Cerebrovascular hemodynamics association with brain structure and function in Multiple Sclerosis.

BACKGROUND: Vascular risk factors seem to contribute to disease progression in Multiple Sclerosis (MS), but the mechanistic connection between vascular risk and MS is unknown. Understanding cerebrovascular hemodynamics (CVH) in MS may help advance our understanding of the link between vascular risk and MS. OBJECTIVES: Examine the relationship between CVH [dynamic cerebral autoregulation (dCA) and vasoreactivity (VR)] and brain structure (MRI) and function (cognition, and gait) in individuals with MS. METHODS: Transcranial Doppler ultrasound (TCD) was utilized to assess two key markers of CVH: dCA and VR. dCA (reported as phase and gain) is calculated from the spontaneous blood pressure and flow velocity oscillations. VR is calculated as the slope of change in cerebral blood flow velocity in response to end-tidal CO2. Global gray matter (GM), white matter (WM), WM hyperintensity (WMH) volumes and WM lesion counts were measured from brain MRI. All participants underwent detailed cognitive and gait assessments. RESULTS: Eighty participants were included (age 44 ± 11, 26 % male); 75 had relapsing-remitting MS (94 %), with disease duration of 8 (11) years [median (IQR)] since MS diagnosis and an Expanded Disability Status Scale (EDSS) of 2.0 (4.0). Higher phase (better dCA) was associated with greater GM volume, lower WHM burden and higher cognitive scores in the memory and global cognitive domains (all P values <0.05). There was no relationship between CVH and gait speed in our study participants. There was no relationship between VR and any measures of brain structure and function. CONCLUSIONS: More efficient cerebral autoregulation is associated with better brain structure (larger GM and lower WMH volumes) and function (cognition, but not gait) in patients with MS.

Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study.

OBJECTIVES: Cervical artery dissection (CeAD) accounts for 25% of ischemic strokes in young adults. This study evaluated the benefits and harms of intravenous thrombolysis (IVT) in patients presenting with spontaneous CeAD and acute ischemic stroke symptoms. METHODS: This analysis used data from the retrospective STOP-CAD study and included patients with spontaneous CeAD who presented within 1 day of acute ischemic stroke symptoms. Patients were dichotomized into those who received IVT and those managed without IVT. We assessed the association between IVT and 90-day functional independence (modified Rankin Scale scores 0-2) and the incidence of symptomatic intracranial hemorrhage (ICH, defined as ICH causing new or worsening neurologic symptoms within 72 hours after CeAD diagnosis). RESULTS: This study included 1,653 patients from the original STOP-CAD cohort of 4,023. The median age was 49 years, and 35.1% were women; 512 (31.0%) received IVT. IVT was associated with 90-day functional independence (adjusted odds ratio [aOR] = 1.67, 95% CI 1.23-2.28, p = 0.001), but not with symptomatic ICH (aOR = 1.52, 95% CI 0.79-2.92, p = 0.215). DISCUSSION: In patients with spontaneous CeAD and suspected ischemic stroke, IVT improved functional outcomes, without increasing symptomatic ICH risk. These findings support current guideline recommendations to consider thrombolysis for otherwise eligible patients with CeAD. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that IVT significantly increases the probability of 90-day functional independence in patients with CeAD.

Treatment of Ulcerative Lesions with Low-level Laser Therapy in a Patient with SARS-CoV-2.

Ulcerated lesions have been observed in SARS-CoV-2 patients and their treatment is a challenge. We aim to report the treatment of oral lesions with low-level laser therapy (LLLT) in a patient with SARS-CoV-2. The patient diagnosed with COVID-19 was admitted to the intensive care unit, on mechanical ventilation, and on a nasogastric tube diet that persisted due to oral lesions. Painful ulcerated lesions, clinically diagnosed as viral ulcer, were found on the tongue, palate, labial commissure, and oropharynx during the oral evaluation. An antimicrobial photodynamic therapy with methylene blue and red laser (high energy) was performed, followed by treatment with LLLT with red laser. Significant clinical improvement of the lesions was observed after seven sessions of LLLT, with the oral diet being reestablished. Oral mucosal lesions in patients with COVID-19 are usually symptomatic and with onset after systemic symptoms. LLLT has been used in the management of these lesions, with promising results.

