its telemedicine services were able to resume near normal activities within the first week of the post-Ike recovery period, an unimaginable feat in the face of such remarkable devastation. This was primarily due in part to the flexibility of its data network, the rapid response, and plasticity of its telemedicine program. UTMB's experiences in providing rapid and effective medical services in the face of such a disaster offer valuable lessons for local, state, and national disaster preparations, policy, and remote medical delivery models and programs.

Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system.

BACKGROUND: During the past 5 years of Operation Iraqi Freedom (OIF), a significant majority of the severe closed and penetrating head trauma has presented for definitive care at the National Naval Medical Center (NNMC) in Bethesda, MD, and at the Walter Reed Army Medical Center (WRAMC) in Washington, DC. The purpose of this article is to review our experience with this population of patients. MATERIALS: A retrospective review of all inpatient admissions from OIF was performed during a 5-year period (April 2003 to April 2008). Criteria for inclusion in this study included either a closed or penetrating head trauma suffered during combat operations in Iraq who subsequently received a neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all patients for whom primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow coma scale (GCS) and injury severity score at admission, and Glasgow outcome scale (GOS) at discharge, 6 months, and 1 to 2 years. RESULTS: Five hundred thirteen consultations were performed by the neurosurgery service on the aforementioned population. Four hundred eight patients met the inclusion criteria for this study (401:7, male: female; 228 penetrating brain injury, 139 closed head injury, 41 not specified). Explosive blast injury (229 patients; 56%) constituted the predominant mechanism of injury. The rates of pulmonary embolism (7%), cerebrospinal fluid leak (8.6%), meningitis (9.1%), spinal cord or column injury (9.8%), and cerebrovascular injury (27%) were characterized. Cerebrospinal fluid leak, vasospasm, penetrating head injury, and lower presenting GCS were statistically associated with longer intensive care unit stays and higher presenting injury severity scores (p < 0.05). While presenting GCS 3-5 correlated with worsened short-term and long-term GOS scores (p < 0.001), almost half of these patients achieved GOS >or=3 at 1- to 2-year follow-up. Total mortality after reaching NNMC/WRAMC was 4.4%. CONCLUSIONS: OIF has resulted in the highest concentration of severe closed and penetrating head trauma to return to NNMC and WRAMC since the Vietnam Conflict. Management scenarios were complex, incorporating principles designed to maximize outcomes in all body systems. Meaningful survival can potentially be achieved in a subset of patients with presenting GCS

Arthroscopic Resection of Symptomatic Bennett Lesions.

Bennett lesions, also known as "thrower's exostosis" of the shoulder, involve ossification of the posteroinferior glenoid and are not uncommon in overhead throwing athletes. The literature surrounding the optimal operative management of the symptomatic Bennett lesion is limited. The purpose of this article is to describe the arthroscopic surgical technique for the visualization and excision of the symptomatic extra-articular pathologic ossification involving the posteroinferior glenoid. Because many surgeons may not be familiar with this problem or procedure, we present a straightforward method that allows for identification and excision of the exostosis through an arthroscopic posterior arthrotomy.

Thrombospondin-3 augments injury-induced cardiomyopathy by intracellular integrin inhibition and sarcolemmal instability.

Thrombospondins (Thbs) are a family of five secreted matricellular glycoproteins in vertebrates that broadly affect cell-matrix interaction. While Thbs4 is known to protect striated muscle from disease by enhancing sarcolemmal stability through increased integrin and dystroglycan attachment complexes, here we show that Thbs3 antithetically promotes sarcolemmal destabilization by reducing integrin function, augmenting disease-induced decompensation. Deletion of Thbs3 in mice enhances integrin membrane expression and membrane stability, protecting the heart from disease stimuli. Transgene-mediated overexpression of α7ß1D integrin in the heart ameliorates the disease predisposing effects of Thbs3 by augmenting sarcolemmal stability. Mechanistically, we show that mutating Thbs3 to contain the conserved RGD integrin binding domain normally found in Thbs4 and Thbs5 now rescues the defective expression of integrins on the sarcolemma. Thus, Thbs proteins mediate the intracellular processing of integrin plasma membrane attachment complexes to regulate the dynamics of cellular remodeling and membrane stability.

Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment.

Combat exposure is associated with increased rates of mental health problems such as post-traumatic stress disorder, depression, and anxiety when Soldiers return home. Another important health consequence of combat exposure involves the potential for increased risk-taking propensity and unsafe behavior among returning service members. Survey responses regarding 37 different combat experiences were collected from 1252 US Army Soldiers immediately upon return home from combat deployment during Operation Iraqi Freedom. A second survey that included the Evaluation of Risks Scale (EVAR) and questions about recent risky behavior was administered to these same Soldiers 3 months after the initial post-deployment survey. Combat experiences were reduced to seven factors using principal components analysis and used to predict post-deployment risk-propensity scores. Although effect sizes were small, specific combat experiences, including greater exposure to violent combat, killing another person, and contact with high levels of human trauma, were predictive of greater risk-taking propensity after homecoming. Greater exposure to these combat experiences was also predictive of actual risk-related behaviors in the preceding month, including more frequent and greater quantities of alcohol use and increased verbal and physical aggression toward others. Exposure to violent combat, human trauma, and having direct responsibility for taking the life of another person may alter an individual's perceived threshold of invincibility and slightly increase the propensity to engage in risky behavior upon returning home after wartime deployment. Findings highlight the importance of education and counseling for returning service members to mitigate the public health consequences of elevated risk-propensity associated with combat exposure.

Botulinum toxin type-a in the prevention of migraine: a double-blind controlled trial.