Invasive candidiasis in dogs: A case report and review of the literature.

Invasive candidiasis is characterized by the systemic dissemination of Candida spp. and colonization of multiple organs. We are reporting a case of invasive candidiasis in a 3.5-year-old female mixed-breed dog with a history of limb injury. After clinical evaluation and complementary examinations a sepsis diagnose was established. The patient remained hospitalized under antibiotic therapy, dying three days later. Necropsy revealed white, nodular (pyogranulomas), and multifocal areas on the liver, button ulcers in the stomach and intestines, and a random lung consolidation. Impression smears were made from the liver and lung surface lesions during necropsy showing yeast and pseudohyphae structures. Fragments of these organs were sent for fungal culture and subsequent molecular etiologic characterization, identifying it as Candida albicans. Histological examination of different organs showed pyogranulomatous inflammation surrounding the necrosis areas, which were full of yeast and pseudohyphae, as evidenced by periodic acid Schiff and immunohistochemistry. Neutropenia, as a consequence of sepsis, associated with the use of antibiotics may have allowed yeast invasion and proliferation in the mucosa of the gastrointestinal tract, reaching the liver and lungs through hematogenous route. Invasive candidiasis is a rare canine disease, and no other cases of neutropenia associated with antibiotic therapy, as a predisposing factors, have been reported.

Efficacy and Safety of Diode Laser Transscleral Cyclophotocoagulation in Patients with Glaucoma.

Purpose: To evaluate the efficacy and safety of transscleral diode cyclophotocoagulation (TSCPC) at 2 years of follow up. Methods: This is a retrospective review of the records of all adult patients who underwent their first TSCPC treatment between 2014 and 2019 at Unidade Local de Saúde de São João, Porto, Portugal. Data regarding intraocular pressure (IOP), best corrected visual acuity, number of IOP-lowering medications, use of oral acetazolamide, retreatments and complications during a 2-year period following TSCPC were registered. The primary outcome was overall success at 2 years, defined as IOP≥ 6 and ≤21 mmHg, with at least 20% IOP reduction from baseline, with or without IOP-lowering medications (qualified and complete success, respectively), without the development of phthisis bulbi or loss of light perception due to glaucoma and no further glaucoma procedures except TSCPC retreatment. Results: Ninety-six eyes from 96 patients were included, mean age was 63 (±14) years. Mean IOP at baseline was 39.1 (±13.3) mmHg. Mean IOP reduction at 2 years was 18.5 (42.9%) mmHg (±16.0, min -16.0, max 56.0) (p < 0.001) and a significant reduction in the number of IOP-lowering medications and use of oral acetazolamide was observed. IOP reduction at 2 years was positively correlated with baseline IOP (r=0.682; p < 0.001). Overall success (including complete and qualified) was achieved in 42 patients (43.8%), with 34 (35.4%) presenting qualified success. Neovascular glaucoma (NVG) was the predominant diagnosis (n = 30, 31.3%), with a higher mean baseline IOP of 46.3 mmHg (±11.8, min 21.0, max 70.0) and a larger mean IOP reduction at 2 years of 24.7 (51.0%) mmHg (±16.4, min -2.0, max 55.0). Thirteen patients (13.5%) developed persistent hypotony, eight of which converted to phthisis bulbi, of which half had NVG. Conclusion: TSCPC can be an effective IOP-lowering procedure, demonstrating a stronger effect when the preoperative IOP is highest. However, there is a wide variability in the effect (specially in eyes with NVG) and some relevant complications, including 8.3% of patients developing phthisis bulbi after 2 years of follow up.

Comparison of bone mineral density between female amateur triathletes and nonathletes: A cross-sectional study.

PURPOSE: Physical inactivity is considered an important risk factor for osteoporosis, however, some athletes performing extremely high training volumes can also develop bone mass loss. Moreover, the effect of total body mass or body surface area on bone mineral density remains controversial. Therefore, the aim of this study was to compare the absolute bone mineral density and bone mineral density adjusted to body surface area between amateur triathletes and nonactive women. METHODS: Forty-two healthy women (23 amateur triathletes and 19 nonactive individuals) were evaluated for body composition using a dual-energy X-ray absorptiometry system. RESULTS: Compared to nonactive women, amateur triathletes exhibited lower body mass index (p < 0.001), lower bone mineral density (p < 0.001), and body surface area (p < 0.001). However, bone mineral density adjusted by body surface area in the triathletes was higher than in the nonactive women (p = 0.03). CONCLUSION: These findings showed that amateur triathles presented lower absolute bone mineral density, but higher bone mineral density adjusted to body surface area. Future studies are recommended to identify if the higher bone mineral density adjusted to body surface area are associated with a lower bone fragility.

Assessing the efficacy of oral Tranexamic Acid as adjuvant of Topic Triple Combination Cream Therapy in Melasma: A Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Melasma is a skin pigmentation disorder that lacks consistent treatment success despite various methods used. Tranexamic Acid (TXA) has shown hypopigmentation properties, but whether TXA administration should be combined with standard treatment or not, is still not clarified. We aimed to perform an investigation of oral TXA effectiveness and safety as an adjuvant of Triple Combination Cream (TCC) Therapy in melasma. METHODS: We searched PubMed, EMBASE and Cochrane Central for studies comparing TCC plus adjuvant TXA to TCC therapy alone in patients with melasma. Outcomes of interest included change from the baseline of Melasma Area Severity Index (MASI) score, recurrence of melasma and adverse events. Statistical analysis was performed using R Studio 4.3.2. RESULTS: Four trials, involving 480 patients were included. In the pooled analysis, the decrease from baseline in the MASI score (mean difference [MD] -3.10; 95% confidence interval [CI] -5.85 to -0.35) was significantly higher in patients treated with oral tranexamic acid as an adjuvant to TCC compared to TCC alone. Melasma recurrence (RR 0.28; 95% CI 0.16-0.49) was significantly lower in the group treated with TCC and TXA. Regarding erythema (RR 0.63; 95% CI 0.34-1.17) and burning (RR 0.59; 95% CI 0.30-1.17), there was no significant difference. CONCLUSION: This meta-analysis demonstrated statistically significant benefits of TCC plus TXA combination treatment compared with TCC alone. Furthermore, the results suggest that the addition of TXA to TCC therapy may reduce melasma recurrence.

One spinal manipulation session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain: a randomised, placebo-controlled trial.

BACKGROUND: Clinical practice guidelines recommend spinal manipulation for patients with low back pain. However, the effects of spinal manipulation have contradictory findings compared to placebo intervention. Therefore, this study investigated the immediate effects of lumbar spinal manipulation on pressure pain threshold (PPT) and postural stability in people with chronic low back pain (cLBP). Second, we investigated the immediate effect of lumbar spinal manipulation on pain intensity and the interference of the participant beliefs about which treatment was received in the PPT, postural stability, and pain intensity. METHODS: A two-arm, randomised, placebo-controlled, double-blind trial was performed. Eighty participants with nonspecific cLPB and a minimum score of 3 on the Numeric Pain Rating Scale received one session of lumbar spinal manipulation (n = 40) or simulated lumbar spinal manipulation (n = 40). Primary outcomes were local and remote PPTs and postural stability. Secondary outcomes were pain intensity and participant's perceived treatment allocation. Between-group mean differences and their 95% confidence intervals (CIs) estimated the treatment effect. One-way analysis of covariance (ANCOVA) was performed to assess whether beliefs about which treatment was received influenced the outcomes. RESULTS: Participants had a mean (SD) age of 34.9 (10.5) years, and 50 (62.5%) were women. Right L5 [between-group mean difference = 0.55 (95%CI 0.19 to 0.90)], left L5 [between-group mean difference = 0.45 (95%CI 0.13 to 0.76)], right L1 [between-group mean difference = 0.41 (95%CI 0.05 to 0.78)], left L1 [between-group mean difference = 0.57 (95%CI 0.15 to 0.99)], left DT [between-group mean difference = 0.35 (95%CI 0.04 to 0.65)], and right LE [between-group mean difference = 0.34 (95%CI 0.08 to 0.60)] showed superior treatment effect in the spinal manipulation group than sham. Neither intervention altered postural stability. Self-reported pain intensity showed clinically significant decreases in both groups after the intervention. A higher proportion of participants in the spinal manipulation group achieved more than two points of pain relief (spinal manipulation = 90%; sham = 60%). The participants' perceived treatment allocation did not affect the outcomes. CONCLUSION: One spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to a sham session in individuals with cLPB. Self-reported pain intensity lowered in both groups and a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. The participant's belief in receiving the manipulation did not appear to have influenced the outcomes since the adjusted model revealed similar findings.