INTRODUCTION: Migraine is a frequent medical complaint. In military populations, migraine can be detrimental to productivity and troop readiness, and can be disqualifying for service in some military duty specialties. This study assessed the effectiveness of botulinum neurotoxin type-A (BTX-A) in reducing the frequency of migraines in known migraineurs. METHODS: There were 32 subjects (control = 17, test n = 15) who completed the assessment battery at baseline and monthly for 3 mo. Adult subjects with migraine headaches occurring more than 5 times/month were recruited and randomized to receive placebo saline injection vs. BTX-A. The primary efficacy parameter was the average frequency of headache days for 3 mo. Secondary outcome measures were severity of attacks and quality of life. RESULTS: Quadratic trends were noted for headache severity (F (2,29) = 14.1, p = 0.001) and headache indexes (F (2,29) = 4.5, p = 0.042) for both groups, suggesting changes in severity of head pain and overall intensity of headaches experienced over time; however, results were not significant for headache frequency and severity between groups. Paired t-tests of the headache index scores for the control group revealed a significant increase from the first to the third follow-up periods (t = -2.58, p = 0.020). Such a trend was not observed for the BTX-A group. Both groups, however, reported similarly low to moderate quality of life as a result of their migraines. CONCLUSIONS: This controlled trial failed to demonstrate efficacy of BTX-A in reducing the frequency of migraine headaches. The pattern headache index in the botox group, however, suggested a protective effect for botox against the headache severity.

Eosinophilic meningitis after implantation of a rifampin and minocycline-impregnated ventriculostomy catheter in a child. Case report.

Eosinophilic meningitis has been defined as meningitis in which a total cerebrospinal fluid (CSF) sample is found to have more than 10 eosinophils per millimeter or is composed of greater than 10% eosinophils. The differential diagnosis is broad and the clinical presentation, lacking an internalized CSF diversion system, is often nonspecific. With respect to patients with shunt systems, a positive correlation exists between CSF eosinophilia and eventual shunt failure requiring revision. In this paper the authors present the highest reported level of CSF eosinophilia in conjunction with a rifampin and minocycline-impregnated ventriculostomy catheter recently approved by the Food and Drug Administration.

Assessing risk propensity in American soldiers: preliminary reliability and validity of the Evaluation of Risks (EVAR) scale--English version.

Risk-taking propensity is a critical component of judgment and decision-making in military operations. The Evaluation of Risks scale (EVAR) was recently developed to measure state and trait aspects of risk proneness. The scale, however, was psychometrically normed in French and no data are available for the English translation. We administered the English version of the EVAR to 165 U.S. soldiers to obtain reliability, validity, and normative data for English-speaking respondents. Confirmatory factor analysis suggested that the factor structure of the English EVAR differs from that obtained in the French studies. Instead, a three-factor solution, including recklessness/impulsivity, self-confidence, and need for control, emerged. Internal consistency was comparable to the French version. EVAR scores correlated with age, military rank, and years of service, and discriminated soldiers with histories of high-risk behavior. The data support the reliability and validity of the English version of the EVAR for evaluating risk propensity in U.S. soldiers.

Effects of perceived treatment on quality of life and medical outcomes in a double-blind placebo surgery trial.

CONTEXT: This study was part of a large double-blind sham surgery-controlled trial designed to determine the effectiveness of transplantation of human embryonic dopamine neurons into the brains of persons with advanced Parkinson's disease. This portion of the study investigated the quality of life (QOL) of participants during the 1 year of double-blind follow-up. OBJECTIVES: To determine whether QOL improved more in the transplant group than in the sham surgery group and to investigate outcomes at 1 year based on perceived treatment (the type of surgery patients thought they received). DESIGN: Participants were randomly assigned to receive either the transplant or sham surgery. Reported results are from the 1-year double-blind period. SETTING: Participants were recruited from across the United States and Canada. Assessment and surgery were conducted at 2 separate university medical centers. PARTICIPANTS: A volunteer sample of 40 persons with idiopathic Parkinson's disease participated in the transplant ("parent") study, and 30 agreed to participate in the related QOL study: 12 received the transplant and 18 received sham surgery. INTERVENTIONS: Interventions in the parent study were transplantation and sham brain surgery. Assessments of QOL were made at baseline and 4, 8, and 12 months after surgery. MAIN OUTCOME MEASURES: Comparison of the actual transplant and sham surgery groups and the perceived treatment groups on QOL and medical outcomes. We also investigated change over time. RESULTS: There were 2 differences or changes over time in the transplant and sham surgery groups. Based on perceived treatment, or treatment patients thought they received, there were numerous differences and changes over time. In all cases, those who thought they received the transplant reported better scores. Blind ratings by medical staff showed similar results. CONCLUSIONS: The placebo effect was very strong in this study, demonstrating the value of placebo-controlled surgical trials.

Human biovibrations: assessment of human life signs, motor activity, and cognitive performance using wrist-mounted actigraphy.

The application of miniature motion sensors (accelerometers) to study the macro- (gross) and micro- (barely discernible) activities associated with human motion has been termed actigraphy. In countless human sleep studies, actigraphy has mostly been applied to distinguish between when a person is asleep or awake. Use of sleep/wake information has been applied to the development of mathematical models that aim to predict aspects of cognitive performance. However, wrist-mounted actigraphy potentially has many more applications to cognitive and physical assessment beyond sleep/wake discrimination. For example, studies reveal that micro-miniature accelerometric sensors can discriminate heart rate, breathing, and life cessation (death) via actigraphically measured biovibration signals. This paper briefly reviews the development of wrist-mounted actigraphy; presents the data showing wrist-monitored ballistocardioimpulses, respirations, and life-signs signals; discusses the application of sophisticated signal processing for new clinical, operational, and cognitive-assessment-related applications; and concludes with recommendations for further research for demodulating the complex actigram signal.