A multi-evidence approach in an Amazonian river based on land use, water quality, histopathological effects and habitat selection behavior in fish.

The Amazon rivers constitute the largest river basin in the world, with a high level of biodiversity. The Tocantins River is one of the most important rivers in this region, which has been impacted by different land uses. The objective of this study was to carry out a multi-evidence analysis focusing on the water quality of the Tocantins River, close to the municipality of Marabá-PA. We analyzed forest cover and water quality and, using the model organism Danio rerio, performed toxicity tests for histopathological effects, as well as the habitat selection approach by exposing fish to different river water samples in a multi-compartment device. The results showed that the studied area has already lost almost 30% of its forests in recent decades. Regarding water quality, the upstream (C1) and downstream (C5) points are the least impacted. On the other hand, the other points (C2-C4), closer to the city, greater input of pollutants was detected. Fish exposed to water samples from the most impacted sites showed several oedemas and hyperplastic cells in the gills. Regarding habitat selection behavior, there was a marked avoidance by samples with the highest contamination load. The results of this study lead to the understanding of the potential negative effects of human activities on local Amazonian biodiversity, since the potential toxicity of the environment, in conjunction with changes in the habitat selection process, could lead to a decline in populations of aquatic organisms, altering the environmental balance.

Leukotriene receptor antagonists as adjuvant therapy of antihistamines in chronic urticaria: a systematic review and meta-analysis.

Certain guidelines recommend a second-generation H1-antihistamine (AH) as first-line treatment for patients with chronic urticaria (CU). However, some patients show insufficient response to a standard dose of this therapy and might benefit from adding leukotriene receptor antagonists (LTA). Therefore, we aimed to perform a systematic review and meta-analysis comparing LTA plus antihistamines with antihistamines alone. We performed a systematic review and meta-analysis, searching PubMed, EMBASE, and Cochrane Central for randomized clinical trial (RCT) data comparing LTA plus AH treatment to AH alone in patients with CU. Statistical analysis was performed using R Studio 4.3.2. Heterogeneity was assessed with I2 statistics. Three studies comprising 234 patients with urticaria were included. The mean age was 37.23 years in the leukotriene antagonist + antihistamines (LTA + AH) group and 39.14 years in the antihistamines (AH) group. Follow-up ranged from 2 to 18 months between studies. There was no statistically significant difference between groups in terms of TSS level (SMD: -74.82; 95% CI: -222.66 to 73.02; P = 0.32; I2 = 98%), neither in terms of pruritus (MD: -0.07; 95% CI: -0.42 to 0.28; P = 0.70; I2 = 74%). After sensitivity analysis, with the systematic exclusion of each study from the grouped estimates, the result for TSS level did not change. These findings suggest that leukotriene receptor antagonists with antihistamines do not have better outcomes than antihistamines alone regarding TSS and pruritus in patients with CU.

Neurosonology Survey in Europe and Beyond.

Purpose To provide an overview on education, training, practice requirements, and fields of application of neurosonology in Europe and beyond. Materials and Methods National representatives and experts in neurosonology were surveyed regarding neurosonology requirements and practice in their countries. Descriptive statistics were used to report the data. Results Between February 1 and March 31, 2023, 42/46 (91.3%) national representatives responded to our questionnaire and the completion rate was 100%. Most countries (71.4%) offer a neurosonology training program during neurology residency, but it is part of the undergraduate medical program only in 30.9%. National certification is available in 47.6% of the countries surveyed and most countries (76.2%) require certification to practice. In 50% of the countries, candidates are assessed by a board examination, while in 26.2% they just need to document their practice. There is no formal accreditation of neurosonology centers in 78.6% of the countries surveyed. Only a few require certified personnel and appropriate equipment. Adequate teaching and research activities are only rarely necessary elements for laboratory accreditation. Conclusion Our results indicate that there is a substantial need for transnational harmonization of neurosonological standards to guarantee uniformity and quality of performance. This survey will also provide guidance to promote an international accrediting council and create a quality-controlled laboratory network for implementing neurosonology in clinical trials.

Early Mobilization Decision after an Acute Ischemic Stroke: Protocol for an Umbrella Review.

INTRODUCTION: Stroke is considered one of the greatest public health challenges worldwide, with the ischemic subtype being the most prevalent. Various acute stroke clinical guidelines recommend early rehabilitation interventions, including very early mobilization. However, despite the studies conducted in recent years regarding when to initiate mobilization after an acute stroke, there are few systematic and personalized protocols based on the factors for which patient mobilization should ideally be performed. We aim to conduct an umbrella review of systematic reviews and meta-analyses to study the early mobilization decision after an acute ischemic stroke in comparison with conventional care and correlate the different approaches with patient clinical outcomes. METHODS AND ANALYSIS: We will perform a systematic search on PubMed/MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Epistemonikos and Web of Science Core Collection databases. Retrieved studies will be independently reviewed by two authors and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. We will use the 16-item Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist as the critical appraisal tool to assess cumulative evidence and risk of bias of the different studies. This will be the first umbrella review that compares early mobilization approaches in post-acute ischemic stroke. This study may help to define the optimal early mobilization strategy in stroke patients. PROSPERO registration number: CRD42023430494.

Automatic multi-view pose estimation in focused cardiac ultrasound.

Focused cardiac ultrasound (FoCUS) is a valuable point-of-care method for evaluating cardiovascular structures and function, but its scope is limited by equipment and operator's experience, resulting in primarily qualitative 2D exams. This study presents a novel framework to automatically estimate the 3D spatial relationship between standard FoCUS views. The proposed framework uses a multi-view U-Net-like fully convolutional neural network to regress line-based heatmaps representing the most likely areas of intersection between input images. The lines that best fit the regressed heatmaps are then extracted, and a system of nonlinear equations based on the intersection between view triplets is created and solved to determine the relative 3D pose between all input images. The feasibility and accuracy of the proposed pipeline were validated using a novel realistic in silico FoCUS dataset, demonstrating promising results. Interestingly, as shown in preliminary experiments, the estimation of the 2D images' relative poses enables the application of 3D image analysis methods and paves the way for 3D quantitative assessments in FoCUS examinations.

Acute management of cerebral venous thrombosis: Indications, technique, and outcome of endovascular treatment in two high-volume centers.

INTRODUCTION: After several uncontrolled studies and one randomized clinical trial, there is still uncertainty regarding the role of endovascular treatment (EVT) in cerebral venous thrombosis (CVT). This study aims to describe and assess different acute management strategies in the treatment of CVT. METHODS: We performed a retrospective analysis of an international two-center registry of CVT patients admitted since 2019. Good outcome was defined as a return to baseline modified Rankin scale at three months. We described and compared EVT versus no-EVT patients. RESULTS: We included 61 patients. Only one did not receive systemic anticoagulation. EVT was performed in 13/61 (20%) of the cases, with a median time from diagnosis to puncture of 4.5 h (1.25-28.5). EVT patients had a higher median baseline NIHSS [6 (IQR 2-17) vs 0 (0-2.7), p = 0.002)] and a higher incidence of intracerebral hemorrhage (53.8% vs 20.3%, p = 0.03). Recanalization was achieved in 10/13 (77%) patients. Thrombectomy was performed in every case with angioplasty in 7 out of 12 patients and stenting in 3 cases. No postprocedural complication was reported. An improvement of the median NIHSS from baseline to discharge [6 (2-17) vs 1(0-3.75); p < 0.001] was observed in EVT group. A total of 31/60 patients (50.8%) had good outcomes. Adjusting to NIHSS and ICH, EVT had a non-significant increase in the odds of a good outcome [aOR 1.42 (95%CI 0.73-2.8, p = 0.307)]. CONCLUSIONS: EVT in combination with anticoagulation was safe in acute treatment of CVT as suggested by NIHSS improvement. Selected patients may benefit from this treatment.

A single session of a beach volleyball exergame did not improve state anxiety level in healthy adult women.

This study evaluated the acute effect of the exergame Kinect Sports® beach volleyball on state anxiety level in adult women. Thirty healthy adult women (age: 21 [4] years, body mass: 54.70 [19.50] kg, height: 1.61 ± 0.05 m, and body mass index: 21.87 [5.76] kg/m2, data are expressed as median [interquartile range] and as the mean ± standard deviation) were assigned to play an exergame of beach volleyball in singleplayer mode session (intervention session) for ~ 30 min using the Xbox 360 Kinect® or remained seated (control session). State anxiety was evaluated before and after the intervention and control sessions through the State-Trait Anxiety Inventory. State anxiety obtained in both sessions (exergame and control) was classified as intermediate before (median: 36.00 [IQR: 4.75] and mean = 38.73 ± 7.23, respectively) and after (mean: 34.86 ± 6.81 and mean: 37.66 ± 8.44, respectively). Friedman test found no time significant effect on state anxiety of the sessions (χ2 [3] = 6.45, p-value = 0.092, Kendall's W = 0.07 "trivial"). In conclusion, the present study showed that there were no significant differences in the state anxiety level after an acute session of the exergame beach volleyball.

KEY POINTS: • Exergame beach volleyball presented high enjoyment and a moderate to strong future engagement possibility. • A session of the volleyball exergame did not improve affectivity and state anxiety level compared with control condition. • A session of the volleyball exergame elicited moderate physical exercise intensity.

Experimental and Computational Analysis of Synthesis Conditions of Hybrid Nanoflowers for Lipase Immobilization.

This work presents a framework for evaluating hybrid nanoflowers using Burkholderia cepacia lipase. It was expanded on previous findings by testing lipase hybrid nanoflowers (hNF-lipase) formation over a wide range of pH values (5-9) and buffer concentrations (10-100 mM). The free enzyme activity was compared with that of hNF-lipase. The analysis, performed by molecular docking, described the effect of lipase interaction with copper ions. The morphological characterization of hNF-lipase was performed using scanning electron microscopy. Fourier Transform Infrared Spectroscopy performed the physical-chemical characterization. The results show that all hNF-lipase activity presented values higher than that of the free enzyme. Activity is higher at pH 7.4 and has the highest buffer concentration of 100 mM. Molecular docking analysis has been used to understand the effect of enzyme protonation on hNF-lipase formation and identify the main the main binding sites of the enzyme with copper ions. The hNF-lipase nanostructures show the shape of flowers in their micrographs from pH 6 to 8. The spectra of the nanoflowers present peaks typical of the amide regions I and II, current in lipase, and areas with P-O vibrations, confirming the presence of the phosphate group. Therefore, hNF-lipase is an efficient biocatalyst with increased catalytic activity, good nanostructure formation, and improved stability.

Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.

BACKGROUND: Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation. METHODS: This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments. RESULTS: The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; Pinteraction=0.009). CONCLUSIONS: Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.

Investigating academic performance and perceptions of human physiology and exercise physiology courses among undergraduate students of physical education at a Brazilian public university.

PURPOSE: To compare the academic performance of undergraduate students in physical education who studied exercise physiology before and after studying human physiology and investigate students' perceptions of human physiology and exercise physiology courses. METHODS: This study included 311 undergraduate students pursuing a bachelor's degree in physical education. Participants were divided into two groups: those who had previously attended and completed the human physiology course (group 1, n = 212, 68.2%) and those who had not previously attended or had attended but failed the human physiology course (group 2, n = 99, 31.8%). The prevalence ratio (PR) and 95% confidence interval (95% CI) were calculated using a Poisson regression model with a robust variance estimator. The second aim comprised 67 students with bachelor's degrees in physical education who completed an electronic questionnaire about their perceptions of human physiology and exercise physiology curriculum. RESULTS: Compared with those who attended human physiology and passed, those who had not previously attended or had attended but failed the human physiology course have a higher PR of 2.37 (95% CI, 1.68-3.34) for failing exercise physiology. Regarding the students' perceptions of human physiology and exercise physiology courses, most students reported that they were challenging (58.2% and 64.2%, respectively), but they also recognized the importance of these courses for professional practice (59.7% and 85.1%, respectively). CONCLUSION: Human physiology should be considered a prerequisite for an undergraduate course leading to a bachelor's degree in physical education. Furthermore, students considered human physiology and exercise physiology courses important yet challenging. Therefore, continuous student assessment is vital for improving the teaching-learning process.

A machine learning system to optimise triage in an adult ophthalmic emergency department: a model development and validation study.

Background: A substantial proportion of attendances to ophthalmic emergency departments are for non-urgent presentations. We developed and evaluated a machine learning system (DemDx Ophthalmology Triage System: DOTS) to optimise triage, with the aim of reducing inappropriate emergency attendances and streamlining case referral when necessary. Methods: DOTS was built using retrospective tabular data from 11,315 attendances between July 1st, 2021, to June 15th, 2022 at Moorfields Eye Hospital Emergency Department (MEH) in London, UK. Demographic and clinical features were used as inputs and a triage recommendation was given ("see immediately", "see within a week", or "see electively"). DOTS was validated temporally and compared with triage nurses' performance (1269 attendances at MEH) and validated externally (761 attendances at the Federal University of Minas Gerais - UFMG, Brazil). It was also tested for biases and robustness to variations in disease incidences. All attendances from patients aged at least 18 years with at least one confirmed diagnosis were included in the study. Findings: For identifying ophthalmic emergency attendances, on temporal validation, DOTS had a sensitivity of 94.5% [95% CI 92.3-96.1] and a specificity of 42.4% [38.8-46.1]. For comparison within the same dataset, triage nurses had a sensitivity of 96.4% [94.5-97.7] and a specificity of 25.1% [22.0-28.5]. On external validation at UFMG, DOTS had a sensitivity of 95.2% [92.5-97.0] and a specificity of 32.2% [27.4-37.0]. In simulated scenarios with varying disease incidences, the sensitivity was ≥92.2% and the specificity was ≥36.8%. No differences in sensitivity were found in subgroups of index of multiple deprivation, but the specificity was higher for Q2 when compared to Q4 (Q4 is less deprived than Q2). Interpretation: At MEH, DOTS had similar sensitivity to triage nurses in determining attendance priority; however, with a specificity of 17.3% higher, DOTS resulted in lower rates of patients triaged to be seen immediately at emergency. DOTS showed consistent performance in temporal and external validation, in social-demographic subgroups and was robust to varying relative disease incidences. Further trials are necessary to validate these findings. This system will be prospectively evaluated, considering human-computer interaction, in a clinical trial. Funding: The Artificial Intelligence in Health and Care Award (AI_AWARD01671) of the NHS AI Lab under National Institute for Health and Care Research (NIHR) and the Accelerated Access Collaborative (AAC).